Advocate Health Care Network Plan-Humana PPO - Advocate Benefits

Advocate Health Care Network Plan-Humana PPO Coverage Period: 01/01/2013 – 12/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: PPO
Common
Medical Event
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
If you need help
recovering or have
other special health
needs
If your child needs
dental or eye care
Your Cost If Your Cost If You
Services You May Need
You Use an Use an
In-network Out-of-network
Limitations & Exceptions
Provider Provider
Mental/Behavioral health outpatient services 20% coinsurance 40% coinsurance ---none---
Preauthorization applies. Your cost
Mental/Behavioral health inpatient services 20% coinsurance 40% coinsurance if prior authorization is not received
is 50%.
Substance use disorder outpatient services 20% coinsurance 40% coinsurance ---none---
Preauthorization applies. Your cost
Substance use disorder inpatient services 20% coinsurance 40% coinsurance if prior authorization is not received
is 50%.
Prenatal and postnatal care 20% coinsurance 40% coinsurance ----none----
Delivery and all inpatient services 20% coinsurance 40% coinsurance ----none----
Preauthorization applies. Your
Home health care 20% coinsurance 40% coinsurance cost if prior authorization is not
received is 50%.
Rehabilitation services 20% coinsurance 40% coinsurance 60 visits per benefit period.
Habilitation services 20% coinsurance 40% coinsurance 60 visits per benefit period.
Preauthorization applies. Your
Skilled nursing care 20% coinsurance 40% coinsurance cost if prior authorization is not
received is 50%.
Benefits are limited to items used to
serve a medical purpose. DME
Durable medical equipment 20% coinsurance 40% coinsurance benefits are provided for both
purchase and rental equipment (up
to the purchase price).
Preauthorization applies. Your cost
Hospice service 20% coinsurance 40% coinsurance if prior authorization is not received
is 50%.
Eye exam Not Covered Not Covered ---none---
Glasses Not Covered Not Covered ---none---
Dental check-up Not Covered Not Covered ---none---