Consumer Driven Healthcare Plan Clermont County OHIO NATIONAL POS CDHP 100/70 PLAN HSA COMPATIBLE ParticiPATING providers Embedded Deductible and Out-of-Pocket Maximum Options (per calendar year; deductibles apply to out-of-pocket maximum) (4) Individual deductible $2,600 Family deductible Individual out-of-pocket maximum Family out-of-pocket maximum Preventive Care Routine immunizations (to age 18) Routine Pap smear Routine mammogram Routine lab test and X-ray Routine exams (18 years and above) Routine child exams (to age 18) Preventive endoscopy (includes colonoscopy, proctosigmoidoscopy and sigmoidoscopy Physician Services Office visits Diagnostic tests, lab and X-rays Allergy testing and injections Inpatient services Outpatient services Office surgery Two times individual participating deductible NONParticiPATING providers Two times individual participating deductible Two times family participating deductible 100% 70% after deductible 100% after deductible 70% after deductible Emergency room physician visits (1) 100% after deductible 100% after participating deductible Hospital Services Inpatient care (semiprivate room, ancillary services, nursing care, ICU) Outpatient surgery Outpatient nonsurgical care Hospital emergency services (facility charge only) (1) $2,600 Two times individual participating Two times individual participating deductible out-of-pocket maximum Two times family participating deductible 100% after deductible 70% after deductible 100% after deductible 100% after participating deductible OH25281HHCC 1012 Page 1 of 3
NATIONAL POS CDHP 100/70 PLAN HSA COMPATIBLE Prescription Drugs ParticiPatiNG providers NONParticiPatiNG providers Benefit per prescription or refill (2) 100% after deductible 70% after deductible Other Medical Services (3) Skilled nursing facility (up to 120 days per calendar year) Home health care (up to 30 visits per calendar year) Physical and occupational therapy (up to 60 visits per calendar year) Urgent care Speech therapy (up to 20 visits per calendar year) 100% after deductible 70% after deductible Durable medical equipment 100% after deductible 50% after deductible Ambulance (1) 100% after deductible 100% after participating deductible Transplant services Lifetime Maximum Benefit Behavioral Health (mental health and substance abuse) Inpatient services Outpatient and office therapy 100% after deductible (when services are received from a Humana Transplant Network provider.) 70% after deductible (covered expenses are limited to a maximum benefit of $35,000 per transplant) Unlimited (participating and nonparticipating combined) 100% after deductible (7) 70% after deductible (7) OH25281HHCC 1012 Page 2 of 3
Prior authorization - Humana sometimes requires preauthorization for some services and procedures your physician or other provider may recommend for you. Humana does this solely to determine whether the service or procedure qualifies for payment under your benefit plan. You and your health care provider decide whether you should have such services or procedures. Humana s preauthorization determination relates solely to payment by Humana. To find a list of services and supplies that require preauthorization for coverage, please visit our Website at /members/tools/ or call Customer Service. Failure to obtain necessary preauthorization when required may result in a reduction of otherwise payable benefits. Your health care practitioner should call Customer Service to obtain preauthorization. Payments - Participating providers agree to accept amounts negotiated with Humana as payment in full. The member is responsible for any required deductible, coinsurance, or other copayments. Plan benefits paid to nonparticipating providers are based on maximum allowable fees, as defined in your Summary Plan Description. Nonparticipating providers may balance bill you for charges in excess of the maximum allowable fee. You will be responsible for charges in excess of the maximum allowable fee in addition to any applicable deductible, coinsurance, or copayment. Additionally, any amount you pay the provider in excess of the maximum allowable fee will not apply to your out-of-pocket limit or deductible. Participating primary care and specialist physicians and other providers in Humana s networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgment or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. To be covered, expenses must be medically necessary and specified as covered. Please see your Summary Plan Description for more information on medical necessity and other specific plan benefits (1) Ambulance transportation and/or services received in an emergency room are not covered unless required because of emergency care, as defined in your Summary Plan Description. (2) Coverage is limited to drugs included in the Humana HDHP Drug List. Coverage for some drugs may be subject to dispensing limitations. Additionally, some drugs may need prior authorization in order to be covered. (3) Day/visit limits are combined for participating and nonparticipating providers. (4) Deductible and out-of-pocket limits for participating and nonparticipating benefits calculate separately. (5) For other than single coverage, the family deductible applies. The single deductible applies to single coverage policies only. (6) For other than single coverage, the family out-of-pocket maximum applies. The single out-of-pocket maximum applies to single coverage policies only. (7) Limits are a combined total for mental health and substance abuse, which includes participating and nonparticipating benefits. Biologically-based mental illness (BMI) is covered same as any other illness. The amount of benefits provided depends upon the plan selected. Premiums will vary according to the selection made. For general questions about the plan, contact your benefits administrator. Administered by Humana Health Plan, Inc. OH25281HHCC 1012 Page 3 of 3
NPOS - Copay Clermont County OHIO 2015 MAJOR PLAN BENEFITS Preventive Care Immunizations Mammogram and Pap smear Adult routine physical exam Well-child care Well-woman exam Physician Services Office visits in conjunction with a sickness or injury Diagnostic tests, lab and X-rays (when billed as an in-office procedure) Allergy tests/serum Office surgery Physician visits to emergency room (1) Allergy injections Inpatient services Outpatient services Office therapy/chiropractic adjustment (up to 12 visits per calendar year) Hospital Services Inpatient care (semiprivate room and ancillary services) Outpatient surgery Outpatient nonsurgical care Emergency room ParticiPatinG providers NONParticiPatinG providers 100% 60% after deductible 100% after $20 copayment to primary 60% after deductible care physician or $40 copayment to specialist 100% 60% after deductible 80% after deductible 60% after deductible 100% after $40 specialist copayment 60% after deductible 80% after deductible 70% after applicable deductible 100% after $200 copayment (waived if admitted) (1) 100% after $200 copayment (waived if admitted) (1) OH24778HHCC 1013 Page 1 of 4
2015 MAJOR PLAN BENEFITS Prescription Drugs Retail pharmacy (Rx4) (30-day supply) Mail order (Rx4) (90-day supply) RightSource ONLY Other Medical Services PARTICIPATING providers 100% after: Level One $10 copayment Level Two $30 copayment Level Three $50 copayment Level Four 25% 100% after: Level One $20 copayment Level Two $60 copayment Level Three $100 copayment Level Four 25% NONPARTICIPATING providers 70% after applicable copayment Not covered Skilled nursing facility (up to 120 days per plan year) (2) Home health care (up to 30 visits per plan year) (2) Durable medical equipment (2) 80% after deductible 60% after deductible Hospice services (2) 100% 60% after deductible Physical and occupational therapy (up to 60 visits per calendar year) Speech therapy (up to 20 visits per calendar year) 100% after $20 copayment 60% after deductible Urgent care facility 100% after $35 copayment 60% after deductible Deductible Individual $1,000 $2,000 Family $2,000 $4,000 Maximum Out-Of-Pocket Expense Limit Individual $3,000 $6,000 Family $6,000 $12,000 Prescription Out-Of-Pocket Limit Individual $3,500 N/A* Family $7,000 N/A* Combined Out-Of-Pocket Limit Individual $6,250 N/A* Family $12,500 N/A* Lifetime Maximum Benefit Per member benefit paid by plan Behavioral Health (mental health and substance abuse) Unlimited Inpatient-covered services 80% after deductible 60% after deductible Outpatient and office therapy-covered services 100% after a $40 copayment per visit 60% after deductible OH24778HHCC 1013 Page 2 of 4
Prior authorization - Humana sometimes requires preauthorization for some services and procedures your physician or other provider may recommend for you. Humana does this solely to determine whether the service or procedure qualifies for payment under your benefit plan. You and your health care provider decide whether you should have such services or procedures. Humana s preauthorization determination relates solely to payment by Humana. To find a list of services and supplies that require preauthorization for coverage, please visit our Website at /members/tools/ or call Customer Service. Failure to obtain necessary preauthorization when required may result in a reduction of otherwise payable benefits. Your health care practitioner should call Customer Service to obtain preauthorization. Nonparticipating pharmacy coverage* - You may also purchase prescribed medications from a nonparticipating pharmacy. You will be required to pay for your prescriptions according to the following rule. You pay 100 percent of the default rate. You file a claim form with Humana (address is on the back of ID card). Claim is paid at 70 percent of the default rate, after it is first reduced by the applicable copayment. Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change if Humana receives any retrospective volume discounts or prescription drug rebates. * In Georgia, the nonparticipating benefits are paid the same as the participating benefits, per state regulation. Your coverage includes the following: A 30-day supply or the amount prescribed, whichever is less, for each prescription or refill. Contraceptives. For Arizona, coverage also includes FDA approved contraceptive devices. Certain self-administered injectable drugs and related supplies approved by Humana. Certain drugs, medicines or medications that, under federal or state law, may be dispensed only by prescription from a physician. Some drugs may be subject to prior authorization requirements for coverage under the plan. Additionally, some drugs may have dispensing limitations, which limit coverage based on duration, age, gender or dosage criteria. To determine whether a drug prescribed for you may be affected by these coverage limitations, please contact Customer Service or visit our Website. For a complete listing of participating pharmacies, please refer to your participating provider directory, or visit our Website at Payments - Plan pays benefits based on maximum allowable fees as defined in your Certificate. Participating providers agree to accept maximum allowable fees, as listed in negotiated payment schedules, as payment in full. For services rendered by nonparticipating physicians, the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Summary Plan Description. For services from other nonparticipating providers, the member is responsible for amounts which exceed maximum allowable fees, as defined in your Summary Plan Description. Primary care and specialist physicians and other providers in Humana s networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgment or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. To be covered, expenses must be medically necessary and specified as covered. Please see your Summary Plan Description for more information on medical necessity and other specific plan benefits. (1) Ambulance transportation and/or services received in an emergency room are not covered unless required because of emergency care, as defined in your Summary Plan Description. (2) Failure to preauthorize may result in denial of payment. For general questions about the plan, contact your Human Resources office. OH24778HHCC 1013 Page 3 of 4
This is a brief plan description. It is not the plan document and does not include all of the benefits, limitations and exclusions of the plan. More complete terms of the plan are contained in the Summary Plan Description. Administered by Humana Health Plan, Inc. OH24778HHCC 1013 Page 4 of 4