Fillable Humana National POS Texas 100/70 Copay plan Plan (eHealth Medicare & Health Insurance)

Fill Online, Printable, Fillable, Blank Humana National POS Texas 100/70 Copay plan Plan (eHealth Medicare & Health Insurance) Form

Use Fill to complete blank online EHEALTH MEDICARE & HEALTH INSURANCE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Humana National POS Texas 100/70 Copay plan Plan (eHealth Medicare & Health Insurance)

The Humana National POS Texas 100/70 Copay plan Plan (eHealth Medicare & Health Insurance) form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 1 other field

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your eHealth Medicare & Health Insurance forms online.

BROWSE EHEALTH MEDICARE & HEALTH INSURANCE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Office visit copayment
Deductible
• per calendar year
• copayments do not apply
Out-of-pocket maximum
• per calendar year
• deductibles and
copayments do not apply
Preventive care
Physician services
Facility services
Other medical services
Lifetime maximum benefit
Basic mental health,
1
chemical and alcohol
dependency
• individual
• family
• individual
• family
• preventive office visits
• preventive lab and X-ray
• Pap smear and mammogram
• prostate screening
• child immunizations to age 18
• flu and pneumonia immunizations
• endoscopic services (including, but not limited to colonoscopy)
• office visits
• diagnostic lab and X-ray
• allergy testing
• injections (including allergy and serums)
• inpatient and outpatient services
• surgery
• emergency room visits
• inpatient and outpatient services
• outpatient advanced imaging (PET, MRI, MRA, CAT, SPECT)
—hospital, freestanding facility and clinic
• emergency services (copayment waived if admitted)
• skilled nursing facility (up to 60 days per calendar year)
• hospice
• home health care
• physical, occupational, cognitive, speech and audiology
therapy (combined limit up to 25 visits per calendar year)
• urgent care facility
• spinal manipulations, adjustments and modalities
(combined limit up to 20 visits per calendar year)
• durable medical equipment
(limited to $2,500 of covered services per calendar year)
• ambulance
• maternity
• transplant services
• inpatient services (up to 15 days per calendar year)
• outpatient & office therapy (up to 20 visits per calendar year)
Plan pays for services from
PARTICIPATING providers
100% after office visit copayment
100%
100% after deductible
100% after office visit copayment
100%
100% after $5 copayment per visit
100% after deductible
100%
100% after deductible
100% after $150 copayment
100% after deductible
100% after specialist copayment
per visit
100% after deductible
100% after deductible
Same as any other illness
Same as any other illness when
services are received from a Humana
Transplant Network provider
100% after deductible
100% after specialist office
visit copayment
Plan pays for services from
NONPARTICIPATING providers
70% after deductible
70% after deductible
70% after deductible
70% after deductible
70% after deductible
70% after deductible
70% after deductible
100%
70% after deductible
100% after $150 copayment
70% after deductible
70% after deductible
70% after participating deductible
100% after participating deductible
Same as any other illness
Covered expenses are limited to
a maximum benefit of $35,000
per transplant
70% after deductible
70% after deductible
$5,000,000
continued on back ❯
Texas
100/70 Copay plan
Humana National POS
1
Serious mental illness payable the same as any other illness up to 45 inpatient days and 60 outpatient visits per calendar year.
—Included for groups of 51 or more employees
—Available option for groups of 2-50 employees
$30 primary care/$50 specialist
Not applicable
$6,000
$2,000
$4,000
$12,000
$4,000
Not applicable
$8,000
Not applicable
This is not a complete disclosure of plan qualifications and limitations. Your group may have specific limitations and exclusions not included on this list. Please
check your Certificate of Coverage for this complete listing. The Certificate of Coverage is the document upon which benefit payment will be determined. The
amount of benefits provided depends upon the plan selected. Premiums will vary according to the selection made.
Providers
Pharmacy
Detailed drug lists are available at www.humana.com for each pharmacy plan and level.
Insured by Humana Insurance Company
Offered by Humana Health Plan, Inc.
Texas
Humana National POS 100/70 Copay plan
TX-51098-SB-C 12/06
Rx4
Mail order (up to 90-day supply):
Copayment maximum (Level 4 drugs only):
Level 1 Level 2 Level 3 Level 4
$10 $35 $55 25%
2.5 times the retail copayment
$2,500 per member per calendar year
Note: If a nonparticipating pharmacy is used, the claim will be covered at 70 percent after applicable copayment.
National POS-Open Access
Humana National POS-Open Access is one of our largest provider offerings and is growing daily. It combines the best of
Humana's fee-for-service provider contracts, providing improved discounts while maintaining broad provider scope.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Humana National POS Texas 10070 Copay plan Plan (eHealth Medicare & Health Insurance)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document