Out-of- None 100% after $3,000 100% $3,000 for Pocket for In-Network In and Out-of- services per plan Network services per year (If you reach plan year (If you this maximum, no reach this maximum, further out-of-pocket no further will be required of will be you for covered required of you for expenses during the covered expenses year. Expenses for during the year. outpatient Part D Expenses for prescription outpatient Part D drugs and plan prescription drugs, premiums do not care during foreign apply toward this travel, and plan maximum) premiums do not Physician Office visits in 80% $147 100% per visit after 100% per visit after apply toward this Services conjunction with deductible $5 copayment to $5 copayment to maximum) an illness or injury primary care primary care physician; or 100% physician; or 100% per after per visit after $20 copayment $20 copayment to specialists to specialists Allergy 80% after $147 100% 100% injections and deductible serum Diagnostic 80% after $147 100% 100% tests and deductible Medicare- 100% 100% 100% approved lab services
Out-of- Pocket None 100% after $3,000 for In-Network services per plan year (If you reach this maximum, no further out-of-pocket will be required of you for covered expenses during the year. Expenses for outpatient Part D prescription drugs and plan premiums do not apply toward this maximum) 100% $3,000 for In and Out-of- Network services per plan year (If you reach this maximum, no further will be required of you for covered expenses during the year. Expenses for outpatient Part D prescription drugs, care during foreign travel, and plan premiums do not apply toward this maximum) Physician Services Office visits in conjunction with an illness or injury 80% $147 deductible 100% per visit after $5 copayment to primary care physician; or 100% per after $20 copayment to specialists 100% per visit after $5 copayment to primary care physician; or 100% per visit after $20 copayment to specialists Allergy injections and serum 80% after $147 deductible 100% 100% Diagnostic tests and 80% after $147 deductible 100% 100% lab services 100% 100% 100% Medicare- approved
2015%20Humana%20Summary.docx