Enrollment codes for this plan:
High Option MS1 Self Only
MS2 Self
and Family
Standard Option MS4 Self Only
MS5 Self and Family
2002
RI 73-054
Serving: The Kansas City metropolitan area
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 7 for requirements.
This plan has Commendable accreditation from the NCQA. See the 2002 Guide
for more information on NCQA 1
1 Page 2 3
2002 Humana Health
Plan, Inc. 2 Table of Contents
Table of Contents
Introduction………………………………………………………………….
............................................................... 4
Plain
Language………………………………………………………………...............................................................
4
Inspector General Advisory……………………………………………………………………………………………. 5
Section 1. Facts about this HMO
plan..........................................................................................................................
6
How we pay
providers.................................................................................................................................
6
Who provides my health care?…………………………………………………………………………….. 6
Your
Rights
.................................................................................................................................................
6
Service Area
................................................................................................................................................
7
Section 2. How we change for 2002………………………………………..
............................................................... 8
Program-wide changes
................................................................................................................................
8
Changes to this Plan
....................................................................................................................................
8
Section 3. How you get care …………...
................................................................................................................
9-11
Identification cards
......................................................................................................................................
9
Where you get covered care
........................................................................................................................
9
. Plan providers
.......................................................................................................................................
9
. Plan facilities
........................................................................................................................................
9
What you must do to get covered
care....................................................................................................
9-10
. Primary
care..........................................................................................................................................
9
. Specialty
care........................................................................................................................................
9
. Hospital care
.......................................................................................................................................
10
Circumstances beyond our control
............................................................................................................
11
Services requiring our prior approval
........................................................................................................
11
Section 4. Your costs for covered
services.................................................................................................................
12
. Copayments
........................................................................................................................................
12
Your out-of-pocket
maximum...................................................................................................................
12
Section 5.
Benefits………………………………………………………….........................................................
13-41
Overview
...................................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals ......... 14-22
(b) Surgical and anesthesia services
provided by physicians and other health care professionals...... 23-27
(c)
Services provided by a hospital or other facility, and ambulance
services.................................... 28-31
(d) Emergency services/
accidents
.......................................................................................................
32-33
(e) Mental health and substance abuse benefits
..................................................................................
34-35
(f) Prescription drug
benefits..............................................................................................................
36-38
(g) Special
features...................................................................................................................................
39
. Services for deaf and hearing impaired……………………………………………………….
. High
risk pregnancies…………………………………………………………………………
. Centers of excellence for
transplants/ heart surgery/ etc……………………………………… 2
2
Page 3 4
2002
Humana Health Plan, Inc. 3 Table of Contents
. 24-hour nurse
line…………………………………………………………………………….
. Smoking
cessation……………………………………………………………………………
(h) Dental
benefits....................................................................................................................................
40
(i) Non-FEHB benefits available to Plan members
.................................................................................
41
Section 6. General exclusions – things we don't cover
...............................................................................................
42
Section 7. Filing a claim for covered services
............................................................................................................
43
Section 8. The disputed claims process
................................................................................................................
44-45
Section 9. Coordinating benefits with other coverage
..........................................................................................
46-50
When you have…
. Other health coverage
.........................................................................................................................
46
. Original Medicare
.........................................................................................................................
46-49
. Medicare managed care
plan.........................................................................................................
49-50
TRICARE/ Workers' Compensation/
Medicaid...........................................................................................
50
Other Government
agencies.......................................................................................................................
50
When others are responsible for
injuries....................................................................................................
50
Section 10. Definitions of terms we use in this brochure
.......................................................................................
51-52
Section 11. FEHB facts
..........................................................................................................................................
53-55
Coverage information
................................................................................................................................
53
. No pre-existing condition limitation
...................................................................................................
53
. Where you get information about enrolling in the FEHB Program
.................................................... 53
. Types of coverage
available for you and your
family.........................................................................
53
. When benefits and premiums
start......................................................................................................
53
. Your medical and claims records are confidential
..............................................................................
54
. When you
retire...................................................................................................................................
54
When you lose
benefits........................................................................................................................
54-55
. When FEHB coverage ends
................................................................................................................
54
. Spouse equity
coverage.......................................................................................................................
54
. Temporary Continuation of Coverage (TCC)
.....................................................................................
54
. Converting to individual
coverage......................................................................................................
55
. Getting a Certificate of Group Health Plan
Coverage.........................................................................
55
Long term care insurance coming later in .2002……………………………………………………………..……
56-57
Department of Defense/ FEHB Demonstration
Project..........................................................................................
58-59
Index............................................................................................................................................................................
60
Summary of
benefits..............................................................................................................................................
62-63
Rates
..............................................................................................................................................................
Back cover 3
3 Page
4 5
2002 Humana Health Plan, Inc. 4
Introduction/ Plain Language
Introduction
Humana Health
Plan, Inc. 10450 Holmes
Kansas City, MO 64131
This brochure describes
the benefits of Humana Health Plan, under our contract (CS 1773) with the Office
of Personnel Management (OPM), as authorized by the Federal Employees Health
Benefits law. This brochure is the
official statement of benefits. No oral
statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002, and
changes are summarized on page 6. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
. Except for necessary technical terms, we use
common words. For instance, "you" means the enrollee or family
member; "we"
means Humana Health Plan, Inc. . We limit acronyms to ones you know. FEHB is the
Federal Employees Health Benefit Program. OPM is the
Office of Personnel Management. If we use others, we tell you what they mean
first. . Our brochure and other FEHB plans' brochures have the same format and
similar descriptions to help you
compare plans.
If you have comments or
suggestions about how to improve the structure of this brochure, let OPM know.
Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or email OPM at
fehbpwebcomments@ opm. gov. You may
also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900
E Street, NW Washington, DC 20415-3650 4
4 Page 5 6
2002 Humana Health
Plan, Inc. 5 Introduction/ Plain Language
Inspector General
Advisory
Stop health care fraud! Fraud increases the cost of health care
for everyone. If you suspect that a physician, pharmacy, or hospital has charged
you for services you did not
receive, billed you twice for the same service,
or misrepresented any information, do the following:
. Call the provider and ask for an explanation. There may be an error.
.
If the provider does not resolve the matter, call us at
1-800/ 4HUMANA and
explain the situation.
. If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The United States
Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate
anyone who uses an ID card if the person tries to obtain
services for someone who is not an eligible family member, or are no longer
enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 Humana Health
Plan, Inc. 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and other providers that contract with us.
These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When
you receive emergency services from
non-Plan providers, you may have to submit claim forms.
You should
join an HMO because you prefer the plan's benefits, not because a particular
provider is available. You cannot change plans because a provider leaves our
Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under
contract with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments.
Who provides my health care?
The Humana HMO operates in the Kansas
City area. All covered services are provided or authorized by primary care
physicians you may select from over 350 physicians in group practices and
individual practices throughout our service
area. In addition, Humana has
contracted with over 1,300 specialists and 19 hospitals. Each family member may
choose their own primary doctor and may change doctors at any time by calling
Member Services.
Your Rights
OPM requires that all FEHB Plans to provide certain
information to their FEHB members. You may get information about us, our
networks, providers and facilities. OPM's FEHB website (www. opm. gov/ insure)
lists the specific types
of information that we must make available to you. Some of the required
information is listed below.
. Medical case management is a special Humana
program that communicates the provision of care and the management of benefit in
cases of catastrophic illness or injury, transplant management and disease
management.
The program strives to ensure that patients receive the most appropriate,
cost-effective care and also derive maximum advantage from plan benefits.
. Humana has adopted preventative care guidelines based on the United States
Preventative Health Task Force and subscribes to their Healthy People 2000
goals. Our Patterns of Preventative Care (POPC) program monitors the
delivery of well care and uses an automated reminder system to help assure
that our members schedule routine preventative services
. Humana provides comprehensive disease management programs to plan members.
Key to each program is ongoing education, communication and coordination. Each
contracted vendor offers plan members access to a staff of highly
specialized nurses and doctors, experienced in the respective disease field.
The programs focus on linking the plan member with a specialized nurse or
interdisciplinary team to ensure an individualized care development approach.
These nurses work closely with the plan member, member's family, member's
primary care physician (PCP) and other involved providers to provide
information, education and assistance when needed.
. Nationally, Humana has been in the health care business since 1961.
Locally, Humana has been in existence since 1982.
. Humana is a for profit
corporation which is publicly traded on the New York Stock Exchange (NYSE).
If you want more information about us, call 1-800/ 4HUMANA, or write to the
Plan at 10450 Holmes, Kansas City, MO 64131. You may also contact us by fax at
920/ 430-0131 or visit our website at www. humana. com. 6
6 Page 7 8
2002 Humana Health Plan, Inc. 7 Section 1
Service Area
To enroll in this Plan, you must live in or work
in our Service Area. This is where our providers practice. Our Service Area is:
The Kansas counties of Johnson, Leavenworth, Miami and Wyandotte and
the Missouri counties of Carroll, Cass, Clay, Jackson, Johnson,
Lafayette, Platte and Ray.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our Service Area, we will pay only for emergency care
benefits. We will not pay for any other health care services out of our service
area unless the services have prior plan approval.
If you or a covered
family member move outside of our Service Area, you can enroll in another plan.
If your dependents live out of the area (for example, if your child goes to
college in another state), you should consider enrolling in a fee-for-service
plan or an HMO that has agreements with affiliates in other areas. If you or
a family member move, you do not have to wait until Open Season to change plans.
Contact your employing or retirement office. 7
7
Page 8 9
2002
Humana Health Plan, Inc. 8 Section 2
Section 2. How we change
for 2002 Do not rely on these change descriptions; this page is not an
official statement of benefits. For that, go to Section 5
Benefits. Also, we
edited and clarified language throughout the brochure; any language change not
shown here is a clarification that does not change benefits.
Program-wide changes
. We no longer limit total blood cholesterol
tests to certain age groups (Section 5( a))
Changes to this Plan
. Your share of the High Option non-Postal
premium will increase by 0.2% for Self Only and decrease by 10.6% for
Self
and Family.
. Your share of the Standard Option non-Postal premium will decrease by 1.5%
for Self Only and Self and Family.
. We have changed our name to Humana
Health Plan, Inc.
. We no longer limit total blood cholesterol tests to
certain age groups. (Section5( a))
. You pay an office visit copay for chemotherapy and radiation therapy.
.
We increased speech therapy benefits by removing the requirement that services
must be required to restore
functional speech. (Section 5( a))
. We now cover certain intestinal transplants. (Section 5( b))
. We
clarified the durable medical equipment benefit to show a maximum plan payment
of up to $1,000 per member
per calendar year under High Option and up to a
$1,000 per member per lifetime plan payment under Standard Option.
. Smoking cessation programs are covered for up to $100 per member per
lifetime.
. You pay a $25 copay (High Option) or a $50 copay (Standard
Option) for services received in an outpatient hospital
or ambulatory
surgical center.
. You pay a $50 copay (Standard Option) for ambulance service.
. You pay
a $20 copay (High Option) or a $25 copay (Standard Option) for brand name drugs
with no generic
equivalent and a $40 copay (High Option) or a $45 copay
(Standard Option) for generic or name brand drugs not on our Drug List.
. We changed the Mental Health and Substance Abuse provider from Magellan
Behavioral Health to New Directions.
(Section 5( e)) 8
8 Page 9 10
2002 Humana Health Plan, Inc. 9 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must show it whenever you
receive services from a
Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your
ID card, use your copy of the Health
Benefits Election Form, SF-2809, your
health benefits enrollment confirmation (for annuitants), or your Employee
Express confirmation
letter.
If you do not receive your ID card within
30 days after the effective date of your enrollment, or if you need replacement
cards, call us at
1-800/ 4HUMANA or 1-800/ 448-6262.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and you will not have to file
claims.
. Plan providers Plan providers are physicians and other health care
professionals in our
service area that we contract with to provide covered
services to our members. We credential Plan providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website at www. humana. com.
. Plan facilities Plan facilities are hospitals and other facilities
in our service area that we
contract with to provide covered services to our
members. We list these in the provider directory, which we update periodically.
The list is also
on our website at www. humana. com.
What you must do to get covered care It depends on the type of care
you need. First, you and each family member
must choose a primary care
physician. This decision is important since your primary care physician provides
or arranges for most of your health
care. You may choose your primary care
physician from our Provider Directory or our website, or you may call us for
assistance.
. Primary care Your primary care physician can be a family
practitioner, internist or
pediatrician. Your primary care physician will
provide most of your health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
. Specialty care Your primary care physician will refer you to a
specialist for needed care.
When you receive a referral from your primary
care physician, you must return to your primary care physician after the
consultation, unless your
primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or
authorize
follow-up care. Do not go to the specialist for your return visit unless your
primary care physician gives you a referral. However, you
may see the
following participating providers without a referral:
. OB/ GYN providers
for your annual well-woman exam
. Another doctor your primary care physician
has designated to provide
patient care when he or she is not available. 9
9 Page 10 11
2002 Humana Health Plan, Inc. 10 Section 3
Here are other things you should know about specialty care:
. If you
need to see a specialist frequently because of a chronic, complex, or serious
medical condition, your primary care physician will develop a
treatment plan that allows you to see your specialist for a certain number of
visits without additional referrals. Your primary care physician will
use
our criteria when creating your treatment plan (the physician may have to get an
authorization or approval beforehand).
. If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will
decide what
treatment you need. If he or she decides to refer you to a specialist, ask if
you can see your current specialist. If your
current specialist does not
participate with us, you must receive treatment from a specialist who does.
Generally, we will not pay
for you to see a specialist who does not
participate with our Plan.
. If you are seeing a specialist and your
specialist leaves the Plan, call your primary care physician, who will arrange
for you to see another
specialist. You may receive services from your current specialist until we
can make arrangements for you to see someone else.
. If you have a chronic or disabling condition and lose access to your
specialist because we:
. terminate our contract with your specialist for
other than cause; or
. drop out of the Federal Employees Health Benefits
(FEHB) Program and you enroll in another FEHB Plan; or
. reduce our service area and you enroll in another FEHB Plan;
you may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of
the program, contact your new plan.
If you are in the third trimester of
pregnancy and you lose access to your specialist based on the above
circumstances, you can continue to see your
specialist until the end of your postpartum care, even if it is beyond the 90
days.
. Hospital care Your Plan primary care physician or specialist
will make necessary hospital arrangements and supervise your care. This includes
admission
to a skilled nursing or other type of facility.
If you are in
the hospital when your enrollment in our Plan begins, call our customer service
department immediately at 1-800/ 4HUMANA. If
you are new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:
. You are discharged, not merely moved to an alternative care center; or
. The day your benefits from your former plan run out; or
. The 92 nd
day after you become a member of this Plan, whichever happens first.
These provisions apply only to the hospital benefits of the hospitalized
person. 10
10 Page
11 12
2002 Humana Health Plan, Inc.
11 Section 3
Circumstances beyond our control Under
certain extraordinary circumstances, such as natural disasters, we may have to
delay your services or we may be unable to provide them. In that case,
we
will make all reasonable efforts to provide you with the necessary care.
Services requiring our Your primary care physician has authority to
refer you for most services. prior approval For certain services,
however, your physician must obtain approval from
us. Before giving
approval, we consider if the service is covered, medically necessary, and
follows generally accepted medical practice.
We call this review and approval process precertification. Your physician
must obtain precertification for the following services:
. Growth hormone
therapy .
Organ/ Tissue transplants . All elective medical and surgical
hospitalizations
. MRI of the lumbar and cervical spine .
Uvulopalatopharyngoplasty (UPPP)
. Gastric bypass
. All durable medical equipment (DME) over $750 .
Acute rehabilitation
services . Home health care services
. Genetic testing .
Infertility services . Pain Management services
. PET and SPECT scans .
Sclerotherapy . Occupational and Physical
therapies
Your physician must obtain our approval before sending you to a hospital,
referring you to a specialist, or recommending follow-up care
from a
specialist. 11
11 Page
12 13
2002 Humana Health Plan, Inc.
12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
.
Copayments A copayment is a fixed amount of money you pay to the
provider,
facility, pharmacy, etc. when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit under the High Option and $15 under
the Standard Option. When you go in the hospital, you pay nothing under the
High Option and $100 per admission copay under the Standard
Option.
. Deductible We do not have a deductible.
. Coinsurance We
do not have coinsurance.
Your catastrophic protection out-of-pocket
maximum
for copayments After your copayments or coinsurance total $500
per person or $1,250 per family enrollment in any calendar year, you do not have
to pay any
more for covered services. However, copayments for the following
services do not count toward your out-of-pocket maximum, and you must
continue to pay copayments for these services:
. Prescription drugs
Be sure to keep accurate records of your copayments since you are responsible
for informing us when you reach the maximum. 12
12
Page 13 14
2002
Humana Health Plan, Inc. 13 Section 5
Section 5. Benefits –
OVERVIEW (See page 6 for how our benefits changed this year and pages
51-52 for a benefits summary.)
NOTE: This benefits section is
divided into subsections. Please read the important things you should keep in
mind at the beginning of each subsection. . Also read the General Exclusions in
Section 6; they apply to the benefits in the
following subsections. To
obtain claims forms, claims filing advice, or more information about our
benefits, contact us 1-800/ 4HUMANA or at our website at www. humana. com.
(a) Medical services and supplies provided by physicians and other health
care professionals .......................... 14-22
. Diagnostic and
treatment services
. Lab, x-ray, and other diagnostic tests
. Preventive
care, adult
. Preventive care, children
. Maternity care
. Family
planning
. Infertility services
. Allergy care
. Treatment therapies
. Physical and occupational therapies
. Speech therapy
. Hearing services (testing, treatment, and
supplies) .
Vision services (testing, treatment, and supplies)
. Foot care
. Orthopedic and prosthetic devices
. Durable medical
equipment (DME)
. Home health services
. Chiropractic
. Alternative
treatments
(b) Surgical and anesthesia services provided by physicians and other health
care professionals....................... 23-27
. Surgical procedures
.
Reconstructive surgery
. Oral and maxillofacial surgery
. Organ/ tissue
transplants
. Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services..................................................... 28-31
.
Inpatient hospital
. Outpatient hospital or ambulatory surgical
center
. Extended care benefits/ skilled nursing care
facility benefits .
Hospice care .
Ambulance
(d) Emergency services/ accidents
........................................................................................................................
32-33
. Medical emergency . Ambulance
(e) Mental health and substance abuse benefits
...................................................................................................
34-35
(f) Prescription drug
benefits...............................................................................................................................
36-38
(g) Special
features.....................................................................................................................................................
39
. Services for deaf and hearing impaired .
High risk pregnancies .
Centers of excellence for transplants/ heart surgery/ etc.
. 24-hour nurse line .
Smoking cessation
(h) Dental
benefits......................................................................................................................................................
40
(i) Non-FEHB benefits available to Plan members
...................................................................................................
41
Summary of
benefits..............................................................................................................................................
62-63 13
13 Page
14 15
2002 Humana Health Plan, Inc.
14 Section 5( a)
Section 5 (a). Medical services and supplies
provided by physicians and other health care professionals
I M
P O
R
T
A N
T
Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations, and
exclusions in this brochure and are payable only when we
determine they are medically necessary.
. Plan physicians must provide or arrange your care.
. Be sure to read
Section 4, Your costs for covered services, for valuable
information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services You pay -Standard Option You pay -High
Option
Professional services of physicians
. In physician's office
. In an urgent care center
. Office medical consultations
. Second
surgical opinion
. At home
$15 per office visit $10 per office visit
Professional services of physicians
. During a hospital stay
. In a
skilled nursing facility
Nothing Nothing
Lab, x-ray and other diagnostic tests
Tests, such as:
. Blood
tests
. Urinalysis
. Non-routine pap tests
. Pathology
. X-rays
.
Non-routine Mammograms
. CAT Scans/ MRI
. Ultrasound
.
Electrocardiogram and EEG
Nothing Nothing 14
14 Page
15 16
2002 Humana Health Plan, Inc.
15 Section 5( a)
Preventive care, adult You pay – Standard
Option You pay – High Option
Routine screenings, such as:
. Total
Blood Cholesterol – once every
three years.
. Colorectal Cancer Screening, including .
Fecal occult blood test .
Sigmoidoscopy, screening – every
five years starting at age 50
. Prostate Specific Antigen (PSA test) –
one annually for men age 40 and older
. Routine pap test
. Chlamydial infection screening
Note: The office visit is covered if pap
test is received on the same day; see Diagnostic
and treatment services, above.
Nothing Nothing
Routine mammogram – covered for women age 35 and older, as follows:
.
From age 35 through 39, one during this
five year period
. From age 40 through 64, one every
calendar year
. At age 65 and older, one every two
consecutive calendar years
. When prescribed by the doctor as
medically necessary to diagnose or
treat illness
Nothing Nothing
Not covered: physical exams and immunizations required for obtaining or
continuing employment or insurance, attending schools or camp, or travel.
All charges All charges
Routine immunizations, limited to:
. Tetanus-diphtheria (Td) booster –
once
every 10 years, ages19 and over (except as provided for under Childhood
immunizations)
. Influenza/ Pneumococcal vaccines,
annually, age 65
and over
Nothing Nothing
. Vitamin B-12
. Gold
. Certain hormones (estrogen,
progesterone,
depotestosterone, depoluprin, depoprovera and
depoestradiol)
$4 per injection $4 per injection 15
15 Page 16 17
2002 Humana
Health Plan, Inc. 16 Section 5( a)
Preventive care, children
You pay – Standard Option You pay – High Option
. Childhood
immunizations recommended
by the American Academy of Pediatrics Nothing
Nothing
. Well-child care charges for routine
examinations (including
comprehensive history), immunizations and care (under
age 22)
Nothing Nothing
. Examinations, such as: .
Eye exams through age 17 to determine the need
for vision
correction. . Ear exams through age 17 to determine
the need for hearing
correction . Examinations done on the day of
immunizations (through age 22)
$15 per office visit $10 per office visit
Maternity care
Complete maternity (obstetrical) care, such as:
. Prenatal care
. Delivery
. Postnatal care
Note: Here are some things to keep in mind:
. You may remain in the
hospital up to 48
hours after a regular delivery and 96 hours after a
cesarean delivery. We will
extend your inpatient stay if medically necessary.
. We cover routine nursery care of the
newborn child during the covered
portion of the mother's maternity stay. We will
cover other care of an infant who requires non-routine treatment only if we
cover the infant under a Self and Family enrollment.
. We pay hospitalization and surgeon
services (delivery) the same as for
illness and injury. See Hospital benefits
(Section 5c) and Surgery benefits (Section 5b).
Nothing Nothing
Not covered: routine sonograms to determine fetal age, size or sex All
charges All charges 16
16 Page 17 18
2002 Humana
Health Plan, Inc. 17 Section 5( a)
Family planning You pay
-Standard Option You pay -High Option
A broad range of voluntary family
planning services, limited to:
. Voluntary sterilization
. Surgically
implanted contraceptives
(such as Norplant)
. Contraceptive devices
. Injectable contraceptive drugs (such as
Depo provera)
. Intrauterine devices (IUD's)
. Diaphragms
Note: We cover oral contraceptive drugs covered under
prescription drug benefits. See Section 5 (f).
Nothing Nothing
Not covered: reversal of voluntary surgical sterilization All charges All
charges
Infertility services
. Diagnosis and treatment of
infertility, such
as: $20 per office visit $20 per office visit
. Artificial insemination: .
intravaginal insemination (IVI) .
intracervical insemination (ICI)
. intrauterine insemination (IUI)
$200 per surgical
procedure
$200 per surgical
procedure
Not covered:
. Fertility drugs
. Assisted
reproductive technology (ART)
procedures, such as: . in vitro
fertilization
. embryo transfer, gamete GIFT and
zygote ZIFT
. Zygote transfer
. Services and supplies related to excluded
ART
procedures
. Cost of donor sperm
. Cost of donor egg
All charges All charges
Allergy care
. Allergy testing and treatment
. Allergy serum
Nothing Nothing
. Allergy injections $4 per injection $4 per injection 17
17 Page 18 19
2002 Humana Health Plan, Inc. 18 Section 5(
a)
Not covered: provocative food testing and sublingual allergy
desensitization All charges All charges
Treatment therapies You pay
-Standard Option You pay -High Option
. Chemotherapy and radiation
therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are
limited to those transplants listed under Organ/ Tissue Transplants on page
23.
. Respiratory and inhalation therapy
. Dialysis – Hemodialysis and
peritoneal
dialysis
. Intravenous (IV)/ Infusion Therapy – Home
IV and antibiotic therapy
. Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover Growth Hormone Therapy if the treatment is
precertified and
there is a laboratory confirmed diagnosis of Growth Hormone
Deficiency. You will need
to call the precertification telephone number on
the back of your medical ID
(identification) card. We will also ask that
your physician submit information that
establishes that the GHT is medically
necessary. GHT must be authorized before
you begin treatment.
See
Services requiring our prior approval in Section 3.
$15 per visit $10 per visit
Physical and occupational therapies
. Up to 60 treatments or two
consecutive
months per condition if significant improvement can be expected
within two
months. Includes the services of each of the following:
. . qualified
physical therapists; and . .
occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a
total
or partial loss of bodily function due to illness or injury. Occupational
therapy is
limited to services that assist the member to achieve and
maintain self-care and
improved functioning in other activities of daily
living.
$15 per outpatient visit
Nothing per visit during covered inpatient
admission.
$10 per outpatient visit
Nothing per visit during covered inpatient
admission. 18
18 Page
19 20
2002 Humana Health Plan, Inc.
19 Section 5( a)
Physical and occupational therapies
(continued) You pay -Standard Option You pay -High Option
. Cardiac
rehabilitation following a heart
transplant, bypass surgery or a myocardial
infarction, is provided for up
to two months.
$15 per office visit $10 per office visit
Not covered:
. long-term rehabilitative therapy
.
exercise programs
All charges. All charges
Speech therapy
. Speech therapy provided by speech
therapists
$15 per outpatient visit
Nothing per visit during covered inpatient
admission.
$10 per outpatient visit
Nothing per visit during covered inpatient
admission.
Hearing services (testing, treatment, and supplies)
. Hearing
tests, including audiograms
. Hearing testing for children through age
17 (see Preventive care, children)
$15 per office visit $10 per office visit
Not covered:
. hearing aids, testing and examinations
for
them
All charges. All charges.
Vision services (testing, treatment, and supplies)
. One pair of
eyeglasses or contact lenses to
correct an impairment directly caused by
accidental ocular injury or intraocular
surgery (such as for cataracts)
Nothing Nothing
. Diagnosis and treatment of diseases of the
eye.
. Screening eye exam to determine the need
for vision correction for
children through age 17 (see preventive care)
$15 per office visit $10 per office visit
Not covered:
. eyeglasses or contact lenses and,
examinations for them
. eye exercises and orthoptics
. radial keratotomy and other
refractive
surgery
All charges All charges 19
19 Page 20 21
2002 Humana
Health Plan, Inc. 20 Section 5( a)
Foot care You pay -Standard
Option You pay -High Option
. Routine foot care when you are under
active treatment for a metabolic or peripheral vascular disease, such as
diabetes.
See orthopedic and prosthetic devices for information on
podiatric shoe inserts.
$15 per office visit $10 per office visit
Not covered, podiatric services:
. cutting, trimming or removal
of corns,
calluses, or the free edge of toenails, and similar routine
treatment of conditions of
the foot, except as stated above
. treatment of weak, strained
or flat feet or
bunions or spurs; and of any instability, imbalance or
subluxation of the foot
(unless the treatment is by open cutting surgery)
All charges. All charges.
Orthopedic and prosthetic devices
. Artificial limbs
.
Externally worn breast prostheses and
surgical bras, including necessary
replacements, following a mastectomy
. Specialized braces
. Artificial eyes
. Internal prosthetic devices,
such as
artificial joints. Note: See 5( b) for coverage of the surgery to
insert the
device.
. Corrective orthopedic appliances for non-dental
treatment
of temporomandibular joint (TMJ) pain dysfunction syndrome.
Nothing Nothing
Not covered:
. foot orthotics
. dental prosthesis
. orthopedic braces
. orthopedic and corrective shoes
. arch supports
. heel pads and heel cups
.
lumbosacral supports
. corsets, trusses, elastic stockings,
support
hose, and other supportive devices
. prosthetic replacements unless required
by growth or change in
medical condition or incorrect initial placement
All charges All charges 20
20 Page 21 22
2002 Humana
Health Plan, Inc. 21 Section 5( a)
Durable medical equipment
(DME) You pay -Standard Option You pay -High Option
Rental or purchase,
at our option, including repair and adjustment, of durable medical
equipment
prescribed by your Plan physician, such as dialysis equipment.
. Standard Option -Benefits are
provided up to a maximum Plan payment of
$1,000 per member per
lifetime.
. High Option – Benefits are provided to
a maximum Plan
payment of $1,000 per member per calendar year.
Under this benefit, we also cover:
. Hospital beds
. Wheelchairs
Nothing Nothing
. Oxygen $25 per month $25 per month
Not covered:
.
Equipment such as exercise equipment,
air cleaners, heating pads or
lights, bed lifts
All charges All charges
Home health services
. Home health care ordered by a Plan
physician and provided by a registered nurse (R. N.), licensed practical
nurse
(L. P. N.), licensed vocational nurse (L. V. N.), or home health aide.
. Services include oxygen therapy,
intravenous therapy and medications.
Nothing Nothing
Not covered:
. nursing care requested by, or for the
convenience of, the patient or the patient's family;
. home care primarily for personal
assistance that does not include a
medical component and is not diagnostic,
therapeutic, or rehabilitative.
All charges All charges 21
21 Page 22 23
2002 Humana
Health Plan, Inc. 22 Section 5( a)
Chiropractic You pay
-Standard Option You pay -High Option
. Chiropractic services
.
Manipulation of the spine and
extremities; . Adjunctive procedures such as
ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack
application.
$15 per office visit $10 per office visit
Alternative treatments
No benefit All charges All charges
Educational classes and programs
. Smoking cessation -Up to $100 for
one (1) smoking cessation program per
member per lifetime. Nothing Nothing
. Primary care visits for smoking cessation. $15 per office visit $10 per
office visit 22
22 Page
23 24
2002 Humana Health Plan, Inc.
23 Section 5( b)
Section 5 (b). Surgical and anesthesia
services provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations,
and exclusions in this brochure and are payable only when we
determine they are medically necessary.
. Plan physicians must provide or arrange your care.
. Be sure to read
Section 4, Your costs for covered services for valuable
information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.
. The amounts listed below are for the charges billed by a physician or other
health care professional for your surgical care. Look in Section 5( c) for
charges associated with the facility (i. e. hospital, surgical center, etc.).
. YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME
SURGICAL
PROCEDURES. Please refer to the precertification information shown in Section 3
to be sure which services require
precertification and identify which surgeries require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures You pay – Standard
Option You pay – High Option
A comprehensive range of services, such as:
. Operative procedures
. Treatment of fractures, including casting
.
Normal pre-and post-operative care by
the surgeon
. Endoscopy procedures
. Biopsy procedures
. Removal of tumors and
cysts
. Correction of congenital anomalies (see
reconstructive surgery)
. Surgical treatment of morbid obesity – a
condition in which an
individual weighs 100 pounds or 100% over his or her
normal weight according to current underwriting standards; eligible members
must be age 18 or over.
. Insertion of internal prosthetic devices.
See 5( a) – Orthopedic and prosthetic devices for device coverage
information.
. Voluntary sterilization
. Treatment of burns
Note: Generally, we
pay for internal prostheses (devices) according to where the procedure is
done. For example, we pay Hospital benefits for a pacemaker and Surgery
benefits for
insertion of the pacemaker.
Nothing for inpatient $15 per office visit Nothing for inpatient $10 per
office visit
Not covered:
. reversal of voluntary sterilization
All
charges All charges 23
23 Page 24 25
2002 Humana
Health Plan, Inc. 24 Section 5( b)
Reconstructive surgery You
pay – Standard Option You pay – High Option
. Surgery to correct a
functional defect
. Surgery to correct a condition caused by
injury or
illness if: . the condition produced a major effect on
the member's appearance and . the condition can reasonably be expected
to
be corrected by such surgery
. Surgery to correct a condition that existed
at or from birth and is a significant deviation from the common form or
norm.
Examples of congenital anomalies are: protruding ear deformaties; cleft lip;
cleft
palate; birth marks; webbed fingers; and webbed toes.
. All stages of breast reconstruction surgery
following a mastectomy,
such as: . surgery to produce a symmetrical
appearance on the other breast; . treatment of any physical complications,
such as lymphedemas; . breast prostheses and surgical bras and
replacements (see Prosthetic devices)
Note: If you need a mastectomy,
you may choose to have the procedure performed on
an inpatient basis and remain in the hospital up to 48 hours after the
procedure.
Nothing Nothing
Not covered:
. cosmetic surgery – any surgical procedure
(or any portion of a procedure) performed primarily to improve physical
appearance
through change in bodily form, except repair of accidental injury
. surgeries related to sex transformation
All charges All charges 24
24 Page 25 26
2002 Humana
Health Plan, Inc. 25 Section 5( b)
Oral and maxillofacial
surgery You pay – Standard Option You pay – High Option
Oral surgical
procedures, limited to:
. Reduction of fractures of the jaws or
facial
bones;
. Surgical correction of cleft lip, cleft
palate or severe functional
malocclusion;
. Removal of stones from salivary ducts;
. Excision of leukoplakia or
malignancies;
. Excision of cysts and incision of
abscesses when done as
independent procedures; and
. Other surgical procedures that do not
involve the teeth or their
supporting structures. 0
Nothing Nothing
Not covered:
. oral implants and transplants
.
procedures that involve the teeth or their
supporting structures (such as
the periodontal membrane, gingiva, and
alveolar bone)
. dental care involved in the treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome
All charges All charges 25
25 Page 26 27
2002 Humana
Health Plan, Inc. 26 Section 5( b)
Organ/ tissue transplants
You pay – Standard Option You pay – High Option
Limited to:
. Cornea
. Heart
. Lung: Single-Double
. Heart/ Lung
. Kidney
.
Kidney/ Pancreas
. Liver
. Pancreas
. Allogeneic (donor) bone marrow
transplants
. Autologous bone marrow transplants
(autologous stem cell and peripheral
stem cell support) for the following conditions:
acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma;
breast cancer; multiple myeloma; epithelial ovarian cancer; Wiskott-Aldrich
syndrome; severe combined immunodeficiency syndrome; aplastic
anemia;
ewings sarcoma; and testicular, mediastinal, retroperitoneal and ovarian
germ cell tumors.
Intestinal transplants (small intestine) and the small
intestine with the liver or small
intestine with multiple organs such as the liver, stomach, and pancreas.
Humana has a National Transplant Network with over 35 facilities within 20
states.
Limited Benefits – Treatment for breast cancer, multiple myeloma,
and epithelial
ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated
center of excellence and if approved by
the Plan's medical director in
accordance with the Plan's protocols. Note:
We cover related medical and
hospital expenses of the donor when we cover
the recipient. Donor expenses are
covered subject to coordination of
benefits with any coverage the donor may have. All
transplants must be
precertified.
Nothing Nothing 26
26 Page
27 28
2002 Humana Health Plan, Inc.
27 Section 5( b)
Not covered:
. donor screening tests and
donor search
expenses, except those performed for the actual donor
. implants of artificial organs
. transplants not listed as
covered
All charges All charges
Anesthesia You pay – Standard Option You pay – High Option
Professional services provided in –
. Hospital (inpatient)
Nothing Nothing
Professional services provided in –
. Hospital outpatient department
. Skilled nursing facility
. Ambulatory surgical center
. Office
Nothing Nothing 27
27 Page
28 29
2002 Humana Health Plan, Inc.
28 Section 5( c)
Section 5( c). Services provided by a
hospital or other facility, and ambulance services
I M
P O
R T
A
N
T
Here are some important things to remember about these benefits:
.
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they
are medically necessary.
. Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.
. Be sure to read Section 4, Your costs for covered services, for
valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
. The amounts listed below are for the charges billed by the facility (i. e.,
hospital or surgical center) or ambulance service for your surgery or care.
Any costs associated with the professional charge (i. e., physicians, etc.) are
covered in Section 5( a) or (b).
. YOUR PHYSICIAN MUST GET
PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure
which services
require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital You pay – Standard
Option You pay – High Option
Room and board, such as
. Semiprivate,
intensive care or cardiac
care accommodations;
. Private accommodations when medically
necessary;
. General nursing care;
. Private duty nursing when Plan doctor
determines medically necessary; and
. Meals and special diets.
Note: If you want a private room when it is not medically necessary, you pay
the
additional charge above the semiprivate room rate.
$100 per admission Nothing 28
28 Page 29 30
2002 Humana
Health Plan, Inc. 29 Section 5( c)
Inpatient hospital
(Continued) You pay – Standard Option You pay – High Option
Other hospital services and supplies, such as:
. Operating,
recovery, maternity, and other
treatment rooms
. Prescribed drugs and medicines
. Diagnostic laboratory tests and x-rays
. Administration of blood, blood plasma,
and other biologicals
. Blood and blood components if not
replaced
. Dressings, splints, casts, and sterile tray
services
. Medical supplies and equipment,
including oxygen
. Anesthetics, including nurse anesthetist
services
. Take-home items
. Medical supplies, appliances, medical
equipment,
and any covered items billed by a hospital for use at home
Nothing Nothing
Not covered:
. Cost of blood and blood components if
replaced
. Non-covered facilities, such as , nursing
homes and schools
. Personal comfort items, such as
telephone, television, barber
services, guest meals and beds
All charges All charges 29
29 Page 30 31
2002 Humana
Health Plan, Inc. 30 Section 5( c)
Outpatient hospital or
ambulatory surgical center You pay – Standard Option You pay – High Option
. Operating, recovery, and other treatment
rooms
. Prescribed drugs and medicines
. Laboratory tests, x-rays, and
pathology
services
. Administration of blood, blood plasma,
and other biologicals
. Blood and blood components if not
replaced
. Pre-surgical testing
. Dressings, casts, and sterile tray services
. Medical supplies, including oxygen
. Anesthetics and anesthesia
service
Note: We cover hospital services and supplies related to dental procedures
when
necessitated by a non-dental physical impairment. We do not cover the dental
procedures.
$50 per visit $25 per visit
Not covered: Cost of blood and blood components if replaced All charges
All charges
Extended care benefits/ skilled nursing care facility
benefits
Extended care benefit:
. Up to 60 days per calendar year,
including . bed and board;
. general nursing care .
drugs, biologicals, supplies and equipment
provided by the facility
Note: Coverage is provided when full-time skilled nursing care is necessary
and
confinement in a skilled nursing facility is medically appropriate as
determined by a
Plan doctor and approved by the Plan.
Nothing Nothing
Not covered: custodial care, rest cures, domiciliary or convalescent care
All charges All charges 30
30 Page 31 32
2002 Humana
Health Plan, Inc. 31 Section 5( c)
Hospice care You pay –
Standard Option You pay – High Option
. Supportive and palliative care
for a
terminally ill member is covered in the home. Care must be arranged
through
our case management program.
Note: These services are provided under the
direction of a Plan doctor who certifies that
the patient is in the terminal stages of illness, with a life expectancy of
approximately six
months or less.
Nothing Nothing
Not covered: independent nursing, homemaker services All charges All
charges
Ambulance
. Local professional ambulance service,
when medically appropriate $50 per visit Nothing 31
31 Page 32 33
2002 Humana Health Plan, Inc. 32 Section 5(
d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations,
and exclusions in this brochure.
. Be sure to read Section 4, Your costs for covered services, for
valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or surgical care. Some
problems are emergencies because, if not treated promptly, they might become
more serious; examples include deep cuts and broken bones. Others are
emergencies because they are potentially life-threatening, such as heart
attacks, strokes, poisonings, gunshot wounds, or sudden inability to
breathe. There are many other acute conditions that we may determine are medical
emergencies – what they all have in common is the need for quick
action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care doctor.
In extreme emergencies, if you are unable to contact your doctor, contact the
local emergency
system (e. g., the 911 telephone system) or go to the
nearest hospital emergency room. Be sure to tell the emergency room personnel
that you are a Plan member so they can notify the Plan. You or a family member
must notify the Plan within 48 hours unless it was not reasonably possible
to do so. It is your responsibility to ensure that the Plan has been timely
notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your admission, unless it was not reasonably
possible to notify the Plan within that time. If you are hospitalized
in
non-Plan facilities and a Plan doctor believes care can be better provided in a
Plan hospital, you will be transferred when medically feasible with any
ambulance charges covered in full.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan provider would result in death,
disability or significant jeopardy to your condition.
To be covered by this
Plan, any follow-up care recommended by non-Plan providers must be approved by
the Plan or provided by Plan providers.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must
be notified within 48 hours or on the first working day following your
admission, unless it was not reasonably possible to notify the Plan within that
time. If a Plan doctor believes
care can be better provided in a Plan
hospital, you will be transferred when medically feasible with any ambulance
charges covered in full.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan or provided by Plan providers. 32
32 Page 33 34
2002 Humana Health Plan, Inc. 33 Section 5(
d)
Benefit Description You pay
Emergency within our service area
You pay – Standard Option You pay -High Option
. Emergency care at a doctor's office
. Emergency care at an urgent care
center
$15 per visit $10 per visit
. Emergency care as an outpatient at a
hospital, including doctors'
services $25 per visit; if the emergency results in admission to a hospital the
copay is waived. $25 per visit; if the emergency results in admission to a
hospital, the
copay is waived.
Not covered: elective care or non-emergency care All charges All charges
Emergency outside our service area
. Emergency care at a doctor's
office
. Emergency care at an urgent care center $15 per visit $10 per visit
. Emergency care as an outpatient at a hospital, including doctors' services
$25 per visit; if the emergency results in admission to a
hospital the copay
is waived.
$25 per visit; if the emergency results in
admission to a
hospital, the copay is waived.
Not covered: . elective care or non-emergency care
.
emergency care provided outside the service area if the need for care could
have been
foreseen before leaving the service area . medical and
hospital costs resulting from
a normal full-term delivery of a baby outside
the service area
All charges All charges
Ambulance
. Professional ambulance service when ordered or
authorized by a Plan doctor,
See 5( c) for non-emergency service.
Note: Air ambulance is covered only when point of pick-up is inaccessible
by land
vehicle; or great distances or other obstacles are involved in getting a
patient to the nearest
hospital with appropriate facilities when prompt
admission is essential
$50 per visit Nothing 33
33 Page 34 35
2002 Humana
Health Plan, Inc. 34 Section 5( e)
Section 5 (e). Mental
health and substance abuse benefits
I M
P O
R T
A N
T
Parity
When you get our approval for services and follow a
treatment plan we approve, cost-sharing and limitations for Plan mental health
and substance
abuse benefits will be no greater than for similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
. All benefits are subject to the definitions, limitations, and
exclusions in this
brochure.
. Be sure to read Section 4, Your costs for covered services for
valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
. YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
instructions after the benefits description below.
I M
P O
R T
A N
T
Description You pay
Mental health and substance abuse benefits You pay
-Standard Option You pay -High Option
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan may
include services, drugs, and supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive the care as
part of
a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illness
or conditions.
Your cost sharing responsibilities are no
greater than
for other illness or conditions.
. Professional services, including
individual or group therapy by
providers such as psychiatrists,
psychologists, or clinical social workers
. Medication management
$15 per office visit $10 per office visit
. Diagnostic tests Nothing Nothing
. Services provided by a hospital or
other facility .
Services in approved alternative care settings such as partial
hospitalization,
half-way house, residential treatment, full-day hospitalization, facility
based
intensive outpatient treatment
$100 per admission Nothing
Mental health and substance abuse benefits – Continued on next page.
34
34 Page 35
36
2002 Humana Health Plan, Inc. 35 Section
5( e)
Mental health and substance abuse benefits –
CONTINUED
Not covered: services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally
not order
us to pay or provide one clinically appropriate treatment plan in
favor of
another.
All charges. All charges.
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all of the following authorization processes.
. Please contact New Directions at 1-800/ 851-9536 to obtain Mental
Health/ Substance Abuse treatment services.
Limitation We may limit your benefits if you do not follow your
treatment plan. 35
35 Page
36 37
2002 Humana Health Plan, Inc.
36 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
. We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
. All benefits are subject to the definitions, limitations and exclusions in
this
brochure and are payable only when we determine they are medically
necessary.
. Be sure to read Section 4, Your costs for covered services for
valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
. Who can write your prescription. A plan physician or referral
doctor must write the
prescription.
. Where you can obtain them. You must fill the prescription at a plan
pharmacy, or by mail
for a prescribed maintenance medication. Maintenance
medications are drugs that are generally prescribed for the treatment of long
term chronic sicknesses or injuries.
. We use a Drug List. Our Drug Lis a continually updated list of drug
products including
strengths, dispensing limits and any prior authorization
requirements that represent the current clinical judgment of the members of our
Pharmacy and Therapeutics Committee. This
committee is comprised of both physicians and pharmacists. The Drug List
contains both brand name and generic drugs, all of which have FDA approval. We
cover non-Drug List drugs
prescribed by a Plan doctor.
A generic drug is
a drug that is manufactured, distributed and available from several
pharmaceutical manufacturers and identified by the chemical name; or as defined
by the
national pricing standard used by Us.
A brand name drug is a drug that is
manufactured and distributed by only one pharmaceutical manufacturer; or as
defined by the national pricing standard used by Us.
Proposed additions or deletions to the Formulary are welcomed at any time and
will be reviewed by the Committee.
We have an open Drug List. If your physician believe s a name brand product
is necessary or there is no generic available, your physician may prescribe a
name brand drug from a formulary
list. This list of name brand drugs is a
preferred list of drugs that we selected to meet patient needs at a lower cost.
To order a prescription Drug List brochure, call 1-800/ 4-HUMANA or 1-
800/
448-6262.
. These are the dispensing limitations. Prescription drugs
dispensed at a Plan pharmacy will
be dispensed for up to a 30-day supply.
You may receive up to a 90-day supply of a prescribed maintenance medication
through our mail-order program. A generic equivalent will
be dispensed if it is available, unless your physician specifically requires
a name brand. If you receive a name brand drug when a Federally-approved generic
drugs is available, and your
physician has not specified Dispense as Written
for the name brand drug, you have to pay the difference in cost between the name
brand drug and the generic.
. Why use generic drugs? Generic drugs are lower-priced drugs that are
the therapeutic
equivalent to more expensive brand-named drugs. They must
contain the same active ingredients and must be equivalent in strength and
dosage to the original brand-name product.
Generics cost less that the equivalent brand-name product. The U. S. Food and
Drug Administration sets quality standards for generic drugs to ensure that
these drugs meet the
same standards of quality and strength as brand-name
drugs.
. You can save money by using generic drugs. However, you and your
physician have the
option to request a name-brand if a generic option is
available. Using the most cost-effective medication saves money. 36
36 Page 37 38
2002 Humana Health Plan, Inc. 37 Section 5(
f)
Benefit Description You pay
Covered medications and supplies
You pay – Standard Option You pay – High Option
We cover the following medications and supplies prescribed by a Plan
physician and
obtained from a Plan pharmacy or through our mail order
program:
. Drugs and medicines that by Federal law of the United States require a
physician's
prescription for their purchase, except those listed as Not
Covered..
. Insulin
. Disposable needles and syringes for the
administration of covered medications
. Diabetic supplies including
testing agents, lancet devices, alcohol swabs,
glucose elevating agents, insulin delivery devices and blood glucose
monitors.
. Self administered injectable drugs
. Oral contraceptive
drugs and
contraceptive devices
. Drugs for sexual dysfunction
Note: Drugs to treat sexual dysfunction
are limited. Contact the Plan for dosage limits.
You pay the applicable drug copay up to the dosage limits, and all charges
after that.
$10 for generic drugs on our Drug List
$25 for brand name drugs with no
generic equivalent
on our Drug List .
$45 for generic or brand name
drugs not on our Drug
List .
3 applicable copays for a 90-day supply of prescribed
maintenance drugs, when ordered through our
mail-order program.
Note:
If there is no generic equivalent available, you
pay the applicable brand name formulary copay.
$5 for generic drugs on our Drug List
$20 for brand name drugs with no
generic equivalent
on our Drug List .
$40 for generic or brand name
drugs not on our Drug
List .
3 applicable copays for a 90-day supply of prescribed
maintenance drugs, when ordered through our
mail-order program.
Note:
If there is no generic equivalent available, you
pay the applicable brand name formulary copay 37
37
Page 38 39
2002
Humana Health Plan, Inc. 38 Section 5( f)
Covered medications
and supplies (Continued) You pay – Standard Option You pay – High
Option
Not covered:
. drugs available without a
prescription, or
for which there is a non-prescription equivalent available
. drugs and supplies for cosmetic purposes
(such as Rogaine)
. vitamins, fluoride, nutrients and food
supplements even if a
physician prescribes or administers them
. drugs obtained at a non-Plan pharmacy
except for out of area
emergencies
. drugs to enhance athletic performance
. smoking cessation
drugs and
medications, including nicotine patches
. any drug used for the purpose of weight
control
. prescriptions that are to be taken by or
administered to the member
in whole or part, while a patient in a hospital, skilled
nursing facility, convalescent hospital, inpatient facility or other
facility where
drugs are ordinarily provided by the facility on an inpatient
basis
. medical supplies such as dressings and
antiseptics
. fertility drugs
All charges All charges 38
38 Page 39 40
2002 Humana
Health Plan, Inc. 39 Section 5( g)
Section 5 (g). Special
Features
Feature Description
Services for deaf and hearing impaired Humana offers telecommunication
devices for the deaf (TDD) and Teletype (TTY) phone lines for the hearing
impaired. Call
1-800-432-7482 to access the service.
High risk pregnancies HumanaBeginnings is an outreach program that
provides high-risk plan members support and educational materials so care can
be actively managed during pregnancy.
Centers of excellence for transplants/ heart
surgery/ etc.
Members can use any facility that is within Humana's contracted National
Transplant Network. This network has over
35 transplant facilities located
in more than 20 states.
Smoking cessation HumanaHealth offers a telephonic smoking cessation
program called "Ready to Quit". Members can call 1-888-QUIT-123 or
1-888-784-8123.
24-hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call HumanaFirst at 1-800-622-9529 and talk with a
registered nurse who will discuss treatment options and answer your health
questions. 39
39 Page
40 41
2002 Humana Health Plan, Inc.
40 Section 5( h)
Section 5 (h). Dental benefits
I M
P
O
R T
A N
T
Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations, and
exclusions in this brochure and are payable only when we
determine they are medically necessary.
. Plan dentists must provide or arrange your care.
. We cover
hospitalization for dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the
health of the patient; we do not cover the dental procedure unless it is
described below.
. Be sure to read Section 4, Your costs for covered services, for
valuable information
about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay – Standard Option You pay – High Option
We cover restorative services and supplies necessary to promptly repair
(but not
replace) sound natural teeth. The need for these services must
result from an
accidental injury.
Nothing Nothing
Dental benefits
We have no other dental benefits. 40
40 Page 41 42
2002 Humana Health Plan, Inc. 41 Section 5(
i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium,
and you cannot file an FEHB disputed claim about them. Fees you pay for
these services do not count toward FEHB deductibles or out-of-pocket
maximums.
. All dental services at discounted fees as listed in the separate plan
description. Services available from general dentist only.
. No additional premium required; no application to complete.
.
Administered by HumanaDental 1-800-955-0782.
. Discounts (listed in the separate Plan description) for frames and lenses
(including contacts) at participating vision care providers.
. No additional premium required.
. Vision One Discount Program .
Discounts available at
participating providers for eye exams, frames and lenses. (see separate plan
description on how to locate a provider
nearest you). . Mail Order Contact Lens Replacement Program
. Vision
Correction (LASIK or PRK) for less than $1,000 per eye. (see
separate Plan
description on how to receive the discount) . No additional premium required.
Medicare prepaid plan enrollment – This plan offers Medicare
recipients the opportunity to enroll in the Plan through Medicare. As indicated
on page 47, annuitants and former spouses with FEHB coverage and Medicare Part B
may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan
when one is available in their area. They may then later reenroll in the FEHB
program. Most Federal annuitants have Medicare Part A. Those without
Medicare Part A may join this Medicare prepaid plan, but will probably have
to pay for hospital coverage in addition to the Part B premium. Before you join
the plan, ask whether the plan covers hospital benefits and, if so, what you
will have to pay. Contact your retirement system for information on dropping
your FEHB enrollment and changing to a Medicare prepaid plan. Contact us at 800/
238-7157 for information on the Medicare prepaid plan and the cost of
that
enrollment.
Dental benefits . DEN-490
Vision care . VIS-606 41
41 Page 42 43
2002 Humana Health Plan, Inc. 42 Section 6
Section 6. General exclusions – things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury or condition.
We do not cover the
following:
. Care by non-Plan providers except for authorized referrals or
emergencies (see Emergency Benefits);
. Services, drugs, or supplies you
receive while you are not enrolled in this Plan;
. Services, drugs, or
supplies that are not medically necessary;
. Services, drugs, or supplies
not required according to accepted standards of medical, dental, or psychiatric
practice;
. Experimental or investigational procedures, treatments, drugs or devices;
. Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the
fetus were carried to term or when the
pregnancy is the result of an act of rape or incest;
. Services, drugs, or supplies related to sex transformations; or
.
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program. 42
42 Page
43 44
2002 Humana Health Plan, Inc.
43 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and
facilities, or obtain your prescription drugs at Plan pharmacies, you will not
have to file claims. Just present your identification card and pay your
copayment.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form.
Facilities will file on the UB-92 form. For claims
questions and assistance, call us at 1-800/ 4HUMANA or 1-800-448-6262.
When you must file a claim – such as for out-of-area care – submit it on the
HCFA-1500 or a claim form that includes the information shown
below. Bills
and receipts should be itemized and show:
. Covered member's name and ID number;
. Name and address of the
physician or facility that provided the service
or supply;
. Dates you received the services or supplies;
. Diagnosis;
. Type of
each service or supply;
. The charge for each service or supply;
. A
copy of the explanation of benefits, payments, or denial from any
primary
payer – such as the Medicare Summary Notice (MSN); and
. Receipts, if you paid for your services.
Submit your claims to: Humana Health Plan, Inc. P. O. Box 14601
Lexington, Kentucky 40512-4601
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you
received the service, unless timely filing was prevented
by administrative operations of Government or legal incapacity, provided the
claim was
submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 43
43 Page
44 45
2002 Humana Health Plan, Inc.
44 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on your claim or request for services,
drugs, or supplies – including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must: (a) Write to us within 6 months from the date of our
decision; and
(b) Send your request to us at: Humana Health Plan, Inc., ;
and
(c) Include a statement about why you believe our initial decision was
wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial – go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request – go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with
our decision, you may ask OPM to review it.
You must write to OPM within:
. 90 days after the date of our letter upholding our initial decision; or
. 120 days after you first wrote to us – if we did not answer that request
in some way within 30 days; or
. 120 days after we asked for additional
information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.
The disputed claims process – Continued on next page 44
44 Page 45 46
2002 Humana Health Plan, Inc. 45 Section 8
Step Description
Send OPM the following information:
. A
statement about why you believe our decision was wrong, based on specific
benefit provisions in this
brochure;
. Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical
records, and explanation of benefits (EOB)
forms;
. Copies of all letters you sent to us about the claim;
. Copies of all
letters we sent to you about the claim; and
. Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable
to meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs or supplies or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim decision. This information will become
part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits, and payment of benefits.
The Federal court will base its review on the record that was
before OPM
when OPM decided to uphold or overturn our decision. You may recover only the
amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at 1-800/ 4HUMANA and we will
expedite our review; or
(b) We denied your initial request for care or
preauthorization/ prior approval, then:
. If we expedite our review and
maintain our denial, we will inform OPM so that they can give your
claim
expedited treatment too, or
. You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737
between 8 a. m. and 5 p. m.
eastern time. 45
45
Page 46 47
2002
Humana Health Plan, Inc. 46 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under
another
group health plan or have automobile insurance that pays health care expenses
without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as
the primary payer and the other plan pays a reduced benefit as the
secondary
payer. We, like other insurers, determine which coverage is primary according to
the National Association of Insurance
Commissioners' guidelines.
When we
are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance. If we are the
secondary payer, we may be entitled to receive payment from
your primary
plan.
What is Medicare? Medicare is a Health Insurance Program for:
. People 65 years of age and older.
. Some people with disabilities, under 65 years of age.
. People with
end-stage renal disease (permanent kidney failure
requiring dialysis or a
transplant).
Medicare has two parts:
. Part A (Hospital Insurance). Most people do not
have to pay for Part A.
If you or your spouse worked for at least 10 years
in Medicare-covered employment, you should be able to qualify for premium-free
Part A insurance. (Someone who was a Federal employee on January 1, 1983 or
since automatically qualifies.) Otherwise, if you
are age 65 or older, you
may be able to buy it. Contact 1-800-MEDICARE for more information.
. Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social
Security check or your
retirement check.
If you are eligible for Medicare, you may have choices in
how you get your health care. Medicare managed care plan is the term used to
describe the
various health plan choices available to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan you have. 46
46 Page 47 48
2002 Humana Health Plan, Inc. 47 Section 9
The Original Medicare Plan Part A or Part B The Original
Medicare Plan (Original Medicare) is available everywhere
in the United
States. It is the way everyone used to get Medicare benefits and is the way most
people get their Medicare Part A and Part B benefits
now. You may go to any
doctor, specialist, or hospital that accepts Medicare. The Original Medicare
Plan pays its share and you pay your
share. Some things are not covered
under Original Medicare, like prescription drugs.
When you are enrolled in
Original Medicare along with this Plan, you still need to follow the rules in
this brochure for us to cover your care.
Your care must continue to be
authorized by your Plan PCP.
We will not waive any of our copayments or
coinsurance.
Tell us if you or a family member is enrolled in Medicare Part
A or B. Medicare will determine who is responsible for paying medical services
and we will coordinate the payments. On occasion, you may need to file a
Medicare claim form.
(Primary payer chart begins on next page.) 47
47 Page 48 49
2002 Humana Health Plan, Inc. 48 Section 9
The following chart illustrates whether the Original Medicare Plan
or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that
you tell us if you or
a covered family member has Medicare coverage so we
can administer these requirements correctly.
Primary Payer Chart
Then
the primary payer is… A. When either you – or your covered spouse – are age 65
or
over and … Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or
a family member are eligible for Medicare solely because of a
disability),
2) Are an annuitant,
3) Are a reemployed annuitant with
the Federal government when…
a) The position is excluded from FEHB,
b) Or the position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only,
regardless of your employment status, (for Part B
services) (for other
services)
6) Are a former Federal employee receiving Workers' Compensation
and the Office of Workers' Compensation Programs has determined
that you are unable to return to duty, (except for claims related to Workers'
Compensation.)
B. When you – or a covered family member – have Medicare based on end
stage renal disease (ESRD) and…
1) Are within the first 30 months of
eligibility to receive Part A benefits solely because of ESRD,
2) Have
completed the 30-month ESRD coordination period and are still eligible for
Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after
Medicare became primary for you under another provision,
C. When you or a
covered family member have FEHB and…
1) Are eligible for Medicare based
on disability,
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an
active employee 48
48 Page
49 50
2002 Humana Health Plan, Inc.
49 Section 9
Claims process when you have the Original
Medicare Plan – You probably will never have to file a claim form when you
have both our
Plan and the Original Medicare Plan.
. When we are the
primary payer, we process the claim first.
. When Original Medicare is the
primary payer, Medicare processes your
claim first. In most cases, your
claims will be coordinated automatically and we will pay the balance of covered
charges. You
will not need to do anything. To find out if you need to do something about
filing your claims, contact us at 1-800/ 4HUMANA.
We do not waive costs when you have the Original Medicare Plan – When
Original Medicare is the primary payer, we will not waive out-of-pocket
costs.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan --a
Medicare managed care plan. These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care
plans, you
can only go to doctors, specialists, or hospitals that are part
of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more
about enrolling in a Medicare managed care plan, contact Medicare
at
1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov. If you enroll in a
Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB
plan. In this case, we do not waive any of our copayments, coinsurance, or
deductibles for your FEHB coverage.
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled
in our FEHB plan. We will still provide benefits when your Medicare managed care
plan is primary, even out of the managed care
plan's network and/ or service
area (if you use our Plan providers), but we will not waive any of our
copayments. If you enroll in a Medicare
managed care plan, tell us. We will
need to know whether you are in the Original Medicare Plan or in a Medicare
managed care plan so we can
correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care
plan: If
you are an annuitant or former spouse, you can suspend your FEHB coverage and
enroll in a Medicare managed care plan, eliminating
your FEHB premium. (OPM
does not contribute to your medicare managed care plan premium.) For information
on suspending your
FEHB enrollment, contact your retirement office. If you
later want to re-enroll in the FEHB Program, generally you may do so only at the
next
open season unless you involuntarily lose coverage or move out of the
Medicare managed care plan's service area. 49
49
Page 50 51
2002
Humana Health Plan, Inc. 50 Section 9
. If you do not enroll
in
Medicare Part A or Part B If you do not have one or both Parts of
Medicare, you can still be covered under the FEHB Program. We will not require
you to enroll in Medicare
Part B and, if you can't get premium-free Part A, we will not ask you to
enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons, and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that: . you need
because of a workplace-related illness or injury that the
Office of Workers'
Compensation Programs (OWCP) or a similar Federal or State agency determines
they must provide; or
. OWCP or a similar agency pays for through a third
party injury
settlement or other similar proceeding that is based on a claim
you filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital for injuries care for injuries or illness caused
by another person, you must reimburse
us for any expenses we paid. However,
we will cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation
procedures. 50
50 Page
51 52
2002 Humana Health Plan, Inc.
51 Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on
December 31 of the same year.
Copayment A
copayment is a fixed amount of money you pay when you receive covered services.
See page 9.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial Care Services provided to you such as assistance
with dressing, bathing, preparation and feeding of special diets, walking,
supervision of
medication which is ordinarily self-administered, getting in and out of bed,
and maintaining continence and are not likely to improve your
condition.
Durable Medical Equipment (DME) Equipment recognized as such by
Medicare Part B, that meets all of the
following criteria:
. it can stand repeated use; and
. it is
primarily and customarily used to serve a medical purpose
rather than being
primarily for comfort or convenience; and
. it is usually not useful to a person in the absence of Sickness or
Injury; and
. it is appropriate for home use; and
. it is related to the patient's
physical disorder; and the equipment
must be used in the Member's home.
Experimental or investigational services A drug, biological product,
device, medical treatment, or procedure is
determined to be experimental or investigational if reliable evidence shows
it meets one of the following criteria:
. when applied to the circumstances of a particular patient is the subject
of ongoing phase I, II or III clinical trials, or
. when applied to the circumstances of a particular patient is under study
with written protocol to determine maximum tolerated dose, toxicity, safety,
efficacy, or efficacy in comparison to conventional alternatives, or
. is being delivered or should be delivered subject to the approval and
supervision of an Institutional Review Board as required and defined by the
USFDA or Department of Health and Human Services
. is not generally accepted by the medical community
Reliable evidence
means, but is not limited to, published reports and articles in authoritative
medical scientific literature or regulations and
other official actions and publications issued by the USFDA or the Department
of Health and Human Services. 51
51 Page 52 53
2002 Humana
Health Plan, Inc. 52 Section 10
Medical Necessity Services
necessary for the treatment or product that a licensed Physician or licensed
healthcare provider would provide his or her patient for the
purpose of
diagnosing, treating a sickness, illness, disease or its symptoms.
Morbid Obesity Morbid or clinically severe obesity correlated with a
Body Mass Index (BMI) or 40k/ m2 or with being 100 pounds over ideal body
weight.
Oral Surgery Procedures to correct diseases, injuries and
defects of the jaw and mouth structures.
Participating Provider A
Hospital, Physician, or any other health services provider who has been
designated to provide services to covered members under this plan.
Service Area The geographic area where the Participating Provider
services are available to covered members.
Transplant Services for
pre-transplant; the transplant including any chemotherapy, associated services
and post-discharge services, and treatment of
complications after
transplant.
Us/ We Us and we refer to Humana Health Plan, Inc.
You You refers to the enrollee and each covered family member. 52
52 Page 53 54
2002 Humana Health Plan, Inc. 53 Section 11
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had limitation
before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm.
gov/ insure. Also, your employing or retirement office about enrolling in the
can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you need to make an informed decision about:
. When you may change your enrollment;
. How you can cover your family
members;
. What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
. When your enrollment ends; and
. When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot
change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self
Only coverage is for you alone. Self and Family coverage is for for you and
your family you, your spouse, and your unmarried dependent children under
age 22,
including any foster children or stepchildren your employing or retirement
office authorizes coverage for. Under certain circumstances,
you may also
continue coverage for a disabled child 22 years of age or older who is incapable
of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may
change your enrollment 31 days before to 60 days after that event. The Self and
Family enrollment begins on the first day of the pay period
in which the
child is born or becomes an eligible family member. When you change to Self and
Family because you marry, the change is effective
on the first day of the
pay period that begins after your employing office receives your enrollment
form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members from your
coverage for any reason, including divorce, or when your child
under age 22
marries or turns 22.
If you or one of your family members is enrolled in one
FEHB plan, that person may not be enrolled in or covered as a family member by
another
FEHB plan.
When benefits and The benefits in this brochure are
effective on January 1. premiums start If you joined this Plan during
Open Season, your coverage begins on the
first day of your first pay period that starts on or after January 1.
Annuitants' coverage and premiums begin on January 1. If you joined at
any
other time during the year, your employing office will tell you the effective
date of coverage. 53
53 Page
54 55
2002 Humana Health Plan, Inc.
54 Section 11
Your medical and claims We will keep your
medical and claims information confidential. Only records are confidential
the following will have access to it:
. OPM, this Plan, and
subcontractors when they administer this contract;
. This Plan and
appropriate third parties, such as other insurance plans
and the Office of
Workers' Compensation Programs (OWCP), when coordinating benefit payments and
subrogating claims;
. Law enforcement officials when investigating and/ or prosecuting
alleged civil or criminal actions;
. OPM and the General Accounting Office when conducting audits;
.
Individuals involved in bona fide medical research or education that
does
not disclose your identity; or
. OPM, when reviewing a disputed claim or defending litigation about a
claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years
of your Federal service. If you do not meet this requirement, you may be
eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
. When FEHB
coverage ends You will receive an additional 31 days of coverage, for no
additional
premium, when:
. Your enrollment ends, unless you cancel your enrollment, or
. You are a
family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of
Coverage.
. Spouse equity If you are divorced from a Federal employee or
annuitant, you may not
coverage continue to get benefits under your
former spouse's enrollment. But, you may be eligible for your own FEHB coverage
under the spouse equity
law. If you are recently divorced or are anticipating a divorce, contact your
ex-spouse's employing or retirement office to get RI 70-5, the
Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, or other
information about your coverage
choices.
. Temporary continuation
of coverage (TCC) If you leave
Federal service, or if you lose coverage because you no longer qualify as a
family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if you are
not able to continue your FEHB enrollment after you retire, if
you lose your
job, if you are a covered dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC,
and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, from
your employing or retirement office or from www. opm. gov/ insure.
It
explains what you have to do to enroll. 54
54
Page 55 56
2002
Humana Health Plan, Inc. 55 Section 11
. Converting to
individual coverage
You may convert to a non-FEHB individual policy if:
. Your coverage under TCC or the spouse equity law ends ( If you
canceled
your coverage or did not pay your premium, you cannot convert);
. You decided not to receive coverage under TCC or the spouse equity
law;
or
. You are not eligible for coverage under TCC or the spouse equity
law.
If you leave Federal service, your employing office will notify you of your
right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who is
losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer
eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of Group Health Plan Coverage The Health
Insurance Portability and Accountability Act of 1996.
(HIPAA) is a Federal
law offers limited Federal protection for health coverage availability and
continuity to people who lose employer group
coverage. If you leave the FEHB
Program, we will give you a Certificate of Group Health Plan Coverage that
indicates how long you have been
enrolled with us. You can use this
certificate when getting health insurance or other health care coverage. Your
new plan must reduce or
eliminate waiting periods, limitations, or
exclusions for health related conditions based on the information in the
certificate, as long as you
enroll within 63 days of losing coverage under
this Plan. If you have been enrolled with us for less than 12 months, but were
previously
enrolled in other FEHB plans, you may also request a certificate
from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHP Program. See also the
FEHBP web site (www.
opm. gov/ insure/ health): refer to the "TCC and HIPAA" frequently asked
question. These highlight HIPAA rules, such
as the requirement that Federal
employees must exhaust any TCC eligibility as one condition for guaranteed
access to individual health
coverage under HIPAA, and have information about
Federal and State agencies you can contact for more information. 55
55 Page 56 57
2002 Humana Health Plan, Inc.. 56
Long
Term Care Insurance Is Coming Later in 2002!
The Office of
Personnel Management (OPM) will sponsor a high-quality long term care insurance
program effective in October 2002. As part of its educational effort, OPM asks
you to consider these questions:
. It's insurance to help pay for
long term care services you may need
if you can't take care of yourself
because of an extended illness or injury, or an age-related disease such as
Alzheimer's.
. LTC insurance can provide broad, flexible benefits for nursing home
care, care in an assisted living facility, care in your home, adult day
care, hospice care, and more. LTC insurance can supplement care
provided by family members, reducing the burden you place on them.
. Welcome to the club! .
76% of Americans believe they will never need
long term care, but the facts are that about half of them will. And it's not
just the old
folks. About 40% of people needing long term care are under age 65. They may
need chronic care due to a serious accident, a stroke,
or developing
multiple sclerosis, etc. . We hope you will never need long term care, but
everyone should
have a plan just in case. Many people now consider long
term care insurance to be vital to their financial and retirement planing.
. Yes, it can be very expensive. A year in a nursing home can exceed
$50,000. Home care for only three 8-hour shifts a week can exceed $20,000 a
year. And that's before inflation!
. Long term care can easily exhaust your savings. Long term care
insurance can protect your savings.
. Not FEHB. Look at the "Not covered" blocks in sections 5( a) and
5( c) of your FEHB brochure. Health plans don't cover custodial care or a
stay in an assisted living facility or a continuing need for a
home health aide to help you get in and out of bed and with other activities
of daily living. Limited stays in skilled nursing facilities
can be covered
in some circumstances. . Medicare only covers skilled nursing home care (the
highest level of
nursing care) after a hospitalization for those who are
blind, age 65 or older or fully disabled. It also has a 100 day limit.
.
Medicaid covers long term care for those who meet their state's
poverty
guidelines, but has restrictions on covered services and where they can be
received. Long term care insurance can provide
choices of care and preserve your independence.
. Employees will
get more information from their agencies during the
LTC open enrollment
period in the late summer/ early fall of 2002. . Retirees will receive
information at home.
. Many FEHB enrollees think that their health plan and/ or Medicare will
cover their long-term care needs. Unfortunately, they are WRONG!
.
How are YOU planning to pay for the future custodial or chronic care you may
need? .
You should consider buying long-term care insurance.
What is long term care (LTC) insurance?
I'm healthy. I won't need long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan, Medicare or
Medicaid cover
my long term care?
When will I get more information on how to apply for this new
insurance coverage? 56
56 Page 57 58
2002 Humana
Health Plan, Inc. 57
. Our toll-free teleservice center will begin in
mid-2002. In the
meantime, you can learn more about the program on our web
site at www. opm. gov/ insure/ ltc. How can I find out more about the program
NOW? 57
57 Page
58 59
2002 Humana Health Plan, Inc..
58
Department of Defense/ FEHB Demonstration Project
What is it?
The Department of Defense/ FEHB Demonstration Project allows some active and
retired uniformed service members and their dependents to enroll in the
FEHB
Program. The demonstration will last for three years and began with the 1999
open season for the year 2000. Open season enrollments will be effective
January 1, 2002. DoD and OPM have set up some special procedures to
implement the Demonstration Project, noted below. Otherwise, the provisions
described in this brochure apply.
Who is eligible DoD determines who is eligible to enroll in the FEHB
Program. Generally, you may enroll if:
. You are an active or retired
uniformed service member and are eligible for
Medicare;
. You are a
dependent of an active or retired uniformed service member and
are eligible
for Medicare;
. You are a qualified former spouse of an active or retired
uniformed service
member and you have not remarried; or .
You are a survivor dependent of a deceased active or retired uniformed
service member; and
. You live in one of the geographic demonstration areas.
If you are
eligible to enroll in a plan under the regular Federal Employees Health Benefits
Program, you are not eligible to enroll under the DoD/ FEHBP
Demonstration
Project.
The demonstration areas . Dover AFB, DE . Commonwealth of Puerto Rico
. Fort Knox, KY . Greensboro/ Winston Salem/ High Point, NC
. Dallas, TX .
Humboldt County, CA area
. New Orleans, LA . Naval Hospital, Camp Pendleton,
CA .
Adair County, IA area . Coffee County, GA area
When you can join You may enroll under the FEHB/ DoD Demonstration
Project during the 2000 open season, November 12, 2001, through December 10,
2001. Your coverage
will begin January 1, 2002. DoD has set-up an
Information Processing Center (IPC) in Iowa to provide you with information
about how to enroll. IPC staff will
verify your eligibility and provide you
with FEHB Program Information, plan brochures, enrollment instructions and
forms. The toll-free phone number
for the IPC is 1-877/ DOD-FEHB (1-877/
363-3342).
You may select coverage for yourself (Self Only) or for you and
your family (Self and Family) during open season. Your coverage will begin
January 1, 2002.
If you become eligible for the DoD/ FEHB Demonstration Project outside of
open season, contact the IPC to find out how to enroll and when your coverage
will begin.
DoD has a web site devoted to the Demonstration Project. You can view
information such as their Marketing/ Beneficiary Education Plan, Frequently
Asked Questions, demonstration area locations and zip code lists at www.
tricare. osd. mil/ fehbp. You can also view information about the
demonstration project, including "The 2002 Guide to Federal Employees Health
Benefits Plans Participating in the DoD/ FEHB Demonstration Project," on the
OPM web site at www. opm. gov. 58
58 Page 59 60
2002 Humana
Health Plan, Inc. 59
Temporary continuation of coverage (TCC) See
Section 11, FEHB Facts; it explains temporary continuation of coverage
(TCC). Under this DoD/ FEHB Demonstration Project the only individual
eligible for TCC is one who ceases to be eligible as a "member of family" under
your self
and family enrollment. This occurs when a child turns 22, for
example, or if you divorce and your spouse does not qualify to enroll as an
unremarried former
spouse under title 10, United States Code. For these
individuals, TCC begins the day after their enrollment in the DoD/ FEHB
Demonstration Project ends. TCC
enrollment terminates after 36 months or the
end of the Demonstration Project, whichever occurs first. You, your child, or
another person must notify the IPC
when a family member loses eligibility
for coverage under the DoD/ FEHB Demonstration Project.
TCC is not available if you move out of a DoD/ FEHB Demonstration Project
area, you cancel your coverage, or your coverage is terminated for any reason.
TCC is
not available when the demonstration project ends.
Other features The 31-day extension of coverage and right to convert
do not apply to the DoD/ FEHB Demonstration Project. 59
59 Page 60 61
2002 Humana Health Plan, Inc. 60 Index
Index
Do not rely on this page; it is for your convenience
and may not show all pages where the terms appear.
Allergy care
................................ 17 Alternative treatment .................. 22
Allogenetic (donor) bone marrow transplant………………..… 26
Ambulance............................ 31, 33 Anesthesia
............................ 27, 29
Autologous bone marrow transplant
............................. 26
Blood and blood plasma .............
29 Breast cancer screening ......... 14-15
Casts
...................................... 29-30 Changes for
2001.......................... 8
Chemotherapy ............................
18 Cholesterol tests ......................... 15
Childbirth…………………….… 16
Chiropractic ................................ 22
Claims......................................... 43 Colorectal cancer
screening........ 15
Congenital anomalies ................. 24 Contraceptive
devices
and drugs ....................... 17, 37 Coordination of benefits
........ 46-50
Covered services......................... 51 Covered
providers ................... 9-10
Definitions
............................. 51-52 Dental
care.................................. 40
Diagnostic services...............
14, 29 Dialysis....................................... 18
Disputed claims
review ......... 44-45 Donor expenses (transplants)...... 26
Dressings
............................... 29-30 Durable medical equipment
(DME)
................................. 21 Effective date of enrollment .......
53
Emergency............................. 32-33 Experimental or
investigational.. 51
Eyeglasses .................................. 19
Family planning ......................... 17
Fecal occult blood test
................ 15 Foot care..................................... 20
General Exclusions..................... 42 Hearing services
......................... 19
Home health services.................. 21
Hospice care ............................... 31
Home nursing
care...................... 21 Hormones ................................... 15
Hospital ................................. 28-30
Immunizations....................... 15-16
Infertility..................................... 17 Inhospital physician care
...... 14, 23
Inpatient Hospital Benefits .... 28-29
Insulin......................................... 37
Laboratory and
pathological services .................... 14, 29, 30
Machine
diagnostic tests............................... 14, 29
Magnetic
Resonance Imagings (MRIs) ................................. 14
Mail-order
prescription drugs............................... 36-38
Mammograms........................ 14-15 Maternity Benefits
...................... 16
Medicaid..................................... 50
Medical necessity ....................... 52
Medicare................................ 46-50
Members....................................... 6
Mental Conditions/
Substance Abuse Benefits ............... 34-35
Newborn
care.............................. 16 Non-FEHB Benefits ...................
41
Nurse Licensed Practical Nurse .......... 21
Licensed Vocational
Nurse....... 21 Nurse Anesthetist...................... 27
Registered Nurse
...................... 21 Obstetrical care ............. 9-10, 16
Occupational therapy ............. 18 Office visits
................................ 14
Oral and maxillofacial
surgery................................. 25
Orthopedic devices
..................... 20 Out-of-pocket expenses .............. 12
Outpatient
facility care ............... 30 Oxygen ................................. 21, 29
Pap test .................................. 14-15 Physical
examination............. 15-16
Physical therapy.......................... 18
Physician ................................. 9-10
Preventive care, adult
................. 15 Preventive care, children ............ 16
Prescription
drugs.................. 36-38 Preventive services ................ 15-16
Prior approval ............................. 11 Prostate cancer
screening............ 15
Prosthetic devices ....................... 20
Psychologist................................ 34
Radiation therapy
....................... 18 Room and board..................... 28-29
Second surgical opinion.............. 14 Skilled nursing facility
care ........ 30
Smoking cessation ................ 22, 39 Speech
therapy............................ 19
Splints
......................................... 29 Sterilization procedures
.............. 17
Subrogation................................. 50 Substance
abuse..................... 34-35
Surgery ..................................
23-27 Anesthesia .......................... 27
Oral..................................... 25 Outpatient
........................... 27
Reconstructive .................... 24
Syringes ...................................... 37
Temporary
continuation of coverage .......................... 59
Transplants
................................. 26 Treatment therapies .................... 18
Vision services............................ 19 Well child
care............................ 16
Wheelchairs
................................ 21 Workers' compensation .............. 50
X-rays................................ 14, 30 60
60 Page 61 62
2002 Humana Health Plan, Inc. 61 Rates
NOTES: 61
61 Page 62 63
2002 Humana
Health Plan, Inc. 62 Rates
NOTES: 62
62 Page 63 64
2002 Humana Health Plan, Inc. 63 Rates
NOTES: 63
63 Page 64 65
2002 Humana
Health Plan, Inc. 64 Rates
NOTES: 64
64 Page 65 66
2002 Humana Health Plan, Inc. 65 Rates
Summary of benefits for Humana Health Plan, Inc. – 2002 High Option
. Do not rely on this chart alone. All benefits are provided in
full unless indicated and are subject to the
definitions, limitations, and
exclusions in this brochure. On this page we summarize specific expenses we
cover; for more detail, look inside.
. If you want to enroll or change your enrollment in this Plan, be sure to
put the correct enrollment code from
the cover on your enrollment form. .
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
. Diagnostic and treatment services provided in the office.......... Office
visit copay: $10 primary care;
$10 specialist 14
Services provided by a hospital:
.
Inpatient.....................................................................................
. Outpatient
..................................................................................
Nothing
$25 per visit
28-29
30
Emergency benefits:
. In-area (at a
hospital).................................................................
. In-area (at a doctor's office or urgent care center) ....................
. Out-of-area
................................................................................
$25 per visit
$10 per visit
$25 per visit
33
33
33
Mental health and substance abuse treatment...............................
Regular cost sharing 34-35
Prescription drugs:
. Generic formulary
drugs............................................................
. Brand name formulary
drugs.....................................................
. Non formulary
drugs .................................................................
. Maintenance drugs (90-day supply) when ordered through
our mail-order
program .............................................................
$5 copay
$20 copay
$40 copay
3 applicable copays
37
37
37
37
Dental Care .
Accidental injury
benefit........................................................... Nothing 40
Vision Care No benefit 19
Special features: , TDD and TTY phone lines; HumanaBeginnings; National
Transplant Network; HumanaHealth and HumanaFirst 39
Out-of-pocket
maximum ..............................................................
Nothing after $500/ per person or $1,250/ per family enrollment.
Some
costs do not count toward this protection.
12 65
65 Page 66 67
2002 Humana Health Plan, Inc. 66 Rates
Summary of benefits for Humana Health Plan, Inc. – 2002 Standard
Option
. Do not rely on this chart alone. All benefits are
provided in full unless indicated and are subject to the
definitions,
limitations, and exclusions in this brochure. On this page we summarize specific
expenses we cover; for more detail, look inside.
. If you want to enroll or change your enrollment in this Plan, be sure to
put the correct enrollment code from
the cover on your enrollment form.
. We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians: .
Diagnostic and treatment services provided in the office.......... Office
visit copay: $15 primary care; $15 specialist 14
Services provided by a hospital: .
Inpatient.....................................................................................
.
Outpatient..................................................................................
$100 per admission up to the out-of-pocket maximum
$50 per visit
28-29
30
Emergency benefits: .
In-area (at a
hospital).................................................................
.
In-area (at a doctor's office or urgent care center) ....................
. Out-of-area
................................................................................
$25 per visit
$15 per visit
$25 per visit
33
33
33
Mental health and substance abuse treatment...............................
Regular cost sharing 34-35
Prescription drugs: .
Generic formulary drugs
...........................................................
. Brand name formulary
drugs.....................................................
. Non formulary
drugs .................................................................
.
Maintenance drugs (90-day supply) when ordered through
our mail-order
program.............................................................
$10 copay
$25 copay
$45 copay
3 applicable copays
37
37
37
37
Dental Care .
Accidental injury
benefit........................................................... Nothing 40
Vision Care No Benefit 19
Special features: TDD and TTY phone lines; HumanaBeginnings; National
Transplant Network; HumanaHealth and HumanaFirst 39
Out-of-pocket
maximum.............................................................. Nothing
after $500/ per person or $1,250/ per family enrollment.
Some costs do not
count toward this protection.
12 66
66 Page 67
2002 Humana Health Plan, Inc. 67
Rates
2002 Rate Information for Humana Health Plan, Inc.
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB Guide for that category or
contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United States Postal Service Employees, RI
70-2. Different postal rates apply and
special FEHB guides are published for
Postal Service Nurses RI 70-2B; and for Postal Service Inspectors and Office of
Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable
FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
High Option
Self Only MS1 $85.27 $28.42 $184.75 $61.58 $100.90 $12.79
High Option
Self and Family MS2 $204.56 $68.19 $443.22 $147.74 $242.07
$30.68
Standard Option
Self Only MS4 $64.99 $21.66 $140.81 $46.93 $76.90
$9.75
Standard Option
Self and Family MS5 $155.89 $51.96 $337.76 $112.58
$184.47 $23.38 67