Medical Benefits

Name: Axiom
Address: United States

Find a doctor at www.humana.com // Network: Humana/ChoiceCare Network PPO

	In-Network	Out-of-Network
Deductible (Individual/Family)	$1,000/$2,000	$2,000/$4,000
Member Coinsurance	20%	50%
Out-of-Pocket Max (Individual/Family)	$4,000/$8,000	$12,000/$24,000
Physician Office Visit	$25 Copay	Deductible + 30%
Preventive Care	Covered at 100%	Deductible + 30%
Doctor on Demand Telemedicine - General Medicine Virtual Visit - Behavioral Health Virtual Visit	$25 Copay $25 Copay	Deductible + 30%
Specialist Visit	$50 Copay	Deductible + 30%
Inpatient Hospital	Deductible + 20%	Deductible + 50%
Outpatient Hospital	Deductible + 20%	Deductible + 20%
Ambulance—Ground or Air	Deductible + 20%	Deductible + 20%
Urgent Care	$100 Copay	Deductible + 50%
Emergency Room	$400 Copay	$400 Copay
Mental Health Services: Therapy	$25 Copay/Visit	Deductible + 30%

Prescription Drugs	In-Network	Out-of-Network
Retail
Tier 1	$10 Copay	Retail Copay + 30%
Tier 2	$30 Copay	Retail Copay + 30%
Tier 3	$50 Copay	Retail Copay + 30%
Tier 4	25% Coinsurance	Retail Copay + 30%
Specialty	35% Coinsurance (Retail) 25% Coinsurance (Preferred Specialty)	50% Coinsurance
Mail Order Drugs
Level 1	$25 Copay	Retail Copay + 30%
Level 2	$75 Copay	Retail Copay + 30%
Level 3	$125 Copay	Retail Copay + 30%
Level 4	25% Coinsurance	Retail Copay + 30%

Downloads

Find a doctor at www.humana.com // Network: Humana/ChoiceCare Network PPO

	In-Network	Out-of-Network
Deductible (Individual/Family)	$3,000/$6,000	$6,000/$12,000
Member Coinsurance	20%	50%
Out-of-Pocket Max (Individual/Family)	$6,500/$13,000	$19,500/$35,000
Physician Office Visit	$35 Copay	Deductible + 50%
Preventive	Covered at 100%	Deductible + 50%
Specialist Visit	$60 Copay	Deductible + 50%
Doctor on Demand Telemedicine - General Medicine Virtual Visit - Behavioral Health Virtual Visit	$35 Copay $35 Copay	Deductible + 30%
Inpatient Hospital	Deductible + 20%	Deductible + 50%
Outpatient Hospital	Deductible + 20%	Deductible + 50%
Ambulance—Ground or Air	Deductible + 20%	Deductible + 20%
Urgent Care	$100 Copay	Deductible + 50%
Emergency Room	$350 Copay	$350 Copay
Mental Health Services: Therapy	$35 Copay/Visit	Deductible + 30%

Prescription Drugs
Retail
Tier 1	$10 Copay	Retail Copay + 30%
Tier 2	$45 Copay	Retail Copay + 30%
Tier 3	$90 Copay	Retail Copay + 30%
Tier 4	25% Coinsurance	Retail Copay + 30%
Specialty	35% Coinsurance (Retail) 25% Coinsurance (Preferred Specialty)	50% Coinsurance
Mail Order
Tier 1	$25 Copay	Retail Copay + 30%
Tier 2	$112.50 Copay	Retail Copay + 30%
Tier 3	$225 Copay	Retail Copay + 30%
Tier 4	25% Coinsurance	Retail Copay + 30%
Specialty	N/A	N/A

Downloads

Group Number

773745

Provided By

Humana

Provider Website