Humana WA

Covered Services	Gold Choice 269	GCH 270	GCH 271
Monthly premium	$59	$79	$49
Prescription Drugs
- Deductible	$0	$0	$295
- Tier 1	$7 copay*	$5 copay *	25%
- Tier 2	$40 copay	$35 copay	25%
- Tier 3	$60 copay	$65 copay	25%
- Tier 4	33%	33%	25%
Office visits
PCP	$15	$15	$15
Specialist	$30	$30	$30
X-Rays	$15 PCP/$30 Spec	$15 PCP/$30 Spec	$15 PCP/$30 Spec
Laboratory services	$15 PCP/$30 Spec	$15 PCP/$30 Spec	$15 PCP/$30 Spec
Inpatient Hospital	$950 copayment	$950 copayment	$950 copayment
	for each hospital stay	for each hospital stay	for each hospital stay
Outpatient Surgery	20-25%	$75/$100	20-25%
Emergency Room	20% up $50	20% up $50	20% up $50
Urgent Care	$15	$15	$15
Ambulance Services	20%	20%	20%
Preventive Care
- Annual Physical Exam	$0	$0	$0
- Immunizations	$0	$0	$0
- GYN exams	$0	$0	$0
- Screening Mammograms	$0	$0	$0
- Bone Mass Measurements	$0	$0	$0
- Colorectal Screening Exams	$0	$0	$0
- Prostate Screening Exams	$0	$0	$0
Vision	n/a	n/a	n/a
Hearing	n/a	n/a	n/a
Dental	n/a	n/a	n/a
* Mail order $0 for 90day supply
For specific details or a comprehensive outline of the complete summary of benefits call us at (503) 936-8905.