Maximum out-of-pocket 
responsibility  This plan does not have amaximum out-of-pocket responsibility. 
Covered Medical and Hospital Benefits 
N/A WHAT YOU PAY ON THIS HUMANA PLAN 
ACUTE INPATIENT HOSPITAL CARE 
N/A $0 copay 
OUTPATIENT HOSPITAL COVERAGE 
Outpatient surgery at 
outpatient hospital $0 copay 
Outpatient surgery at 
ambulatory surgical center $0 copay 
DOCTOR OFFICE VISITS 
Primary care provider (PCP) $0 copay 
Specialists $0 copay 
PREVENTIVE CARE