Monogram: Total Plus Rx - Indiana
| BENEFIT CATEGORY | NETWORK: You Pay | NON-NETWORK: You Pay |
Deductible Options1
per calendar year -copayments do not apply - |
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Individual • |
$7,500 | $15,000 | |
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Family (two family members must each meet the individual deductible) • |
$15,000 | $30,000 | |
| Deductible Carryover Applies - Covered expenses incurred in the last three months of the calendar year and applied to the deductible will be credited to the next calendar year deductible. | |||
| Office Visit Copayment | Not applicable | Not applicable | |
Coinsurance out-of-pocket limit1
per calendar year -deductibles and copayments do not apply - |
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Individual • |
$0 | $5,000 | |
Family • |
$0 | $10,000 | |
| BENEFIT CATEGORY | NETWORK: Plan Pays | NON-NETWORK: Plan Pays |
| Preventive Care | |||
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Preventive Office Visits2 •Child Immunizations to age 182 •Pap Smear2 •Mammogram •Prostate Screening2 •Colorectal Cancer Screening, Related Exams and Lab Tests • |
100% | Not covered | |
Preventive Lab and X-ray2 • |
100% after deductible | Not covered | |
| Physician Services | |||
Office Visits (including allergy injections) •Diagnostic Lab and X-Ray3 •Allergy Testing •Allergy Serum •Inpatient and Outpatient Services •Surgery • |
100% after deductible | 75% after deductible | |
| Facility Services | |||
Inpatient and Outpatient Services •Outpatient Surgery • |
100% after deductible | 75% after deductible | |
Emergency Services (copayment waived if admitted) • |
100% after $125 copayment per visit and deductible | 75% after $125 copayment per visit and deductible | |
Rx4 Prescription Drug4
medical out-of-pocket maximum does not apply - |
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Deductible per Individual • |
Separate $1,000 deductible (does not apply to Level 1 drugs) | ||
Copayment for each Prescription or Refill • |
Level 1:
Level 2: Level 3: Level 4 : $15 copayment (deductible does not apply) $40 copayment $65 copayment 25% copayment |
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Copayment Maximum (applies to Level 4 drugs only) • |
$2500 per individual per calendar year | ||
Benefit per Prescription or Refill • |
100% after prescription copayment | 70% after prescription copayment | |
Mail Order (up to 90-day supply) • |
100% after 3x retail copayment | 70% after 3x retail copayment | |
Other Medical Services
prior authorization required in order to be eligible for these benefits -
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Skilled Nursing Facility (up to 30 days per calendar year) •Hospice5 •Home Health Care (up to 60 visits per calendar year) •Durable Medical Equipment •Pregnancy Complications and Sick Baby Services (no prior authorization required) • |
100% after deductible | 75% after deductible | |
Transplant Services • |
100% after deductible when services are received from a Humana Transplant Network provider | 75% after deductible - covered expenses are limited to a maximum allowance of $35,000 per transplant | |
| Lifetime Maximum Benefit | $2,000,000 per covered person | ||
| Mental Health6 | |||
Inpatient Services •Outpatient and Office Therapy Sessions • |
100% after deductible | 75% after deductible | |
Chemical and Alcohol Dependency
services other than for treatment of mental illness -$2,500 per calendar year -medical out-of-pocket maximum does not apply -
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Inpatient Services •Outpatient and Office Therapy Sessions (outpatient services not to exceed $500 of the total benefit) • |
50% after deductible | 50% after deductible | |
Optional Benefits
these are available to add for an additional cost -medical out-of-pocket maximum does not apply to drug coverage - |
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Prescription Drug Deductible • |
Not available with this plan | ||
Lifetime Maximum • |
Increase to $5,000,000 per covered person | ||
Supplemental Accident Benefit ($500 or $1000) •(treatment must be provided within 90 days of the injury) |
First $500 per accident at 100%, then base plan benefits apply, or First $1,000 per accident at 100%, then base plan benefits apply | ||
To be covered, expenses must be medically necessary and specified as covered. Please see your policy for more information on medical necessity and other specific plan benefits.
When you obtain care from non-network providers:
50% of your out-of-pocket costs are credited to the out-of-pocket maximum for network providers.
Once you meet your deductible and out-of-pocket expense limits, the plan pays 100% for covered services.
Benefit maximum for preventive care is limited to $300 per person per calendar year, subject to applicable coinsurance.
MRI, CAT, EEG, EKG, ECG, cardiac catheterization or pulmonary function studies are subject to applicable coinsurance after deductible.
If a non-network pharmacy is used you must pay 100 percent of the actual charges and file a claim with Humana for reimbursement. The covered person will also be responsible for 30% of the actual charge made by the dispensing pharmacy, after the applicable copayment.
Counseling for the hospice patient and immediate family is limited to 15 visits per family per lifetime. Medical Social Services limited to $100 per family per lifetime.
Including chemical and alcohol dependency when services are required in the treatment of a mental illness.
Payments
Network providers agree to accept amounts negotiated with Humana as payment in full. The member is responsible for any required deductible, coinsurance, or other copayments. Plan benefits paid to non-network providers are based on maximum allowable fees, as defined in your policy.
Non-network providers may balance bill you for charges in excess of the maximum allowable fee. You will be responsible for charges in excess of the maximum allowable fee in addition to any applicable deductible, coinsurance, or copayment. Additionally, any amount you pay the provider in excess of the maximum allowable fee will not apply to your out-of-pocket limit or deductible.
Network primary care and specialist physicians and other providers in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgment or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you.
Medical Limitations and Exclusions
This is an outline of the limitations and exclusions for the HumanaOne individual health plan listed above. It is designed for convenient reference. Consult the policy for a complete list of limitations and exclusions. Your policy is guaranteed renewable as long as premiums are paid. Other termination provisions apply as listed in the policy.
Eligibility
The issue ages for HumanaOne individual health plans are two months to 64.5 years. The maximum age for a dependent child is 25 years if the child is a full-time student and 24 years if the child is not a full-time student.
Pre-existing conditions
A pre-existing condition is a sickness or bodily injury which was treated within the 24-month period prior to the covered person's effective date of coverage or which produced symptoms that would cause an ordinarily prudent person to seek medical diagnosis or treatment within the 12-month period prior to the covered person's effective date of coverage. Benefits for pre-existing conditions are not payable until the covered person's coverage has been in force for 12 consecutive months with Humana. Humana will waive the pre-existing conditions limitation for those conditions disclosed on the application provided benefits relating to those conditions are not excluded. Conditions specifically excluded by rider are never covered.
Unless stated otherwise no benefits are payable for expenses arising from:
Services not medically necessary or which are experimental, investigational or for research purposes
Services not authorized or prescribed by a healthcare practitioner or for which no charge is made
Services while confined in a hospital or other facility owned or operated by the United States government, provided by a person who ordinarily resides in the covered person's home or who is a family member, or that are performed in association with a service that is not covered under the policy
Charges in excess of the maximum allowable fee or which exceed any policy benefit maximum
Expenses incurred before the effective date or after the date coverage terminated
Cosmetic procedures and any related complications except as stated in the policy
Custodial or maintenance care
Infertility services
Pregnancy and well-baby expenses
Elective medical or surgical procedures; sterilization, including tubal ligation and vasectomy; reversal of sterilization; abortion; gender change or sexual dysfunction
Vision therapy; all types of refractive keratoplasties or any other procedures, treatments or devices for refractive correction; eyeglasses; contact lenses; hearing aids; dental exams
Hearing and eye exams; routine physical examinations for occupation, employment, school, travel, purchase of insurance or premarital tests
Services received in an emergency room unless required because of emergency care
Dental services (except for dental injury), appliances or supplies
War or any act of war, whether declared or not; commission or attempt to commit a civil or criminal battery or felony
Standby physician or assistant surgeon, unless medically necessary; private duty nursing; communication or travel time; lodging or transportation, except as stated in the policy
Any treatment for the purpose of reducing obesity, or any use of obesity reduction procedures to treat sickness or injury caused by, complicated by, or exacerbated by obesity, including but not limited to surgical procedures, unless qualified as morbid obesity
Nicotine habit or addiction; educational or vocation therapy, services and schools; light treatment for Seasonal Affective Disorder (S.A.D.); alternative medicine; marital counseling; genetic testing, counseling or services; sleep therapy or services rendered in a premenstrual syndrome clinic or holistic medicine clinic
Foot care services
Charges for nonmedical purposes or used for environmental control or enhancement (whether or not prescribed by a healthcare practitioner)
Health clubs or health spas, aerobic and strength conditioning, work hardening programs and related material and products for these programs; personal computers and related or similar equipment; communication devices other than due to surgical removal of the larynx or permanent lack of function of the larynx
Hair prosthesis, hair transplants or implants and wigs
Temporomandibular joint disorder, craniomaxillary disorder, craniomandibular disorders and any treatment for jaw, joint or head and neck
Injury or sickness arising out of or in the course of any occupation, employment or activity for compensation, profit or gain, whether or not benefits are available under Workers' Compensation. This exclusion does not apply to a covered person qualifying as a sole proprietor, officer or partner under state law, and such benefits are not covered under any Workers' Compensation plan, provided the covered person is not covered under a Workers' Compensation plan, except for certain professions or activities as stated in the policy
Attempted suicide or intentionally self-inflicted injury, whether sane or insane
Charges covered by other medical payments insurance
Organ transplants not approved based on established criteria or investigational, experimental or for research purposes
Charges incurred for a hospital stay beginning on a Friday or Saturday unless due to emergency care or surgery is performed on the day admitted
Any drug, medicine or device which is not FDA approved
Contraceptives other than oral, including implant systems and devices regardless of the purpose for which prescribed
Medications, drugs or hormones to stimulate growth
Legend drugs not recommended or deemed necessary by a healthcare practitioner or drugs prescribed for a non-covered injury or sickness
Drugs prescribed for intended use other than for indications approved by the FDA or recognized off-label indications through peer-reviewed medical literature; experimental or investigational use drugs
Over the counter drugs (except insulin) or drugs available in prescription strength without a prescription
Drugs used in treatment of nail fungus
Prescription refills exceeding the number specified by the healthcare practitioner or dispensed more than one year from the date of the original order
Vitamins, dietary products and any other nonprescription supplements
Inpatient services when in an observation status or when the stay is due to behavioral, social maladjustment, lack of discipline or other antisocial actions not a result of a mental disorder
Insured by Humana Insurance Company Applications are subject to approval. Waiting periods, limitations and exclusions apply. The HumanaOne brand of individual products are insured by subsidiaries of Humana, Inc.
This document contains a general summary of benefits, exclusions and limitations. Please refer to the policy for the actual terms and conditions that apply. In the event there are discrepancies with the information given in this document, the terms and conditions of the policy will govern.
