Arizona Medical Insurance > Humana One > Monogram Total Plus Rx Benefits

Quote & Apply - Electronic application

	Plan pays for services at PARTICIPATING providers	Plan pays for services at NON-PARTICIPATING providers
Annual Deductible1, 2 Annual amount (does not apply to maximum out-of-pocket expense)	Single Deductible - $7,500 Family Deductible* - $15,000	Single Deductible - $15,000 Family Deductible* - $30,000
Deductible carryover	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 *Two family members must meet their individual deductible.
Maximum Out-of-Pocket Expense Limit1, 2	$0 - Individual	$5,000 - Individual
	$0 -  Family	$10,000 - Family
Lifetime Maximum	$2,000,000 per covered person
Preventive Care
Routine annual physical exam4, 5	100%	Not Covered
Routine immunizations4, 5 (to age 18)
Routine Pap smears and PSA4, 5, 6
Routine Mammograms6	100%	75% after deductible
Routine lab, pathology and X-ray4, 5	100% after deductible	Not Covered
Physician Services
Office Visits (includes diagnostic lab and X-ray)	100% after deductible	75% after deductible
Allergy testing, injections and serum
Inpatient services
Outpatient services (includes surgery) 7
Hospital Services
Inpatient Care	100% after deductible	75% after deductible
Outpatient surgery - facility 7
Outpatient nonsurgical
Emergency room (including physician visits)	100% after $125 copayment per visit and deductible (copayment waived if admitted)	75% after $125 copayment per visit and deductible (copayment waived if admitted)
Prescription Drugs 8
Prescription drug deductible (Covered prescription drugs are assigned to one of four different levels with corresponding copayment amounts.)2	$1,000 prescription drug deductible per individual	$1,000 prescription drug deductible per individual
Benefit for each prescription or refill (up to 30-day supply)	100% after:	70% after:
Level One - lowest copayment for lowest cost generic and brand-name drugs	$15 copayment is not subject to prescription drug deductible	$15 copayment is not subject to prescription drug deductible
Level Two - higher copayment for higher cost generic and brand-name drugs	$40 copayment after prescription drug deductible	$40 copayment after prescription drug deductible
Level Three - higher copayment than Level Two for higher cost, mostly brand-name drugs that may have generic or therapeutic equivalents in Levels One or Two	$65 copayment after prescription drug deductible	$65 copayment after prescription drug deductible
Level Four - highest copayment for high-technology drugs (certain brand-name drugs, biotechnology drugs and self-administered injectable medications)	25% copayment after prescription deductible up to $2,500 maximum out-of-pocket per calendar year	25% copayment after prescription deductible up to $2,500 maximum out-of-pocket per calendar year
Mail order (90-day supply)	100% after three times the retail copayment	70% after three times the retail copayment
Other Medical Services
Skilled nursing facility 9 (up to 30 days per calendar year)	100% after deductible	75% after deductible
Home healthcare 9
Durable medical equipment 9
Hospice 9, 10
Complications of pregnancy and sick baby services
Transplant services 9 (organ)	100% after deductible (when services are performed at a National Transplant Network provider)	75% after deductible (limited to $35,000 per covered transplant)
Mental Health (includes mental disorders, alcohol and chemical dependence) 4
Inpatient and Outpatient care (Combined $2,500 per calendar year maximum. Outpatient care not to exceed $500 of the $2,500 calendar year maximum.)	50% after deductible	50% after deductible
Optional Benefits 11
Lifetime maximum benefit	$5,000,000 per covered person	$5,000,000 per covered person
$500 Supplemental Accident Benefit (Treatment must be provided within 90 days of the injury.)	First $500 per accident at 100%, then base plan benefits apply	First $500 per accident at 100%, then base plan benefits apply
$1,000 Supplemental Accident Benefit (Treatment must be provided within 90 days of the injury.)	First $1,000 per accident at 100%, then base plan benefits apply	First $1,000 per accident at 100%, then base plan benefits apply
Optional Dental Benefits (with teeth whitening) 12	You can choose any dentist, but you can save up to 30 percent on out-of-pocket costs when you visit one of the more than 75,000 dentist locations in the PPO network.
	Preventive services plan pays 100% no deductible Oral examinations Routine cleanings X-rays Sealants Topical fluoride treatment Basic services plan pays 50% after deductible Emergency exams and palliative care for pain relief Thumb sucking and harmful habit appliances Space maintainers Amalgam, composite fillings Oral surgery Extractions (routine) Non-cast stainless steel crowns Partial or complete denture repairs/adjustments Teeth whitening services plan pays 50% after deductible $200 lifetime maximum	Major services plan pays 50% after deductible Endodontics (root canals) Periodontics Crowns Inlays and onlays Partial or complete dentures Denture relines/rebases Orthodontia discount Members can receive up to 20 percent discount if they visit an orthodontist from the HumanaDental PPO Network and ask for the discount. Removable or fixed bridgework Annual Deductible $50 individual $150 family Annual maximum benefit $1,000

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.

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.

(1) When you obtain care from nonparticipating providers:
          - 50 percent of your payment toward the deductible is credited to the deductible for participating providers.
          - 50 percent of your out-of-pocket costs are credited to the out-of-pocket maximum for participating providers.
Once you meet your deductible and out-of-pocket expense limits, the plan pays 100 percent for covered services.
(2) Copayments do not apply to the deductible or out-of-pocket maximum. The medical out-of-pocket maximum does not apply to prescription drugs or mental health services.
(3) Two family members must meet their individual deductible.
(4) Benefit payable after a 90-day waiting period for preventive care and 12 month waiting period for mental health.
(5) $300 of covered expenses per person per calendar year, subject to applicable coinsurance.
(6) Age and/or frequency limits apply.
(7) Outpatient benefits payable after 90-day waiting period for nonemergency removal of tonsils and/or adenoids, and 180-day waiting period for nonemergency surgical treatment for bunions, varicose veins, hemorrhoids or hernia (does not include strangulated or incarcerated hernia).
(8) If a nonparticipating pharmacy is used you must pay 100 percent of the actual charges and file a claim with Humana for reimbursement.
(9) Prior authorization required in order to be eligible for these benefits.
(10) 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.
(11) These benefits are optional and can be added to your plan for an additional cost. Optional benefits may not be available in all areas.
(12) This is not a complete disclosure of plan qualifications and limitations. Waiting periods apply: six months on basic services and teeth whitening, 12 months on major services. Please review the specific Dental limitations & exclusions before applying for coverage.