March 16, 2010

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Humana – Monogram with Dental – NORTH CAROLINA

A comparison of the Monogram with Dental offered by Humana is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application Monogram with Dental Application Monogram with Dental Application
Brochure Monogram with Dental Brochure Monogram with Dental Brochure
Copay N/A N/A
Office Visit 100% after deductible 75% after deductible
Deductible $7,500 (Two family members must meet their individual deductibles) $15,000 (Two family members must meet their individual deductibles)
Coinsurance 100% 75%
Coinsurance Limit Maximum Out-of-Pocket Expense Limit: $0 Individual and $0 Family. Maximum Out-of-Pocket Expense Limit: $5,000 Individual and $10,000 Family.
Out-of-Pocket Maximum Maximum Out-of-Pocket Expense Limit: $0 Individual and $0 Family. Maximum Out-of-Pocket Expense Limit: $5,000 Individual and $10,000 Family.
Lifetime Maximum $2,000,000 per covered person $2,000,000 per covered person
Prescription Drugs
  • $1,000 prescription drug deductible per individual.
  • 100% after Copayments (up to 30-day supply):
    • Level One (lowest copayment for lowest cost generic and brand-name drugs)- $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.
    • 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.
    • Level Four (highest copayment for high-technology drugs)- 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.
    		•
  • $1,000 prescription drug deductible per individual.
  • 70% after Copayments (up to 30-day supply):
    • Level One (lowest copayment for lowest cost generic and brand-name drugs)- $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.
    • 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.
    • Level Four (highest copayment for high-technology drugs)- 25% copayment after prescription deductible up to $2,500 maximum out-of-pocket per calendar year.
  • Mail Order (90-day supply)- 70% after three times the retail copayment.
    		•
    Emergency Room 100% after $125 copayment per visit and deductible (copayment waived if admitted) 75% after $125 copayment per visit and deductible (copayment waived if admitted)
    Adult Preventative Care
  • Routine annual PSA and digital rectal exam, and annual mammograms- 100%.
  • Annual physical exam (age 13 and older), Routine Pap smears, Routine lab, pathology, and X-ray- 100% ($300 of covered expenses per person per calendar year, subject to applicable coinsurance).
    		•
  • Well-child care (Including immunizations) (birth to age 13)- 75%.
  • Routine annual physical exam (age 13 and older) and Routine immunizations (age 13 to age 18)- Not Covered.
    		•
    Child Preventative Care
  • Well-child care (Including immunizations) (birth to age 13) and Routine annual physical exam (age 13 and older, $300 of covered expenses per person per calendar year, subject to applicable coinsurance)- 100%.
  • Routine immunizations (age 13 to age 18, $300 of covered expenses per person per calendar year, subject to applicable coinsurance)- 100%.
    		•
  • Well-child care (Including immunizations) (birth to age 13)- 75%.
  • Routine annual physical exam (age 13 and older) and Routine immunizations (age 13 to age 18)- Not Covered.
    		•
    Lab / X-Ray Monogram with Dental Monogram with Dental
    Maternity Complications of pregnancy and sick baby services- 100% after deductible. Complications of pregnancy and sick baby services- 75% after deductible.
    Physical Therapy Monogram with Dental Monogram with Dental
    Skilled Nursing 100% after deductible (up to 30 days per calendar year). 75% after deductible (up to 30 days per calendar year).
    Home Health Care 100% after deductible (up to 60 days per calendar year). 75% after deductible (up to 60 days per calendar year).
    Mental Health
  • 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.
    		•
  • 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.
    		•
    Hospital Care 100% after deductible 75% after deductible
    Optional Benefits Lifetime maximum benefit
  • $500 Supplemental Accident Benefit
  • $1,000 Supplemental Accident Benefit
    		•  Lifetime maximum benefit
  • $500 Supplemental Accident Benefit
  • $1,000 Supplemental Accident Benefit
    		•