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These are the summary of benefits for the plan named Humana Community HMO H1036-236. This plan is available in the county of Jefferson in Kentucky. This plan applies to the year 2023. The Pre-Enrollment Checklist includes Understanding the Benefits. Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 1-800-833-2364 (TTY: 711).

Understanding the Benefits. The Evidence of Coverage (EOC) provides a complete list of all coverage and services. It is important to review plan coverage, costs and benefits before you enroll. Visit Humana.com/medicare or call 1-800-833-2364 (TTY: 711) to view a copy of the Evidence of Coverage EOC. Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor.

Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions. Review the formulary to make sure your drugs are covered. Here are important Rules. You must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.

Benefits, premiums and/or copayments/co-insurance may change on January 1, 2024. Except in emergency or urgent situations, we do not cover services by out-of-network providers. Out-of-network providers are doctors who are not listed in the provider directory. To find out more about the Humana Community HMO plan, including the health and drug services it covers in this easy-to-use guide.

To be eligible to join the Humana Community HMO plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and live in our service area. If you are a member of this plan, call toll-free 1-800-457-4708. If you are not a member of this plan, call toll free 1-800-833-2364. From October 1 to March 31, call 7 days a week from 8am to 8pm. From April 1st to September 30th, you can call from Monday to Friday from 8am to 8pm. Our website is https://humana.com/medicare .

Here is more information about the Humana Community (HMO). Do you have Medicare and Medicaid? If you are a dual-eligible beneficiary enrolled in both Medicare and the state's program, you may not have to pay the medical costs displayed in this booklet and your prescription drug costs will be lower, too.

If you have Medicaid, be sure to show your Medicaid ID card in addition to your Humana membership card to make your provider aware that you may have additional coverage. Your services are paid first by Humana and then by Medicaid. As a member you must select an in-network doctor to act as your Primary Care Provider (PCP).

Humana Community (HMO) has a network of doctors, hospitals, pharmacies and other providers. If you use providers who aren't in our network, the plan may not pay for these services. Here is information about the Monthly Plan Premium, Deductible and Limits. The Monthly Plan Premium is $0 . You must keep paying your Medicare Part B premium. This plan does not have a medical deductible. This plan does not have a Pharmacy (Part D) deductible.

The maximum out-of-pocket responsibility is $3,900 for in-network costs. The most you pay for copays, coinsurance and other costs for covered medical services for the year. Here are the Covered Medical and Hospital Benefits. Acute inpatient hospital care has a $250 copay per day for days 1 through 7 and a $0 copay per day for days 8 through 90 . Your plan covers an unlimited number of days for an inpatient stay.

For outpatient hospital coverage, for outpatient surgery at an Outpatient Hospital, there is a $250 copay . For outpatient surgery at an Ambulatory Surgical Center, there is a $200 copay . For primary care Doctor visits , the copay is $0. For Specialists the copay is $15.

You do not need a referral to receive covered services from plan providers. Certain procedures, services and drugs may need advance approval from your plan. This is called a "prior authorization" or "preauthorization." Please contact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from the plan. PCP means your Primary Care Provider. Your Primary Care Provider is your primary doctor.

For preventive care, our plan covers many preventive services at no cost when you see an in-network provider. Abdominal aortic aneurysm screening is a preventative service. Alcohol misuse counseling is a preventative service. Bone mass measurement is a preventative service. Breast cancer screening (mammogram) is a preventative service. Cardiovascular disease (behavioral therapy) is a preventative service. Cardiovascular screenings is a preventative service.

Cervical and vaginal cancer screening is a preventative service. Colorectal cancer screenings (colonoscopy, fecal occult blood test, flexible sigmoidoscopy) is a preventative service. Depression screening is a preventative service. Diabetes screenings is a preventative service. HIV screening is a preventative service. Medical nutrition therapy services is a preventative service. Obesity screening and counseling is a preventative service.

Prostate cancer screenings (PSA) is a preventative service. Sexually transmitted infections screening and counseling is a preventative service. Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) is a preventative service. Vaccines, including flu shots, hepatitis B shots, pneumococcal shots is a preventative service. "Welcome to Medicare" preventive visit (one-time) is a preventative service. Annual Wellness Visit is a preventative service.

Lung cancer screening is a preventative service. Routine physical exam is a preventative service. Medicare diabetes prevention program is a preventative service. Any additional preventive services approved by Medicare during the contract year will be covered. Here is information about emergency care . The Emergency room copay is $110. If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for the emergency care.

Urgently needed services $20 copay at an urgent care center Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical attention. Here is information about OUTPATIENT CARE AND SERVICES . For diagnostic services, labs and imaging , cost share may vary depending on the service and where service is provided . For Diagnostic mammography there is a $0 to $15 copay . For Diagnostic colonoscopy there is a $0 copay .

For Diagnostic radiology, there is a $180 to $300 copay . For Lab services, there is a $0 to $20 copay . For Diagnostic tests and procedures there is a $0 to $100 copay . For Outpatient X-rays there is a $0 to $75 copay . For Radiation therapy, there is a $15 copay or 20% of the cost . Here is information about outpatient Hearing benefits. Medicare-covered hearing exam there is a $15 copay .

Routine hearing that is In-Network, called HER963, there is a $0 copay for routine hearing exams up to 1 per year. There is a $0 copay for each Advanced level hearing aid up to 1 per ear every 3 years. There is a $299 copay for each Premium level hearing aid up to 1 per ear every 3 years.

A hearing aid purchase includes unlimited follow-up provider visits during first year following a TruHearing hearing aid purchase . The hearing aid purchase has a 60-day trial period and a 3-year extended warranty and 80 batteries per aid for non-rechargeable models . You must see a TruHearing provider to use this benefit. Call 1-844-255-7144 to schedule an appointment (for TTY, dial 711). Medicare-covered dental services have a $15 copay .

For a routine dental service, the cost-share indicated below is what you pay for the covered service. For In-Network, DEN046 , there is a $0 copay for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. There is a $0 copay for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years.

There is a $0 copay for bridges, complete dentures, crown recementation, denture recementation, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years. There is a $0 copay for crown, root canal, root canal retreatment up to 1 per tooth per lifetime. There is a $0 copay for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. There is a $0 copay for adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, tissue

conditioning up to 1 per year. There is a $0 copay for emergency treatment for pain, fluoride treatment, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year. There is a $0 copay for periodontal maintenance up to 4 per year. There is a $0 copay for amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year.

There is a $3000 maximum benefit coverage amount per year for preventive and comprehensive benefits. Dental services are subject to our standard claims review procedures which could include dental history to approve coverage. Dental benefits under this plan may not cover all American Dental Association procedure codes. Information regarding each plan is available at Humana.com/sb .

Network dentists have agreed to provide services at contracted fees (the in-network fee schedules, of INFS). If a member visits a participating network dentist, the member will not receive a bill for charges more than the negotiated fee schedule on covered services (coinsurance payment still applies). Use the HumanaDental Medicare network for the Mandatory Supplemental Dental. The provider locator can be found at

Humana.com > Find a Doctor > from the Search Type drop down select Dental > under Coverage Type select All Dental Networks > enter zip code > from the network drop down select HumanaDental Medicare. Medicare-covered vision services have a $15 copay. A Medicare-covered diabetic eye exam has a $0 copay . A Medicare-covered glaucoma screening has a $0 copay . Medicare-covered eyewear that is post-cataract has a $0 copay .

Routine vision that is In-Network with the code VIS733 , has a $0 copay for routine exam up to 1 per year. There is a $300 maximum benefit coverage amount per year for contact lenses or eyeglasses-lenses and frames, fitting for eyeglasses-lenses and frames. Eyeglass lens options may be available with the maximum benefit coverage amount up to 1 pair per year. The maximum benefit coverage amount is limited to one time use per year.

The provider locator for routine vision can be found online at Humana.com > Find a Doctor > select Vision care icon > Vision coverage through Medicare Advantage plans. For Mental health services that are Inpatient, there is a $250 copay per day for days 1 through 6. And there is a $0 copay per day for days 7 through 90 . Your plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital.

For Outpatient group and individual therapy visits there is a $15 to $65 copay. Cost share may vary depending on where service is provided. For a Skilled nursing facility (SNF) there is a $0 copay per day for days 1 through 20 . And there is a $196 copay per day for days 21-100 . Your plan covers up to 100 days in a SNF or Skilled nursing facility. For Physical Therapy, there is a $15 copay . For Ambulance service, there is a $270 copay per date of service.

For the Transportation benefit, there is a $0 copay for a plan approved location with up to 48 one-way trips per year. This benefit is not to exceed 25 miles per trip. The member must contact transportation vendor to arrange transportation and should contact Customer Care to be directed to their plan's specific transportation provider. For Medicare Part B drugs, for Chemotherapy drugs, you are responsible for 19% of the cost . For Other Part B drugs you are responsible for 19% of the cost .

This plan has Prescription Drug Benefits . Here is information about what You Pay for Vaccines . Our plan covers most Part D vaccines at no cost to you, no matter what cost-sharing tier it’s on . Here is information about What You Pay for Insulin . You won’t pay more than $35 for a one-month (up to 30-day) supply of each Part D insulin product covered by our plan, no matter what cost-sharing tier it’s on . This applies to all Part D covered insulins,

including the Select Insulins covered under the Insulin Savings Program as described below. What you pay for prescription drugs depends on whether you receive "Extra Help" or not. If you receive "Extra Help", you will still pay no more than $35 for a one-month supply for each Part D covered insulin. Please see your Prescription Drug Guide to find all Part D insulins covered by your plan. This plan does not have a deductible for prescription drugs.

If you don't receive Extra Help for your drugs, you'll pay a different amount based on the type of cost-sharing option you use.

For the Initial coverage, you are responsible to pay for a 30-day supply or a 90-day supply the amount based on the tier of the prescription drug. A prescription drug can be either in tier 1 preferred generic, tier 2 generic, tier 3 preferred brand, tier 4 non-preferred drug, or tier 5 specialty tier. You are responsible to pay for prescription drugs until the total yearly drug costs reach $4,660 . The total yearly drug costs are the total drug costs paid by both you and our plan. Once you reach this amount, you will enter the Coverage Gap.

There are two different kinds of cost-sharing for prescription drugs, including Mail Order Cost-Sharing and Retail Cost-Sharing. There are two different kinds of Mail Order pharmacy options, Standard and Preferred. The Mail order pharmacy option called Standard includes Walmart Mail, PillPack and other pharmacies that are also available in our network. To find pharmacy mail order options go to Humana.com/pharmacyfinder . The second type of mail order pharmacy option is the Preferred pharmacy option, which includes only the CenterWell Pharmacy.

For the Standard Mail order pharmacy option, for Tier 1 Preferred Generic drugs, the 30-day supply costs $10 and the 90-day supply costs $30. For the Standard Mail order pharmacy option, for Tier 2 Generic drugs, the 30-day supply costs $20 and the 90-day supply costs $60. For the Standard Mail order pharmacy option, for Tier 3 Preferred Brand drugs, the 30-day supply costs $47 and the 90-day supply costs $141.

For the Standard Mail order pharmacy option, for Tier 4 Non-Preferred drugs, the 30-day supply costs $100 and the 90-day supply costs $300. For the Standard Mail order pharmacy option, for Tier 5 Specialty Tier drugs, the 30-day supply costs 33% and the 90-day supply is not available. For the Preferred CenterWell Pharmacy Mail order pharmacy option, for Tier 1 Preferred Generic drugs, the 30-day supply costs $0 and the 90-day supply costs $0.

For the Preferred CenterWell Pharmacy Mail order pharmacy option, for Tier 2 Generic drugs, the 30-day supply costs $0 and the 90-day supply costs $0. For the Preferred CenterWell Pharmacy Mail order pharmacy option, for Tier 3 Preferred Brand drugs, the 30-day supply costs $42 and the 90-day supply costs $116. For the Preferred CenterWell Pharmacy Mail order pharmacy option, for Tier 4 Non-Preferred drugs, the 30-day supply costs $100 and the 90-day supply costs $290.

For the Preferred CenterWell Pharmacy Mail order pharmacy option, for Tier 5 Specialty Tier drugs, the 30-day supply costs 33% and the 90-day supply is not available. The other kind of prescription drug cost sharing is called Retail Cost-Sharing, which means that you can physically go to the pharmacy. You can go to any network retail pharmacy. To find the retail pharmacies near you, go to Humana.com/pharmacyfinder

For the retail pharmacy option, for Tier 1 Preferred Generic drugs, the 30-day supply costs $0 and the 90-day supply costs $0. For the retail pharmacy option, for Tier 2 Generic drugs, the 30-day supply costs $0 and the 90-day supply costs $0. For the retail pharmacy option, for Tier 3 Preferred Brand drugs, the 30-day supply costs $42 and the 90-day supply costs $116. For the retail pharmacy option, for Tier 4 Non-Preferred drugs, the 30-day supply costs $100 and the 90-day supply costs $300.

For the retail pharmacy option, for Tier 5 Specialty Tier drugs, the 30-day supply costs 33% and the 90-day supply is not available. Your plan participates in the Insulin Savings Program. You will pay no more than $35 for a one-month (up to a 30-day) supply for Select Insulins, no matter what cost-sharing tier it’s on . To identify which Select Insulins are included within the Insulin Savings Program, look for the ISP indicator in your Prescription

Drug Guide. You are not eligible for this program if you receive "Extra Help". Your plan also provides enhanced insulin coverage which means you will pay no more than $35 for a one-month (up to 30-day) supply for all Part D insulins covered by our plan, including Select Insulins, no matter what cost-sharing tier it’s on . The enhanced insulin coverage is available, even if you receive "Extra Help".

Your share of the cost for Select Insulins depends on whether you choose the Mail Order Cost-Sharing option for Select Insulins or the Retail Cost-Sharing options for Select Insulins. There are two mail order cost-sharing pharmacy options, including the Standard option which includes Walmart Mail, PillPack and any other pharmacies that are available in our network. To find pharmacy mail order options, go to Humana.com/pharmacyfinder

The second cost-sharing pharmacy option is the Preferred CenterWell Pharmacy. For the Standard mail order cost-sharing pharmacy option for select insulins, for tier 3 preferred brand insulin drugs the 30-day supply costs $35 and the 90-day supply costs $105. For the preferred CenterWell mail order cost-sharing pharmacy option for select insulins, for tier 3 preferred brand insulin drugs the 30-day supply costs $35 and the 90-day supply costs $95.

For the retail cost-sharing option for buying select insulin drugs, you can got to any in network retailer pharmacies. For the retail cost-sharing option for buying select insuling drugs, for the tier 3 preferred brand option the 30-day supply costs $35 and the 90-day supply costs $105.

If you receive Extra Help for your drugs, you'll pay the following copay depending on whether you choose generic drugs and depending on whether you choose a 30-day supply or a 90-day supply. This plan does not have a deductible. For generic drugs, for a 30-day supply, you pay a $0 copay and for a 90-day supply you pay a $0 copay or you can also just pay 15% of the cost.

For brand name drugs that happen to be treated as generic drugs, you pay a $1.45 copay for a 30-day supply and for a 90-day supply you pay a $1.45 copay or you can also just pay 15% of the cost. Note that some drugs are only limited to a 30-day supply. In addition, Erectile dysfunction (ED) drugs are covered at the Tier 1 cost-share amount. Anti-Obesity drugs are Covered at the Tier 2 cost-share amount. Prescription Vitamins are Covered at the Tier 1 cost-share amount.

Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the Part D benefit and if you qualify for "Extra Help." To find out if you qualify for "Extra Help," please contact the Social Security Office at 1-800-772-1213 Monday — Friday, 7 a.m. — 7 p.m. TTY users should call 1-800-325-0778. For more information on your prescription drug benefit, please call us or access your "Evidence of Coverage" online.

If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy. After you enter the coverage gap, you pay 25 percent of the plan's cost for covered brand name drugs and 25 percent of the plan's cost for covered generic drugs until your out-of-pocket costs total $7,400 — which is the end of the coverage gap. Not everyone will enter the coverage gap.

Under this plan, you may pay even less for the following, all Tier 1 (Preferred Generic) Drugs , all Tier 2 (Generic) drugs and for select insulin tier 3 preferred brand drugs. For more information on cost sharing in the coverage gap, please call us or access your Evidence of Coverage online.

For Catastrophic Coverage , after your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,4 00 you pay the greater of 5% of the cost, or $4.15 copay for generic (including brand drugs treated as generic) and a $10.35 copay for all other drugs . Medicare-covered foot care (podiatry) has a $15 copay . Medicare-covered chiropractic services has a $20 copay .

Medical equipment/ supplies cost share may vary depending on the service and where service is provided . Forf Durable medical equipment (like wheelchairs or oxygen) you pay 16% of the cost . For Medical supplies you pay 20% of the cost . For Prosthetics (such as artificial limbs or braces) you pay 20% of the cost . For Diabetic monitoring supplies you pay a $0 copay or 10% to 20% of the cost . For Rehabilitation services such as Occupational and speech therapy you pay a $15 copay .

For Rehabilitation services such as Cardiac rehabilitation there is a $10 copay . For Rehabilitation services such as Pulmonary rehabilitation there is a $10 copay . For Telehealth services (in addition to Original Medicare) for the Primary care provider (PCP) there is a $0 copay . For Telehealth services (in addition to Original Medicare) for Specialist there is a $15 copay . For Telehealth services (in addition to Original Medicare) for Urgent care services there is a $0 copay .

For Telehealth services (in addition to Original Medicare) for Substance abuse and behavioral health services there is a $0 copay . This summary of benefits is only a summary of the full set of benefits that are listed in the Evidence of Coverage (EOC), which is a document that provides a complete list of coverage and services. Visit Humana.com/medicare to view a copy of the EOC or call 1-800-833-2364 .

For the Humana Flex Allowance , there is a $1000 annual allowance on a prepaid card to use toward out of pocket costs for the plan's preventive and comprehensive dental, vision, or hearing services including copays. Members can use this benefit at participating providers where the primary business is Dental Care, Vision Services, or Hearing Services and Visa is accepted. This Cannot be used for procedures such as cosmetic dentistry and teeth whitening. Unused amount expires at the end of the plan year.

Allowance amounts cannot be combined with other benefit allowances. Limitations and restrictions may apply. There is a Over-the-Counter (OTC) Allowance of $50 maximum benefit coverage amount per month for over-the-counter (OTC) prepaid card to purchase eligible OTC health and wellness products at participating retailers. Unused funds carry over to the next month and expire at the end of the plan year.

The Allowance amounts cannot be combined with other benefit allowances. Limitations and restrictions may apply.

For the Humana Spending Account Card , the allowances listed below will be loaded onto this prepaid card. Each allowance is separate from any other allowance listed. Allowances shown are accessed by using this card. Allowance amounts cannot be combined with other benefit allowances. Limitations and restrictions may apply. This includes the Humana Flex Allowance and the OTC Allowance . The Special Supplemental Benefits for the Chronically Ill (SSBCI) Humana

Flexible Care Assistance is available to members with chronic health conditions, who are participating in care management services, and meet program criteria. Eligible members may receive medical expense assistance and other additional benefits, either primarily health related or non-primarily health related, to address the member's unique individual needs. Benefits are limited up to $1,000 per year and must be coordinated and authorized by a care manager. There is no cost to participate.

For routine Chiropractic services , there is a $0 copay per visit for unlimited visits. For Routine foot care there is a $0 copay per visit for up to 12 visits . The Humana Well Dine Meal Program is Humana's home delivered meal program for members following an inpatient stay in the hospital or nursing facility. Go365 is the Humana Rewards and Incentives program for completing certain preventive health screenings and health and wellness activities.

The SilverSneakers fitness program is a Basic fitness center membership including fitness classes.