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{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | Deductible This plan has a $505 deductible .You pay the full cost of your drugs until you reach $505 .
Then, you only pay your cost-share.
Initial coverage (after you pay your deductible)
You pay the following until your total yearly drug costs reach $4,660 .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.
Mail Order Cost-Sharing
Pharmacy options Standard
Walmart Mail ,PillPack
Other pharmacies are |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | drug costs paid by both you and our plan. Once you reach this amount, you will enter the Coverage Gap.
Mail Order Cost-Sharing
Pharmacy options Standard
Walmart Mail ,PillPack
Other pharmacies are
available in our network. To find
pharmacy mail order options go to
Humana.com/pharmacyfinder Preferred
CenterWell Pharmacy ™
N/A 30-day supply 90-day supply* 30-day supply 90-day supply*
Tier 1: Preferred Generic $1 $3 $0 $0
Tier 2: Generic $2 $6 $1 $0
Tier 3: Preferred Brand 23% 23% 19% 15% |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | CenterWell Pharmacy ™
N/A 30-day supply 90-day supply* 30-day supply 90-day supply*
Tier 1: Preferred Generic $1 $3 $0 $0
Tier 2: Generic $2 $6 $1 $0
Tier 3: Preferred Brand 23% 23% 19% 15%
Tier 4: Non-Preferred
Drug 45% 45% 41% 30%
Tier 5: Specialty Tier 25% N/A 25% N/A S5884138000SB23 Summary of Benefits 7S5884138000
Retail Cost-Sharing
Pharmacy options Standard All other network retail
pharmacies. Preferred
To find the preferred cost-share
retail pharmacies near you, go to |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | Retail Cost-Sharing
Pharmacy options Standard All other network retail
pharmacies. Preferred
To find the preferred cost-share
retail pharmacies near you, go to
Humana.com/pharmacyfinder
N/A 30-day supply 90-day supply* 30-day supply 90-day supply*
Tier 1: Preferred Generic $1 $3 $0 $0
Tier 2: Generic $2 $6 $1 $3
Tier 3: Preferred Brand 23% 23% 19% 19%
Tier 4: Non-Preferred
Drug 45% 45% 41% 41%
Tier 5: Specialty Tier 25% N/A 25% N/A |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | Tier 1: Preferred Generic $1 $3 $0 $0
Tier 2: Generic $2 $6 $1 $3
Tier 3: Preferred Brand 23% 23% 19% 19%
Tier 4: Non-Preferred
Drug 45% 45% 41% 41%
Tier 5: Specialty Tier 25% N/A 25% N/A
If you receive Extra Help for your drugs, you'll pay the following:
Deductible You may pay $0 or $104 depending on your level of "Extra Help" .If your deductible is $104 ,
you pay the full cost of your drugs until you reach $104 .Then, you only pay your cost-share.
Pharmacy cost-sharing
For generic drugs |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | you pay the full cost of your drugs until you reach $104 .Then, you only pay your cost-share.
Pharmacy cost-sharing
For generic drugs
(including 30-day supply 90-day supply*
brand drugs treated as
generic), either: $0 copay; or
$1.45 copay; or
$4.15 copay ;or
15% of the cost $0 copay; or
$1.45 copay; or
$4.15 copay ;or
15% of the cost
For all other drugs,
either: $0 copay; or
$4 .30 copay; or
$10.35 copay ;or
15% of the cost $0 copay; or
$4 .30 copay; or
$10.35 copay ;or |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | $1.45 copay; or
$4.15 copay ;or
15% of the cost
For all other drugs,
either: $0 copay; or
$4 .30 copay; or
$10.35 copay ;or
15% of the cost $0 copay; or
$4 .30 copay; or
$10.35 copay ;or
15% of the cost
Other pharmacies are available in our network.
*Some drugs are limited to a30-day supply
Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | Other pharmacies are available in our network.
*Some drugs are limited to a30-day supply
Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the
Part Dbenefit 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, 7a.m. —7p.m. TTY users should call |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | the Social Security Office at 1-800-772-1213 Monday —Friday, 7a.m. —7p.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 along-term care facility, you pay the same as at astandard retail pharmacy.
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network
pharmacy.
Coverage Gap |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network
pharmacy.
Coverage Gap
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. 8 Summary of Benefits S5884138000SB23 S5884138000
Catastrophic Coverage |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | which is the end of the coverage gap. Not everyone will enter the coverage gap. 8 Summary of Benefits S5884138000SB23 S5884138000
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 9 |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | 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 9
S5884_SB_PD_PDP_138000_2023_M Summary of Benefits S5884138000SB23 To find out more about the coverage and costs of Original Medicare, look in the current “Medicare &You”
handbook. View it online at http://www.medicare.gov or get acopy by calling 1-800-MEDICARE (1-800-633-4227), |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | handbook. View it online at http://www.medicare.gov or get acopy by calling 1-800-MEDICARE (1-800-633-4227),
24 hours aday, seven days aweek. TTY users should call 1-877-486-2048.
The Humana Prescription Drug Plan (PDP) pharmacy network includes limited lower-cost, preferred pharmacies in
urban areas of CT, DE, IA, MA, ME, MN, MO, MS, ND, NJ, NY, PR, RI, SD; suburban areas of CT, MA, ME, MN, MT, ND, |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | urban areas of CT, DE, IA, MA, ME, MN, MO, MS, ND, NJ, NY, PR, RI, SD; suburban areas of CT, MA, ME, MN, MT, ND,
NH, NJ, NY, PA, PR, RI; and rural areas of IA, MN, MT, ND, NE, SD, VT, WY. There are an extremely limited number of
preferred cost share pharmacies in urban areas in the following states: DE, ME, MN, MS, ND; suburban areas of: MT
and ND; and rural areas of: ND. The lower costs advertised in our plan materials for these pharmacies may not be |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | and ND; and rural areas of: ND. The lower costs advertised in our plan materials for these pharmacies may not be
available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether
there are any lower-cost preferred pharmacies in your area, please call Customer Care at 1-800-281-6918 (TTY:
711) or consult the online pharmacy directory at Humana.com .You can see our plan's pharmacy directory at our website at |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | 711) or consult the online pharmacy directory at Humana.com .You can see our plan's pharmacy directory at our website at
humana.com/finder/pharmacy/ or call us at the number listed at the beginning
of this booklet and we will send you one.
You can see our plan's drug guide at our website at
humana.com/medicaredruglist or call us at the number listed at the beginning
of this booklet and we will send you one. Find out more Notes Notes 12 Summary of Benefits S5884138000SB23 S5884138000 |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | humana.com/medicaredruglist or call us at the number listed at the beginning
of this booklet and we will send you one. Find out more Notes Notes 12 Summary of Benefits S5884138000SB23 S5884138000
GHHLNNXEN 0522 Important________________________________________________
At Humana, it is important you are treated fairly.
Humana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color, national |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | At Humana, it is important you are treated fairly.
Humana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color, national
origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity, marital status,
religion, or language. Discrimination is against the law. Humana and its subsidiaries comply with applicable
federal civil rights laws. If you believe that you have been discriminated against by Humana or its |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | federal civil rights laws. If you believe that you have been discriminated against by Humana or its
subsidiaries, there are ways to get help.
•You may file acomplaint, also known as agrievance:
Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.
If you need help filing agrievance, call 1-877-320-1235 or if you use a TTY ,call 711 .
•You can also file acivil rights complaint with the U.S. Department of Health and Human Services ,Office |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | If you need help filing agrievance, call 1-877-320-1235 or if you use a TTY ,call 711 .
•You can also file acivil rights complaint with the U.S. Department of Health and Human Services ,Office
for Civil Rights electronically through their Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf ,or at U.S. Department of Health and Human Services ,
200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | https://ocrportal.hhs.gov/ocr/portal/lobby.jsf ,or at U.S. Department of Health and Human Services ,
200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019,
800-537-7697 (TDD) .Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html .
•California residents: You may also call California Department of Insurance toll-free hotline number:
1-800-927-HELP (4357) ,to file agrievance. |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | •California residents: You may also call California Department of Insurance toll-free hotline number:
1-800-927-HELP (4357) ,to file agrievance.
Auxiliary aids and services, free of charge, are available to you.
1-877-320-1235 (TTY: 711)
Humana provides free auxiliary aids and services, such as qualified sign language interpreters, video remote
interpretation, and written information in other formats to people with disabilities when such auxiliary aids |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | interpretation, and written information in other formats to people with disabilities when such auxiliary aids
and services are necessary to ensure an equal opportunity to participate. S5884138000SB23 Summary of Benefits 13 S5884138000 14 Summary of Benefits S5884138000SB23 S5884138000 Humana Basic Rx Plan (PDP)
S5884138000 ENG
States of Indiana and Kentucky
Humana.com
GNHH4HIEN_23_C Summary of Benefits S5884138000SB23 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Summary of Benefits
Optional Supplemental BenefitsSBOSB045
HumanaChoice H5216-324 (PPO)
Kentucky
Kentucky and Southern Indiana 2023
GNHH4HGEN_23_C Summary of Benefits H5216324000SB23 Pre-Enrollment Checklist
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 acustomer service representative at 1-800-833-2364 (TTY:
711) .
Understanding the Benefits |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | have any questions, you can call and speak to acustomer service representative at 1-800-833-2364 (TTY:
711) .
Understanding the Benefits
The Evidence of Coverage (EOC) provides acomplete 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 acopy of the EOC.
Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 1-800-833-2364 (TTY: 711) to view acopy of the 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 anew 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 anew pharmacy for your
prescriptions. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | in the network. If the pharmacy is not listed, you will likely have to select anew pharmacy for your
prescriptions.
Review the formulary to make sure your drugs are covered.
Understanding Important Rules
In addition to your monthly plan premium, you must continue to pay your Medicare Part Bpremium.
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. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 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.
Our plan allows you to see providers outside of our network (non-contracted providers). However,
while we will pay for covered services, the provider must agree to treat you. Except in an emergency
or urgent situations, non-contracted providers may deny care. In addition, you may pay ahigher |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | while we will pay for covered services, the provider must agree to treat you. Except in an emergency
or urgent situations, non-contracted providers may deny care. In addition, you may pay ahigher
co-pay for services received by non-contracted providers. Summary of Benefits
HumanaChoice H5216-324 (PPO)
Kentucky
Kentucky and Southern Indiana 2023 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | co-pay for services received by non-contracted providers. Summary of Benefits
HumanaChoice H5216-324 (PPO)
Kentucky
Kentucky and Southern Indiana 2023
H5216_SB_MAPD_PPO_324000_2023_M Summary of Benefits H5216324000SB23 Our service area includes the following county/counties in Indiana: Clark, Floyd, Harrison
Kentucky: Adair, Allen, Anderson, Ballard, Barren, Bath, Bell, Bourbon, Boyd, Boyle, Bracken, |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Kentucky: Adair, Allen, Anderson, Ballard, Barren, Bath, Bell, Bourbon, Boyd, Boyle, Bracken,
Breathitt, Breckinridge, Bullitt, Butler, Caldwell, Calloway, Carlisle, Carroll, Carter, Casey,
Christian, Clark, Clay, Crittenden, Cumberland, Daviess, Edmonson, Elliott, Estill, Fayette,
Fleming, Floyd, Franklin, Fulton, Gallatin, Garrard, Graves, Grayson, Green, Greenup, Hancock,
Hardin, Harlan, Harrison, Hart, Henry, Hickman, Hopkins, Jackson, Jefferson, Jessamine, |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Fleming, Floyd, Franklin, Fulton, Gallatin, Garrard, Graves, Grayson, Green, Greenup, Hancock,
Hardin, Harlan, Harrison, Hart, Henry, Hickman, Hopkins, Jackson, Jefferson, Jessamine,
Johnson, Knott, Knox, Larue, Laurel, Lawrence, Lee, Leslie, Letcher, Lewis, Lincoln, Livingston,
Logan, Lyon, Madison, Magoffin, Marion, Marshall, Martin, Mason, McCracken, McCreary,
McLean, Meade, Menifee, Mercer, Metcalfe, Monroe, Montgomery, Morgan, Muhlenberg, |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Logan, Lyon, Madison, Magoffin, Marion, Marshall, Martin, Mason, McCracken, McCreary,
McLean, Meade, Menifee, Mercer, Metcalfe, Monroe, Montgomery, Morgan, Muhlenberg,
Nelson, Nicholas, Ohio, Oldham, Owen, Owsley, Perry, Pike, Powell, Pulaski, Robertson,
Rockcastle, Rowan, Russell, Scott, Shelby, Simpson, Spencer, Taylor, Todd, Trigg, Trimble,
Union, Warren, Washington, Wayne, Webster, Whitley, Wolfe, Woodford. H5216324000SB23 Summary of Benefits 5H5216324000
Let's talk about HumanaChoice |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Union, Warren, Washington, Wayne, Webster, Whitley, Wolfe, Woodford. H5216324000SB23 Summary of Benefits 5H5216324000
Let's talk about HumanaChoice
H5216-324 (PPO)
Find out more about the HumanaChoice H5216-324 (PPO) plan -including the health
and drug services it covers -in this easy-to-use guide.
HumanaChoice H5216-324 (PPO) is aMedicare Advantage PPO plan with aMedicare
contract. Enrollment in this Humana plan depends on contract renewal. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | HumanaChoice H5216-324 (PPO) is aMedicare Advantage PPO plan with aMedicare
contract. Enrollment in this Humana plan depends on contract renewal.
The benefit information provided is asummary of what we cover and what you pay. It
doesn't list every service that we cover or list every limitation or exclusion. For a
complete list of services we cover, ask us for the "Evidence of Coverage".
To be eligible
To join HumanaChoice H5216-324
(PPO), you must be entitled to Medicare |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | complete list of services we cover, ask us for the "Evidence of Coverage".
To be eligible
To join HumanaChoice H5216-324
(PPO), you must be entitled to Medicare
Part A, be enrolled in Medicare Part B
and live in our service area.
Plan name:
HumanaChoice H5216-324 (PPO)
How to reach us:
If you're amember of this plan, call
toll-free: 1-800-457-4708 (TTY: 711) .
If you're not amember of this plan,
call toll free: 1-800-833-2364 (TTY:
711) .
October 1-March 31:
Call 7days aweek from 8a.m. -8p.m. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | toll-free: 1-800-457-4708 (TTY: 711) .
If you're not amember of this plan,
call toll free: 1-800-833-2364 (TTY:
711) .
October 1-March 31:
Call 7days aweek from 8a.m. -8p.m.
April 1-September 30:
Call Monday -Friday, 8a.m. -8p.m.
Or visit our website:
Humana.com/medicare More about HumanaChoice
H5216-324 (PPO)
Doyou 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 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | H5216-324 (PPO)
Doyou 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. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 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 amember it's agood idea to select adoctor
as your Primary Care Provider (PCP).
HumanaChoice H5216-324 (PPO) has anetwork
of doctors, hospitals, pharmacies and other
providers. If you use providers who aren't in our
network, you may be subject to higher
copayments/coinsurance.
Ahealthy partnership |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | of doctors, hospitals, pharmacies and other
providers. If you use providers who aren't in our
network, you may be subject to higher
copayments/coinsurance.
Ahealthy partnership
Get more from your plan —with extra
services and resources provided by
Humana! You do not need areferral 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 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 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 aprior authorization from the
plan .
c
6 Summary of Benefits H5216324000SB23 H5216324000
Monthly Premium, Deductible and Limits
PLAN COSTS
Monthly plan premium
You must keep paying your
Medicare Part Bpremium. $74
If you receive premium assistance, your plan
premium may be reduced. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Monthly Premium, Deductible and Limits
PLAN COSTS
Monthly plan premium
You must keep paying your
Medicare Part Bpremium. $74
If you receive premium assistance, your plan
premium may be reduced.
Medical deductible This plan does not have adeductible.
Pharmacy (Part D) deductible No deductible for Tier 1, Tier 2and Tier 3
$250 for Tier 4, Tier 5
Maximum out-of-pocket
responsibility
The most you pay for copays,
coinsurance and other costs for
covered medical services for the |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | $250 for Tier 4, Tier 5
Maximum out-of-pocket
responsibility
The most you pay for copays,
coinsurance and other costs for
covered medical services for the
year. $2,200 in-network
$2,200 combined in- and out-of-network
Covered Medical and Hospital Benefits
IN-NETWORK OUT-OF-NETWORK
ACUTE INPATIENT HOSPITAL CARE
N/A $500 copay per day for days 1-5
$0 copay per day for days 6-90
Your plan covers an unlimited
number of days for an inpatient
stay. $500 copay per day for days 1-5 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | ACUTE INPATIENT HOSPITAL CARE
N/A $500 copay per day for days 1-5
$0 copay per day for days 6-90
Your plan covers an unlimited
number of days for an inpatient
stay. $500 copay per day for days 1-5
$0 copay per day for days 6-90
OUTPATIENT HOSPITAL COVERAGE
Outpatient surgery at
outpatient hospital $300 copay $300 copay
Outpatient surgery at
ambulatory surgical center $250 copay $250 copay
DOCTOR OFFICE VISITS
Primary care provider (PCP) $0 copay $0 copay
Specialists $30 copay $30 copay |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Outpatient surgery at
ambulatory surgical center $250 copay $250 copay
DOCTOR OFFICE VISITS
Primary care provider (PCP) $0 copay $0 copay
Specialists $30 copay $30 copay
PREVENTIVE CARE
N/A Our plan covers many preventive
services at no cost when you see
an in-network provider including:
•Abdominal aortic aneurysm
screening $0 copay
Any additional preventive services
approved by Medicare during the |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | services at no cost when you see
an in-network provider including:
•Abdominal aortic aneurysm
screening $0 copay
Any additional preventive services
approved by Medicare during the
contract year will be covered. You do not need areferral 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 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 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 aprior authorization from the
plan .
c
H5216324000SB23 Summary of Benefits 7H5216324000
Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
•Alcohol misuse counseling
•Bone mass measurement
•Breast cancer screening
(mammogram)
•Cardiovascular disease
(behavioral therapy) |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | IN-NETWORK OUT-OF-NETWORK
•Alcohol misuse counseling
•Bone mass measurement
•Breast cancer screening
(mammogram)
•Cardiovascular disease
(behavioral therapy)
•Cardiovascular screenings
•Cervical and vaginal cancer
screening
•Colorectal cancer screenings
(colonoscopy, fecal occult blood
test, flexible sigmoidoscopy)
•Depression screening
•Diabetes screenings
•HIV screening
•Medical nutrition therapy
services
•Obesity screening and
counseling
•Prostate cancer screenings
(PSA) |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | test, flexible sigmoidoscopy)
•Depression screening
•Diabetes screenings
•HIV screening
•Medical nutrition therapy
services
•Obesity screening and
counseling
•Prostate cancer screenings
(PSA)
•Sexually transmitted infections
screening and counseling
•Tobacco use cessation
counseling (counseling for
people with no sign of
tobacco-related disease)
•Vaccines, including flu shots,
hepatitis Bshots,
pneumococcal shots
•"Welcome to Medicare"
preventive visit (one-time) |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | counseling (counseling for
people with no sign of
tobacco-related disease)
•Vaccines, including flu shots,
hepatitis Bshots,
pneumococcal shots
•"Welcome to Medicare"
preventive visit (one-time)
•Annual Wellness Visit
•Lung cancer screening
•Routine physical exam
•Medicare diabetes prevention
program
Any additional preventive services
approved by Medicare during the |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | •Annual Wellness Visit
•Lung cancer screening
•Routine physical exam
•Medicare diabetes prevention
program
Any additional preventive services
approved by Medicare during the
contract year will be covered. You do not need areferral 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 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 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 aprior authorization from the
plan .
c
8 Summary of Benefits H5216324000SB23 H5216324000
Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
EMERGENCY CARE
Emergency room
If you are admitted to the
hospital within 24 hours, you do
not have to pay your share of the |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
EMERGENCY CARE
Emergency room
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. $125 copay $125 copay
Urgently needed services
Urgently needed services are
provided to treat a
non-emergency, unforeseen
medical illness, injury or condition
that requires immediate medical
attention. $35 copay at an urgent care
center $35 copay at an urgent care
center |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | provided to treat a
non-emergency, unforeseen
medical illness, injury or condition
that requires immediate medical
attention. $35 copay at an urgent care
center $35 copay at an urgent care
center
OUTPATIENT CARE AND DIAGNOSTIC SERVICES, LABS AND IMAGING
Cost share may vary depending on the service and where service is provided
Diagnostic mammography $0 to $30 copay $0 to $30 copay
Diagnostic colonoscopy $0 copay $0 copay
Diagnostic radiology $180 to $300 copay $180 to $300 copay |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Diagnostic mammography $0 to $30 copay $0 to $30 copay
Diagnostic colonoscopy $0 copay $0 copay
Diagnostic radiology $180 to $300 copay $180 to $300 copay
Lab services $0 to $35 copay $0 to $35 copay
Diagnostic tests and procedures $0 to $105 copay $0 to $105 copay
Outpatient X-rays $0 to $90 copay $0 to $90 copay
Radiation therapy $30 copay or 20% of the cost $30 copay or 20% of the cost
HEARING SERVICES |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Outpatient X-rays $0 to $90 copay $0 to $90 copay
Radiation therapy $30 copay or 20% of the cost $30 copay or 20% of the cost
HEARING SERVICES
Medicare-covered hearing $30 copay $30 copay You do not need areferral 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 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 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 aprior authorization from the
plan .
c
H5216324000SB23 Summary of Benefits 9H5216324000
Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
Routine hearing HER941
•$0 copay for routine hearing
exams up to 1per year.
•$699 copay for each Advanced
level hearing aid up to 1per ear |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | IN-NETWORK OUT-OF-NETWORK
Routine hearing HER941
•$0 copay for routine hearing
exams up to 1per year.
•$699 copay for each Advanced
level hearing aid up to 1per ear
per year.
•$999 copay for each Premium
level hearing aid up to 1per ear
per year.
Hearing aid purchase includes:
•Unlimited follow-up provider
visits during first year following
TruHearing hearing aid
purchase
•60-day trial period
•3-year extended warranty
•80 batteries per aid for
non-rechargeable models HER941 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | visits during first year following
TruHearing hearing aid
purchase
•60-day trial period
•3-year extended warranty
•80 batteries per aid for
non-rechargeable models HER941
•$0 copay for routine hearing
exams up to 1per year.
•$699 copay for each Advanced
level hearing aid up to 1per ear
per year.
•$999 copay for each Premium
level hearing aid up to 1per ear
per year.
You must see aTruHearing
provider to use this benefit. Call
1-844-255-7144 to schedule an
appointment (for TTY, dial 711). |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | •$999 copay for each Premium
level hearing aid up to 1per ear
per year.
You must see aTruHearing
provider to use this benefit. Call
1-844-255-7144 to schedule an
appointment (for TTY, dial 711).
DENTAL SERVICES
The cost-share indicated below is what you pay for the covered service.
Medicare-covered dental $30 copay $30 copay
Routine dental
Dental services are subject to our
standard claims review
procedures which could include
dental history to approved
coverage. Dental benefits under |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Routine dental
Dental services are subject to our
standard claims review
procedures which could include
dental history to approved
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 .
Out-of-network dentists have not
agreed to provide services at
contracted fees. Benefits received
out-of-network are subject to any
in-network benefits maximums, |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | at Humana.com/sb .
Out-of-network dentists have not
agreed to provide services at
contracted fees. Benefits received
out-of-network are subject to any
in-network benefits maximums,
limitations, and/or exclusions.
You may be billed by the
out-of-network provider for any DEN373
•0% of the cost for
comprehensive oral evaluation
or periodontal exam up to 1
every 3years.
•0% of the cost for panoramic
film or diagnostic x-rays up to 1
every 5years.
•0% of the cost for bitewing |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | comprehensive oral evaluation
or periodontal exam up to 1
every 3years.
•0% of the cost for panoramic
film or diagnostic x-rays up to 1
every 5years.
•0% of the cost for bitewing
x-rays, intraoral x-rays up to 1
set(s) per year.
•0% of the cost for emergency
diagnostic exam up to 1per
year.
•0% of the cost for fluoride
treatment, periodic oral exam,
prophylaxis (cleaning) up to 2
per year.
•0% of the cost for periodontal
maintenance up to 4per year. DEN373
•0% of the cost for |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | year.
•0% of the cost for fluoride
treatment, periodic oral exam,
prophylaxis (cleaning) up to 2
per year.
•0% of the cost for periodontal
maintenance up to 4per year. DEN373
•0% of the cost for
comprehensive oral evaluation
or periodontal exam up to 1
every 3years.
•0% of the cost for panoramic
film or diagnostic x-rays up to 1
every 5years.
•0% of the cost for bitewing
x-rays, intraoral x-rays up to 1
set(s) per year.
•0% of the cost for emergency
diagnostic exam up to 1per |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | film or diagnostic x-rays up to 1
every 5years.
•0% of the cost for bitewing
x-rays, intraoral x-rays up to 1
set(s) per year.
•0% of the cost for emergency
diagnostic exam up to 1per
year.
•0% of the cost for fluoride
treatment, periodic oral exam,
prophylaxis (cleaning) up to 2
per year.
•0% of the cost for periodontal
maintenance up to 4per year. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | per year.
•0% of the cost for periodontal
maintenance up to 4per year. You do not need areferral 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 aprior authorization from the
plan .
c
10 Summary of Benefits H5216324000SB23 H5216324000 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
10 Summary of Benefits H5216324000SB23 H5216324000
Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
amount greater than the
payment made by Humana to
the provider.
Use the HumanaDental Medicare
network for the Mandatory
Supplemental Dental. The
provider locator can be found at
Humana.com >Find aDoctor >
from the Search Type drop down |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | the provider.
Use the HumanaDental Medicare
network for the Mandatory
Supplemental Dental. The
provider locator can be found at
Humana.com >Find aDoctor >
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. •0% of the cost for necessary
anesthesia with covered service
up to unlimited per year.
•$25 copay for scaling and root
planing (deep cleaning) up to 1 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | HumanaDental Medicare. •0% of the cost for necessary
anesthesia with covered service
up to unlimited per year.
•$25 copay for scaling and root
planing (deep cleaning) up to 1
per quadrant every 3years.
•$25 copay for scaling for
moderate inflammation up to 1
every 3years.
•$25 copay for crown
recementation, denture
recementation up to 1every 5
years.
•$25 copay for emergency
treatment for pain up to 2per
year.
•$25 copay per tooth for
amalgam and/or composite |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | •$25 copay for crown
recementation, denture
recementation up to 1every 5
years.
•$25 copay for emergency
treatment for pain up to 2per
year.
•$25 copay per tooth for
amalgam and/or composite
filling, simple or surgical
extraction up to unlimited per
year.
•50% of the cost for occlusal
adjustment up to 1every 3
years.
•50% of the cost for bridges up
to 1every 5years.
•50% of the cost for crown, root
canal, root canal retreatment
up to 1per tooth per lifetime. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | adjustment up to 1every 3
years.
•50% of the cost for bridges up
to 1every 5years.
•50% of the cost for crown, root
canal, root canal retreatment
up to 1per tooth per lifetime.
•50% of the cost for oral surgery
up to 2per year.
•$2000 combined maximum
benefit coverage amount per
year for preventive and
comprehensive benefits. •0% of the cost for necessary
anesthesia with covered service
up to unlimited per year.
•$25 copay for scaling and root
planing (deep cleaning) up to 1 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | comprehensive benefits. •0% of the cost for necessary
anesthesia with covered service
up to unlimited per year.
•$25 copay for scaling and root
planing (deep cleaning) up to 1
per quadrant every 3years.
•$25 copay for scaling for
moderate inflammation up to 1
every 3years.
•$25 copay for crown
recementation, denture
recementation up to 1every 5
years.
•$25 copay for emergency
treatment for pain up to 2per
year.
•$25 copay per tooth for
amalgam and/or composite |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | •$25 copay for crown
recementation, denture
recementation up to 1every 5
years.
•$25 copay for emergency
treatment for pain up to 2per
year.
•$25 copay per tooth for
amalgam and/or composite
filling, simple or surgical
extraction up to unlimited per
year.
•50% of the cost for occlusal
adjustment up to 1every 3
years.
•50% of the cost for bridges up
to 1every 5years.
•50% of the cost for crown, root
canal, root canal retreatment
up to 1per tooth per lifetime. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | adjustment up to 1every 3
years.
•50% of the cost for bridges up
to 1every 5years.
•50% of the cost for crown, root
canal, root canal retreatment
up to 1per tooth per lifetime.
•50% of the cost for oral surgery
up to 2per year.
•$2000 combined maximum
benefit coverage amount per
year for preventive and
comprehensive benefits.
•Benefits received
out-of-network are subject to
any in-network benefit
maximums, limitations, and/or |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | benefit coverage amount per
year for preventive and
comprehensive benefits.
•Benefits received
out-of-network are subject to
any in-network benefit
maximums, limitations, and/or
exclusions. You do not need areferral 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 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 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 aprior authorization from the
plan .
c
H5216324000SB23 Summary of Benefits 11 H5216324000
Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
VISION SERVICES
Medicare-covered vision
services $30 copay $30 copay
Medicare-covered diabetic eye
exam $0 copay $0 copay |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
VISION SERVICES
Medicare-covered vision
services $30 copay $30 copay
Medicare-covered diabetic eye
exam $0 copay $0 copay
Medicare-covered glaucoma
screening $0 copay $0 copay
Medicare-covered eyewear
(post-cataract) $0 copay $0 copay
Routine vision
The provider locator for routine
vision can be found at
Humana.com >Find aDoctor >
select Vision care icon >Vision
coverage through Medicare
Advantage plans. VIS751 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Routine vision
The provider locator for routine
vision can be found at
Humana.com >Find aDoctor >
select Vision care icon >Vision
coverage through Medicare
Advantage plans. VIS751
•$0 copay for routine exam up
to 1per year.
•$75 combined maximum
benefit coverage amount per
year for routine exam.
•$100 combined 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 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | •$100 combined 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
1pair per year.
•Maximum benefit coverage
amount is limited to one time
use per year. VIS751
•$0 copay for routine exam up
to 1per year.
•$75 combined maximum
benefit coverage amount per
year for routine exam.
•$100 combined maximum
benefit coverage amount per |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | use per year. VIS751
•$0 copay for routine exam up
to 1per year.
•$75 combined maximum
benefit coverage amount per
year for routine exam.
•$100 combined 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
1pair per year.
•Maximum benefit coverage
amount is limited to one time
use per year.
•Benefits received |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | •Eyeglass lens options may be
available with the maximum
benefit coverage amount up to
1pair per year.
•Maximum benefit coverage
amount is limited to one time
use per year.
•Benefits received
out-of-network are subject to
any in-network benefit
maximums, limitations, and/or
exclusions.
MENTAL HEALTH SERVICES
Inpatient
Your plan covers up to 190 days
in alifetime for inpatient mental
health care in apsychiatric
hospital $500 copay per day for days 1-4 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | exclusions.
MENTAL HEALTH SERVICES
Inpatient
Your plan covers up to 190 days
in alifetime for inpatient mental
health care in apsychiatric
hospital $500 copay per day for days 1-4
$0 copay per day for days 5-90 $500 copay per day for days 1-4
$0 copay per day for days 5-90 You do not need areferral 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 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 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 aprior authorization from the
plan .
c
12 Summary of Benefits H5216324000SB23 H5216324000
Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
Outpatient group and individual
therapy visits
Cost share may vary depending |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
Outpatient group and individual
therapy visits
Cost share may vary depending
on where service is provided. $30 to $80 copay $30 to $80 copay
SKILLED NURSING FACILITY (SNF)
Your plan covers up to 100 days
in aSNF $0 copay per day for days 1-20
$196 copay per day for days
21-100 $0 copay per day for days 1-20
$196 copay per day for days
21-100
PHYSICAL THERAPY
Cost share may vary depending
on the service and where service |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | $196 copay per day for days
21-100 $0 copay per day for days 1-20
$196 copay per day for days
21-100
PHYSICAL THERAPY
Cost share may vary depending
on the service and where service
is provided. $20 to $30 copay $20 to $30 copay
AMBULANCE
Ambulance $290 copay per date of service $290 copay per date of service
TRANSPORTATION
N/A Not covered Not covered
MEDICARE PART BDRUGS
Chemotherapy drugs 20% of the cost 20% of the cost |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | AMBULANCE
Ambulance $290 copay per date of service $290 copay per date of service
TRANSPORTATION
N/A Not covered Not covered
MEDICARE PART BDRUGS
Chemotherapy drugs 20% of the cost 20% of the cost
Other Part Bdrugs 20% of the cost 20% of the cost H5216324000SB23 Summary of Benefits 13 H5216324000
Prescription Drug Benefits
PRESCRIPTION DRUGS
Important Message About What You Pay for Vaccines |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Other Part Bdrugs 20% of the cost 20% of the cost H5216324000SB23 Summary of Benefits 13 H5216324000
Prescription Drug Benefits
PRESCRIPTION DRUGS
Important Message About What You Pay for Vaccines
Our plan covers most Part Dvaccines at no cost to you, no matter what cost-sharing tier it’s on ,even if
you haven’t paid your deductible .
Important Message About What You Pay for Insulin
You won’t pay more than $35 for aone-month (up to 30-day) supply of each Part Dinsulin product |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | you haven’t paid your deductible .
Important Message About What You Pay for Insulin
You won’t pay more than $35 for aone-month (up to 30-day) supply of each Part Dinsulin product
covered by our plan, no matter what cost-sharing tier it’s on ,even if you haven’t paid your deductible .This
applies to all Part Dcovered insulins, including the Select Insulins covered under the Insulin Savings
Program as described below. If you receive "Extra Help", you will still pay no more than $35 for a |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Program as described below. If you receive "Extra Help", you will still pay no more than $35 for a
one-month supply for each Part Dcovered insulin. Please see your Prescription Drug Guide to find all Part D
insulins covered by your plan.
If you don't receive Extra Help for your drugs, you'll pay the following:
Deductible No deductible for Tier 1, Tier 2and Tier 3. This plan has a $250 deductible for Tier 4, Tier 5 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | If you don't receive Extra Help for your drugs, you'll pay the following:
Deductible No deductible for Tier 1, Tier 2and Tier 3. This plan has a $250 deductible for Tier 4, Tier 5
drugs .You pay the full cost of these drugs until you reach $250 .Then, you only pay your cost-share.
Initial coverage (after you pay your deductible)
You pay the following until your total yearly drug costs reach $4,660 .Total yearly drug costs are the total |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Initial coverage (after you pay your deductible)
You pay the following until your total yearly drug costs reach $4,660 .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.
Mail Order Cost-Sharing
Pharmacy options Standard
Walmart Mail ,PillPack
Other pharmacies are
available in our network. To find
pharmacy mail order options go to
Humana.com/pharmacyfinder Preferred
CenterWell Pharmacy ™ |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Pharmacy options Standard
Walmart Mail ,PillPack
Other pharmacies are
available in our network. To find
pharmacy mail order options go to
Humana.com/pharmacyfinder Preferred
CenterWell Pharmacy ™
N/A 30-day supply 90-day supply* 30-day supply 90-day supply*
Tier 1: Preferred Generic $10 $30 $2 $0
Tier 2: Generic $20 $60 $8 $0
Tier 3: Preferred Brand $47 $141 $47 $131
Tier 4: Non-Preferred
Drug $100 $300 $100 $290 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Tier 1: Preferred Generic $10 $30 $2 $0
Tier 2: Generic $20 $60 $8 $0
Tier 3: Preferred Brand $47 $141 $47 $131
Tier 4: Non-Preferred
Drug $100 $300 $100 $290
Tier 5: Specialty Tier 29% N/A 29% N/A 14 Summary of Benefits H5216324000SB23 H5216324000
Retail Cost-Sharing
Pharmacy options Retail All network retail pharmacies. To find the retail pharmacies near
you, go to Humana.com/pharmacyfinder
N/A 30-day supply 90-day supply*
Tier 1: Preferred Generic $2 $6
Tier 2: Generic $8 $24 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | you, go to Humana.com/pharmacyfinder
N/A 30-day supply 90-day supply*
Tier 1: Preferred Generic $2 $6
Tier 2: Generic $8 $24
Tier 3: Preferred Brand $47 $141
Tier 4: Non-Preferred
Drug $100 $300
Tier 5: Specialty Tier 29% N/A
Your plan participates in the Insulin Savings Program. You will pay no more than $35 for aone-month (up
to a30-day) supply for Select Insulins, no matter what cost-sharing tier it’s on ,even if you haven’t paid |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | to a30-day) supply for Select Insulins, no matter what cost-sharing tier it’s on ,even if you haven’t paid
your deductible .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 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 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 Dinsulins covered by our plan, including Select Insulins, no
matter what cost-sharing tier it’s on ,even if you haven’t paid your deductible .The enhanced insulin
coverage is available, even if you receive "Extra Help".
Your share of the cost for Select Insulins:
Mail Order Cost-Sharing for Select Insulins
Pharmacy
options Standard |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | coverage is available, even if you receive "Extra Help".
Your share of the cost for Select Insulins:
Mail Order Cost-Sharing for Select Insulins
Pharmacy
options Standard
Walmart Mail ,PillPack
Other pharmacies are available in
our network. To find pharmacy mail
order options, go to
Humana.com/pharmacyfinder
Walmart Mail ,PillPack Preferred
CenterWell Pharmacy ™
- 30-day supply 90-day supply* 30-day supply 90-day supply* |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | our network. To find pharmacy mail
order options, go to
Humana.com/pharmacyfinder
Walmart Mail ,PillPack Preferred
CenterWell Pharmacy ™
- 30-day supply 90-day supply* 30-day supply 90-day supply*
Tier 3: Preferred Brand $35 $105 $35 $95 H5216324000SB23 Summary of Benefits 15 H5216324000
Retail Cost-Sharing for Select Insulins
Pharmacy
options Retail
All network retail pharmacies. To find the retail pharmacies near you, go
to Humana.com/pharmacyfinder
- 30-day supply 90-day supply* |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Pharmacy
options Retail
All network retail pharmacies. To find the retail pharmacies near you, go
to Humana.com/pharmacyfinder
- 30-day supply 90-day supply*
Tier 3: Preferred Brand $35 $105
If you receive Extra Help for your drugs, you'll pay the following:
Deductible You may pay $0 or $104 depending on your level of "Extra Help" (for Tier 4, Tier 5) .If your
deductible is $104 ,you pay the full cost of these drugs until you reach $104 .Then, you only pay your
cost-share. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | deductible is $104 ,you pay the full cost of these drugs until you reach $104 .Then, you only pay your
cost-share.
Pharmacy cost-sharing
For generic drugs
(including 30-day supply 90-day supply*
brand drugs treated as
generic), either: $0 copay; or
$1.45 copay; or
$4.15 copay ;or
15% of the cost $0 copay; or
$1.45 copay; or
$4.15 copay ;or
15% of the cost
For all other drugs,
either: $0 copay; or
$4 .30 copay; or
$10.35 copay ;or
15% of the cost $0 copay; or
$4 .30 copay; or |