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{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Tier 6: Select Care Drugs $0 $0 $0 $0 12 Summary of Benefits H1036234000SB23 H1036234000
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 $0 $0
Tier 2: Generic $0 $0
Tier 3: Preferred Brand $42 $126
Tier 4: Non-Preferred
Drug $100 $300
Tier 5: Specialty Tier 33% N/A
Tier 6: Select Care Drugs $0 $0 |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Tier 1: Preferred Generic $0 $0
Tier 2: Generic $0 $0
Tier 3: Preferred Brand $42 $126
Tier 4: Non-Preferred
Drug $100 $300
Tier 5: Specialty Tier 33% N/A
Tier 6: Select Care Drugs $0 $0
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 .To identify which Select |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | to a30-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 Dinsulins covered by our plan, including Select Insulins, no |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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 .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
Walmart Mail ,PillPack
Other pharmacies are available in
our network. To find pharmacy mail
order options, go to
Humana.com/pharmacyfinder Preferred |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.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 ™
- 30-day supply 90-day supply* 30-day supply 90-day supply*
Tier 3: Preferred Brand $35 $105 $35 $95
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 |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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*
Tier 3: Preferred Brand $35 $105 H1036234000SB23 Summary of Benefits 13 H1036234000
If you receive Extra Help for your drugs, you'll pay the following:
Deductible This plan does not have adeductible.
Pharmacy cost-sharing
For generic drugs
(including 30-day supply 90-day supply* |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | If you receive Extra Help for your drugs, you'll pay the following:
Deductible This plan does not have adeductible.
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 |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.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
ADDITIONAL DRUG COVERAGE
Erectile dysfunction (ED)
drugs Covered at Tier 1cost-share amount.
Anti-Obesity drugs Covered at Tier 2cost-share amount. |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | *Some drugs are limited to a30-day supply
ADDITIONAL DRUG COVERAGE
Erectile dysfunction (ED)
drugs Covered at Tier 1cost-share amount.
Anti-Obesity drugs Covered at Tier 2cost-share amount.
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/HMO_Diabetes_and_Heart_H1036234000SB23.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 aretail 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/HMO_Diabetes_and_Heart_H1036234000SB23.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.
Under this plan, you may pay even less for the following: |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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:
Tier 1(Preferred Generic) - All Drugs
Tier 2(Generic) - All Drugs
Tier 3(Preferred Brand) - Select Insulin Drugs
For more information on cost sharing in the coverage gap, please call us or access your Evidence of
Coverage online. 14 Summary of Benefits H1036234000SB23 H1036234000
Catastrophic Coverage |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | For more information on cost sharing in the coverage gap, please call us or access your Evidence of
Coverage online. 14 Summary of Benefits H1036234000SB23 H1036234000
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 |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.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
Additional Benefits
Medicare-covered foot care
(podiatry) $15 copay
Medicare-covered chiropractic
services $20 copay
Medical equipment/ supplies
Cost share may vary depending
on the service and where service
is provided •Durable medical equipment (like wheelchairs or oxygen): 20% of
the cost |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | services $20 copay
Medical equipment/ supplies
Cost share may vary depending
on the service and where service
is provided •Durable medical equipment (like wheelchairs or oxygen): 20% of
the cost
•Medical supplies: 20% of the cost
•Prosthetics (artificial limbs or braces): 20% of the cost
•Diabetic monitoring supplies: $0 copay or 10% to 20% of the cost
Rehabilitation services •Occupational and speech therapy: $15 copay
•Cardiac rehabilitation: $0 copay |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | •Diabetic monitoring supplies: $0 copay or 10% to 20% of the cost
Rehabilitation services •Occupational and speech therapy: $15 copay
•Cardiac rehabilitation: $0 copay
•Pulmonary rehabilitation: $0 copay
Telehealth services
(in addition to Original
Medicare) •Primary care provider (PCP): $0 copay
•Specialist: $15 copay
•Urgent care services: $0 copay
•Substance abuse and behavioral health services: $0 copay H1036234000SB23 Summary of Benefits 15 H1036234000 |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | •Specialist: $15 copay
•Urgent care services: $0 copay
•Substance abuse and behavioral health services: $0 copay H1036234000SB23 Summary of Benefits 15 H1036234000
More benefits with your plan
Enjoy some of these extra benefits included in your plan .
This is asummary of what we cover. It doesn't list every service that we cover or list
every limitation or exclusion. The Evidence of Coverage (EOC) provides acomplete list of |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | This is asummary of what we cover. It doesn't list every service that we cover or list
every limitation or exclusion. The Evidence of Coverage (EOC) provides acomplete list of
coverage and services. Visit Humana.com/medicare to view acopy of the EOC or call
1-800-833-2364 .
Humana Flex Allowance
$1000 annual allowance on aprepaid
card to use toward out of pocket costs
for the plan's preventive and
comprehensive dental, vision, or hearing
services including copays. |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Humana Flex Allowance
$1000 annual allowance on aprepaid
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.
Cannot be used for procedures such as
cosmetic dentistry and teeth whitening.
Unused amount expires at the end of
the plan year. |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Services, or Hearing Services and Visa®
is accepted.
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.
Humana Healthy Options Allowance
$75 automatically loaded on aprepaid
card every month to use toward the
purchase of food, over-the-counter
(OTC) products, and home supplies from |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Humana Healthy Options Allowance
$75 automatically loaded on aprepaid
card every month to use toward the
purchase of food, over-the-counter
(OTC) products, and home supplies from
anational network of retailers. The card
may also be used to pay for
non-medical transportation, general
supports for living (such as rent
assistance, internet, and utilities), social
needs, aging support and assistive
devices, pest control, and pet care and
supplies. Unused funds will roll over to |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | supports for living (such as rent
assistance, internet, and utilities), social
needs, aging support and assistive
devices, pest control, and pet care and
supplies. Unused funds will roll over to
the next month and expire at the end of
the plan year. Allowance amounts
cannot be combined with other benefit
allowances. Limitations and restrictions
may apply. Humana Spending Account Card
The allowances listed below will be
loaded onto this prepaid card. Each
allowance is separate from any other |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | allowances. Limitations and restrictions
may apply. 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.
*Healthy Options Allowance
*Humana Flex Allowance
Special Supplemental Benefits for
the Chronically Ill (SSBCI) Humana |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | other benefit allowances. Limitations
and restrictions may apply.
*Healthy Options Allowance
*Humana Flex Allowance
Special Supplemental Benefits for
the Chronically Ill (SSBCI) Humana
Flexible Care Assistance
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 |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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 acare
manager. There is no cost to participate.
Chiropractic services
Routine chiropractic: |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | limited up to $1,000 per year and must
be coordinated and authorized by acare
manager. There is no cost to participate.
Chiropractic services
Routine chiropractic:
$0 copay per visit for unlimited visits.
Routine foot care
$0 copay per visit for up to 12 visits 16 Summary of Benefits H1036234000SB23 H1036234000
Humana Well Dine ®Meal Program
Humana's meal program for members
with certain special needs plan (SNP)
specific conditions or following an
inpatient stay in the hospital or nursing |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Humana Well Dine ®Meal Program
Humana's meal program for members
with certain special needs plan (SNP)
specific conditions or following an
inpatient stay in the hospital or nursing
facility.
Rewards and Incentives
Go365 by Humana ®aRewards and
Incentive program for completing
certain preventive health screenings and
health and wellness activities.
SilverSneakers ®fitness program
Basic fitness center membership
including fitness classes. H1036234000SB23 Summary of Benefits 17 H1036234000 |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | health and wellness activities.
SilverSneakers ®fitness program
Basic fitness center membership
including fitness classes. H1036234000SB23 Summary of Benefits 17 H1036234000
Humana MyOption optional supplemental benefits (OSB) are only available to members of certain Humana Medicare
Advantage (MA) plans. Members of Humana plans that offer OSBs may enroll in OSBs throughout the year. Benefits |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Advantage (MA) plans. Members of Humana plans that offer OSBs may enroll in OSBs throughout the year. Benefits
may change on January 1each year. Enrollees must use network providers for specific OSBs when stated in the
Evidence of Coverage (EOC); otherwise, covered services may be received from non-network providers at ahigher
cost. Enrollees must continue to pay the Medicare Part Bpremium, their Humana plan premium and the OSB
premium. Optional Supplemental Benefits |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | cost. Enrollees must continue to pay the Medicare Part Bpremium, their Humana plan premium and the OSB
premium. Optional Supplemental Benefits
Customize your coverage for an extra monthly premium when you enroll. You can
choose from the following to help create your Medicare plan.
$33.90 MyOption DEN478
Offers coverage for certain preventive, basic, and major services at both
in-network (HumanaDental Medicare network) and out-of-network |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | $33.90 MyOption DEN478
Offers coverage for certain preventive, basic, and major services at both
in-network (HumanaDental Medicare network) and out-of-network
dentists. These extra benefits –in addition to your basic benefits –have
an additional monthly premium. 18
H1036_SB_MAPD_HMO_234000_2023_M Summary of Benefits H1036234000SB23 To find out more about the coverage and costs of Original Medicare, look in the current “Medicare &You” |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | H1036_SB_MAPD_HMO_234000_2023_M Summary of Benefits H1036234000SB23 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),
24 hours aday, seven days aweek. TTY users should call 1-877-486-2048.
Humana has been approved by the National Committee for Quality Assurance (NCQA) to operate as aSpecial |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 24 hours aday, seven days aweek. TTY users should call 1-877-486-2048.
Humana has been approved by the National Committee for Quality Assurance (NCQA) to operate as aSpecial
Needs Plan (SNP) until 12/31/2023 based on areview of Humana's Model of Care.
Telehealth services shown are in addition to the Original Medicare covered telehealth. Your cost may be different
for Original Medicare telehealth. |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Telehealth services shown are in addition to the Original Medicare covered telehealth. Your cost may be different
for Original Medicare telehealth.
Limitations on telehealth services, also referred to as virtual visits or telemedicine, vary by state. These services
are not asubstitute for emergency care and are not intended to replace your primary care provider or other
providers in your network. Any descriptions of when to use telehealth services are for informational purposes only |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | providers in your network. Any descriptions of when to use telehealth services are for informational purposes only
and should not be construed as medical advice. Please refer to your evidence of coverage for additional details
on what your plan may cover or other rules that may apply.
Plans may offer supplemental benefits in addition to Part Cbenefits and Part Dbenefits. You can see our plan's provider and pharmacy directory at our website at |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Plans may offer supplemental benefits in addition to Part Cbenefits and Part Dbenefits. You can see our plan's provider and pharmacy directory at our website at
humana.com/finder/search 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 |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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 H1036_OSB_23_96_M H1036234000OSB23 Optional
Supplemental Benefits
Humana Community HMO Diabetes and Heart (HMO C-SNP)
H1036-234
Louisville
Jefferson County 2023 20 – 2023 OPTIONAL SUPPLEMENTAL BENEFITS My Options, My Choice
Adding Benefits to Your Plan |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Humana Community HMO Diabetes and Heart (HMO C-SNP)
H1036-234
Louisville
Jefferson County 2023 20 – 2023 OPTIONAL SUPPLEMENTAL BENEFITS My Options, My Choice
Adding Benefits to Your Plan
You’re unique and have unique needs. That's why Humana offers optional supplemental benefits (OSB). For
an extra monthly premium you can customize your Humana Medicare Advantage plan.
The information in this booklet will tell you about the benefits you can add to your plan. You can add |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | an extra monthly premium you can customize your Humana Medicare Advantage plan.
The information in this booklet will tell you about the benefits you can add to your plan. You can add
these extra benefits when you sign up for your Medicare Advantage plan. You can also add these
benefits after Medicare open enrollment ends on December 7by contacting your agent or calling OSB
sales at 1-888-413-7026. OSB sales is available from 8a.m. –8p.m. local time, seven days aweek |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | benefits after Medicare open enrollment ends on December 7by contacting your agent or calling OSB
sales at 1-888-413-7026. OSB sales is available from 8a.m. –8p.m. local time, seven days aweek
October 1–March 31, and Monday through Friday April 1–September 30.
MyOption (DEN478)
This dental plan covers certain preventive, basic and major dental services. It is an extra benefit you may
choose to add to your Medicare Advantage plan. However, you will have to pay an extra monthly premium
for it. |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | choose to add to your Medicare Advantage plan. However, you will have to pay an extra monthly premium
for it.
In this plan, you may receive your care from either an in-network or out-of-network dentist. If you use an
out-of-network dentist, your share of the cost may be higher.
Monthly Cost
Monthly Premium $33.90
Coverage Information
Maximum plan benefit
(combined in and out-of-network) $2,000 per calendar year
Deductible $0 per calendar year
You may receive the following dental services: |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Coverage Information
Maximum plan benefit
(combined in and out-of-network) $2,000 per calendar year
Deductible $0 per calendar year
You may receive the following dental services:
Plan covers up to $2,000 allowance every year for non-Medicare covered preventive and comprehensive
dental services. You are responsible for any amount above the dental coverage limit. Any amount unused
at the end of the year will expire.
Your benefit can be used for most dental treatments such as: |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | at the end of the year will expire.
Your benefit can be used for most dental treatments such as:
•Preventive dental services, such as exams, routine cleanings, etc.
•Basic dental services, such as fillings, extractions, etc.
•Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges, etc.
Note: The allowance cannot be used on cosmetic services and implants. |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | •Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges, etc.
Note: The allowance cannot be used on cosmetic services and implants.
*Network dentists have agreed to provide services at anegotiated rate. If you see anetwork dentist, you
cannot be billed more than that rate.
Out-of-network dentists have not agreed to provide services at contracted fees. Benefits received |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | cannot be billed more than that rate.
Out-of-network dentists have not agreed to provide services at contracted fees. Benefits received
out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. You may
be billed by the out-of-network provider for any amount greater than the payment made by Humana to
the provider. Please see below for provider locator instructions. 2023 OPTIONAL SUPPLEMENTAL BENEFITS – 21 OPTIONAL SUPPLEMENTAL BENEFITS S(continued) |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | the provider. Please see below for provider locator instructions. 2023 OPTIONAL SUPPLEMENTAL BENEFITS – 21 OPTIONAL SUPPLEMENTAL BENEFITS S(continued)
Dental services are subject to our standard claims review procedures which could include dental history to
approve coverage. Dental benefits may not cover all American Dental Association procedure codes.
Information regarding each plan is available at Humana.com/sb . |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | approve coverage. Dental benefits may not cover all American Dental Association procedure codes.
Information regarding each plan is available at Humana.com/sb .
The Humana Optional Supplemental Dental benefits are provided through the Humana Dental Medicare
Network. The provider locator can be found at Humana.com >Find aDoctor >Select the Dentist icon
from the menu >From the Distance drop down select preferred distance >Enter zip code >From the |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Network. The provider locator can be found at Humana.com >Find aDoctor >Select the Dentist icon
from the menu >From the Distance drop down select preferred distance >Enter zip code >From the
look up method select All Dental Networks >Then select HumanaDental Medicare. Humana is aCoordinated Care plan with aMedicare contract. Enrollment in this Humana plan depends on
contract renewal. Humana MyOption Optional Supplemental Benefits (OSB) are only available to members of |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | contract renewal. Humana MyOption Optional Supplemental Benefits (OSB) are only available to members of
certain Humana Medicare Advantage (MA) plans. Members of Humana plans that offer OSBs may enroll in OSBs
throughout the year. Benefits may change on January 1st each year. Enrollees must use network providers for
specific OSBs when stated in the Evidence of Coverage (EOC); otherwise, covered services may be received from |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | specific OSBs when stated in the Evidence of Coverage (EOC); otherwise, covered services may be received from
non-network providers at ahigher cost. Enrollees must continue to pay the Medicare Part Bpremium, their
Humana premium, and the OSB premium.
Humana.com H1036234000SB23 Summary of Benefits 23 H1036234000
GHHLNNXEN 0522 Important________________________________________________
At Humana, it is important you are treated fairly. |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Humana.com H1036234000SB23 Summary of Benefits 23 H1036234000
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
origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity, marital status, |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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
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. |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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
for Civil Rights electronically through their Complaint Portal, available at |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | •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,
800-537-7697 (TDD) .Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html . |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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.
Auxiliary aids and services, free of charge, are available to you.
1-877-320-1235 (TTY: 711) |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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/HMO_Diabetes_and_Heart_H1036234000SB23.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. 24 Summary of Benefits H1036234000SB23 H1036234000 H1036234000SB23 Summary of Benefits 25 H1036234000 Humana Community HMO Diabetes
and Heart (HMO C-SNP)
H1036234000 ENG
Jefferson County
Humana.com
GNHH4HGEN_23_C Summary of Benefits H1036234000SB23 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Summary of Benefits
Optional Supplemental BenefitsSBOSB045
HumanaChoice H5216-107 (PPO)
Kentucky and Southern Indiana
Select counties in Kentucky 2023
GNHH4HGEN_23_C Summary of Benefits H5216107000SB23 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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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 H5216-107 (PPO)
Kentucky and Southern Indiana
Select counties in Kentucky 2023 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | co-pay for services received by non-contracted providers. Summary of Benefits
HumanaChoice H5216-107 (PPO)
Kentucky and Southern Indiana
Select counties in Kentucky 2023
H5216_SB_MAPD_PPO_107000_2023_M Summary of Benefits H5216107000SB23 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_107_PPO_H5216107000SB23.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, Clinton, 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, |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Fayette, 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, |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Livingston, 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. H5216107000SB23 Summary of Benefits 5H5216107000 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Trimble, Union, Warren, Washington, Wayne, Webster, Whitley, Wolfe, Woodford. H5216107000SB23 Summary of Benefits 5H5216107000
Let's talk about HumanaChoice
H5216-107 (PPO)
Find out more about the HumanaChoice H5216-107 (PPO) plan -including the health
and drug services it covers -in this easy-to-use guide.
HumanaChoice H5216-107 (PPO) is aMedicare Advantage PPO plan with aMedicare
contract. Enrollment in this Humana plan depends on contract renewal. |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | HumanaChoice H5216-107 (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 H5216-107
(PPO), you must be entitled to Medicare |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | complete list of services we cover, ask us for the "Evidence of Coverage".
To be eligible
To join HumanaChoice H5216-107
(PPO), you must be entitled to Medicare
Part A, be enrolled in Medicare Part B
and live in our service area.
Plan name:
HumanaChoice H5216-107 (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_107_PPO_H5216107000SB23.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
H5216-107 (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_107_PPO_H5216107000SB23.pdf')} | H5216-107 (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_107_PPO_H5216107000SB23.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 H5216-107 (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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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 H5216107000SB23 H5216107000
Monthly Premium, Deductible and Limits
PLAN COSTS
Monthly plan premium
You must keep paying your
Medicare Part Bpremium. $132
If you receive premium assistance, your plan
premium may be reduced. |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Monthly Premium, Deductible and Limits
PLAN COSTS
Monthly plan premium
You must keep paying your
Medicare Part Bpremium. $132
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 1and Tier 2
$200 for Tier 3, 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_107_PPO_H5216107000SB23.pdf')} | $200 for Tier 3, 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. $6,700 in-network
$10,000 combined in- and out-of-network
Covered Medical and Hospital Benefits
IN-NETWORK OUT-OF-NETWORK
ACUTE INPATIENT HOSPITAL CARE
N/A $750 copay per admit
Your plan covers an unlimited
number of days for an inpatient
stay. 30% of the cost
OUTPATIENT HOSPITAL COVERAGE
Outpatient surgery at |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | ACUTE INPATIENT HOSPITAL CARE
N/A $750 copay per admit
Your plan covers an unlimited
number of days for an inpatient
stay. 30% of the cost
OUTPATIENT HOSPITAL COVERAGE
Outpatient surgery at
outpatient hospital $390 copay 30% of the cost
Outpatient surgery at
ambulatory surgical center $250 copay 30% of the cost
DOCTOR OFFICE VISITS
Primary care provider (PCP) $10 copay 30% of the cost
Specialists $40 copay 30% of the cost
PREVENTIVE CARE
N/A Our plan covers many preventive |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | DOCTOR OFFICE VISITS
Primary care provider (PCP) $10 copay 30% of the cost
Specialists $40 copay 30% of the cost
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
•Alcohol misuse counseling $0 copay or 30% of the cost ,
depending on the service and |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | services at no cost when you see
an in-network provider including:
•Abdominal aortic aneurysm
screening
•Alcohol misuse counseling $0 copay or 30% of the cost ,
depending on the service and
where service is provided 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_107_PPO_H5216107000SB23.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
H5216107000SB23 Summary of Benefits 7H5216107000
Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
•Bone mass measurement
•Breast cancer screening
(mammogram)
•Cardiovascular disease
(behavioral therapy)
•Cardiovascular screenings |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | IN-NETWORK OUT-OF-NETWORK
•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)
•Sexually transmitted infections |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | •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)
•Annual Wellness Visit
•Lung cancer screening |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | 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
contract year will be covered. Any additional preventive services
approved by Medicare during the |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | program
Any additional preventive services
approved by Medicare during the
contract year will be covered. 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_107_PPO_H5216107000SB23.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 H5216107000SB23 H5216107000
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_107_PPO_H5216107000SB23.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. $90 copay $90 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_107_PPO_H5216107000SB23.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 $40 copay 30% of the cost
Diagnostic colonoscopy $0 copay 30% of the cost
Diagnostic radiology $150 to $300 copay 30% of the cost |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Diagnostic mammography $0 to $40 copay 30% of the cost
Diagnostic colonoscopy $0 copay 30% of the cost
Diagnostic radiology $150 to $300 copay 30% of the cost
Lab services $0 to $35 copay 30% of the cost
Diagnostic tests and procedures $0 to $90 copay 30% of the cost
Outpatient X-rays $10 to $90 copay 30% of the cost
Radiation therapy $40 copay or 20% of the cost 20% of the cost
HEARING SERVICES |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Diagnostic tests and procedures $0 to $90 copay 30% of the cost
Outpatient X-rays $10 to $90 copay 30% of the cost
Radiation therapy $40 copay or 20% of the cost 20% of the cost
HEARING SERVICES
Medicare-covered hearing $40 copay 30% of the cost 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_107_PPO_H5216107000SB23.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
H5216107000SB23 Summary of Benefits 9H5216107000
Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
Routine hearing HER944
•$0 copay for routine hearing
exams up to 1per year.
•$399 copay for each Advanced
level hearing aid up to 1per ear |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | IN-NETWORK OUT-OF-NETWORK
Routine hearing HER944
•$0 copay for routine hearing
exams up to 1per year.
•$399 copay for each Advanced
level hearing aid up to 1per ear
per year.
•$699 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 HER944 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.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 HER944
•$0 copay for routine hearing
exams up to 1per year.
•$399 copay for each Advanced
level hearing aid up to 1per ear
per year.
•$699 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_107_PPO_H5216107000SB23.pdf')} | •$699 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.
Additional dental benefits are available with aseparate monthly premium. Please see the "Optional
Supplemental Benefits" page for details.
Medicare-covered dental $40 copay 30% of the cost
Routine dental |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Supplemental Benefits" page for details.
Medicare-covered dental $40 copay 30% of the cost
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 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | 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,
limitations, and/or exclusions. DEN976
•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. |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | •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 periodic oral
exam, prophylaxis (cleaning) up
to 2per year.
•0% of the cost for necessary
anesthesia with covered service
up to unlimited per year. DEN976
•50% of the cost for
comprehensive oral evaluation |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | exam, prophylaxis (cleaning) up
to 2per year.
•0% of the cost for necessary
anesthesia with covered service
up to unlimited per year. DEN976
•50% of the cost for
comprehensive oral evaluation
or periodontal exam up to 1
every 3years.
•50% of the cost for panoramic
film or diagnostic x-rays up to 1
every 5years.
•50% of the cost for bitewing
x-rays, intraoral x-rays up to 1
set(s) per year.
•50% of the cost for periodic
oral exam, prophylaxis
(cleaning) up to 2per year. |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | every 5years.
•50% of the cost for bitewing
x-rays, intraoral x-rays up to 1
set(s) per year.
•50% of the cost for periodic
oral exam, prophylaxis
(cleaning) up to 2per year.
•50% of the cost for necessary
anesthesia with covered service
up to unlimited per 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 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.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
10 Summary of Benefits H5216107000SB23 H5216107000
Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
You may be billed by the
out-of-network provider for any
amount greater than the
payment made by Humana to
the provider. |