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1
+ Monthly Plan Premium $0
2
+ You must keep paying your Medicare Part B premium.
3
+ Medical deductible This plan does not have a deductible.
4
+ Pharmacy (Part D) deductible This plan does not have a deductible.
5
+ Maximum out-of-pocket
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+ responsibility
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+ $3,900 in-network
8
+ The most you pay for copays, coinsurance and other costs for covered
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+ medical services for the year.
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+ Acute inpatient hospital care $250 copay per day for days 1-7
11
+ $0 copay per day for days 8-90
12
+ Your plan covers an unlimited number of days for an inpatient stay.
13
+ Outpatient hospital coverage • Outpatient surgery at Outpatient Hospital: $250 copay
14
+ • Outpatient surgery at Ambulatory Surgical Center: $200 copay
15
+ Doctor visits • Primary care provider: $0 copay
16
+ • Specialist: $15 copay
17
+ Preventive care Our plan covers many preventive services at no cost when you see
18
+ an in-network provider including:
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+ • Abdominal aortic aneurysm screening
20
+ • Alcohol misuse counseling
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+ • Bone mass measurement
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+ • Breast cancer screening (mammogram)
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+ • Cardiovascular disease (behavioral therapy)
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+ • Cardiovascular screenings
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+ • Cervical and vaginal cancer screening
26
+ • Colorectal cancer screenings (colonoscopy, fecal occult blood test,
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+ flexible sigmoidoscopy)
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+ • Depression screening
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+ • Diabetes screenings
30
+ • HIV screening
31
+ • Medical nutrition therapy services
32
+ • Obesity screening and counseling
33
+ • Prostate cancer screenings (PSA)
34
+ • Sexually transmitted infections screening and counseling
35
+ • Tobacco use cessation counseling (counseling for people with no
36
+ sign of tobacco-related disease)
37
+ • Vaccines, including flu shots, hepatitis B shots, pneumococcal shots
38
+ • "Welcome to Medicare" preventive visit (one-time)
39
+ • Annual Wellness Visit
40
+ • Lung cancer screening
41
+ • Routine physical exam
42
+ • Medicare diabetes prevention program
43
+ Any additional preventive services approved by Medicare during the
44
+ contract year will be covered.
45
+ EMERGENCY CARE
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+ Emergency room $110 copay
47
+ If you are admitted to the hospital within 24 hours, you do not have to
48
+ pay your share of the cost for the emergency care.
49
+ Urgently needed services $20 copay at an urgent care center
50
+ Urgently needed services are provided to treat a non-emergency,
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+ unforeseen medical illness, injury or condition that requires immediate
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+ medical attention.
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+ OUTPATIENT CARE AND SERVICES
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+ Diagnostic services, labs and
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+ imaging
56
+ Cost share may vary depending
57
+ on the service and where service
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+ is provided
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+ • Diagnostic mammography: $0 to $15 copay
60
+ • Diagnostic colonoscopy $0 copay
61
+ • Diagnostic radiology: $180 to $300 copay
62
+ • Lab services: $0 to $20 copay
63
+ • Diagnostic tests and procedures: $0 to $100 copay
64
+ • Outpatient X-rays: $0 to $75 copay
65
+ • Radiation therapy: $15 copay or 20% of the cost
66
+ Hearing Medicare-covered hearing exam: $15 copay
67
+ Routine hearing:
68
+ In-Network:
69
+ HER963
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+ • $0 copay for routine hearing exams up to 1 per year.
71
+ • $0 copay for each Advanced level hearing aid up to 1 per ear every 3
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+ years.
73
+ • $299 copay for each Premium level hearing aid up to 1 per ear every
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+ 3 years.
75
+ Hearing aid purchase includes:
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+ • Unlimited follow-up provider visits during first year following
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+ TruHearing hearing aid purchase
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+ • 60-day trial period
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+ • 3-year extended warranty
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+ • 80 batteries per aid for non-rechargeable models
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+ You must see a TruHearing provider to use this benefit. Call
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+ 1-844-255-7144 to schedule an appointment (for TTY, dial 711).
83
+ Dental Medicare-covered dental services: $15 copay
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+ Routine dental:
85
+ The cost-share indicated below is what you pay for the covered service.
86
+ In-Network:
87
+ DEN046
88
+ • $0 copay for scaling and root planing (deep cleaning) up to 1 per
89
+ quadrant every 3 years.
90
+ • $0 copay for comprehensive oral evaluation or periodontal exam,
91
+ occlusal adjustment, scaling for moderate inflammation up to 1
92
+ every 3 years.
93
+ • $0 copay for bridges, complete dentures, crown recementation,
94
+ denture recementation, panoramic film or diagnostic x-rays, partial
95
+ dentures up to 1 every 5 years.
96
+ • $0 copay for crown, root canal, root canal retreatment up to 1 per
97
+ tooth per lifetime.
98
+ • $0 copay for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
99
+ You do not need a referral to receive covered services from plan providers. Certain procedures, services and drugs
100
+ may need advance approval from your plan. This is called a "prior authorization" or "preauthorization." Please
101
+ contact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from the
102
+ plan . c
103
+ H1036236000SB23 Summary of Benefits 9
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+ H1036236000
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+ Covered Medical and Hospital Benefits (cont.)
106
+ • $0 copay for adjustments to dentures, denture rebase, denture
107
+ reline, denture repair, emergency diagnostic exam, tissue
108
+ conditioning up to 1 per year.
109
+ • $0 copay for emergency treatment for pain, fluoride treatment, oral
110
+ surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
111
+ • $0 copay for periodontal maintenance up to 4 per year.
112
+ • $0 copay for amalgam and/or composite filling, necessary
113
+ anesthesia with covered service, simple or surgical extraction up to
114
+ unlimited per year.
115
+ • $3000 maximum benefit coverage amount per year for preventive
116
+ and comprehensive benefits.
117
+ Dental services are subject to our standard claims review procedures
118
+ which could include dental history to approve coverage. Dental benefits
119
+ under this plan may not cover all American Dental Association
120
+ procedure codes. Information regarding each plan is available at
121
+ Humana.com/sb . Network dentists have agreed to provide services at contracted fees
122
+ (the in-network fee schedules, of INFS). If a member visits a
123
+ participating network dentist, the member will not receive a bill for
124
+ charges more than the negotiated fee schedule on covered services
125
+ (coinsurance payment still applies).
126
+ Use the HumanaDental Medicare network for the Mandatory
127
+ Supplemental Dental. The provider locator can be found at
128
+ Humana.com > Find a Doctor > from the Search Type drop down select
129
+ Dental > under Coverage Type select All Dental Networks > enter zip
130
+ code > from the network drop down select HumanaDental Medicare.
131
+ Vision • Medicare-covered vision services: $15 copay
132
+ • Medicare-covered diabetic eye exam: $0 copay
133
+ • Medicare-covered glaucoma screening: $0 copay
134
+ • Medicare-covered eyewear (post-cataract): $0 copay
135
+ Routine vision:
136
+ In-Network:
137
+ VIS733
138
+ • $0 copay for routine exam up to 1 per year.
139
+ • $300 maximum benefit coverage amount per year for contact
140
+ lenses or eyeglasses-lenses and frames, fitting for eyeglasses-lenses
141
+ and frames.
142
+ • Eyeglass lens options may be available with the maximum benefit
143
+ coverage amount up to 1 pair per year.
144
+ • Maximum benefit coverage amount is limited to one time use per
145
+ year.
146
+ You do not need a referral to receive covered services from plan providers. Certain procedures, services and drugs
147
+ may need advance approval from your plan. This is called a "prior authorization" or "preauthorization." Please
148
+ contact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from the
149
+ plan . c
150
+ 10 Summary of Benefits H1036236000SB23
151
+ H1036236000
152
+ Covered Medical and Hospital Benefits (cont.)
153
+ The provider locator for routine vision can be found at Humana.com >
154
+ Find a Doctor > select Vision care icon > Vision coverage through
155
+ Medicare Advantage plans.
156
+ Mental health services Inpatient:
157
+ • $250 copay per day for days 1-6
158
+ • $0 copay per day for days 7-90
159
+ • Your plan covers up to 190 days in a lifetime for inpatient mental
160
+ health care in a psychiatric hospital.
161
+ Outpatient (group and individual therapy visits): $15 to $65 copay
162
+ Cost share may vary depending on where service is provided.
163
+ Skilled nursing facility (SNF) • $0 copay per day for days 1-20
164
+ • $196 copay per day for days 21-100
165
+ • Your plan covers up to 100 days in a SNF
166
+ Physical Therapy • $15 copay
167
+ ADDITIONAL BENEFITS
168
+ Ambulance $270 copay per date of service
169
+ Transportation $0 copay for plan approved location up to 48 one-way trip(s) per year.
170
+ This benefit is not to exceed 25 miles per trip.
171
+ The member must contact transportation vendor to arrange
172
+ transportation and should contact Customer Care to be directed to
173
+ their plan's specific transportation provider.
174
+ Medicare Part B drugs • Chemotherapy drugs: 19% of the cost
175
+ • Other Part B drugs: 19% of the cost
176
+ H1036236000SB23 Summary of Benefits 11
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+ H1036236000
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+ Prescription Drug Benefits
179
+ PRESCRIPTION DRUGS
180
+ Important Message About What You Pay for Vaccines
181
+ Our plan covers most Part D vaccines at no cost to you, no matter what cost-sharing tier it’s on .
182
+ Important Message About What You Pay for Insulin
183
+ You won’t pay more than $35 for a one-month (up to 30-day) supply of each Part D insulin product
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+ covered by our plan, no matter what cost-sharing tier it’s on . This applies to all Part D covered insulins,
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+ including the Select Insulins covered under the Insulin Savings Program as described below. If you receive
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+ "Extra Help", you will still pay no more than $35 for a one-month supply for each Part D covered insulin.
187
+ Please see your Prescription Drug Guide to find all Part D insulins covered by your plan.
188
+ If you don't receive Extra Help for your drugs, you'll pay the following:
189
+ Deductible This plan does not have a deductible.
190
+ Initial coverage
191
+ You pay the following until your total yearly drug costs reach $4,660 . Total yearly drug costs are the total
192
+ drug costs paid by both you and our plan. Once you reach this amount, you will enter the Coverage Gap.
193
+ Mail Order Cost-Sharing
194
+ Pharmacy options Standard
195
+ Walmart Mail , PillPack
196
+ Other pharmacies are
197
+ available in our network. To find
198
+ pharmacy mail order options go to
199
+ Humana.com/pharmacyfinder
200
+ Preferred
201
+ CenterWell Pharmacy ™
202
+ N/A 30-day supply 90-day supply* 30-day supply 90-day supply*
203
+ Tier 1: Preferred Generic $10 $30 $0 $0
204
+ Tier 2: Generic $20 $60 $0 $0
205
+ Tier 3: Preferred Brand $47 $141 $42 $116
206
+ Tier 4: Non-Preferred
207
+ Drug
208
+ $100 $300 $100 $290
209
+ Tier 5: Specialty Tier 33% N/A 33% N/A
210
+ 12 Summary of Benefits H1036236000SB23
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+ H1036236000
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+ Retail Cost-Sharing
213
+ Pharmacy options Retail All network retail pharmacies. To find the retail pharmacies near
214
+ you, go to Humana.com/pharmacyfinder
215
+ N/A 30-day supply 90-day supply*
216
+ Tier 1: Preferred Generic $0 $0
217
+ Tier 2: Generic $0 $0
218
+ Tier 3: Preferred Brand $42 $126
219
+ Tier 4: Non-Preferred
220
+ Drug
221
+ $100 $300
222
+ Tier 5: Specialty Tier 33% N/A
223
+ Your plan participates in the Insulin Savings Program. You will pay no more than $35 for a one-month (up
224
+ to a 30-day) supply for Select Insulins, no matter what cost-sharing tier it’s on . To identify which Select
225
+ Insulins are included within the Insulin Savings Program, look for the ISP indicator in your Prescription
226
+ Drug Guide. You are not eligible for this program if you receive "Extra Help".
227
+ Your plan also provides enhanced insulin coverage which means you will pay no more than $35 for a
228
+ one-month (up to 30-day) supply for all Part D insulins covered by our plan, including Select Insulins, no
229
+ matter what cost-sharing tier it’s on . The enhanced insulin coverage is available, even if you receive "Extra
230
+ Help".
231
+ Your share of the cost for Select Insulins:
232
+ Mail Order Cost-Sharing for Select Insulins
233
+ Pharmacy
234
+ options
235
+ Standard
236
+ Walmart Mail , PillPack
237
+ Other pharmacies are available in
238
+ our network. To find pharmacy mail
239
+ order options, go to
240
+ Humana.com/pharmacyfinder
241
+ Preferred
242
+ CenterWell Pharmacy ™
243
+ - 30-day supply 90-day supply* 30-day supply 90-day supply*
244
+ Tier 3: Preferred Brand $35 $105 $35 $95
245
+ Retail Cost-Sharing for Select Insulins
246
+ Pharmacy
247
+ options
248
+ Retail
249
+ All network retail pharmacies. To find the retail pharmacies near you, go
250
+ to Humana.com/pharmacyfinder
251
+ - 30-day supply 90-day supply*
252
+ Tier 3: Preferred Brand $35 $105
253
+ H1036236000SB23 Summary of Benefits 13
254
+ H1036236000
255
+ If you receive Extra Help for your drugs, you'll pay the following:
256
+ Deductible This plan does not have a deductible.
257
+ Pharmacy cost-sharing
258
+ For generic drugs
259
+ (including
260
+ 30-day supply 90-day supply*
261
+ brand drugs treated as
262
+ generic), either:
263
+ $0 copay; or
264
+ $1.45 copay; or
265
+ $4.15 copay ; or
266
+ 15% of the cost
267
+ $0 copay; or
268
+ $1.45 copay; or
269
+ $4.15 copay ; or
270
+ 15% of the cost
271
+ For all other drugs,
272
+ either:
273
+ $0 copay; or
274
+ $4 .30 copay; or
275
+ $10.35 copay ; or
276
+ 15% of the cost
277
+ $0 copay; or
278
+ $4 .30 copay; or
279
+ $10.35 copay ; or
280
+ 15% of the cost
281
+ Other pharmacies are available in our network.
282
+ *Some drugs are limited to a 30-day supply
283
+ ADDITIONAL DRUG COVERAGE
284
+ Erectile dysfunction (ED)
285
+ drugs
286
+ Covered at Tier 1 cost-share amount.
287
+ Anti-Obesity drugs Covered at Tier 2 cost-share amount.
288
+ Prescription Vitamins Covered at Tier 1 cost-share amount.
289
+ Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the
290
+ Part D benefit and if you qualify for "Extra Help." To find out if you qualify for "Extra Help," please contact
291
+ the Social Security Office at 1-800-772-1213 Monday — Friday, 7 a.m. — 7 p.m. TTY users should call
292
+ 1-800-325-0778. For more information on your prescription drug benefit, please call us or access your
293
+ "Evidence of Coverage" online.
294
+ If you reside in a long-term care facility, you pay the same as at a retail pharmacy.
295
+ You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network
296
+ pharmacy.
297
+ Coverage Gap
298
+ After you enter the coverage gap, you pay 25 percent of the plan's cost for covered brand name drugs
299
+ 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.
300
+ Under this plan, you may pay even less for the following:
301
+ Tier 1 (Preferred Generic) - All Drugs
302
+ Tier 2 (Generic) - All Drugs
303
+ Tier 3 (Preferred Brand) - Select Insulin Drugs
304
+ For more information on cost sharing in the coverage gap, please call us or access your Evidence of
305
+ Coverage online.
306
+ 14 Summary of Benefits H1036236000SB23
307
+ H1036236000
308
+ Catastrophic Coverage
309
+ After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and
310
+ through mail order) reach $7,4 00 you pay the greater of:
311
+ • 5% of the cost, or
312
+ • $4.15 copay for generic (including brand drugs treated as generic) and a $10.35 copay for all other
313
+ drugs
314
+ Additional Benefits
315
+ Medicare-covered foot care
316
+ (podiatry)
317
+ $15 copay
318
+ Medicare-covered chiropractic
319
+ services
320
+ $20 copay
321
+ Medical equipment/ supplies
322
+ Cost share may vary depending
323
+ on the service and where service
324
+ is provided
325
+ • Durable medical equipment (like wheelchairs or oxygen): 16% of
326
+ the cost
327
+ • Medical supplies: 20% of the cost
328
+ • Prosthetics (artificial limbs or braces): 20% of the cost
329
+ • Diabetic monitoring supplies: $0 copay or 10% to 20% of the cost
330
+ Rehabilitation services • Occupational and speech therapy: $15 copay
331
+ • Cardiac rehabilitation: $10 copay
332
+ • Pulmonary rehabilitation: $10 copay
333
+ Telehealth services
334
+ (in addition to Original
335
+ Medicare)
336
+ • Primary care provider (PCP): $0 copay
337
+ • Specialist: $15 copay
338
+ • Urgent care services: $0 copay
339
+ • Substance abuse and behavioral health services: $0 copay
340
+ H1036236000SB23 Summary of Benefits 15
341
+ H1036236000
342
+ More benefits with your plan
343
+ Enjoy some of these extra benefits included in your plan . This is a summary of what we cover. It doesn't list every service that we cover or list
344
+ every limitation or exclusion. The Evidence of Coverage (EOC) provides a complete list of
345
+ coverage and services. Visit Humana.com/medicare to view a copy of the EOC or call
346
+ 1-800-833-2364 .
347
+ Humana Flex Allowance
348
+ $1000 annual allowance on a prepaid
349
+ card to use toward out of pocket costs
350
+ for the plan's preventive and
351
+ comprehensive dental, vision, or hearing
352
+ services including copays.
353
+ Members can use this benefit at
354
+ participating providers where the
355
+ primary business is Dental Care, Vision
356
+ Services, or Hearing Services and Visa®
357
+ is accepted.
358
+ Cannot be used for procedures such as
359
+ cosmetic dentistry and teeth whitening.
360
+ Unused amount expires at the end of
361
+ the plan year.
362
+ Allowance amounts cannot be
363
+ combined with other benefit allowances.
364
+ Limitations and restrictions may apply.
365
+ Over-the-Counter (OTC) Allowance
366
+ $50 maximum benefit coverage
367
+ amount per month for over-the-counter
368
+ (OTC) prepaid card to purchase eligible
369
+ OTC health and wellness products at
370
+ participating retailers.
371
+ Unused funds carry over to the next
372
+ month and expire at the end of the plan
373
+ year.
374
+ Allowance amounts cannot be
375
+ combined with other benefit allowances.
376
+ Limitations and restrictions may apply.
377
+ Humana Spending Account Card
378
+ The allowances listed below will be
379
+ loaded onto this prepaid card. Each
380
+ allowance is separate from any other
381
+ allowance listed. Allowances shown are
382
+ accessed by using this card. Allowance
383
+ amounts cannot be combined with
384
+ other benefit allowances. Limitations
385
+ and restrictions may apply.
386
+ *Humana Flex Allowance
387
+ *OTC Allowance
388
+ Special Supplemental Benefits for
389
+ the Chronically Ill (SSBCI) Humana
390
+ Flexible Care Assistance
391
+ Humana Flexible Care Assistance is
392
+ available to members with chronic
393
+ health conditions, who are participating
394
+ in care management services, and meet
395
+ program criteria. Eligible members may
396
+ receive medical expense assistance and
397
+ other additional benefits, either
398
+ primarily health related or non-primarily
399
+ health related, to address the member's
400
+ unique individual needs. Benefits are
401
+ limited up to $1,000 per year and must
402
+ be coordinated and authorized by a care
403
+ manager. There is no cost to participate.
404
+ Chiropractic services
405
+ Routine chiropractic:
406
+ $0 copay per visit for unlimited visits.
407
+ Routine foot care
408
+ $0 copay per visit for up to 12 visits
409
+ 16 Summary of Benefits H1036236000SB23