Delete Summary of Benefits.txt

Summary of Benefits.txt

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-Monthly Plan Premium $0 
-You must keep paying your Medicare Part B premium. 
-Medical deductible This plan does not have a deductible. 
-Pharmacy (Part D) deductible This plan does not have a deductible. 
-Maximum out-of-pocket 
-responsibility 
-$3,900 in-network 
-The most you pay for copays, coinsurance and other costs for covered 
-medical services for the year. 
-Acute inpatient hospital care $250 copay per day for days 1-7 
-$0 copay per day for days 8-90 
-Your plan covers an unlimited number of days for an inpatient stay. 
-Outpatient hospital coverage • Outpatient surgery at Outpatient Hospital: $250 copay 
-• Outpatient surgery at Ambulatory Surgical Center: $200 copay 
-Doctor visits • Primary care provider: $0 copay 
-• Specialist: $15 copay
-Preventive care Our plan covers many preventive services at no cost when you see 
-an in-network provider including: 
-• Abdominal aortic aneurysm screening 
-• 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) 
-• 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 B shots, 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. 
-EMERGENCY CARE 
-Emergency room $110 copay 
-If you are admitted to the hospital within 24 hours, you do not have to 
-pay your share of the cost for the emergency care. 
-Urgently needed services $20 copay at an urgent care center 
-Urgently needed services are provided to treat a non-emergency, 
-unforeseen medical illness, injury or condition that requires immediate 
-medical attention.
-OUTPATIENT CARE AND SERVICES 
-Diagnostic services, labs and 
-imaging 
-Cost share may vary depending 
-on the service and where service 
-is provided 
-• Diagnostic mammography: $0 to $15 copay 
-• Diagnostic colonoscopy $0 copay 
-• Diagnostic radiology: $180 to $300 copay 
-• Lab services: $0 to $20 copay 
-• Diagnostic tests and procedures: $0 to $100 copay 
-• Outpatient X-rays: $0 to $75 copay 
-• Radiation therapy: $15 copay or 20% of the cost 
-Hearing Medicare-covered hearing exam: $15 copay 
-Routine hearing: 
-In-Network: 
-HER963 
-• $0 copay for routine hearing exams up to 1 per year. 
-• $0 copay for each Advanced level hearing aid up to 1 per ear every 3 
-years. 
-• $299 copay for each Premium level hearing aid up to 1 per ear every 
-3 years. 
-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 
-You must see a TruHearing provider to use this benefit. Call 
-1-844-255-7144 to schedule an appointment (for TTY, dial 711). 
-Dental Medicare-covered dental services: $15 copay 
-Routine dental: 
-The cost-share indicated below is what you pay for the covered service. 
-In-Network: 
-DEN046 
-• $0 copay for scaling and root planing (deep cleaning) up to 1 per 
-quadrant every 3 years. 
-• $0 copay for comprehensive oral evaluation or periodontal exam, 
-occlusal adjustment, scaling for moderate inflammation up to 1 
-every 3 years. 
-• $0 copay for bridges, complete dentures, crown recementation, 
-denture recementation, panoramic film or diagnostic x-rays, partial 
-dentures up to 1 every 5 years. 
-• $0 copay for crown, root canal, root canal retreatment up to 1 per 
-tooth per lifetime. 
-• $0 copay for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. 
-You do not need a referral to receive covered services from plan providers. Certain procedures, services and drugs 
-may need advance approval from your plan. This is called a "prior authorization" or "preauthorization." Please 
-contact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from the 
-plan . c
-H1036236000SB23 Summary of Benefits 9
-H1036236000 
-Covered Medical and Hospital Benefits (cont.) 
-• $0 copay for adjustments to dentures, denture rebase, denture 
-reline, denture repair, emergency diagnostic exam, tissue 
-conditioning up to 1 per year. 
-• $0 copay for emergency treatment for pain, fluoride treatment, oral 
-surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year. 
-• $0 copay for periodontal maintenance up to 4 per year. 
-• $0 copay for amalgam and/or composite filling, necessary 
-anesthesia with covered service, simple or surgical extraction up to 
-unlimited per year. 
-• $3000 maximum benefit coverage amount per year for preventive 
-and comprehensive benefits. 
-Dental services are subject to our standard claims review procedures 
-which could include dental history to approve coverage. Dental benefits 
-under this plan may not cover all American Dental Association 
-procedure codes. Information regarding each plan is available at 
-Humana.com/sb . Network dentists have agreed to provide services at contracted fees 
-(the in-network fee schedules, of INFS). If a member visits a 
-participating network dentist, the member will not receive a bill for 
-charges more than the negotiated fee schedule on covered services 
-(coinsurance payment still applies). 
-Use the HumanaDental Medicare network for the Mandatory 
-Supplemental Dental. The provider locator can be found at 
-Humana.com > Find a Doctor > from the Search Type drop down select 
-Dental > under Coverage Type select All Dental Networks > enter zip 
-code > from the network drop down select HumanaDental Medicare. 
-Vision • Medicare-covered vision services: $15 copay 
-• Medicare-covered diabetic eye exam: $0 copay 
-• Medicare-covered glaucoma screening: $0 copay 
-• Medicare-covered eyewear (post-cataract): $0 copay 
-Routine vision: 
-In-Network: 
-VIS733 
-• $0 copay for routine exam up to 1 per year. 
-• $300 maximum benefit coverage amount per year for contact 
-lenses or eyeglasses-lenses and frames, fitting for eyeglasses-lenses 
-and frames. 
-• Eyeglass lens options may be available with the maximum benefit 
-coverage amount up to 1 pair per year. 
-• Maximum benefit coverage amount is limited to one time use per 
-year. 
-You do not need a referral to receive covered services from plan providers. Certain procedures, services and drugs 
-may need advance approval from your plan. This is called a "prior authorization" or "preauthorization." Please 
-contact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from the 
-plan . c
-10 Summary of Benefits H1036236000SB23 
-H1036236000 
-Covered Medical and Hospital Benefits (cont.) 
-The provider locator for routine vision can be found at Humana.com > 
-Find a Doctor > select Vision care icon > Vision coverage through 
-Medicare Advantage plans. 
-Mental health services Inpatient: 
-• $250 copay per day for days 1-6 
-• $0 copay per day for days 7-90 
-• Your plan covers up to 190 days in a lifetime for inpatient mental 
-health care in a psychiatric hospital. 
-Outpatient (group and individual therapy visits): $15 to $65 copay 
-Cost share may vary depending on where service is provided. 
-Skilled nursing facility (SNF) • $0 copay per day for days 1-20 
-• $196 copay per day for days 21-100 
-• Your plan covers up to 100 days in a SNF 
-Physical Therapy • $15 copay 
-ADDITIONAL BENEFITS 
-Ambulance $270 copay per date of service 
-Transportation $0 copay for plan approved location up to 48 one-way trip(s) per year. 
-This benefit is not to exceed 25 miles per trip. 
-The member must contact transportation vendor to arrange 
-transportation and should contact Customer Care to be directed to 
-their plan's specific transportation provider. 
-Medicare Part B drugs • Chemotherapy drugs: 19% of the cost 
-• Other Part B drugs: 19% of the cost 
-H1036236000SB23 Summary of Benefits 11 
-H1036236000 
-Prescription Drug Benefits 
-PRESCRIPTION DRUGS 
-Important Message About What You Pay for Vaccines 
-Our plan covers most Part D vaccines at no cost to you, no matter what cost-sharing tier it’s on .
-Important Message About What You Pay for Insulin 
-You won’t pay more than $35 for a one-month (up to 30-day) supply of each Part D insulin product 
-covered by our plan, no matter what cost-sharing tier it’s on . This applies to all Part D covered insulins, 
-including the Select Insulins covered under the Insulin Savings Program as described below. If you receive 
-"Extra Help", you will still pay no more than $35 for a one-month supply for each Part D covered insulin. 
-Please see your Prescription Drug Guide to find all Part D insulins covered by your plan. 
-If you don't receive Extra Help for your drugs, you'll pay the following: 
-Deductible This plan does not have a deductible. 
-Initial coverage 
-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 ™
-N/A 30-day supply 90-day supply* 30-day supply 90-day supply* 
-Tier 1: Preferred Generic $10 $30 $0 $0 
-Tier 2: Generic $20 $60 $0 $0 
-Tier 3: Preferred Brand $47 $141 $42 $116 
-Tier 4: Non-Preferred 
-Drug 
-$100 $300 $100 $290 
-Tier 5: Specialty Tier 33% N/A 33% N/A 
-12 Summary of Benefits H1036236000SB23 
-H1036236000 
-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 
-Your plan participates in the Insulin Savings Program. You will pay no more than $35 for a one-month (up 
-to a 30-day) supply for Select Insulins, no matter what cost-sharing tier it’s on . To identify which Select 
-Insulins are included within the Insulin Savings Program, look for the ISP indicator in your Prescription 
-Drug Guide. You are not eligible for this program if you receive "Extra Help". 
-Your plan also provides enhanced insulin coverage which means you will pay no more than $35 for a 
-one-month (up to 30-day) supply for all Part D insulins covered by our plan, including Select Insulins, no 
-matter what cost-sharing tier it’s on . The enhanced insulin coverage is available, even if you receive "Extra 
-Help". 
-Your share of the cost for Select Insulins: 
-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 
-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 
-- 30-day supply 90-day supply* 
-Tier 3: Preferred Brand $35 $105 
-H1036236000SB23 Summary of Benefits 13 
-H1036236000 
-If you receive Extra Help for your drugs, you'll pay the following: 
-Deductible This plan does not have a deductible. 
-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 
-15% of the cost 
-Other pharmacies are available in our network. 
-*Some drugs are limited to a 30-day supply 
-ADDITIONAL DRUG COVERAGE 
-Erectile dysfunction (ED) 
-drugs 
-Covered at Tier 1 cost-share amount. 
-Anti-Obesity drugs Covered at Tier 2 cost-share amount. 
-Prescription Vitamins Covered at Tier 1 cost-share amount. 
-Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the 
-Part D benefit and if you qualify for "Extra Help." To find out if you qualify for "Extra Help," please contact 
-the Social Security Office at 1-800-772-1213 Monday — Friday, 7 a.m. — 7 p.m. TTY users should call 
-1-800-325-0778. For more information on your prescription drug benefit, please call us or access your 
-"Evidence of Coverage" online. 
-If you reside in a long-term care facility, you pay the same as at a retail pharmacy. 
-You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network 
-pharmacy. 
-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: 
-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 H1036236000SB23 
-H1036236000 
-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 
-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): 16% 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: $10 copay 
-• Pulmonary rehabilitation: $10 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 
-H1036236000SB23 Summary of Benefits 15 
-H1036236000 
-More benefits with your plan 
-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 
-every limitation or exclusion. The Evidence of Coverage (EOC) provides a complete list of 
-coverage and services. Visit Humana.com/medicare to view a copy of the EOC or call 
-1-800-833-2364 .
-Humana Flex Allowance 
-$1000 annual allowance on a prepaid 
-card to use toward out of pocket costs 
-for the plan's preventive and 
-comprehensive dental, vision, or hearing 
-services including copays. 
-Members can use this benefit at 
-participating providers where the 
-primary business is Dental Care, Vision 
-Services, or Hearing Services and Visa® 
-is accepted. 
-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. 
-Over-the-Counter (OTC) Allowance 
-$50 maximum benefit coverage 
-amount per month for over-the-counter 
-(OTC) prepaid card to purchase eligible 
-OTC health and wellness products at 
-participating retailers. 
-Unused funds carry over to the next 
-month and expire at the end of the plan 
-year. 
-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 
-allowance listed. Allowances shown are 
-accessed by using this card. Allowance 
-amounts cannot be combined with 
-other benefit allowances. Limitations 
-and restrictions may apply. 
-*Humana Flex Allowance 
-*OTC 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 
-primarily health related or non-primarily 
-health related, to address the member's 
-unique individual needs. Benefits are 
-limited up to $1,000 per year and must 
-be coordinated and authorized by a care 
-manager. There is no cost to participate. 
-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 H1036236000SB23