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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