Summary of Benefits.txt

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