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+ Monthly Plan Premium $0
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+ You must keep paying your Medicare Part B premium.
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+ Medical deductible This plan does not have a deductible.
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+ Pharmacy (Part D) deductible This plan does not have a deductible.
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+ Maximum out-of-pocket
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+ responsibility
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+ $3,900 in-network
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+ 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
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+ $0 copay per day for days 8-90
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+ Your plan covers an unlimited number of days for an inpatient stay.
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+ Outpatient hospital coverage • Outpatient surgery at Outpatient Hospital: $250 copay
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+ • Outpatient surgery at Ambulatory Surgical Center: $200 copay
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+ Doctor visits • Primary care provider: $0 copay
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+ • Specialist: $15 copay
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+ Preventive care Our plan covers many preventive services at no cost when you see
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+ an in-network provider including:
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+ • Abdominal aortic aneurysm screening
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+ • 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
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+ • 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
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+ • HIV screening
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+ • Medical nutrition therapy services
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+ • Obesity screening and counseling
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+ • Prostate cancer screenings (PSA)
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+ • Sexually transmitted infections screening and counseling
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+ • Tobacco use cessation counseling (counseling for people with no
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+ sign of tobacco-related disease)
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+ • Vaccines, including flu shots, hepatitis B shots, pneumococcal shots
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+ • "Welcome to Medicare" preventive visit (one-time)
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+ • Annual Wellness Visit
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+ • Lung cancer screening
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+ • Routine physical exam
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+ • Medicare diabetes prevention program
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+ Any additional preventive services approved by Medicare during the
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+ contract year will be covered.
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+ EMERGENCY CARE
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+ Emergency room $110 copay
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+ If you are admitted to the hospital within 24 hours, you do not have to
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+ pay your share of the cost for the emergency care.
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+ Urgently needed services $20 copay at an urgent care center
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+ 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
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+ Cost share may vary depending
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+ on the service and where service
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+ is provided
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+ • Diagnostic mammography: $0 to $15 copay
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+ • Diagnostic colonoscopy $0 copay
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+ • Diagnostic radiology: $180 to $300 copay
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+ • Lab services: $0 to $20 copay
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+ • Diagnostic tests and procedures: $0 to $100 copay
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+ • Outpatient X-rays: $0 to $75 copay
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+ • Radiation therapy: $15 copay or 20% of the cost
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+ Hearing Medicare-covered hearing exam: $15 copay
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+ Routine hearing:
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+ In-Network:
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+ HER963
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+ • $0 copay for routine hearing exams up to 1 per year.
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+ • $0 copay for each Advanced level hearing aid up to 1 per ear every 3
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+ years.
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+ • $299 copay for each Premium level hearing aid up to 1 per ear every
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+ 3 years.
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+ 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).
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+ Dental Medicare-covered dental services: $15 copay
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+ Routine dental:
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+ The cost-share indicated below is what you pay for the covered service.
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+ In-Network:
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+ DEN046
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+ • $0 copay for scaling and root planing (deep cleaning) up to 1 per
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+ quadrant every 3 years.
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+ • $0 copay for comprehensive oral evaluation or periodontal exam,
91
+ occlusal adjustment, scaling for moderate inflammation up to 1
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+ every 3 years.
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+ • $0 copay for bridges, complete dentures, crown recementation,
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+ denture recementation, panoramic film or diagnostic x-rays, partial
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+ dentures up to 1 every 5 years.
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+ • $0 copay for crown, root canal, root canal retreatment up to 1 per
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+ tooth per lifetime.
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+ • $0 copay for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
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+ You do not need a referral to receive covered services from plan providers. Certain procedures, services and drugs
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+ may need advance approval from your plan. This is called a "prior authorization" or "preauthorization." Please
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+ contact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from the
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+ plan . c
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+ H1036236000SB23 Summary of Benefits 9
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+ H1036236000
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+ Covered Medical and Hospital Benefits (cont.)
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+ • $0 copay for adjustments to dentures, denture rebase, denture
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+ reline, denture repair, emergency diagnostic exam, tissue
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+ conditioning up to 1 per year.
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+ • $0 copay for emergency treatment for pain, fluoride treatment, oral
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+ surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
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+ • $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
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+ under this plan may not cover all American Dental Association
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+ procedure codes. Information regarding each plan is available at
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+ Humana.com/sb . Network dentists have agreed to provide services at contracted fees
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+ (the in-network fee schedules, of INFS). If a member visits a
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+ participating network dentist, the member will not receive a bill for
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+ charges more than the negotiated fee schedule on covered services
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+ (coinsurance payment still applies).
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+ Use the HumanaDental Medicare network for the Mandatory
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+ Supplemental Dental. The provider locator can be found at
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+ Humana.com > Find a Doctor > from the Search Type drop down select
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+ Dental > under Coverage Type select All Dental Networks > enter zip
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+ code > from the network drop down select HumanaDental Medicare.
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+ Vision • Medicare-covered vision services: $15 copay
132
+ • Medicare-covered diabetic eye exam: $0 copay
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+ • Medicare-covered glaucoma screening: $0 copay
134
+ • Medicare-covered eyewear (post-cataract): $0 copay
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+ Routine vision:
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+ In-Network:
137
+ VIS733
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+ • $0 copay for routine exam up to 1 per year.
139
+ • $300 maximum benefit coverage amount per year for contact
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+ lenses or eyeglasses-lenses and frames, fitting for eyeglasses-lenses
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+ and frames.
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+ • Eyeglass lens options may be available with the maximum benefit
143
+ coverage amount up to 1 pair per year.
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+ • Maximum benefit coverage amount is limited to one time use per
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+ year.
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+ 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
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+ plan . c
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+ 10 Summary of Benefits H1036236000SB23
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+ H1036236000
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+ Covered Medical and Hospital Benefits (cont.)
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+ The provider locator for routine vision can be found at Humana.com >
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+ Find a Doctor > select Vision care icon > Vision coverage through
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+ 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
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+ • $196 copay per day for days 21-100
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+ • Your plan covers up to 100 days in a SNF
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+ Physical Therapy • $15 copay
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+ ADDITIONAL BENEFITS
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+ Ambulance $270 copay per date of service
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+ Transportation $0 copay for plan approved location up to 48 one-way trip(s) per year.
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+ This benefit is not to exceed 25 miles per trip.
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+ The member must contact transportation vendor to arrange
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+ transportation and should contact Customer Care to be directed to
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+ their plan's specific transportation provider.
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+ Medicare Part B drugs • Chemotherapy drugs: 19% of the cost
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+ • Other Part B drugs: 19% of the cost
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+ H1036236000SB23 Summary of Benefits 11
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+ H1036236000
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+ Prescription Drug Benefits
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+ PRESCRIPTION DRUGS
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+ Important Message About What You Pay for Vaccines
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+ Our plan covers most Part D vaccines at no cost to you, no matter what cost-sharing tier it’s on .
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+ Important Message About What You Pay for Insulin
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+ 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.
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+ Please see your Prescription Drug Guide to find all Part D insulins covered by your plan.
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+ If you don't receive Extra Help for your drugs, you'll pay the following:
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+ Deductible This plan does not have a deductible.
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+ Initial coverage
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+ You pay the following until your total yearly drug costs reach $4,660 . Total yearly drug costs are the total
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+ drug costs paid by both you and our plan. Once you reach this amount, you will enter the Coverage Gap.
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+ Mail Order Cost-Sharing
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+ Pharmacy options Standard
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+ Walmart Mail , PillPack
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+ Other pharmacies are
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+ available in our network. To find
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+ pharmacy mail order options go to
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+ Humana.com/pharmacyfinder
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+ Preferred
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+ CenterWell Pharmacy ™
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+ N/A 30-day supply 90-day supply* 30-day supply 90-day supply*
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+ Tier 1: Preferred Generic $10 $30 $0 $0
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+ Tier 2: Generic $20 $60 $0 $0
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+ Tier 3: Preferred Brand $47 $141 $42 $116
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+ Tier 4: Non-Preferred
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+ Drug
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+ $100 $300 $100 $290
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+ Tier 5: Specialty Tier 33% N/A 33% N/A
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+ 12 Summary of Benefits H1036236000SB23
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+ H1036236000
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+ Retail Cost-Sharing
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+ Pharmacy options Retail All network retail pharmacies. To find the retail pharmacies near
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+ you, go to Humana.com/pharmacyfinder
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+ N/A 30-day supply 90-day supply*
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+ Tier 1: Preferred Generic $0 $0
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+ Tier 2: Generic $0 $0
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+ Tier 3: Preferred Brand $42 $126
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+ Tier 4: Non-Preferred
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+ Drug
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+ $100 $300
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+ Tier 5: Specialty Tier 33% N/A
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+ 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
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+ Insulins are included within the Insulin Savings Program, look for the ISP indicator in your Prescription
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+ Drug Guide. You are not eligible for this program if you receive "Extra Help".
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+ Your plan also provides enhanced insulin coverage which means you will pay no more than $35 for a
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+ one-month (up to 30-day) supply for all Part D insulins covered by our plan, including Select Insulins, no
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+ 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
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+ Standard
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+ Walmart Mail , PillPack
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+ Other pharmacies are available in
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+ 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
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+ H1036236000SB23 Summary of Benefits 13
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+ H1036236000
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+ 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
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+ H1036236000
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+ Catastrophic Coverage
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+ 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
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+ • Cardiac rehabilitation: $10 copay
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+ • Pulmonary rehabilitation: $10 copay
333
+ Telehealth services
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+ (in addition to Original
335
+ Medicare)
336
+ • Primary care provider (PCP): $0 copay
337
+ • Specialist: $15 copay
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+ • Urgent care services: $0 copay
339
+ • Substance abuse and behavioral health services: $0 copay
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+ H1036236000SB23 Summary of Benefits 15
341
+ H1036236000
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+ 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