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SBOSB0282022Summary of BenefitsHumana Honor (PPO) H5216-256Treasure CoastSelect Counties in FloridaGNHH4HIEN 22 CH5216256000SB22

Pre-Enrollment ChecklistBefore making an enrollment decision, it is important that you fully understand our benefits and rules. If youhave any questions, you can call and speak to a customer service representative at 1-800-833-2364 (TTY:711).Understanding the BenefitsReview the full list of benefits found in the Evidence of Coverage (EOC), especially for those servicesthat you routinely see a doctor. Visit Humana.com/medicare or call 1-800-833-2364 (TTY: 711) toview a copy of the EOC.Review the provider directory (or ask your doctor) to make sure the doctors you see now are in thenetwork. If they are not listed, it means you will likely have to select a new doctor.Understanding Important RulesYou do not pay a separate monthly plan premium for this Humana plan but, you must continue topay your Medicare Part B premium. This premium is normally taken out of your Social Security checkeach month.Benefits, premiums and/or copayments/co-insurance may change on January 1, 2023.Our plan allows you to see providers outside of our network (non-contracted providers). However,while we will pay for covered services provided by a non-contracted provider, the provider must agreeto treat you. Except in an emergency or urgent situations, non-contracted providers may deny care.In addition, you may pay a higher co-pay for services received by non-contracted providers.

2022Summary of BenefitsHumana Honor (PPO) H5216-256Treasure CoastSelect Counties in FloridaH5216 SB MA PPO 256000 2022 MH5216256000SB22

Our service area includes the following county/counties in Florida: Brevard, Glades, IndianRiver, Martin, Okeechobee, St. Lucie.

Find out more about the Humana Honor (PPO) plan - including the health and drugservices it covers - in this easy-to-use guide.H5216256000Let's talk about Humana Honor (PPO)Humana Honor (PPO) is a Medicare Advantage PPO plan with a Medicare contract.Enrollment in this Humana plan depends on contract renewal.The benefit information provided is a summary of what we cover and what you pay. Itdoesn't list every service that we cover or list every limitation or exclusion. For acomplete list of services we cover, ask us for the "Evidence of Coverage".To be eligibleMore about Humana Honor (PPO)To join Humana Honor (PPO), you mustbe entitled to Medicare Part A, beenrolled in Medicare Part B and live inour service area.Do you have Medicare and Medicaid? If you are adual-eligible beneficiary enrolled in both Medicareand the state's program, you may not have to paythe medical costs displayed in this booklet.If you have Medicaid, be sure to show your MedicaidID card in addition to your Humana membershipcard to make your provider aware that you mayhave additional coverage. Your services are paid firstby Humana and then by Medicaid.Plan name:Humana Honor (PPO)How to reach us:If you're a member of this plan, calltoll-free: 1-800-457-4708 (TTY: 711).If you're not a member of this plan,call toll free: 1-800-833-2364 (TTY:711).October 1 - March 31:Call 7 days a week from 8 a.m. - 8 p.m.April 1 - September 30:Call Monday - Friday, 8 a.m. - 8 p.m.As a member it's a good idea to select a doctor asyour Primary Care Provider (PCP). Humana Honor(PPO) has a network of doctors, hospitals,pharmacies and other providers. If you use providerswho aren't in our network, you may be subject tohigher copayments/coinsurance.A healthy partnershipGet more from your plan — with extraservices and resources provided byHumana!Or visit our website:Humana.com/medicare2022-5-Summary of Benefits

H5216256000Monthly Premium, Deductible and LimitsPLAN COSTSMonthly plan premiumYou must keep paying yourMedicare Part B premium.Part B premium reduction 0Your plan will reduce your Monthly Part B premium by up to 144Medical deductibleThis plan does not have a deductible.Maximum out-of-pocketresponsibility 4,900 in-network 6,700 combined in- and out-of-networkThe most you pay for copays,coinsurance and other costs formedical services for the year.Covered Medical and Hospital BenefitsIN-NETWORKOUT-OF-NETWORK 225 copay per day for days 1-8 0 copay per day for days 9-90Your plan covers an unlimitednumber of days for an inpatientstay. 225 copay per day for days 1-8 0 copay per day for days 9-90Outpatient surgery atoutpatient hospital 225 copay50% of the costOutpatient surgery atambulatory surgical center 150 copay50% of the costPrimary care provider (PCP) 0 copay 65 copaySpecialists 40 copay 65 copayACUTE INPATIENT HOSPITAL CAREN/AOUTPATIENT HOSPITAL COVERAGEDOCTOR OFFICE VISITSYou do not need a referral to receive covered services from plan providers. Certain procedures, services and drugsmay need advance approval from your plan. This is called a "prior authorization" or "preauthorization." Pleasecontact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from theplan.2022-6-Summary of Benefits

IN-NETWORKOUT-OF-NETWORKPREVENTIVE CAREN/AOur plan covers many preventive 0 copay or 50% of the cost ,services at no cost when you see depending on the service andan in-network provider including: where service is provided Abdominal aortic aneurysmscreeningAny additional preventive services Alcohol misuse counselingapproved by Medicare during the Bone mass measurementcontract year will be covered. Breast cancer screening(mammogram) Cardiovascular disease(behavioral therapy) Cardiovascular screenings Cervical and vaginal cancerscreening Colorectal cancer screenings(colonoscopy, fecal occultblood test, flexiblesigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapyservices Obesity screening andcounseling Prostate cancer screenings(PSA) Sexually transmitted infectionsscreening and counseling Tobacco use cessationcounseling (counseling forpeople with no sign oftobacco-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 preventionprogramYou do not need a referral to receive covered services from plan providers. Certain procedures, services and drugsmay need advance approval from your plan. This is called a "prior authorization" or "preauthorization." Pleasecontact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from theplan.2022-7-Summary of BenefitsH5216256000Covered Medical and Hospital Benefits (cont.)

IN-NETWORKOUT-OF-NETWORKAny additional preventive servicesapproved by Medicare during thecontract year will be covered.EMERGENCY CAREEmergency roomIf you are admitted to thehospital within 24 hours, you donot have to pay your share of thecost for the emergency care.Urgently needed services 90 copay 90 copay 15 copay at an urgent carecenter 65 copay at an urgent carecenterUrgently needed services areprovided to treat anon-emergency, unforeseenmedical illness, injury or conditionthat requires immediate medicalattention.OUTPATIENT CARE AND DIAGNOSTIC SERVICES, LABS AND IMAGINGCost share may vary depending on the service and where service is providedDiagnostic mammography 40 copay or 20% of the cost 65 copay or 50% of the costDiagnostic radiology 150 to 225 copay50% of the costLab services 0 to 15 copay or 20% of thecost 65 copay or 50% of the costDiagnostic tests and procedures 0 to 200 copay or 20% of thecost 65 copay or 50% of the costOutpatient X-rays 0 to 40 copay or 20% of thecost 65 copay or 50% of the costRadiation therapy 40 copay or 20% of the cost 65 copay or 50% of the cost 40 copay 65 copayHEARING SERVICESMedicare-covered hearingYou do not need a referral to receive covered services from plan providers. Certain procedures, services and drugsmay need advance approval from your plan. This is called a "prior authorization" or "preauthorization." Pleasecontact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from theplan.2022-8-Summary of BenefitsH5216256000Covered Medical and Hospital Benefits (cont.)

IN-NETWORKRoutine hearingOUT-OF-NETWORKHER726HER726 0 copayment for 50% coinsurance forfitting/evaluation, routinefitting/evaluation, routinehearing exams up to 1 per year.hearing exams up to 1 per year. 500 combined in and out of 500 combined in and out ofnetwork maximum benefitnetwork maximum benefitcoverage amount for eachcoverage amount for eachhearing aid(s) (all types) up to 1hearing aid(s) (all types) up to 1per ear per year.per ear per year. Benefits receivedout-of-network are subject toany in-network benefitmaximums, limitations, and/orexclusions.DENTAL SERVICESThe cost-share indicated below is what you pay for the covered service.Medicare-covered dental 40 copay 65 copayRoutine dentalDEN390DEN390 0 copayment for periodontal 50% coinsurance forDental benefits may not cover allscaling and root planing up to 1periodontal scaling and rootAmerican Dental Associationper quadrant every 3 years.planing up to 1 per quadrantprocedure codes. Information 0 copayment for panoramicevery 3 years.regarding each plan is availablefilm or diagnostic x-rays up to 1 50% coinsurance forat Humana.com/sb .every 3 years.panoramic film or diagnostic 0 copayment for completex-rays up to 1 every 3 years.Use the CAREington Medicaredentures up to 1 set(s) every 5 50% coinsurance for completenetwork for the Mandatoryyears.dentures up to 1 set(s) every 5Supplemental Dental. The 0 copayment for bitewingyears.provider locator can be found atx-rays up to 1 set(s) per year. 50% coinsurance for bitewingHumana.com Find a Doctor 0 copayment for amalgam orx-rays up to 1 set(s) per year.from the Search Type drop downcomposite filling, denture reline, 50% coinsurance for amalgamselect Dental under Coveragescaling for moderateor composite filling, dentureType select All Dental Networks inflammation up to 1 per year.reline, scaling for moderateenter zip code from the 0 copayment for periodic oralinflammation up to 1 per year.network drop down selectexam and/or comprehensive 50% coinsurance for periodicCAREington Medicare.oral evaluation, prophylaxisoral exam and/or(cleaning) up to 2 per year.comprehensive oral evaluation, 0 copayment for periodontalprophylaxis (cleaning) up to 2maintenance up to 4 per year.per year. 0 copayment for necessary 50% coinsurance foranesthesia with coveredperiodontal maintenance up toservice, simple or surgical4 per year.extraction up to unlimited per 50% coinsurance for necessaryyear.anesthesia with coveredYou do not need a referral to receive covered services from plan providers. Certain procedures, services and drugsmay need advance approval from your plan. This is called a "prior authorization" or "preauthorization." Pleasecontact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from theplan.2022-9-Summary of BenefitsH5216256000Covered Medical and Hospital Benefits (cont.)