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2021Summary of BenefitsHumana Gold Plus H5619-130 (HMO)Santa BarbaraSanta Barbara (partial) CountyOur service area includes the following county/counties in California: Santa Barbara**The following ZIP codes only in Santa Barbara: 93013, 93014, 93067, 93101, 93102,93103, 93105, 93106, 93107, 93108, 93109, 93110, 93111, 93116, 93117, 93118,93120, 93121, 93130, 93140, 93150, 93160, 93190.H5619 SB MAPD HMO 130001 2021 MH5619130001SB21
H5619-130 (HMO)H5619130001Let's talk about Humana Gold PlusFind out more about the Humana Gold Plus H5619-130 (HMO) plan - including thehealth and drug services it covers - in this easy-to-use guide.Humana Gold Plus H5619-130 (HMO) is a Medicare Advantage HMO plan with aMedicare 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 eligibleTo join Humana Gold Plus H5619-130(HMO), you must be entitled toMedicare Part A, be enrolled in MedicarePart B and live in our service area.Plan name:Humana Gold Plus H5619-130 (HMO)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.Or visit our website:Humana.com/medicare .2021More about Humana Gold PlusH5619-130 (HMO)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 andyour prescription drug costs will be lower, too.If you have Medicaid, be sure to show yourMedicaid ID card in addition to your Humanamembership card to make your provider awarethat you may have additional coverage. Yourservices are paid first by Humana and then byMedicaid.As a member you must select an in-networkdoctor to act as your Primary Care Provider (PCP).Humana Gold Plus H5619-130 (HMO) has anetwork of doctors, hospitals, pharmacies andother providers. If you use providers who aren't inour network, the plan may not pay for theseservices.A healthy partnershipGet more from your plan — with extraservices and resources provided byHumana!-5-Summary of Benefits
Monthly Plan Premium 49You must keep paying your Medicare Part B premium.Depending on your level of Medicaid eligibility, your plan premiummay be reduced.Medical deductibleThis plan does not have a deductible.Pharmacy (Part D) deductibleThis plan does not have a deductible.Maximum out-of-pocketresponsibility 5,900 in-networkThe most you pay for copays, coinsurance and other costs for medicalservices for the year.Covered Medical and Hospital BenefitsAcute inpatient hospital care 330 copay per day for days 1-5 0 copay per day for days 6-90Your 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: 180 copayDoctor visits Primary care provider: 0 copay Specialist: 10 copayYour primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain otherproviders in the network. This is called a "referral." Certain procedures, services and drugs may need advanceapproval from your plan. This is called a "prior authorization" or "preauthorization." Please contact your PCP or referto the Evidence of Coverage (EOC) for services that require a referral and/or prior authorization from the plan.2021-6-Summary of BenefitsH5619130001Monthly Premium, Deductible and Limits
Preventive care(cont.)Our plan covers many preventive services at no cost when you seean in-network provider including: Abdominal aortic aneurysm screeningAlcohol misuse counselingBone mass measurementBreast cancer screening (mammogram)Cardiovascular disease (behavioral therapy)Cardiovascular screeningsCervical and vaginal cancer screeningColorectal cancer screenings (colonoscopy, fecal occult blood test,flexible sigmoidoscopy)Depression screeningDiabetes screeningsHIV screeningMedical nutrition therapy servicesObesity screening and counselingProstate cancer screenings (PSA)Sexually transmitted infections screening and counselingTobacco use cessation counseling (counseling for people with nosign of tobacco-related disease)Vaccines, including flu shots, hepatitis B shots, pneumococcal shots"Welcome to Medicare" preventive visit (one-time)Annual Wellness VisitLung cancer screeningRoutine physical examMedicare diabetes prevention programAny additional preventive services approved by Medicare during thecontract year will be covered.EMERGENCY CAREEmergency room 90 copayIf you are admitted to the hospital within 24 hours, you do not have topay your share of the cost for the emergency care.Urgently needed services 10 copay at an urgent care centerUrgently needed services are provided to treat a non-emergency,unforeseen medical illness, injury or condition that requires immediatemedical attention.OUTPATIENT CARE AND SERVICESDiagnostic services, labs andimagingCost share may vary dependingon the service and where serviceis provided Diagnostic mammography: 10 to 50 copayDiagnostic radiology: 0 to 250 copayLab services: 0 copayDiagnostic tests and procedures: 0 to 50 copayOutpatient X-rays: 0 to 100 copayRadiation therapy: 20% of the costYour primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain otherproviders in the network. This is called a "referral." Certain procedures, services and drugs may need advanceapproval from your plan. This is called a "prior authorization" or "preauthorization." Please contact your PCP or referto the Evidence of Coverage (EOC) for services that require a referral and/or prior authorization from the plan.2021-7-Summary of BenefitsH5619130001Covered Medical and Hospital Benefits
HearingH5619130001Covered Medical and Hospital Benefits(cont.)Medicare-covered hearing exam: 10 copayRoutine hearing:In-Network:HER937 0 copayment for fitting, routine hearing exams up to 1 per year. 0 copayment for adjustments up to 2 per year. 699 copayment for Advanced level hearing aid up to 1 per ear peryear. 999 copayment for Premium level hearing aid up to 1 per ear peryear. Note: Includes 48 batteries per aid and 3 year warranty. Fitting and adjustments are covered for 1 year after TruHearinghearing aid purchase.TruHearing provider must be used.DentalMedicare-covered dental services: 10 copayRoutine dental:The cost-share indicated below is what you pay for the covered service.In-Network:DEN109 0 copayment for comprehensive oral evaluation or periodontalexam up to 1 every 3 years. 0 copayment for bitewing x-rays up to 1 set(s) per year. 0 copayment for periodic oral exam, prophylaxis (cleaning) up to 2per year. 0 copayment for necessary anesthesia with covered service up tounlimited per year.Dental benefits may not cover all American Dental Associationprocedure codes. Information regarding each plan is available atHumana.com/sbUse the HumanaDental Medicare network for the MandatorySupplemental Dental. The provider locator can be found atHumana.com Find a Doctor from the Search Type drop down selectDental under Coverage Type select All Dental Networks enter zipcode from the network drop down select HumanaDental Medicare.Additional dental benefits are available with a separate monthlypremium. Please see the "Optional Supplemental Benefits" page fordetails.Vision dicare-coveredvision services: 10 copaydiabetic eye exam: 0 copayglaucoma screening: 0 copayeyewear (post-cataract): 0 copayYour primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain otherproviders in the network. This is called a "referral." Certain procedures, services and drugs may need advanceapproval from your plan. This is called a "prior authorization" or "preauthorization." Please contact your PCP or referto the Evidence of Coverage (EOC) for services that require a referral and/or prior authorization from the plan.2021-8-Summary of Benefits
(cont.)Routine vision:In-Network:VIS734 0 copayment for refraction, routine exam up to 1 per year. 100 maximum benefit coverage amount per year for contactlenses or eyeglasses-lenses and frames, fitting for eyeglasses-lensesand frames. Eyeglasses include ultraviolet protection and scratch resistantcoating.Mental health servicesThe provider locator for routine vision can be found at Humana.com Find a Doctor from the Search Type drop down select Vision Visioncoverage through Medicare Advantage plans.Inpatient: 900 copayment per stay Your plan covers up to 190 days in a lifetime for inpatient mentalhealth care in a psychiatric hospital.Outpatient (group and individual therapy visits): 10 to 100 copayCost share may vary depending on where service is provided.Skilled nursing facility (SNF) 0 copay per day for days 1-20 150 copay per day for days 21-100 Your plan covers up to 100 days in a SNFPhysical Therapy 10 copayADDITIONAL BENEFITSAmbulance (ground) 265 copay per date of serviceAmbulance (air)20% of the costTransportation 0 copay for up to 24 one-way trips to plan approved locations. Not toexceed 50 miles per trip.The member must contact transportation vendor to arrangetransportation.Prescription Drug BenefitsMedicare Part B drugs Chemotherapy drugs: 20% of the cost Other Part B drugs: 20% of the costYour primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain otherproviders in the network. This is called a "referral." Certain procedures, services and drugs may need advanceapproval from your plan. This is called a "prior authorization" or "preauthorization." Please contact your PCP or referto the Evidence of Coverage (EOC) for services that require a referral and/or prior authorization from the plan.2021-9-Summary of BenefitsH5619130001Covered Medical and Hospital Benefits
If you don't receive Extra Help for your drugs, you'll pay the following:Deductible This plan does not have a deductible.Initial coverageYou pay the following until your total yearly drug costs reach 4,130. Total yearly drug costs are the totaldrug costs paid by both you and our plan. Once you reach this amount, you will enter the Coverage Gap.As part of the Insulin Savings Program, you will pay no more than 35 for a one-month supply for selectinsulins in the initial coverage stage. See the Additional Drug Coverage section of this document for specificdetails.Preferred cost-sharingPharmacy optionsRetailMail orderTo find the preferred cost-share retailpharmacies near you, go toHumana.com/pharmacyfinderHumana Pharmacy N/A30-day supply90-day supply30-day supply90-day supplyTier 1: Preferred Generic 5 15 5 0Tier 2: Generic 15 45 15 0Tier 3: Preferred Brand 47 141 47 131Tier 4: Non-PreferredDrug 100 300 100 290Tier 5: Specialty Tier33%N/A33%N/AStandard cost-sharingPharmacy optionsRetailMail orderN/AAll other network retail pharmacies.30-day supply90-day supplyWalmart Mail, PillPack30-day supply90-day supplyTier 1: Preferred Generic 10 30 10 30Tier 2: Generic 20 60 20 60Tier 3: Preferred Brand 47 141 47 141Tier 4: Non-PreferredDrug 100 300 100 300Tier 5: Specialty Tier33%N/A33%N/AGeneric drugs may be covered on tiers other than Tier 1 and Tier 2 so please check this plan's HumanaDrug Guide to validate the specific tier on which your drugs are covered.Specialty drugs are limited to a 30 day supply.2021- 10 -Summary of BenefitsH5619130001PRESCRIPTION DRUGS
H5619130001If you receive Extra Help for your drugs, you'll pay the following:Deductible This plan does not have a deductible.Pharmacy cost-sharingFor generic drugs (includingbrand drugs treated as generic),either:30-day supply90-day supply 0 copay; or 1.30 copay; or 3.70 copay ; or15% of the cost 0 copay; or 1.30 copay; or 3.70 copay ; or15% of the costFor all other drugs, either: 0 copay; or 4 copay; or 9.20 copay ; or15% of the cost 0 copay; or 4 copay; or 9.20 copay ; or15% of the costADDITIONAL DRUG COVERAGEErectile dysfunction (ED)drugsCovered at Tier 1 cost-share amount.This plan participates in the Insulin Savings Program which provides affordable, predictable copaymentson select insulins through the first three drug payment stages (Deductible (if applicable), Initial Coverageand Coverage Gap) of the Part D benefit. The Insulin Savings Program does not apply to the CatastrophicCoverage stage. To find out which drugs are select insulins, please check this plan's Humana Drug Guide.You are not eligible for this program if you receive Extra Help.Your share of the cost for select insulins through the Deductible Stage (if applicable), Initial CoverageStage and Coverage Gap Stage as part of the Insulin Savings Program:Preferred cost-sharing for select insulinsPharmacyoptionsRetail To find the preferred cost-share Mail Order Humana Pharmacy retail pharmacies near you, go toHumana.com/pharmacyfinder-30-day supply90-day supply30-day supply90-day supplyTier 3: PreferredBrand 35 105 35 95Standard cost-sharing for select insulinsPharmacyoptionsRetail All other network retailpharmacies.Mail Order Walmart Mail, PillPack-30-day supply90-day supply30-day supply90-day supplyTier 3: PreferredBrand 35 105 35 105Cost sharing may change depending on the pharmacy you choose, when you enter another phase of thePart D benefit and if you qualify for "Extra Help." To find out if you qualify for "Extra Help," please contactthe Social Security Office at 1-800-772-1213 Monday — Friday, 7 a.m. — 7 p.m. TTY users should call1-800-325-0778. For more information on the additional pharmacy-specific cost-sharing and the phasesof the benefit, please call us or access our "Evidence of Coverage" online.2021- 11 -Summary of Benefits
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-networkpharmacy.Days’ Supply AvailableUnless otherwise specified, you can get your Part D drug in the following days’ supply amounts: One month supply (up to 30 days)* Two month supply (31-60 days) Three month supply (61-90 days)*Long term care pharmacy (one month supply 31 days)Coverage GapAfter you enter the coverage gap, you pay 25 percent of the plan's cost for covered brand name drugsand 25 percent of the plan's cost for covered generic drugs until your costs total 6,550 — which is theend of the coverage gap. As part of the Insulin Savings Program, you will pay no more than 35 for aone-month supply for select insulins in the coverage gap. See the Additional Drug Coverage section of thisdocument for specific details. Not everyone will enter the coverage gap.Catastrophic CoverageAfter your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy andthrough mail order) reach 6,550, you pay the greater of: 5% of the cost, or 3.70 copay for generic (including brand drugs treated as generic) and a 9.20 copayment for all otherdrugsAdditional BenefitsMedicare-covered foot care(podiatry) 10 copayMedicare-covered chiropracticservices 10 copayMedical equipment/ supplies Durable medical equipment (like wheelchairs or oxygen): 20% of thecost Medical supplies: 20% of the cost Prosthetics (artificial limbs or braces): 20% of the cost Diabetic monitoring supplies: 0 copay or 10% of the cost Physical, occupational and speech therapy: 10 copay Cardiac rehabilitation: 10 copay Pulmonary rehabilitation: 10 copay Primary care provider (PCP): 0 copay Specialist: 10 copay Urgent care services: 0 copay Substance abuse and behavioral health services: 0 copayCost share may vary dependingon the service and where serviceis providedRehabilitation servicesTelehealth services(in addition to OriginalMedicare)2021- 12 -Summary of BenefitsH5619130001If you reside in a long-term care facility, you pay the same as at a standard retail pharmacy.
H5619130001More benefits with your planEnjoy some of these extra benefits included in your plan.COVID-19 Testing and Treatment 0 copay for testing and treatmentservices for COVID-19.Health Essentials KitKit includes over the counter itemsuseful for preventing the spread ofCOVID-19 and other viruses.Limit one per year.Humana Well Dine Meal ProgramHumana's meal program for membersfollowing an inpatient stay in thehospital or nursing facility.SilverSneakers fitness programBasic fitness center membershipincluding fitness classes.2021- 13 -Summary of Benefits
H5619130001Optional Supplemental BenefitsCustomize your coverage for an extra monthly premium when you enroll. You canchoose from the following to help create your Medicare plan. 27MyOption Dental Enriched DEN786Enhances the dental coverage already included in your Medicare Advantageplan with additional benefits for certain preventive, basic, and major servicesat both in-network (HumanaDental Medicare network) and out-of-networkdentists. These extra benefits – in addition to your basic benefits – have anadditional monthly premium.Humana MyOption optional supplemental benefits (OSB) are only available to members of certain Humana MedicareAdvantage (MA) plans. Members of Humana plans that offer OSBs may enroll in OSBs throughout the year. Benefitsmay change on January 1 each year. Enrollees must use network providers for specific OSBs when stated in theEvidence of Coverage (EOC); otherwise, covered services may be received from non-network providers at a highercost. Enrollees must continue to pay the Medicare Part B premium, their Humana plan premium and the OSBpremium.2021- 14 -Summary of Benefits
15Find out moreYou can see our plan's provider and pharmacy directory at our website athumana.com/finder/search or call us at the number listed at the beginning ofthis booklet and we will send you one.You can see our plan's drug guide at our website athumana.com/medicaredruglist or call us at the number listed at the beginningof this booklet and we will send you one.To find out more about the coverage and costs of Original Medicare, look in the current “Medicare & You”handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227),24 hours a day, seven days a week. TTY users should call 1-877-486-2048.Telehealth services shown are in addition to the Original Medicare covered telehealth. Your cost may be differentfor Original Medicare telehealth.Limitations on telehealth services, also referred to as virtual visits or telemedicine, vary by state. These servicesare not a substitute for emergency care and are not intended to replace your primary care provider or otherproviders in your network. Any descriptions of when to use telehealth services are for informational purposes onlyand should not be construed as medical advice. Please refer to your evidence of coverage for additional detailson what your plan may cover or other rules that may apply.Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.Humana.com
2021OptionalSupplemental BenefitsHumana Gold Plus H5619-130 (HMO)Santa BarbaraSanta Barbara (partial) CountyH5619 OSB 21 512 MH5619130001OSB21
My Options, My ChoiceAdding Benefits to Your PlanYou’re unique and have unique needs. That's why Humana offers optional supplemental benefits (OSB). Foran extra monthly premium you can customize your Humana Medicare Advantage plan.The information in this booklet will tell you about the benefits you can add to your plan. You can addthese extra benefits when you sign up for your Medicare Advantage plan. You can also add thesebenefits after Medicare open enrollment ends on December 7 by contacting your agent or calling OSBsales at 1-888-413-7026. OSB sales is available from 8 a.m. – 8 p.m. local time, seven days a weekOctober 1 – March 31, and Monday through Friday April 1 – September 30.MyOption Dental EnrichedSM (DEN786)The MyOptionSM Dental Enriched benefit helps make it easy for you to plan for your dental care.Here's how the benefit works:Monthly Premium 27Maximum BenefitHumana pays up to 2,000 per calendar yearCovered Dental ServicesIn-Network*You PayOut-OfNetwork**You PayBenefit Limitations PerCalendar YearPreventive and Diagnostic Dental ServicesPeriodic oral exam0%50%Emergency diagnostic exam0%50%Periodontal exam0%50%Comprehensive oral evaluation0%50%One procedure everythree yearsDental prophylaxis (cleanings)0%50%Two per yearFluoride treatment0%50%Two per yearBitewing X-ray0%50%One set per yearIntraoral X-ray0%50%One per yearPanoramic or Diagnostic X-Ray0%50%One every three yearsTwo per yearBasic Dental Services (Minor Restorative)Amalgam restorations (silverfillings)Composite resin restorations(white fillings)50%55%50%55%18 – 2021 OPTIONAL SUPPLEMENTAL BENEFITSTwo per year
OPTIONAL SUPPLEMENTAL BENEFITSS(continued)In-Network*You PayCovered Dental ServicesOut-OfNetwork**You PayBenefit Limitations PerCalendar YearBasic Dental Services (Minor Restorative)Extractions (pulling teeth), simpleor surgical50%55%Two per yearRecementation – Crown50%55%One procedure every five yearsEmergency treatment for pain50%55%Two per yearAnesthesia0%50%Unlimited procedures per yearMajor Dental Services (Endodontics, Periodontics and Oral Surgery)Crowns70%75%Two per yearPeriodontal scaling and rootplaning (deep cleaning)70%75%One procedure for each quadrantevery three yearsScaling – generalized inflammation70%75%One procedure every three yearsPeriodontal maintenance0%50%Four per yearCovered dental services are subject to conditions, limitations, exclusions, and maximums. Please see yourEvidence of Coverage for details.*Network dentists have agreed to provide services at a negotiated rate. If you see a network dentist, youcannot be billed more than that rate.**Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/orexclusions. You may be billed by the out-of-network provider for any amount greater than the paymentmade by Humana to the provider.Some covered services may consider prior tooth history and procedures in conjunction with frequencylimitations noted above. Dental benefits may not cover all American Dental Association procedure codes.Information regarding each plan is available at Humana.com/sb .The Humana Optional Supplemental Dental benefits are provided through the Humana Dental MedicareNetwork. The provider locator can be found at Humana.com Find a Doctor From the Search Type dropdown select Dental Under Coverage Type select All Dental Networks Enter zip code From theNetwork drop down select HumanaDental Medicare.2021 OPTIONAL SUPPLEMENTAL BENEFITS – 19
Humana is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in this Humana plan dependson contract renewal. Humana MyOption Optional Supplemental Benefits (OSB) are only available to members ofcertain Humana Medicare Advantage (MA) plans. Members of Humana plans that offer OSBs may enroll in OSBsthroughout the year. Benefits may change on January 1st each year. Enrollees must use network providers forspecific OSBs when stated in the Evidence of Coverage (EOC); otherwise, covered services may be received fromnon-network providers at a higher cost. Enrollees must continue to pay the Medicare Part B premium, theirHumana premium, and the OSB premium.Humana.com
Important!At Humana, it is important you are treated fairly.Humana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color, nationalorigin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, marital status or religion.Discrimination is against the law. Humana and its subsidiaries comply with applicable Federal Civil Rightslaws. If you believe that you have been discriminated against by Humana or its subsidiaries, there are waysto get help. You may file a complaint, also known as a grievance:Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.If you need help filing a grievance, call 1-877-320-1235 or if you use a TTY, call 711. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Officefor Civil Rights electronically through their Complaint Portal, available athttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf , or at U.S. Department of Health and Human Services,200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019,800-537-7697 (TDD). Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html. California residents: You may also call California Department of Insurance toll-free hotline number:1-800-927-HELP (4357), to file a grievance.Auxiliary aids and services, free of charge, are available to you.1-877-320-1235 (TTY: 711)Humana provides free auxiliary aids and services, such as qualified sign language interpreters, video remoteinterpretation, and written information in other formats to people with disabilities when such auxiliary aidsand services are necessary to ensure an equal opportunity to participate.Language assistance services, free of charge, are available to you.1-877-320-1235 (TTY: 711)GCHJV5REN 0220
Humana Gold Plus H5619-130 (HMO)H5619130001 ENGSanta Barbara (partial) CountyHumana.comH5619130001SB21
doesn't list every service that we cover or list every limitation or exclusion. For a complete list of services we cover, ask us for the "Evidence of Coverage". To be eligible To join Humana Gold Plus H5619-130 (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part Band live in our service area. Plan name:
