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SBOSB0312022Summary of BenefitsHumana Honor (PPO) H5216-236Greater AlabamaGNHH4HIEN 22 CH5216236000SB22

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) H5216-236Greater AlabamaH5216 SB MA PPO 236000 2022 MH5216236000SB22

Our service area includes the following county/counties in Alabama: Autauga, Baldwin,Barbour, Bibb, Blount, Bullock, Butler, Calhoun, Chambers, Cherokee, Chilton, Choctaw, Clarke,Clay, Cleburne, Coffee, Colbert, Conecuh, Coosa, Covington, Crenshaw, Cullman, Dale, Dallas,DeKalb, Elmore, Escambia, Etowah, Fayette, Franklin, Geneva, Greene, Hale, Henry, Houston,Jackson, Jefferson, Lamar, Lauderdale, Lawrence, Lee, Limestone, Lowndes, Macon, Madison,Marengo, Marion, Marshall, Mobile, Monroe, Montgomery, Morgan, Perry, Pickens, Pike,Randolph, Russell, Shelby, St. Clair, Sumter, Talladega, Tallapoosa, Tuscaloosa, Walker,Washington, Wilcox, Winston.

Find out more about the Humana Honor (PPO) plan - including the health and drugservices it covers - in this easy-to-use guide.H5216236000Let'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

H5216236000Monthly 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 50Medical deductibleThis plan does not have a deductible.Maximum out-of-pocketresponsibility 3,400 in-network 5,100 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 550 copayment per admitYour plan covers an unlimitednumber of days for an inpatientstay.30% of the costOutpatient surgery atoutpatient hospital 95 copay30% of the costOutpatient surgery atambulatory surgical center 75 copay30% of the costPrimary care provider (PCP) 0 copay30% of the costSpecialists 25 copay30% of the costACUTE 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 30% 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 BenefitsH5216236000Covered 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 25 copay at an urgent carecenter30% of the cost 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 25 to 45 copay30% of the costDiagnostic radiology 150 copay30% of the costLab services 0 to 35 copay30% of the costDiagnostic tests and procedures 0 to 45 copay30% of the costOutpatient X-rays 0 to 45 copay30% of the costRadiation therapy 25 to 45 copay30% of the cost 25 copay30% of the costHEARING 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 BenefitsH5216236000Covered Medical and Hospital Benefits (cont.)

Routine hearingIN-NETWORKOUT-OF-NETWORKHER944 0 copayment for routinehearing exams up to 1 per year. 399 copayment for eachAdvanced level hearing aid upto 1 per ear per year. 699 copayment for eachPremium level hearing aid up to1 per ear per year.Hearing aid purchase includes: Unlimited follow-up providervisits during first year followingTruHearing hearing aidpurchase 60-day trial period 3-year extended warranty 80 batteries per aid fornon-rechargeable modelsHER944 0 copayment for routinehearing exams up to 1 per year. 399 copayment for eachAdvanced level hearing aid upto 1 per ear per year. 699 copayment for eachPremium level hearing aid up to1 per ear per year.You must see a TruHearingprovider to use this benefit. Call1-844-255-7144 to schedule anappointment (for TTY, dial 711).DENTAL SERVICESThe cost-share indicated below is what you pay for the covered service.Medicare-covered dental 25 copay30% of the costRoutine dentalDEN374DEN374 0% coinsurance for scaling and 0% coinsurance for scaling andDental benefits may not cover allroot planing (deep cleaning) uproot planing (deep cleaning) upAmerican Dental Associationto 1 per quadrant every 3 years.to 1 per quadrant every 3 years.procedure codes. Information 0% coinsurance for 0% coinsurance forregarding each plan is availablecomprehensive oral evaluationcomprehensive oral evaluationat Humana.com/sb .or periodontal exam, occlusalor periodontal exam, occlusaladjustment, scaling foradjustment, scaling forUse the HumanaDental Medicaremoderate inflammation up to 1moderate inflammation up to 1network for the Mandatoryevery 3 years.every 3 years.Supplemental Dental. The 0% coinsurance for complete 0% coinsurance for completeprovider locator can be found atdentures, crown recementation,dentures, crown recementation,Humana.com Find a Doctor panoramic film or diagnosticpanoramic film or diagnosticfrom the Search Type drop downx-rays, partial dentures up to 1x-rays, partial dentures up to 1select Dental under Coverageevery 5 years.every 5 years.Type select All Dental Networks 0% coinsurance for crown up 0% coinsurance for crown upenter zip code from theto 1 per tooth per lifetime.to 1 per tooth per lifetime.network drop down select 0% coinsurance for bitewing 0% coinsurance for bitewingHumanaDental Medicare.x-rays, intraoral x-rays up to 1x-rays, intraoral x-rays up to 1set(s) per year.set(s) per year. 0% coinsurance for 0% coinsurance foradjustments to dentures,adjustments to dentures,denture rebase, denture reline,denture rebase, denture reline,You 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 BenefitsH5216236000Covered Medical and Hospital Benefits (cont.)