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IN-NETWORKOUT-OF-NETWORKor surgical extraction up to 2per year. 1000 combined maximumbenefit coverage amount peryear for preventive andcomprehensive benefits.or surgical extraction up to 2per year. 1000 combined maximumbenefit coverage amount peryear for preventive andcomprehensive benefits. Benefits receivedout-of-network are subject toany in-network benefitmaximums, limitations, and/orexclusions.Medicare-covered visionservices 40 copay30% of the costMedicare-covered diabetic eyeexam 0 copay30% of the costMedicare-covered glaucomascreening 0 copay30% of the costMedicare-covered eyewear(post-cataract) 0 copay30% of the costVISION SERVICESYou 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- 10 -Summary of BenefitsH5216107000Covered Medical and Hospital Benefits (cont.)

Routine visionRefraction is only covered whenbilled as part of the routine visionexam.The provider locator for routinevision can be found atHumana.com Find a Doctor select Vision care icon Visioncoverage through MedicareAdvantage plans.IN-NETWORKOUT-OF-NETWORKVIS751 0 copayment for routine examup to 1 per year. 75 combined maximumbenefit coverage amount peryear for routine exam. 100 combined maximumbenefit coverage amount peryear for contact lenses oreyeglasses-lenses and frames,fitting for eyeglasses-lensesand frames. Eyeglass lens options may beavailable with the maximumbenefit coverage amount up to1 pair per year. Maximum benefit coverageamount is limited to one timeuse per year.VIS751 0 copayment for routine examup to 1 per year. 75 combined maximumbenefit coverage amount peryear for routine exam. 100 combined maximumbenefit coverage amount peryear for contact lenses oreyeglasses-lenses and frames,fitting for eyeglasses-lensesand frames. Eyeglass lens options may beavailable with the maximumbenefit coverage amount up to1 pair per year. Maximum benefit coverageamount is limited to one timeuse per year. Benefits receivedout-of-network are subject toany in-network benefitmaximums, limitations, and/orexclusions. 750 copayment per admit30% of the cost 40 to 90 copay30% of the cost 0 copay per day for days 1-20 188 copay per day for days21-10030% of the cost for days 1-100 20 to 40 copay30% of the costMENTAL HEALTH SERVICESInpatientYour plan covers up to 190 daysin a lifetime for inpatient mentalhealth care in a psychiatrichospitalOutpatient group and individualtherapy visitsCost share may vary dependingon where service is provided.SKILLED NURSING FACILITY (SNF)Your plan covers up to 100 daysin a SNFPHYSICAL THERAPYCost share may vary dependingon the service and where serviceis provided.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- 11 -Summary of BenefitsH5216107000Covered Medical and Hospital Benefits (cont.)

IN-NETWORKOUT-OF-NETWORKAmbulance (ground) 290 copay per date of service 290 copay per date of serviceAmbulance (air)20% of the cost20% of the costNot coveredNot coveredAMBULANCETRANSPORTATIONN/APrescription Drug BenefitsMEDICARE PART B DRUGSChemotherapy drugs20% of the cost20% of the costOther Part B drugs20% of the cost20% of the costPRESCRIPTION DRUGSIf you don't receive Extra Help for your drugs, you'll pay the following:Deductible This plan has a 200 deductible for Tier 3, Tier 4, Tier 5 drugs. You pay the full cost of thesedrugs until you reach 200 . Then, you only pay your cost-share.Initial coverage (after you pay your deductible, if applicable)You pay the following until your total yearly drug costs reach 4,430. 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.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 97 291 97 281Tier 5: Specialty Tier29%N/A29%N/AYou 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- 12 -Summary of BenefitsH5216107000Covered Medical and Hospital Benefits (cont.)

Pharmacy 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 Tier29%N/A29%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.Other pharmacies are available in our network.Specialty drugs are limited to a 30-day supply.If you receive Extra Help for your drugs, you'll pay the following:Deductible You may pay 0 or 99 depending on your level of Extra Help (for Tier 3, Tier 4, Tier 5). If yourdeductible is 99, you pay the full cost of these drugs until you reach 99. Then, you only pay yourcost-share.Pharmacy cost-sharingFor generic drugs (includingbrand drugs treated asgeneric), either:30-day supply90-day supply 0 copay; or 1.35 copay; or 3.95 copay ; or15% of the cost 0 copay; or 1.35 copay; or 3.95 copay ; or15% of the costFor all other drugs, either: 0 copay; or 4 copay; or 9.85 copay ; or15% of the cost 0 copay; or 4 copay; or 9.85 copay ; or15% of the costCost 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 your "Evidence of Coverage" online.If you reside in a long-term care facility, you pay the same as at a standard retail pharmacy.You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-networkpharmacy.2022- 13 -Summary of BenefitsH5216107000Standard cost-sharing

Unless 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 7,050 — which is theend of the coverage gap. 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 7,050, you pay the greater of: 5% of the cost, or 3.95 copay for generic (including brand drugs treated as generic) and a 9.85 copayment for all otherdrugsAdditional BenefitsIN-NETWORKOUT-OF-NETWORKMedicare-covered foot care(podiatry) 40 copay30% of the costMedicare-covered chiropracticservices 20 copay30% of the costDurable medical equipment (likewheelchairs or oxygen)20% of the cost30% of the costMedical Supplies20% of the cost20% of the costProsthetics (artificial limbs orbraces)20% of the cost30% of the costMEDICAL EQUIPMENT/SUPPLIESDiabetic monitoring supplies 0 copay or 10% to 20% of theCost share may vary depending on costwhere service is provided.REHABILITATION SERVICES30% of the costOccupational and speechtherapy30% of the cost 20 to 40 copayCost share may vary depending onthe service and where service isprovided.Cardiac rehabilitation 10 copayPulmonary rehabilitation 10 copay202230% of the cost30% of the cost- 14 -Summary of BenefitsH5216107000Days' Supply Available

H5216107000TELEHEALTH SERVICES (in addition to Original Medicare)Primary care provider (PCP) 0 copayNot CoveredSpecialist 40 copayNot CoveredUrgent care services 0 copayNot CoveredSubstance abuse or behavioralhealth services 0 copayNot Covered2022- 15 -Summary of Benefits

H5216107000More 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.Travel CoverageThe PPO national network gives youin-network coverage across the country,so you can see any doctor who acceptsthe plan terms and conditions. You'll beable to travel with ease or split yourtime between locations. VisitHumana.com or contact Customer Careon the back of your ID card if you needhelp finding an in-network provider.Humana Well Dine Meal ProgramHumana's meal program for membersfollowing an inpatient stay in thehospital or nursing facility.Over-the-Counter (OTC) mail order 75 maximum benefit coverage amountper quarter (3 months) for selectover-the-counter health and wellnessproducts.Rewards and IncentivesGo365 by Humana a Rewards andIncentive program for completingcertain preventive health screenings andhealth and wellness activities.SilverSneakers fitness programBasic fitness center membershipincluding fitness classes.2022- 16 -Summary of Benefits

H5216107000Optional Supplemental BenefitsCustomize your coverage for an extra monthly premium when you enroll. You canchoose from the following to help create your Medicare plan. 25.20MyOption Dental Enriched DEN787 25.20MyOption Enhanced Dental DEN840 34.90MyOption Total Dental DEN984Enhances the dental coverage already included in your MedicareAdvantage plan with additional benefits for certain preventive, basic, andmajor services at both in-network (HumanaDental Medicare network) andout-of-network dentists. These extra benefits – in addition to your basicbenefits – have an additional monthly premium.Enhances the dental coverage already included in your MedicareAdvantage plan with additional benefits for preventive, basic, and majorservices at both in-network (HumanaDental Medicare network) andout-of-network dentists. These extra benefits – in addition to your basicbenefits – have an additional monthly premium.Enhances the dental coverage already included in your MedicareAdvantage plan with additional benefits for certain preventive, basic, andmajor services at both in-network (HumanaDental Medicare network) andout-of-network dentists. These extra benefits – in addition to your basicbenefits – have an additional 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.2022- 17 -Summary of Benefits

18Find 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.Medicare-covered eye refractions during a specialist medical visit are not covered.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.Out-of-network/non-contracted providers are under no obligation to treat Humana members, except inemergency situations. Please call our customer service number or see your Evidence of Coverage for moreinformation, including the cost-sharing that applies to out-of-network services.Humana.com

2022OptionalSupplemental BenefitsHumanaChoice H5216-107 (PPO)KentuckySelect counties in KentuckyH5216 OSB 22 276 MH5216107000OSB22

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 (DEN787)The MyOptionSM Dental Enriched benefit helps you plan for your dental care. This benefit has no deductibleand pays the full cost for two routine exams per year with an in-network provider.Here's how the benefit works:Monthly Premium 25.20Maximum 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 yearsPeriodontal maintenance0%50%Four per year20 – 2022 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)Amalgam restorations (silverfillings)50%55%Composite resin restorations(white fillings)50%55%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 yearTwo 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 yearsCovered 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 select the Dentist iconfrom the menu from the distance drop down select preferred distance enter zip code from thelook up method select all dental networks then select HumanaDental Medicare.MyOptionSM Enhanced Dental (DEN840)The MyOptionSM Enhanced Dental benefit helps make it easy for you to plan for your dental care.Here's how the benefit works:2022 OPTIONAL SUPPLEMENTAL BENEFITS – 21

OPTIONAL SUPPLEMENTAL BENEFITSS(continued)Monthly Premium 25.20Maximum BenefitHumana pays up to 2,000 per calendar yearIn-Network*You PayCovered Dental ServicesOut-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-r

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 HumanaChoice H5216-107 (PPO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and live in our service area. Plan name: