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SBOSB0322021Summary of BenefitsHumanaChoice H5216-064 (PPO)LouisianaSelect Louisiana ParishesGNHH4HIEN 21 CH5216064000SB21
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.Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines isin the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for yourprescriptions.Understanding Important RulesIn addition to your monthly plan premium, you must continue to pay your Medicare Part B premium.This premium is normally taken out of your Social Security check each month.Benefits, premiums and/or copayments/co-insurance may change on January 1, 2022.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.
2021Summary of BenefitsHumanaChoice H5216-064 (PPO)LouisianaSelect Louisiana ParishesH5216 SB MAPD PPO 064000 2021 MH5216064000SB21
Our service area includes the following parish(es) in Louisiana: Acadia, Allen, Ascension,Assumption, Avoyelles, Beauregard, Bossier, Caddo, Calcasieu, Caldwell, Cameron, Catahoula,Concordia, East Baton Rouge, East Carroll, East Feliciana, Evangeline, Franklin, Grant, Iberia,Iberville, Jackson, Jefferson, Jefferson Davis, Lafayette, Lafourche, LaSalle, Lincoln, Livingston,Madison, Morehouse, Orleans, Ouachita, Plaquemines, Pointe Coupee, Rapides, Richland, St.Bernard, St. Charles, St. Helena, St. James, St. John the Baptist, St. Landry, St. Martin, St. Mary,St. Tammany, Tangipahoa, Tensas, Terrebonne, Union, Vermilion, Vernon, Washington,Webster, West Baton Rouge, West Carroll, West Feliciana.
H5216064000Let's talk about HumanaChoiceH5216-064 (PPO)Find out more about the HumanaChoice H5216-064 (PPO) plan - including the healthand drug services it covers - in this easy-to-use guide.HumanaChoice H5216-064 (PPO) is a Medicare Advantage PPO plan with a Medicarecontract. 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 HumanaChoice H5216-064(PPO), you must be entitled to MedicarePart A, be enrolled in Medicare Part Band live in our service area.Plan name:HumanaChoice H5216-064 (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.Or visit our website:Humana.com/medicare .2021-5-More about HumanaChoiceH5216-064 (PPO)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 it's a good idea to select a doctor asyour Primary Care Provider (PCP). HumanaChoiceH5216-064 (PPO) has a network of doctors,hospitals, pharmacies and other providers. If youuse providers who aren't in our network, you maybe subject to higher copayments/coinsurance.A healthy partnershipGet more from your plan — with extraservices and resources provided byHumana!Summary of Benefits
PLAN COSTSMonthly plan premiumYou must keep paying yourMedicare Part B premium.PLAN COSTS 45Depending on your level of Medicaid eligibility,your plan premium may be reduced.IN-NETWORKOUT-OF-NETWORKMedical deductiblePharmacy (Part D) deductibleThis plan does not have adeductible.Maximum out-of-pocketresponsibility 6,700 in-network 10,000 combined in- andout-of-networkThe most you pay for copays,coinsurance and other costs formedical services for the year. 1,000 combined in- andout-of-networkAll services received from innetwork providers are excludedfrom the combined deductible.Services not covered by OriginalMedicare, Ambulance services,Emergency room services,Urgently Needed Services atUrgent Care Centers,Immunizations (Flu &Pneumonia), and COVID-19 Testsand Treatment received fromout-of-network providers are alsoexcluded from the combineddeductible.N/A 10,000 combined in- andout-of-networkYou 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.2021-6-Summary of BenefitsH5216064000Monthly Premium, Deductible and Limits
IN-NETWORKOUT-OF-NETWORK 225 copay per day for days 1-7 0 copay per day for days 8-90Your plan covers an unlimitednumber of days for an inpatientstay.30% of the costOutpatient surgery atoutpatient hospital 225 copay30% of the costOutpatient surgery atambulatory surgical center 175 copay30% of the costPrimary care provider (PCP) 5 copay30% of the costSpecialists 45 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.2021-7-Summary of BenefitsH5216064000Covered Medical and Hospital Benefits
IN-NETWORKOUT-OF-NETWORKPREVENTIVE CAREN/AOur plan covers many preventive 0 copay or 30% to 50% of theservices at no cost when you see cost , 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.2021-8-Summary of BenefitsH5216064000Covered 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 35 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 45 to 70 copay30% of the costDiagnostic radiology 150 to 195 copay30% of the costLab services 0 to 40 copay30% of the costDiagnostic tests and procedures 0 to 75 copay30% of the costOutpatient X-rays 5 to 75 copay30% of the costRadiation therapy 45 to 50 copay30% of the cost 45 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.2021-9-Summary of BenefitsH5216064000Covered Medical and Hospital Benefits (cont.)
Routine hearingIN-NETWORKOUT-OF-NETWORKHER941 0 copayment for fitting,routine hearing exams up to 1per year. 0 copayment for adjustmentsup to 2 per year. 699 copayment for Advancedlevel hearing aid up to 1 per earper year. 999 copayment for Premiumlevel hearing aid up to 1 per earper year. Note: Includes 48 batteries peraid and 3 year warranty. Fitting and adjustments arecovered for 1 year afterTruHearing hearing aidpurchase.TruHearing provider must be used.HER941 0 copayment for fitting,routine hearing exams up to 1per year. 0 copayment for adjustmentsup to 2 per year. 699 copayment for Advancedlevel hearing aid up to 1 per earper year. 999 copayment for Premiumlevel hearing aid up to 1 per earper year. Note: Includes 48 batteries peraid and 3 year warranty. Fitting and adjustments arecovered for 1 year afterTruHearing hearing aidpurchase. TruHearing provider must beused for in and out-of-networkhearing aid benefit. 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 45 copay30% of the costRoutine dentalDEN768DEN768 0% coinsurance for 50% coinsurance forDental benefits may not cover allcomprehensive oral evaluationcomprehensive oral evaluationAmerican Dental Associationor periodontal exam up to 1or periodontal exam up to 1procedure codes. Informationevery 3 years.every 3 years.regarding each plan is available 0% coinsurance for bitewing 50% coinsurance for bitewingat Humana.com/sbx-rays up to 1 set(s) per year.x-rays up to 1 set(s) per year. 0% coinsurance for periodic 50% coinsurance for periodicUse the HumanaDental Medicareoral exam, prophylaxisoral exam, prophylaxisnetwork for the Mandatory(cleaning) up to 2 per year.(cleaning) up to 2 per year.Supplemental Dental. The 0% coinsurance for necessary 50% coinsurance for necessaryprovider locator can be found atanesthesia with covered serviceanesthesia with covered serviceHumana.com Find a Doctor up to unlimited per year.up to unlimited per year.from the Search Type drop downselect Dental under CoverageYou 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.2021- 10 -Summary of BenefitsH5216064000Covered Medical and Hospital Benefits (cont.)
IN-NETWORKOUT-OF-NETWORK 50% coinsurance for amalgamand/or composite filling up to 2per year. 1000 combined maximumbenefit coverage amount peryear for preventive andcomprehensive benefits. 55% coinsurance for amalgamand/or composite filling 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 45 copay30% of the costMedicare-covered diabetic eyeexam 0 copay30% of the costMedicare-covered glaucomascreening 0 copay30% of the costMedicare-covered eyewear(post-cataract) 0 copay 0 copayRoutine visionVIS751 0 copayment for refraction,routine exam up to 1 per year. 75 combined maximumbenefit coverage amount peryear for refraction, routineexam. 100 combined maximumbenefit coverage amount peryear for contact lenses oreyeglasses-lenses and frames,fitting for eyeglasses-lensesand frames. Eyeglasses include ultravioletprotection and scratch resistantcoating.VIS751 0 copayment for refraction,routine exam up to 1 per year. 75 combined maximumbenefit coverage amount peryear for refraction, routineexam. 100 combined maximumbenefit coverage amount peryear for contact lenses oreyeglasses-lenses and frames,fitting for eyeglasses-lensesand frames. Eyeglasses include ultravioletprotection and scratch resistantcoating. Benefits receivedout-of-network are subject toany in-network benefitmaximums, limitations, and/orexclusions.Type select All Dental Networks enter zip code from thenetwork drop down selectHumanaDental Medicare.VISION SERVICESThe provider locator for routinevision can be found atHumana.com Find a Doctor from the Search Type drop downselect Vision Vision coveragethrough Medicare Advantageplans.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.2021- 11 -Summary of BenefitsH5216064000Covered Medical and Hospital Benefits (cont.)
IN-NETWORKOUT-OF-NETWORK 225 copay per day for days 1-7 0 copay per day for days 8-9030% of the cost 40 to 75 copay30% of the cost 0 copay per day for days 1-20 178 copay per day for days21-10030% of the cost for days 1-100 20 copay30% of the costAmbulance (ground) 265 copay per date of service 265 copay per date of serviceAmbulance (air)20% of the cost20% of the costNot coveredNot coveredMENTAL 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 THERAPYAMBULANCETRANSPORTATIONN/APrescription Drug BenefitsMEDICARE PART B DRUGSChemotherapy drugs20% of the cost30% of the costOther Part B drugs20% of the cost30% of the costPRESCRIPTION DRUGSIf 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.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.2021- 12 -Summary of BenefitsH5216064000Covered Medical and Hospital Benefits (cont.)
Pharmacy 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 99 297 99 287Tier 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- 13 -Summary of BenefitsH5216064000Preferred cost-sharing
H5216064000If 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 asgeneric), 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 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 our "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.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. 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 otherdrugs2021- 14 -Summary of Benefits
IN-NETWORKOUT-OF-NETWORKMedicare-covered foot care(podiatry) 45 copay30% of the costMedicare-covered chiropracticservices 20 copay30% of the costDurable medical equipment (likewheelchairs or oxygen)18% of the cost22% of the costMedical Supplies20% of the cost30% 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 SERVICES20% of the costPhysical, occupational andspeech therapy 20 copay30% of the costCardiac rehabilitation 20 copay30% of the costPulmonary rehabilitation 20 copayTELEHEALTH SERVICES (in addition to Original Medicare)30% of the costPrimary care provider (PCP) 0 copayNot CoveredSpecialist 45 copayNot CoveredUrgent care services 0 copayNot CoveredSubstance abuse or behavioralhealth services 0 copayNot Covered2021- 15 -Summary of BenefitsH5216064000Additional Benefits
H5216064000More benefits with your planEnjoy some of these extra benefits included in your plan.COVID-19 Testing and TreatmentOver-the-Counter (OTC) mail order 0 copay for testing and treatmentservices for COVID-19. 25 every quarter (3 months) forapproved select over-the-counter healthand wellness products from HumanaPharmacy mail delivery.Health Essentials KitKit includes over the counter itemsuseful for preventing the spread ofCOVID-19 and other viruses.Limit one per year.SilverSneakers fitness programBasic fitness center membershipincluding fitness classes.Travel CoverageAs a member of a Humana PPO, youhave the benefit to use Humana'snetwork of providers across the U.S. (notavailable in all counties). If you arevisiting another Humana PPO servicearea, simply access a Humana networkprovider to receive your in-network levelof benefits for up to twelve consecutivemonths. You pay your in-network copayor coinsurance when you visit aparticipating provider fornon-emergency care, includingpreventive care, specialist care andhospitalizations. Visit Humana.com orcontact Customer Care on the back ofyour ID card if you need help finding anin-network provider.Humana Well Dine Meal ProgramHumana's meal program for membersfollowing an inpatient stay in thehospital or nursing facility.2021- 16 -Summary of Benefits
17Find 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.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
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
HumanaChoice H5216-064 (PPO)H5216064000 ENGSelect Louisiana ParishesHumana.comH5216064000SB21
and drug services it covers -in this easy-to-use guide. HumanaChoice H5216-064 (PPO) is aMedicare Advantage PPO plan with aMedicare . Humana.com Find aDoctor from the Search Type drop down select Dental under Coverage DEN768 0% coinsurance for comprehensive oral evaluation
