WIXLIB

N/AWHAT YOU PAY ON THISHUMANA PLANMEDICAID USUAL LIMITS ANDCOPAYSDENTAL SERVICESThe cost-share indicated below is what you pay for the covered service.Medicare-covered dental 0 copayCovered services include exams,cleanings, fluoride treatments,restorations, sealants, x-rays, andextractions 750 maximum for PreventiveServices Orthodontic services forchildren up to age 21 withsevere alignment problems andcomplex oral surgeries requireprior approval 3.40 copay**Routine dentalIn-network:Dental benefits may not cover allAmerican Dental Associationprocedure codes. Informationregarding each plan is availableat Humana.com/sbDEN194 0 copayment for scaling androot planing (deep cleaning) upto 1 per quadrant every 3 years. 0 copayment forcomprehensive oral evaluationor periodontal exam up to 1every 3 years. 0 copayment for completedentures, partial dentures up to1 set(s) every 5 years. 0 copayment for panoramicfilm or diagnostic x-rays,recementation up to 1 every 5years. 0 copayment for bitewingx-rays up to 1 set(s) per year. 0 copayment for adjustmentsto dentures, denture reline,intraoral x-rays, root canal upto 1 per year. 0 copayment for amalgamand/or composite filling, crown,emergency treatment for pain,oral surgery, periodic oral examand/or emergency diagnosticexam, prophylaxis (cleaning) upto 2 per year.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.2021-9-Summary of BenefitsH5619082000Covered Medical and Hospital Benefits (cont.)

N/AWHAT YOU PAY ON THISHUMANA PLANMEDICAID USUAL LIMITS ANDCOPAYS 0 copayment for periodontalmaintenance up to 4 per year. 0 copayment for necessaryanesthesia with coveredservice, simple or surgicalextraction up to unlimited peryear. 4000 maximum benefitcoverage amount per year forpreventive and comprehensivebenefits.VISION SERVICESMedicare-covered visionservices 0 copayMedicare-covered diabetic eyeexam 0 copayMedicare-covered glaucomascreening 0 copayMedicare-covered eyewear(post-cataract) 0 copayRoutine visionIn-network:VIS702The provider locator for routinevision can be found atHumana.com Find a Doctor from the Search Type drop downselect Vision Vision coveragethrough Medicare Advantageplans. 3.30 copay per visit to theophthalmologist or optometrist** Exams and visits are countedtoward the 24 visit limit- 0 copayment for refraction,routine exam up to 1 per year. 500 maximum benefitcoverage amount per year forcontact lenses oreyeglasses-lenses and frames,fitting for eyeglasses-lensesand frames. Eyeglasses include ultravioletprotection and scratch resistantcoating.MENTAL HEALTH SERVICESInpatient 0 copayN/AYour plan covers up to 190 daysin a lifetime for inpatient mentalhealth care in a psychiatrichospitalYou 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 BenefitsH5619082000Covered Medical and Hospital Benefits (cont.)

N/AWHAT YOU PAY ON THISHUMANA PLANMEDICAID USUAL LIMITS ANDCOPAYSOutpatient group and individualtherapy visits 0 copayN/AYour plan covers up to 100 daysin a SNFPHYSICAL THERAPY 0 copayN/AN/AAMBULANCE 0 copayN/AAmbulance 0 copayN/A 0 copay for up to 36 one-waytrips to plan approved locations.Not to exceed 75 miles per trip.The member must contacttransportation vendor to arrangetransportation.N/ASKILLED NURSING FACILITY (SNF)TRANSPORTATIONN/APrescription Drug BenefitsWHAT YOU PAY ON THISHUMANA PLANMEDICAID USUAL LIMITS ANDCOPAYSChemotherapy drugs 0 copayN/AOther Part B drugs 0 copayN/ASee chart below for plan coverageinformation for prescription drugs 3.40 copay for Medicaid coveredprescription drugs not covered byMedicare** Limit of 6 prescriptions permonth for non-Medicarebeneficiaries and those over 21years of age who do not have alife threatening illnessN/AMEDICARE PART B DRUGSPRESCRIPTION DRUGSMedicare Part D DrugsMedicaid may cover some drugsthat are not covered by Part D.Contact your Medicaid agency forquestions on drug coverage.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 BenefitsH5619082000Covered Medical and Hospital Benefits (cont.)

Depending on the level of Extra Help you receive, you'll pay one of the following cost-share amounts eachtime you fill your drug. You will always pay 0 for Tier 1 drugs on this plan at a Preferred Cost-SharingRetail or Preferred Cost-Sharing Mail Order Pharmacy.Pharmacy optionsPreferred cost-sharingMail order: Humana Pharmacy Retail: To find the preferred cost-share retail pharmacies near you, goto Humana.com/pharmacyfinderStandard cost-sharingMail order: Walmart MailRetail: All other network retail pharmacies30-day supply90-day supplyFor generic drugs (includingbrand drugs treated as generic),either:For all other drugs, either: 0 copay; or 1.30 copay; or 3.70 copay; 0 copay; or 1.30 copay; or 3.70 copay; 0 copay; or 4 copay; or 9.20 copay; 0 copay; or 4 copay; or 9.20 copay;Specialty drugs are limited to a 30 day supply.Cost 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)Catastrophic CoverageAfter your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy andthrough mail order) reach 6,550, you pay nothing for all drugs.2021- 12 -Summary of BenefitsH5619082000Deductible This plan does not have a deductible.

WHAT YOU PAY ON THISHUMANA PLANMEDICAID USUAL LIMITS ANDCOPAYSMedicare-covered foot care(podiatry) 0 copay 1.15 copay** Not covered unless service isperformed by your Primary CarePhysicianMedicare-covered chiropracticservices 0 copay 1.15 copay** 0 copay 3.40 copay**MEDICAL EQUIPMENT/SUPPLIESDurable medical equipment(like wheelchairs or oxygen) Durable Medical Equipmentthat is under a rent to purchasepayment plan will have the 3.40 copayment split evenlyamong the 10-month rentalpayment scheduleMedical Supplies 0 copayN/AProsthetics (artificial limbs orbraces) 0 copayN/ADiabetic monitoring supplies 0 copayN/APhysical, occupational andspeech therapy 0 copayN/ACardiac rehabilitation 0 copayN/AREHABILITATION SERVICESPulmonary rehabilitation 0 copayTELEHEALTH SERVICES (in addition to Original Medicare)N/APrimary care provider (PCP) 0 copayN/ASpecialist 0 copayN/AUrgent care services 0 copayN/ASubstance abuse or behavioralhealth services 0 copayN/A2021- 13 -Summary of BenefitsH5619082000Additional Benefits

Dual eligible members who meet financial criteria for full Medicaid coverage may also be eligible to receiveall Medicaid services not covered by Medicare. Humana Gold Plus SNP-DE H5619-082 (HMO D-SNP) mayalso offer coverage for these services. The benefits described below are covered by Medicaid. The benefitsdescribed in the Covered Medical and Hospital Benefits section of the Summary of Benefits are covered byMedicare. For each benefit listed below, you can see what the South Carolina Department of Health andHuman Services Medicaid Program covers and what our plan covers. What you pay for covered servicesmay depend on your level of Medicaid eligibility. If you have questions about your Medicaid eligibility andwhat benefits you are entitled to call: 888-549-0820 (TTY: 711).BENEFITWHAT YOU PAY ON THISHUMANA PLANMEDICAID STATE PLANDenturesSee "Dental" benefit in the"Covered Medical and HospitalBenefits" chart aboveNot coveredEyeglassesSee "Vision" benefit in the"Covered Medical and HospitalBenefits" chart above 2 copay per pair of eyeglassesand supplies** 2 copay per repair over 5.00** Prior approval required for allvisual aids Covers eyeglasses, and plasticor combination plastic/metalframes Contact lenses covered inspecial circumstances Repairs over 5 are covered,prior approval required Coverage available forindividuals under age 21 onlyHearing AidsSee "Hearing" benefit in the"Covered Medical and HospitalBenefits" chart above 0 copay Covers conventional monauraland binaural hearing aids onceevery 4 years Covers supplies and batteriesrelated to hearing aid Prior approval required for allservices except batteries Coverage available forindividuals under age 21 onlyPRODUCTS AND DEVICESTRANSPORTATIONNon-Emergency MedicalTransportation Services2021See "Transportation" benefit in the 0 copay"Covered Medical and Hospital Must be medically necessary forBenefits" chart abovean eligible person who has noother means of transportation- 14 -Summary of BenefitsH5619082000Additional Medicaid Covered Services

Inpatient Hospital, NursingFacility and Intermediate CareFacility Services in Institutionsfor Mental Diseases (IMD), age65 and olderNot covered 0 copay Covered for patients 65 andolder or 21 and younger A recipient who turns 21 as aninpatient will be covered untilage 22Inpatient Psychiatric Services,under age 21See "Mental Health" benefit in the"Covered Medical and HospitalBenefits" chart above 0 copay Covered for patients 21 andyoungerIntermediate Care FacilityServices for Individuals withIntellectual DisabilitiesNot Covered 0 copay Covered for patients 65 andolder or 21 and younger A recipient who turns 21 as aninpatient will be covered untilage 22Nursing Facility Services, otherthan in an Institution for MentalDiseasesSee "Skilled Nursing" benefit in the 0 copay"Covered Medical and HospitalBenefits" chart aboveHOME AND COMMUNITY BASED WAIVER SERVICESDual eligible members, who meet the financial criteria for full Medicaid coverage, may also be eligible toreceive Waiver services. Waiver services are limited to individuals who meet additional waiver eligibilitycriteria. For information on waiver services and eligibility, contact Medicaid at 1-888-549-0820 (TTY: 711).**Exemptions. The following categories of recipients are not required to pay a copayment orcoinsurance:(a) Individuals under the age of 21 years.(b) Pregnant women – for pregnancy – related services, including services for medical conditions thatmay complicate the pregnancy. This exemption includes the six week period following the end of thepregnancy.(c) Individuals receiving services in an inpatient hospital setting, long-term care facility, or other medicalinstitution if, as a condition of receiving services in the institution, that individual is required to spendall of his or her income for medical care costs with the exception of the minimal amount required forpersonal needs.(d) Individuals who require emergency services after the sudden onset of a medical condition which, ifleft untreated, would place their health in serious jeopardy.(e) Individuals receiving services or supplies related to family planning.The Additional Medicaid Covered Services table above reflects Medicaid services available on a fee forservice basis for dual eligibles who meet the eligibility requirements for full Medicaid benefits.The Medicaid information included in this section is current as of 7/1/2020. All Medicaid covered servicesare subject to change at any time. For the most current South Carolina Medicaid coverage information,please visit the South Carolina Medicaid website at http://www.scdhhs.gov/ or call the Medicaid Hotline at1-888-549-0820 (TTY: 711).2021- 15 -Summary of BenefitsH5619082000INPATIENT LONG TERM CARE SERVICES

H5619082000More 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. 300 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.Personal Emergency ResponseSystemThe personal emergency responsesystem provides help in emergencysituations. The medical alert servicecomes with an installed in-homecommunication device and a wearablebutton. You have the choice between apush button unit (with or withoutAutoAlert fall detection) or a wrist unit(without AutoAlert).Healthy Foods Card 50 every month to spend atparticipating retailers toward thepurchase of healthy food.Chiropractic servicesRoutine chiropractic: 0 copay per visit for up to 12 visitsSmoking cessation programTo further assist in your effort to quitsmoking or tobacco product use, wecover one additional counseling quitattempt within a 12-month period as aservice with no cost to you. This is inaddition to the two counseling attemptprovided by Medicare and includes up tofour face-to-face visits. This service canbe used for either preventive measuresor for diagnosis with a tobacco relateddisease.Wigs (related to chemotherapytreatment)Up to a 500 maximum benefit peryear.SilverSneakers fitness programBasic fitness center membershipincluding fitness classes.Routine foot care 0 copay per visit for up to 6 visitsHumana 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.Humana has been approved by the National Committee for Quality Assurance (NCQA) to operate as a SpecialNeeds Plan (SNP) until 12/31/2023 based on a review of Humana's Model of Care.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

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 SNP-DE H5619-082(HMO D-SNP)H5619082000 ENGSouth CarolinaHumana.comH5619082000SB21

As amember you must select an in-network doctor to act as your Primary Care Provider (PCP). Humana Gold Plus SNP-DE H5619-082 (HMO D-SNP) has anetwork of doctors, hospitals, pharmacies and other providers. If you use providers who aren't in our network, the plan may not pay for these services. You have access to Care Managers.