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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 copay Under age 21- Covered, butMedicare is primary. Will payfor Medicare Deductibles andCoinsurance. Coverspreventive, diagnostic, andtreatment services covered asmedically necessary. Age 21 and over - NotCovered, but Medicare coverslimited dental benefits. Willpay for Medicare Deductiblesand Coinsurance ONLY ifbeneficiary is QMB eligible oran active SSI beneficiary.Routine dentalIn-network:N/ADental benefits may not cover allAmerican Dental Associationprocedure codes. Informationregarding each plan is availableat Humana.com/sbUse the HumanaDental Medicarenetwork for the MandatorySupplemental Dental. Theprovider locator can be found atHumana.com Find a Doctor from the Search Type drop downselect Dental under CoverageType select All Dental Networks enter zip code from thenetwork drop down selectHumanaDental Medicare.DEN188 0 copayment for scaling androot planing (deep cleaning) upto 1 per quadrant every 3years. 0 copayment forcomprehensive oral evaluationor periodontal exam up to 1every 3 years. 0 copayment for completedentures, partial dentures upto 1 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 treatmentfor pain, fluoride treatment,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 BenefitsH4461022000Covered Medical and Hospital Benefits (cont.)

N/AWHAT YOU PAY ON THISHUMANA PLANMEDICAID USUAL LIMITS ANDCOPAYSoral surgery, periodic oralexam and/or emergencydiagnostic exam, prophylaxis(cleaning) up to 2 per year. 0 copayment for periodontalmaintenance up to 4 per year. 0 copayment for necessaryanesthesia with coveredservice, simple or surgicalextraction up to unlimited peryear. 3000 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 copay Under age 21 – Covered, butMedicare is primary. Will pay forMedicare Deductibles andCoinsurance. Covers preventive,diagnostic, and treatmentservices as medically necessary. Age 21 and older - Coveredwith limits, but Medicare isprimary. (Medicare offerslimited benefits.) See "Care withlimits" below for details aboutTennCare's coverage of thisbenefit. Will pay for MedicareDeductibles and Coinsurance ifbeneficiary is QMB eligible or anactive SSI beneficiary. Will payfor Medicare Deductibles andCoinsurance only if specificservice in this category is aTennCare-covered service ifbeneficiary is NOT QMB eligibleor an active SSI beneficiary.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- 10 -Summary of BenefitsH4461022000Covered Medical and Hospital Benefits (cont.)

N/AWHAT YOU PAY ON THISHUMANA PLANMEDICAID USUAL LIMITS ANDCOPAYSRoutine visionIn-network:VIS733N/AThe provider locator for routinevision can be found atHumana.com Find a Doctor from the Search Type drop downselect Vision Vision coveragethrough Medicare Advantageplans. 0 copayment for refraction,routine exam up to 1 per year. 300 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/A 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 50 miles per trip.The member must contacttransportation vendor to arrangetransportation.N/AYour plan covers up to 190 daysin a lifetime for inpatient mentalhealth care in a psychiatrichospitalOutpatient group and individualtherapy visitsSKILLED NURSING FACILITY (SNF)TRANSPORTATIONN/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.2021- 11 -Summary of BenefitsH4461022000Covered Medical and Hospital Benefits (cont.)

WHAT 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 0.50 - 3 copay for Medicaidcovered prescription drugs notcovered by a Medicare PrescriptionDrug Plan.**N/AMEDICARE PART B DRUGSPRESCRIPTION DRUGSMedicare Part D DrugsAge 21 and older - Not covered.Will not pay for MedicareDeductibles and Coinsurance forPart D Pharmacy Services.Medicaid may cover some drugsthat are not covered by Part D.Contact your Medicaid agency forquestions on drug coverage.Covered for medicine Medicaredoesn't pay for. Will Not pay forMedicare Deductibles andCoinsurance for Part D PharmacyServices.2021- 12 -Summary of BenefitsH4461022000Prescription Drug Benefits

Depending on the level of Extra Help you receive, you'll pay one of the following cost-share amounts eachtime you fill your drug.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- 13 -Summary of BenefitsH4461022000Deductible This plan does not have a deductible.

WHAT YOU PAY ON THISHUMANA PLANMEDICAID USUAL LIMITS ANDCOPAYSMedicare-covered foot care(podiatry) 0 copayN/AMedicare-covered chiropracticservices 0 copayN/ADurable medical equipment(like wheelchairs or oxygen) 0 copayN/AMedical Supplies 0 copayN/AProsthetics (artificial limbs orbraces) 0 copayN/ADiabetic monitoring supplies 0 copayN/APhysical, occupational andspeech therapy 0 copayN/ACardiac rehabilitation 0 copayN/AMEDICAL EQUIPMENT/SUPPLIESREHABILITATION 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/AAdditional Medicaid Covered ServicesDual 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 H4461-022 (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 TennCare Medicaid Program covers andwhat our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility.If you have questions about your Medicaid eligibility and what benefits you are entitled to call:1-866-311-4287 (TTY: 711).2021- 14 -Summary of BenefitsH4461022000Additional Benefits

WHAT 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 0 copay Under age 21 - eyeglasses arecovered. Covered, but Medicareis primary. Will pay for MedicareDeductibles and Coinsurance. Age 21 and older - Coveredwith limits, but Medicare isprimary. (Medicare offerslimited benefits.) Will pay forMedicare Deductibles andCoinsurance if beneficiary isQMB eligible or an active SSIbeneficiary. Will pay forMedicare Deductibles andCoinsurance only if specificservice in this category is aTennCare-covered service ifbeneficiary is NOT QMB eligibleor an active SSI beneficiary.Hearing AidsSee "Hearing" benefit in the"Covered Medical and HospitalBenefits" chart aboveNot coveredPRODUCTS AND DEVICES2021- 15 -Summary of BenefitsH4461022000BENEFIT

Non-Emergency MedicalTransportation ServicesSee "Transportation" benefit in the 0 copay"Covered Medical and Hospital Under Age 21 - Covered, butBenefits" chart aboveMedicare is primary. Will pay forMedicare Deductibles andCoinsurance. Age 21 and older - Covered, butMedicare is primary. Will pay forMedicare Deductibles andCoinsurance if beneficiary isQMB eligible or an active SSIbeneficiary. Will pay forMedicare Deductibles andCoinsurance only if specificservice in this category is aTennCare-covered service ifbeneficiary is NOT QMB eligibleor an active SSI beneficiary. Must lack accessibletransportation for coveredservices One escort is allowed perenrollee if the enrollee requiresassistanceINPATIENT LONG TERM CARE SERVICESInpatient Hospital, NursingFacility and Intermediate CareFacility Services in Institutionsfor Mental Diseases (IMD), age65 and older2021 0 copayUnder Age 21 - Covered, butMedicare is primary. Will pay forMedicare Deductibles andCoinsurance.Age 21 and older - Covered, butMedicare is primary. Will pay forMedicare Deductibles andCoinsurance if beneficiary is QMBeligible or an active SSIbeneficiary. Will pay for MedicareDeductibles and Coinsurance onlyif specific service in this category isa TennCare-covered service ifbeneficiary is NOT QMB eligible oran active SSI beneficiary.Not covered- 16 -Summary of BenefitsH4461022000TRANSPORTATION

See “Mental Health” benefit in the“Covered Medical and HospitalBenefits” chart above 0 copayUnder Age 21 – Covered, butMedicare is primary. Will pay forMedicare Deductibles andCoinsurance.Age 21 and older - Covered, butMedicare is primary. Will pay forMedicare Deductibles andCoinsurance if beneficiary is QMBeligible or an active SSIbeneficiary. Will pay for MedicareDeductibles and Coinsurance onlyif specific service in this category isa TennCare-covered service ifbeneficiary is NOT QMB eligible oran active SSI beneficiary.Intermediate Care FacilityServices for Individuals withIntellectual DisabilitiesNot Covered 0 copayNursing Facility Services, otherthan in an Institution for MentalDiseasesSee “Skilled Nursing” benefit in the 0 copay“Covered Medical and HospitalUnder Age 21 – See CHOICESBenefits” chart abovebenefitsAge 21 and older – See CHOICESbenefitsHOME 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 1-866-311-4287 (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 Tennessee Medicaid coverage information, pleasevisit the Tennessee Medicaid website at http://www.state.tn.us/tenncare/ or call the Medicaid Hotline at1-866-311-4287 (TTY: 711).2021- 17 -Summary of BenefitsH4461022000Inpatient Psychiatric Services,under age 21

H4461022000More 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 25 every month to spend atparticipating retailers toward thepurchase of approved healthy foods.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 an unlimited 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- 18 -Summary of Benefits

19Find 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

Notes

Notes

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, s

As amember you must select an in-network doctor to act as your Primary Care Provider (PCP). Humana Gold Plus SNP-DE H4461-022 (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.