Spaces:

namoopsoo
/

text-audio-video

Running

App Files Files Community

text-audio-video / Summary of Benefits.txt

namoopsoo

Duplicate from Xingde/text-audio-video

86cd435 over 1 year ago

raw history blame contribute delete

No virus

17.9 kB

	Monthly Plan Premium $0
	You must keep paying your Medicare Part B premium.
	Medical deductible This plan does not have a deductible.
	Pharmacy (Part D) deductible This plan does not have a deductible.
	Maximum out-of-pocket
	responsibility
	$3,900 in-network
	The most you pay for copays, coinsurance and other costs for covered
	medical services for the year.
	Acute inpatient hospital care $250 copay per day for days 1-7
	$0 copay per day for days 8-90
	Your plan covers an unlimited number of days for an inpatient stay.
	Outpatient hospital coverage • Outpatient surgery at Outpatient Hospital: $250 copay
	• Outpatient surgery at Ambulatory Surgical Center: $200 copay
	Doctor visits • Primary care provider: $0 copay
	• Specialist: $15 copay
	Preventive care Our plan covers many preventive services at no cost when you see
	an in-network provider including:
	• Abdominal aortic aneurysm screening
	• Alcohol misuse counseling
	• Bone mass measurement
	• Breast cancer screening (mammogram)
	• Cardiovascular disease (behavioral therapy)
	• Cardiovascular screenings
	• Cervical and vaginal cancer screening
	• Colorectal cancer screenings (colonoscopy, fecal occult blood test,
	flexible sigmoidoscopy)
	• Depression screening
	• Diabetes screenings
	• HIV screening
	• Medical nutrition therapy services
	• Obesity screening and counseling
	• Prostate cancer screenings (PSA)
	• Sexually transmitted infections screening and counseling
	• Tobacco use cessation counseling (counseling for people with no
	sign of tobacco-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 prevention program
	Any additional preventive services approved by Medicare during the
	contract year will be covered.
	EMERGENCY CARE
	Emergency room $110 copay
	If you are admitted to the hospital within 24 hours, you do not have to
	pay your share of the cost for the emergency care.
	Urgently needed services $20 copay at an urgent care center
	Urgently needed services are provided to treat a non-emergency,
	unforeseen medical illness, injury or condition that requires immediate
	medical attention.
	OUTPATIENT CARE AND SERVICES
	Diagnostic services, labs and
	imaging
	Cost share may vary depending
	on the service and where service
	is provided
	• Diagnostic mammography: $0 to $15 copay
	• Diagnostic colonoscopy $0 copay
	• Diagnostic radiology: $180 to $300 copay
	• Lab services: $0 to $20 copay
	• Diagnostic tests and procedures: $0 to $100 copay
	• Outpatient X-rays: $0 to $75 copay
	• Radiation therapy: $15 copay or 20% of the cost
	Hearing Medicare-covered hearing exam: $15 copay
	Routine hearing:
	In-Network:
	HER963
	• $0 copay for routine hearing exams up to 1 per year.
	• $0 copay for each Advanced level hearing aid up to 1 per ear every 3
	years.
	• $299 copay for each Premium level hearing aid up to 1 per ear every
	3 years.
	Hearing aid purchase includes:
	• Unlimited follow-up provider visits during first year following
	TruHearing hearing aid purchase
	• 60-day trial period
	• 3-year extended warranty
	• 80 batteries per aid for non-rechargeable models
	You must see a TruHearing provider to use this benefit. Call
	1-844-255-7144 to schedule an appointment (for TTY, dial 711).
	Dental Medicare-covered dental services: $15 copay
	Routine dental:
	The cost-share indicated below is what you pay for the covered service.
	In-Network:
	DEN046
	• $0 copay for scaling and root planing (deep cleaning) up to 1 per
	quadrant every 3 years.
	• $0 copay for comprehensive oral evaluation or periodontal exam,
	occlusal adjustment, scaling for moderate inflammation up to 1
	every 3 years.
	• $0 copay for bridges, complete dentures, crown recementation,
	denture recementation, panoramic film or diagnostic x-rays, partial
	dentures up to 1 every 5 years.
	• $0 copay for crown, root canal, root canal retreatment up to 1 per
	tooth per lifetime.
	• $0 copay for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
	You do not need a referral to receive covered services from plan providers. Certain procedures, services and drugs
	may need advance approval from your plan. This is called a "prior authorization" or "preauthorization." Please
	contact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from the
	plan . c
	H1036236000SB23 Summary of Benefits 9
	H1036236000
	Covered Medical and Hospital Benefits (cont.)
	• $0 copay for adjustments to dentures, denture rebase, denture
	reline, denture repair, emergency diagnostic exam, tissue
	conditioning up to 1 per year.
	• $0 copay for emergency treatment for pain, fluoride treatment, oral
	surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
	• $0 copay for periodontal maintenance up to 4 per year.
	• $0 copay for amalgam and/or composite filling, necessary
	anesthesia with covered service, simple or surgical extraction up to
	unlimited per year.
	• $3000 maximum benefit coverage amount per year for preventive
	and comprehensive benefits.
	Dental services are subject to our standard claims review procedures
	which could include dental history to approve coverage. Dental benefits
	under this plan may not cover all American Dental Association
	procedure codes. Information regarding each plan is available at
	Humana.com/sb . Network dentists have agreed to provide services at contracted fees
	(the in-network fee schedules, of INFS). If a member visits a
	participating network dentist, the member will not receive a bill for
	charges more than the negotiated fee schedule on covered services
	(coinsurance payment still applies).
	Use the HumanaDental Medicare network for the Mandatory
	Supplemental Dental. The provider locator can be found at
	Humana.com > Find a Doctor > from the Search Type drop down select
	Dental > under Coverage Type select All Dental Networks > enter zip
	code > from the network drop down select HumanaDental Medicare.
	Vision • Medicare-covered vision services: $15 copay
	• Medicare-covered diabetic eye exam: $0 copay
	• Medicare-covered glaucoma screening: $0 copay
	• Medicare-covered eyewear (post-cataract): $0 copay
	Routine vision:
	In-Network:
	VIS733
	• $0 copay for routine exam up to 1 per year.
	• $300 maximum benefit coverage amount per year for contact
	lenses or eyeglasses-lenses and frames, fitting for eyeglasses-lenses
	and frames.
	• Eyeglass lens options may be available with the maximum benefit
	coverage amount up to 1 pair per year.
	• Maximum benefit coverage amount is limited to one time use per
	year.
	You do not need a referral to receive covered services from plan providers. Certain procedures, services and drugs
	may need advance approval from your plan. This is called a "prior authorization" or "preauthorization." Please
	contact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior authorization from the
	plan . c
	10 Summary of Benefits H1036236000SB23
	H1036236000
	Covered Medical and Hospital Benefits (cont.)
	The provider locator for routine vision can be found at Humana.com >
	Find a Doctor > select Vision care icon > Vision coverage through
	Medicare Advantage plans.
	Mental health services Inpatient:
	• $250 copay per day for days 1-6
	• $0 copay per day for days 7-90
	• Your plan covers up to 190 days in a lifetime for inpatient mental
	health care in a psychiatric hospital.
	Outpatient (group and individual therapy visits): $15 to $65 copay
	Cost share may vary depending on where service is provided.
	Skilled nursing facility (SNF) • $0 copay per day for days 1-20
	• $196 copay per day for days 21-100
	• Your plan covers up to 100 days in a SNF
	Physical Therapy • $15 copay
	ADDITIONAL BENEFITS
	Ambulance $270 copay per date of service
	Transportation $0 copay for plan approved location up to 48 one-way trip(s) per year.
	This benefit is not to exceed 25 miles per trip.
	The member must contact transportation vendor to arrange
	transportation and should contact Customer Care to be directed to
	their plan's specific transportation provider.
	Medicare Part B drugs • Chemotherapy drugs: 19% of the cost
	• Other Part B drugs: 19% of the cost
	H1036236000SB23 Summary of Benefits 11
	H1036236000
	Prescription Drug Benefits
	PRESCRIPTION DRUGS
	Important Message About What You Pay for Vaccines
	Our plan covers most Part D vaccines at no cost to you, no matter what cost-sharing tier it’s on .
	Important Message About What You Pay for Insulin
	You won’t pay more than $35 for a one-month (up to 30-day) supply of each Part D insulin product
	covered by our plan, no matter what cost-sharing tier it’s on . This applies to all Part D covered insulins,
	including the Select Insulins covered under the Insulin Savings Program as described below. If you receive
	"Extra Help", you will still pay no more than $35 for a one-month supply for each Part D covered insulin.
	Please see your Prescription Drug Guide to find all Part D insulins covered by your plan.
	If you don't receive Extra Help for your drugs, you'll pay the following:
	Deductible This plan does not have a deductible.
	Initial coverage
	You pay the following until your total yearly drug costs reach $4,660 . Total yearly drug costs are the total
	drug costs paid by both you and our plan. Once you reach this amount, you will enter the Coverage Gap.
	Mail Order Cost-Sharing
	Pharmacy options Standard
	Walmart Mail , PillPack
	Other pharmacies are
	available in our network. To find
	pharmacy mail order options go to
	Humana.com/pharmacyfinder
	Preferred
	CenterWell Pharmacy ™
	N/A 30-day supply 90-day supply* 30-day supply 90-day supply*
	Tier 1: Preferred Generic $10 $30 $0 $0
	Tier 2: Generic $20 $60 $0 $0
	Tier 3: Preferred Brand $47 $141 $42 $116
	Tier 4: Non-Preferred
	Drug
	$100 $300 $100 $290
	Tier 5: Specialty Tier 33% N/A 33% N/A
	12 Summary of Benefits H1036236000SB23
	H1036236000
	Retail Cost-Sharing
	Pharmacy options Retail All network retail pharmacies. To find the retail pharmacies near
	you, go to Humana.com/pharmacyfinder
	N/A 30-day supply 90-day supply*
	Tier 1: Preferred Generic $0 $0
	Tier 2: Generic $0 $0
	Tier 3: Preferred Brand $42 $126
	Tier 4: Non-Preferred
	Drug
	$100 $300
	Tier 5: Specialty Tier 33% N/A
	Your plan participates in the Insulin Savings Program. You will pay no more than $35 for a one-month (up
	to a 30-day) supply for Select Insulins, no matter what cost-sharing tier it’s on . To identify which Select
	Insulins are included within the Insulin Savings Program, look for the ISP indicator in your Prescription
	Drug Guide. You are not eligible for this program if you receive "Extra Help".
	Your plan also provides enhanced insulin coverage which means you will pay no more than $35 for a
	one-month (up to 30-day) supply for all Part D insulins covered by our plan, including Select Insulins, no
	matter what cost-sharing tier it’s on . The enhanced insulin coverage is available, even if you receive "Extra
	Help".
	Your share of the cost for Select Insulins:
	Mail Order Cost-Sharing for Select Insulins
	Pharmacy
	options
	Standard
	Walmart Mail , PillPack
	Other pharmacies are available in
	our network. To find pharmacy mail
	order options, go to
	Humana.com/pharmacyfinder
	Preferred
	CenterWell Pharmacy ™
	- 30-day supply 90-day supply* 30-day supply 90-day supply*
	Tier 3: Preferred Brand $35 $105 $35 $95
	Retail Cost-Sharing for Select Insulins
	Pharmacy
	options
	Retail
	All network retail pharmacies. To find the retail pharmacies near you, go
	to Humana.com/pharmacyfinder
	- 30-day supply 90-day supply*
	Tier 3: Preferred Brand $35 $105
	H1036236000SB23 Summary of Benefits 13
	H1036236000
	If you receive Extra Help for your drugs, you'll pay the following:
	Deductible This plan does not have a deductible.
	Pharmacy cost-sharing
	For generic drugs
	(including
	30-day supply 90-day supply*
	brand drugs treated as
	generic), either:
	$0 copay; or
	$1.45 copay; or
	$4.15 copay ; or
	15% of the cost
	$0 copay; or
	$1.45 copay; or
	$4.15 copay ; or
	15% of the cost
	For all other drugs,
	either:
	$0 copay; or
	$4 .30 copay; or
	$10.35 copay ; or
	15% of the cost
	$0 copay; or
	$4 .30 copay; or
	$10.35 copay ; or
	15% of the cost
	Other pharmacies are available in our network.
	*Some drugs are limited to a 30-day supply
	ADDITIONAL DRUG COVERAGE
	Erectile dysfunction (ED)
	drugs
	Covered at Tier 1 cost-share amount.
	Anti-Obesity drugs Covered at Tier 2 cost-share amount.
	Prescription Vitamins Covered at Tier 1 cost-share amount.
	Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the
	Part D benefit and if you qualify for "Extra Help." To find out if you qualify for "Extra Help," please contact
	the Social Security Office at 1-800-772-1213 Monday — Friday, 7 a.m. — 7 p.m. TTY users should call
	1-800-325-0778. For more information on your prescription drug 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 retail pharmacy.
	You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network
	pharmacy.
	Coverage Gap
	After you enter the coverage gap, you pay 25 percent of the plan's cost for covered brand name drugs
	and 25 percent of the plan's cost for covered generic drugs until your out-of-pocket costs total $7,400 — which is the end of the coverage gap. Not everyone will enter the coverage gap.
	Under this plan, you may pay even less for the following:
	Tier 1 (Preferred Generic) - All Drugs
	Tier 2 (Generic) - All Drugs
	Tier 3 (Preferred Brand) - Select Insulin Drugs
	For more information on cost sharing in the coverage gap, please call us or access your Evidence of
	Coverage online.
	14 Summary of Benefits H1036236000SB23
	H1036236000
	Catastrophic Coverage
	After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and
	through mail order) reach $7,4 00 you pay the greater of:
	• 5% of the cost, or
	• $4.15 copay for generic (including brand drugs treated as generic) and a $10.35 copay for all other
	drugs
	Additional Benefits
	Medicare-covered foot care
	(podiatry)
	$15 copay
	Medicare-covered chiropractic
	services
	$20 copay
	Medical equipment/ supplies
	Cost share may vary depending
	on the service and where service
	is provided
	• Durable medical equipment (like wheelchairs or oxygen): 16% of
	the cost
	• Medical supplies: 20% of the cost
	• Prosthetics (artificial limbs or braces): 20% of the cost
	• Diabetic monitoring supplies: $0 copay or 10% to 20% of the cost
	Rehabilitation services • Occupational and speech therapy: $15 copay
	• Cardiac rehabilitation: $10 copay
	• Pulmonary rehabilitation: $10 copay
	Telehealth services
	(in addition to Original
	Medicare)
	• Primary care provider (PCP): $0 copay
	• Specialist: $15 copay
	• Urgent care services: $0 copay
	• Substance abuse and behavioral health services: $0 copay
	H1036236000SB23 Summary of Benefits 15
	H1036236000
	More benefits with your plan
	Enjoy some of these extra benefits included in your plan . This is a summary of what we cover. It doesn't list every service that we cover or list
	every limitation or exclusion. The Evidence of Coverage (EOC) provides a complete list of
	coverage and services. Visit Humana.com/medicare to view a copy of the EOC or call
	1-800-833-2364 .
	Humana Flex Allowance
	$1000 annual allowance on a prepaid
	card to use toward out of pocket costs
	for the plan's preventive and
	comprehensive dental, vision, or hearing
	services including copays.
	Members can use this benefit at
	participating providers where the
	primary business is Dental Care, Vision
	Services, or Hearing Services and Visa®
	is accepted.
	Cannot be used for procedures such as
	cosmetic dentistry and teeth whitening.
	Unused amount expires at the end of
	the plan year.
	Allowance amounts cannot be
	combined with other benefit allowances.
	Limitations and restrictions may apply.
	Over-the-Counter (OTC) Allowance
	$50 maximum benefit coverage
	amount per month for over-the-counter
	(OTC) prepaid card to purchase eligible
	OTC health and wellness products at
	participating retailers.
	Unused funds carry over to the next
	month and expire at the end of the plan
	year.
	Allowance amounts cannot be
	combined with other benefit allowances.
	Limitations and restrictions may apply.
	Humana Spending Account Card
	The allowances listed below will be
	loaded onto this prepaid card. Each
	allowance is separate from any other
	allowance listed. Allowances shown are
	accessed by using this card. Allowance
	amounts cannot be combined with
	other benefit allowances. Limitations
	and restrictions may apply.
	*Humana Flex Allowance
	*OTC Allowance
	Special Supplemental Benefits for
	the Chronically Ill (SSBCI) Humana
	Flexible Care Assistance
	Humana Flexible Care Assistance is
	available to members with chronic
	health conditions, who are participating
	in care management services, and meet
	program criteria. Eligible members may
	receive medical expense assistance and
	other additional benefits, either
	primarily health related or non-primarily
	health related, to address the member's
	unique individual needs. Benefits are
	limited up to $1,000 per year and must
	be coordinated and authorized by a care
	manager. There is no cost to participate.
	Chiropractic services
	Routine chiropractic:
	$0 copay per visit for unlimited visits.
	Routine foot care
	$0 copay per visit for up to 12 visits
	16 Summary of Benefits H1036236000SB23