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+EAch paragraph below is separated by a single new line.
+
+These are the summary of benefits for the plan named Humana Community HMO H1036-236. This plan is available in the county of Jefferson in Kentucky. This plan applies to the year 2023.
+
+The Pre-Enrollment Checklist includes Understanding the Benefits.
+Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 1-800-833-2364 (TTY: 711).
+
+Understanding the Benefits. The Evidence of Coverage (EOC) provides a complete list of all coverage and services. It is important to review plan coverage, costs and benefits before you enroll. Visit Humana.com/medicare or call 1-800-833-2364 (TTY: 711) to view a copy of the EOC.
+Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. 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 is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.
+Review the formulary to make sure your drugs are covered. 
+
+Here are important Rules. 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, 2024.
+Except in emergency or urgent situations, we do not cover services by out-of-network providers. Doctors who are not listed in the provider directory.
+
+To find out more about the Humana Community HMO plan, including the health and drug services it covers in this easy-to-use guide.
+To be eligible to join the Humana Community HMO plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and live in our service area.
+If you are a member of this plan, call toll-free 1-800-457-4708. If you are not a member of this plan, call toll free 1-800-833-2364. From October 1 to March 31, call 7 days a week from 8am to 8pm. From April 1st to September 30th, you can call from Monday to Friday from 8am to 8pm. Our website is https://humana.com/medicare .
+
+Here is more information about the Humana Community (HMO).
+Do you have Medicare and Medicaid? If you are a dual-eligible beneficiary enrolled in both Medicare and the state's program, you may not have to pay the medical costs displayed in this booklet and your prescription drug costs will be lower, too.
+If you have Medicaid, be sure to show your Medicaid ID card in addition to your Humana membership card to make your provider aware that you may have additional coverage. Your services are paid first by Humana and then by Medicaid.
+As a member you must select an in-network doctor to act as your Primary Care Provider (PCP).
+Humana Community (HMO) has a network 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.
+
+Here is information about  the Monthly Plan Premium, Deductible and Limits.
+The Monthly Plan Premium is $0 .  You must keep paying your Medicare Part B premium. 
+This plan does not have a medical deductible.  This plan does not have a Pharmacy (Part D) deductible.
+The maximum out-of-pocket responsibility  is $3,900 for in-network costs.  The most you pay for copays, coinsurance and other costs for covered medical services for the year. 
+
+Here are the Covered Medical and Hospital Benefits.
+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 .
+For primary care Doctor visits , the copay is  $0.
+For Specialists  the copay is $15.
+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.
+Preventive care Our plan covers many preventive services at no cost when you see an in-network provider including the following:
+• 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. 
+
+Here is information about emergency care .
+The Emergency room copay is $110.
+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.
+
+Here is information about OUTPATIENT CARE AND SERVICES .
+For 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 
+
+Here is information about Hearing benefits.
+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 the following.
+• 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
+• $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 
+
+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. 
+
+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 
+
+
+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 
+
+
+
+Humana Well Dine Meal Program
+Humana's home delivered meal program for members following an inpatient stay in the hospital or nursing facility. 
+
+Rewards and Incentives
+Go365 by Humana® a Rewards and Incentive program for completing certain preventive health screenings and health and wellness activities. 
+
+SilverSneakers fitness program
+Basic fitness center membership including fitness classes.