SBOSB046

2024

Summary of Benefits

Humana Value Plus H5619-134 (HMO)

Washington
Select Counties in WA

Our service area includes the following county/counties in Washington: Benton, Clark,
Cowlitz, Franklin, Island, King, Kitsap, Pierce, Skagit, Snohomish, Spokane, Thurston,
Walla Walla, Whatcom.

H5619_SB_MAPD_HMO_134000_2024_M

H5619134000SB24 Summary of Benefits 1

Pre-Enrollment Checklist
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.

Understanding Important Rules

In 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, 2025.

Effect on Current Coverage. If you are currently enrolled in a Medicare Advantage plan, your current
Medicare Advantage healthcare coverage will end once your new Medicare Advantage coverage
starts. If you have Tricare, your coverage may be affected once your new Medicare Advantage
coverage starts. Please contact Tricare for more information. If you have a Medigap plan, once your
Medicare Advantage coverage starts, you may want to drop your Medigap policy because you will be
paying for coverage you cannot use.

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).

2 Summary of Benefits H5619134000SB24

 H5619134000
Let's talk about Humana Value Plus
H5619-134 (HMO)
Find out more about the Humana Value Plus H5619-134 (HMO) plan - including the
health and drug services it covers - in this easy-to-use guide.

Humana Value Plus H5619-134 (HMO) is a Medicare Advantage HMO plan with a
Medicare contract. Enrollment in this Humana plan depends on contract renewal.

The benefit information provided is a summary of what we cover and what you pay. It
doesn't list every service that we cover or list every limitation or exclusion. For a
complete list of services we cover, please refer to the plan's Evidence of Coverage on our
website, Humana.com/plandocuments.

To be eligible More about Humana Value Plus

To join Humana Value Plus H5619-134 H5619-134 (HMO)
(HMO), you must be entitled to Do you have Medicare and Medicaid? If you are a
Medicare Part A, be enrolled in Medicare dual-eligible beneficiary enrolled in both
Part B and live in our service area. Medicare and your state Medicaid program, you
may not have to pay the medical costs displayed
Plan name: in this booklet and your prescription drug costs
may be lower, too.
Humana Value Plus H5619-134 (HMO)
If you have Medicaid, be sure to show your
How to reach us: Medicaid ID card in addition to your Humana
If you're a member of this plan, call membership card to make your provider aware
that you may have additional coverage. Your
toll-free: 1-800-457-4708 (TTY: 711). services are paid first by Humana and then by
Medicaid.
If you're not a member of this plan,
call toll free: 1-800-833-2364 (TTY: As a member you must select an in-network
711). doctor in your service area listed in this
document to act as your Primary Care Provider
October 1 - March 31: (PCP). Humana Value Plus H5619-134 (HMO) has
Call 7 days a week from 8 a.m. - 8 p.m. a network of doctors, hospitals, pharmacies and
other providers. If you use providers who aren't
April 1 - September 30: in our network, the plan may not pay for these
Call Monday - Friday, 8 a.m. - 8 p.m. services.
Or visit our website:
Humana.com/medicare A healthy partnership
Get more from your plan — with extra
services and resources provided by
Humana !

H5619134000SB24 Summary of Benefits 3

 H5619134000
Monthly Premium, Deductible and Limits
Monthly Plan Premium $34
You must keep paying your Medicare Part B premium.
If you receive premium assistance, your plan premium may be
reduced.
Medical deductible $240* in-network Part B deductible

*You pay the same amount as The following services listed are excluded from the in-network Part B
you would with Original Medicare. deductible:
Ambulance Services
Chemotherapy Drugs and Administration
Diabetic Monitoring Supplies
Emergency Room Services
Part A Services (IP, Skilled Nursing and Home Health)
Medicare Covered Preventive Services
Medicare Part B Covered Drugs
Services not covered by Original Medicare
Urgently Needed Services at Urgent Care Centers
Pharmacy (Part D) deductible $545
Maximum out-of-pocket $8,850 in-network
responsibility The most you pay for copays, coinsurance and other costs for covered
medical services for the year.

Covered Medical and Hospital Benefits

INPATIENT HOSPITAL CARE
Your plan covers an unlimited number of days for $2,080 copay per admit
an inpatient stay
OUTPATIENT HOSPITAL COVERAGE
Services listed below may also be covered at other places of treatment. Please refer to specific services
listed in this document for additional information.
Advanced imaging services (MRI, MRA, PET and CT $300 copay
scan)
Basic radiological services (X-rays) 20% of the cost
Cardiac rehabilitation services 20% of the cost
Chemotherapy drugs 20% of the cost

Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other
providers in the network. This is called a "referral." 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 referral and/or prior authorization from the plan.
c

4 Summary of Benefits H5619134000SB24

 H5619134000
Covered Medical and Hospital Benefits (cont.)
Diagnostic colonoscopy $0 copay
Diagnostic mammography $0 copay
Diagnostic procedures and tests - other 20% of the cost
Lab services 20% of the cost
Medicare Part B covered drugs 20% of the cost
Mental health services 20% of the cost
Nuclear medicine services 20% of the cost
Occupational therapy 20% of the cost
Opioid treatment program services 20% of the cost
Physical therapy 20% of the cost
Pulmonary rehabilitation services $15 copay
Renal dialysis services 20% of the cost
Sleep study (facility based) 20% of the cost
Speech therapy 20% of the cost
Substance abuse services 20% of the cost
Supervised Exercise Therapy (SET) for Peripheral $25 copay
Artery Disease (PAD)
Surgery services 20% of the cost
Therapeutic radiology (Radiation therapy) 20% of the cost
Wound care 20% of the cost
AMBULATORY SURGERY CENTER
Diagnostic colonoscopy $0 copay
Surgery services 20% of the cost
DOCTOR OFFICE VISITS
Primary care provider (PCP) 20% of the cost
Specialist 20% of the cost

Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other
providers in the network. This is called a "referral." 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 referral and/or prior authorization from the plan.
c

H5619134000SB24 Summary of Benefits 5

 H5619134000
Covered Medical and Hospital Benefits (cont.)
PREVENTIVE CARE
Our plan covers many preventive services at no • Abdominal aortic aneurysm screening
cost when you see an in-network provider • Alcohol misuse screening & counseling
including: • Annual Wellness Visit (AWV)
• Bone mass measurement
• Breast cancer screening (mammogram)
• Cardiovascular disease risk reduction visit
• Cardiovascular disease screening
• Cervical and vaginal cancer screening
• Colorectal cancer screening
• Depression screening
• Diabetes screening
• Diabetes self-management training
• Glaucoma screening
• HIV screening
• Immunizations
• Lung cancer screening
• Medical nutrition therapy
• Medicare Diabetes Prevention Program (MDPP)
• Obesity screening and therapy
• Prostate cancer screening exams
• Routine physical exam
• Sexually transmitted infections (STIs) screening
and counseling
• Smoking and tobacco use cessation (counseling to
stop smoking or tobacco use)
• "Welcome to Medicare" preventive visit
Any additional preventive services approved by
Medicare during the contract year will be covered.
EMERGENCY CARE
Emergency services at emergency room $100 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.
Physician and professional services at emergency $0 copay
room
URGENTLY NEEDED SERVICES
N/A $55 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.

Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other
providers in the network. This is called a "referral." 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 referral and/or prior authorization from the plan.
c

6 Summary of Benefits H5619134000SB24

 H5619134000
Covered Medical and Hospital Benefits (cont.)
DIAGNOSTIC SERVICES, LABS & IMAGING
Advanced imaging services (MRI, MRA, PET and CT • Freestanding radiological facility: $200 copay
scan) • Primary care physician's office: $200 copay
• Specialist's office: $200 copay
Basic radiological services (X-rays) • Freestanding radiological facility: $50 copay
• Primary care physician's office: 20% of the cost
• Specialist's office: 20% of the cost
• Urgent care center: 20% of the cost
Diagnostic colonoscopy • Ambulatory surgery center: $0 copay
Diagnostic mammography • Freestanding radiological facility: $0 copay
• Specialist's office: $0 copay
Diagnostic procedures and tests • Primary care physician's office: 20% of the cost
• Specialist's office: 20% of the cost
• Urgent care center: 20% of the cost
Lab services • Freestanding laboratory: $10 copay
• Primary care physician's office: $0 copay
• Specialist's office: $0 copay
• Urgent care center: 20% of the cost
Nuclear medicine and services • Freestanding radiological facility: 20% of the cost
Sleep study • Member's home: $0 copay
• Specialist's office: 20% of the cost
Therapeutic radiology (Radiation therapy) • Freestanding radiological facility: 20% of the cost
• Specialist's office: 20% of the cost

Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other
providers in the network. This is called a "referral." 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 referral and/or prior authorization from the plan.
c

H5619134000SB24 Summary of Benefits 7

 H5619134000
Covered Medical and Hospital Benefits (cont.)
HEARING SERVICES
Medicare-covered hearing 20% of the cost
Mandatory supplemental hearing benefit In-Network:
HER945
• $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.
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
• Rechargeable style options available for an
additional $50 per aid.
You must see a TruHearing provider to use this
benefit. Call 1-844-255-7144 to schedule an
appointment (for TTY, dial 711).
DENTAL SERVICES
Medicare-covered dental 20% of the cost
Mandatory supplemental dental benefit The cost-share indicated below is what you pay for
the covered service.
In-Network:
DEN339
• $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 bridge recementation,
bridges-pontic, crown recementation, panoramic
film or diagnostic x-rays up to 1 every 5 years.
• $0 copay for bridges-crown up to 2 every 5 years.
• $0 copay for crown, other restorative services -
core buildup and prefabricated post and core, 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.
• $0 copay for emergency diagnostic exam up to 1
per year.
Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other
providers in the network. This is called a "referral." 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 referral and/or prior authorization from the plan.
c

8 Summary of Benefits H5619134000SB24

 H5619134000
Covered Medical and Hospital Benefits (cont.)

• $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.
• $2,000 maximum benefit coverage amount per
year for all preventive and comprehensive
benefits.
Limitations and exclusions may apply. Submitted
claims are subject to a review process which may
include a clinical review and dental history to
approve coverage. Dental benefits under this plan
may not cover all ADA procedure codes. Any services
received that are not listed will not be covered by the
plan and will be the member's responsibility. The
member is responsible for any amount above the
dental coverage limit. Benefits are offered on a
calendar year basis. Any amount unused at the end
of the year will expire. Information regarding each
plan is available at Humana.com/sb .

In-network dentists have agreed to provide covered

services at contracted rates (per the in-network fee
schedules, or INFS). If a member visits a participating
network dentist, the member cannot be billed for
charges that exceed the negotiated fee schedule
(but coinsurance payment still applies).

The Mandatory Supplemental Dental benefits are

provided through the Humana Dental Medicare
Network. The provider locator can be found at
Humana.com > Find a doctor > Select the Dentist
icon from the menu > Enter Zip code > From the
Distance drop down select the preferred distance >
From the look up method select All Dental Networks
> Then select HumanaDental Medicare.
VISION SERVICES
Eyewear (post cataract surgery) 20% of the cost
Medicare-covered diabetic eye exam $0 copay

Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other
providers in the network. This is called a "referral." 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 referral and/or prior authorization from the plan.
c

H5619134000SB24 Summary of Benefits 9

 H5619134000
Covered Medical and Hospital Benefits (cont.)
Medicare-covered vision services 20% of the cost
The provider location for Medicare-covered vision can
be found at Humana.com > Find a Doctor > select
the Medical icon > enter Zip Code > select look up
Method > Medicare or Medicare-Medicaid > select
your plan Network > select Search Category >
Specialty Physician.
Mandatory supplemental vision benefit In-Network:
VIS735
• $0 copay for routine exam up to 1 per year.
• $200 maximum benefit coverage amount per
year for contact lenses or eyeglasses-lenses and
frames, fitting for eyeglasses-lenses and frames.
• $250 maximum benefit coverage amount per
year at PLUS Provider 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.
• Maximum benefit coverage amounts cannot be
combined.
PLUS providers are part of the Humana Medicare
Insight Network and are indicated in the provider
locator search results.
The provider locator for the Humana Medicare
Insight Network for Mandatory supplemental benefit
vision can be found at Humana.com > Find a Doctor
> select the Vision Care icon > select Medicare >
select Medicare Advantage.

MENTAL HEALTH SERVICES

Inpatient $1,937 copay per admit
Your plan covers up to 190 days in a lifetime for
inpatient mental health care in a psychiatric
hospital
Therapy visits • Partial hospitalization: $70 copay
• Specialist's office: $0 copay

Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other
providers in the network. This is called a "referral." 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 referral and/or prior authorization from the plan.
c

10 Summary of Benefits H5619134000SB24

 H5619134000
Covered Medical and Hospital Benefits (cont.)
SKILLED NURSING FACILITY (SNF)
Your plan covers up to 100 days in a SNF $0 copay per day for days 1-20
$203 copay per day for days 21-65
$0 copay per day for days 66-100
PHYSICAL THERAPY
Comprehensive outpatient rehab facility 20% of the cost
Specialist's office 20% of the cost
AMBULANCE
Air $1250 copay per date of service
Ground $300 copay per date of service
TRANSPORTATION
N/A $0 copay for plan approved location up to 24
one-way trip(s) per year.
This benefit is not to exceed 75 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
Allergy shots and serum • Primary care physician's office: $0 copay
• Specialist's office: $0 copay
Chemotherapy drugs • Specialist's office: 20% of the cost
Other Part B drugs • Pharmacy: $0 copay
Some rebatable Part B drugs may be subject to a • Primary care physician's office: 20% of the cost
lower coinsurance. • Specialist's office: 20% of the cost
You pay no more than $35 for a one-month (up to
30-day) supply for all Part B insulin covered by our
plan, and if your plan has a deductible it does not
apply to Part B insulin.

Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other
providers in the network. This is called a "referral." 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 referral and/or prior authorization from the plan.
c

H5619134000SB24 Summary of Benefits 11

 H5619134000
Prescription Drug Benefits
PLAN HIGHLIGHTS
Insulin costs You won't pay more than $35 for a one-month (up
to 30-day) supply of each insulin product covered by
your plan
100-day supply Up to 100-day supply on eligible drugs
Additional gap coverage Additional gap coverage for the following:
Insulin
$0 vaccines $0 copay for adult Part D covered vaccines
recommended by the Advisory Committee on
Immunization Practices (ACIP)
DEDUCTIBLE
This plan has a $545 deductible . You pay the full cost of your drugs until you reach $545. Then, you only
pay your cost-share.
INITIAL COVERAGE
You pay the following until your total yearly drug costs for covered drugs reach $5,030. 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.

Pharmacy Cost-Sharing
N/A Retail Cost-Sharing Mail-Order Cost-Sharing
Includes all in-network retail
pharmacies
Day supply 30-day 100-day* 30-day 100-day*
All Plan-Covered Part D Drugs 25% 25% 25% 25%
Other pharmacies are available in your network. To find which pharmacies are available in your network,
go to Humana.com/pharmacyfinder .

*Some drugs are limited to a 30-day supply and others may be eligible for up to a 100-day supply.

You won't pay more than $35 for a one-month (up to 30-day) supply of each plan-covered insulin
product , even if you haven't paid your deductible .

Insulin Cost-Sharing
N.A Retail Cost-Sharing Mail-Order Cost-Sharing
Includes all in-network retail
pharmacies
Day supply 30-day 100-day* 30-day 100-day*
All Plan-Covered Part D Insulins $35 $105 $35 $105

12 Summary of Benefits H5619134000SB24

 H5619134000
Other pharmacies are available in your network. To find which pharmacies are available in your network,
go to Humana.com/pharmacyfinder .

*Some drugs are limited to a 30-day supply and others may be eligible for up to a 100-day supply.

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 $8,000 —
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 3 (Preferred Brand) - Insulin
Tier 5 (Specialty Tier) - Insulin
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 reach $8,000 you pay $0 for plan-covered Part D drugs.

EXTRA HELP
If you receive "Extra Help" for your drugs you will have a $0 deductible.

Prior to reaching your annual $8,000 out-of-pocket limit you will pay one of the following depending on
your level of "Extra Help:"

• $4.50 for generic/preferred multi-source drug or biosimilar; $11.20 for any other drug; OR
• $1.55 for generic/preferred multi-source drug or biosimilar; $4.60 for any other drug; OR
• $0 for all drugs

After reaching your annual $8,000 out-of-pocket limit, you will pay $0 for the remainder of the calendar
year, regardless of the level of "Extra Help" you receive. Additional information will be available on your
LIS rider.
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 at an in-network long-term care facility, you pay the same as you would at an in-network
retail pharmacy. Under certain situations you may be able to get drugs from an out-of-network pharmacy
but may pay more than you would pay at an in-network pharmacy.

H5619134000SB24 Summary of Benefits 13

 H5619134000
Additional Benefits
Chiropractic services (Medicare-covered) 20% of the cost
Podiatry services (Medicare-covered) 20% of the cost
Acupuncture services (Medicare-covered) 20% coinsurance for acupuncture for
chronic low back pain visits up to 20
visit(s) per year.
MEDICAL EQUIPMENT/SUPPLIES
Diabetic monitoring supplies • Diabetic supplier: 20% of the cost
• Network retail pharmacy: $0 copay
• Preferred diabetic supplier: $0 copay
Durable medical equipment (DME) and related • Durable medical equipment provider: 20% of the
supplies cost
Medical supplies • Medical supplier: 20% of the cost
Prosthetic devices and related supplies • Prosthetics provider: 20% of the cost
REHABILITATION SERVICES
Cardiac rehabilitation services • Specialist's office: 20% of the cost
Occupational therapy • Comprehensive outpatient rehab facility: 20% of
the cost
• Specialist's office: 20% of the cost
Physical therapy • Comprehensive outpatient rehab facility: 20% of
the cost
• Specialist's office: 20% of the cost
Pulmonary rehabilitation services • Specialist's office: $15 copay
Speech therapy • Comprehensive outpatient rehab facility: 20% of
the cost
• Specialist's office: 20% of the cost
Supervised Exercise Therapy (SET) for Peripheral • Specialist's office: $25 copay
Artery Disease (PAD)
TELEHEALTH SERVICES (in addition to Original Medicare)
Primary care physician's office $0 copay
Specialist 20% of the cost
Substance abuse and behavioral health services $0 copay
Urgent care services $0 copay

14 Summary of Benefits H5619134000SB24

 H5619134000
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/plandocuments to view a copy of the EOC or
call 1-800-833-2364 .

Over-the-Counter (OTC) Allowance Humana Spending Account Card

$100 quarterly allowance on a prepaid The Humana Spending Account Card is
card to buy approved over-the-counter what you use to spend allowances
health and wellness products at included in this plan. If your previous
participating retail locations. plan had a Humana Spending Account
Card, please keep using the same card.
Allowance amount cannot be combined If your previous plan did not have a
with other allowances which may be on Humana Spending Account Card, please
the Card. activate your card as soon as you
receive it in the mail.
Unused amount expires at the end of
the quarter. Please keep this card even after the
allowance is spent as future allowance
• Quarterly allowance amounts are amounts will be added to this card.
available to use at the beginning of • Humana is not responsible for funds
January, April, July, and October. lost due to lost or stolen cards.
• Limitations and restrictions may • Please see the back of your card for
apply. more information.
• Allowance amounts cannot be
See the Humana Spending Account
combined with other benefit
Card section for more details.
allowances on the card.
• Limitations and restrictions may
apply.

Chiropractic services
$0 copay for routine chiropractic visits
up to 12 visit(s) per year.

H5619134000SB24 Summary of Benefits 15

 H5619134000
Smoking cessation program
To further assist in your effort to quit
smoking or tobacco product use, we
cover one additional counseling quit
attempt within a 12-month period as a
service with no cost to you. This is in
addition to the two counseling attempts
provided by Medicare and includes up to
four face-to-face visits. This service can
be used for either preventive measures
or for diagnosis with a tobacco related
disease.

Humana Well Dine® Meal Program

Humana's meal program for members
with certain special needs plan (SNP)
specific conditions or 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 in person and digital fitness
classes.

16 Summary of Benefits H5619134000SB24

 H5619134000
Notes

H5619134000SB24 Summary of Benefits 17

 H5619134000
Notes

18 Summary of Benefits H5619134000SB24

Important________________________________________________

H5619134000
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, national
origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity, marital status,
religion, or language. Discrimination is against the law. Humana and its subsidiaries comply with applicable
federal civil rights laws. If you believe that you have been discriminated against by Humana or its
subsidiaries, there are ways to 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, Office
for Civil Rights electronically through their Complaint Portal, available at
https://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 remote
interpretation, and written information in other formats to people with disabilities when such auxiliary aids
and services are necessary to ensure an equal opportunity to participate.

GHHLNNXEN 0623

H5619134000SB24 Summary of Benefits 19

 H5619134000

20 Summary of Benefits H5619134000SB24

 H5619134000

H5619134000SB24 Summary of Benefits 21

22

Find out more

You can see our plan's provider and pharmacy directory at our website at
humana.com/finder/search or call us at the number listed at the beginning of
this booklet and we will send you one.
You can see our plan's drug guide at our website at
humana.com/medicaredruglist or call us at the number listed at the beginning
of 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 different
for Original Medicare telehealth. Limitations on telehealth services, also referred to as virtual visits or
telemedicine, vary by state. These services are not a substitute for emergency care and are not intended to
replace your primary care provider or other providers in your network. Any descriptions of when to use telehealth
services are for informational purposes only and should not be construed as medical advice. Please refer to your
evidence of coverage for additional details on 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.
All product names, logos, brands and trademarks are property of their respective owners, and any use does not
imply endorsement.

22 Summary of Benefits H5619134000SB24

 The information you need is just a click away.
Visit Humana.com/PlanDocuments to check details about your plan, including benefits and
costs.

If you'd like a printed Evidence of Coverage, Provider Directory, or Drug List mailed to you, you
can request one online at the website above, or call 1-800-457-4708 (TTY: 711), 24 hours a day,
seven days a week. Please have your Humana member ID card ready when you call. When asked
for the reason you've called, say "Evidence of Coverage," "Drug List" or "Provider Directory."

Activate your secure MyHumana account.

Your online MyHumana account is an important part of your Humana membership. Use it to view
your plan details anytime and access important plan documents online, all in one place. It's easy
to use and tailored to you.

Already have an account?

Go to Humana.com/MyHumanaPlan and log in.

Don't have an account yet?

Create one using the same link above in just minutes.

Complete your Medicare Health Assessment

Reply to nine simple questions about your health. Your answers will help us guide you to tools
and resources in your plan that may help you reach your health goals and live the way you want.

Two easy options

Call our automated voice service at 888-445-3379 (TTY: 711). Have your eight-digit member ID
number handy—it’s located on the front of your Humana member ID card.
OR log in to your MyHumana account.

Receiving information about other insurance products

As a Humana member, we may call you to offer other insurance-related products. You can opt
out of those future calls by calling the Customer Care number on the back of your ID card.

H5619134000SB24 Summary of Benefits 23

 Humana Inc.
P.O. Box 14168
Lexington, KY 40512-4168

Important information about your plan

Humana.com
H5619_SB_MAPD_HMO_134000_2024_M

24 Summary of Benefits H5619134000SB24