We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, give you other plans' brochures and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, disability leave, pensions, etc. you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact Humana directly for address updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. 

The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

Contact your carrier to add a family member when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a family member if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.  

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2023 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2022 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment; or
• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31^st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60^th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (a non-FEHB individual policy).

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM’s website at www.opm.gov/healthcare-insurance/healthcare/plan-information/. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn 26.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
• You decided not to receive coverage under TCC or the spouse equity law; or 
• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage. 

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact customer service on the back of your ID card or visit www.HealthCare.gov.

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800-426-2173 or write to us at
P.O. Box 14602, Lexington, KY 40512-4602. You may also request replacement cards through our website at https://feds.humana.com/.

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments or coinsurance, and you will not have to file claims.

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website at https://feds.humana.com/.

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

This plan provides Care Coordinators for complex conditions and can be reached for assistance by calling 1-800-4HUMANA.

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website at https://feds.humana.com/.

FEHB Carriers must have clauses in their in-network (participating) provider agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, coinsurance) contact Humana to enforce the terms of its provider contract.

You get care from "Plan providers" and "Plan facilities." You will only pay copayments and/or coinsurance. You can receive covered services from a participating provider without a required referral from your primary care physician or by another participating provider in the network. We call this open access.

Your primary care physician can be a general practitioner, family practitioner, internist, or pediatrician.  Your primary care physician will provide most of your healthcare or give you a referral to see a specialist.

You may see any participating specialist without a referral, including: 

• Mental health providers
• Vision care providers
• OB/GYN providers for your annual well-woman exam
• Another doctor your primary care physician has designated to provide patient care when he or she is not available.

Here are some other things you should know about specialty care:

If your current specialist does not participate with us, you must receive treatment from a specialist who does. We will not pay for you to see a specialist who does not participate with our Plan.

• If you have a chronic and disabling condition and lose access to your specialist because we:
• terminate our contract with your specialist for other than cause;
• drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan; or
• reduce our Service Area and you enroll in another FEHB plan;

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800-4HUMANA. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;

• the day your benefits from your former plan run out; or

• the 92nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. 

Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain prior approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. You must obtain prior authorization for:

• Organ/tissue transplants
• All elective medical and surgical hospitalizations (Including Inpatient Hospice)
• Non-emergent admissions for mental health, skilled nursing and acute rehabilitation facilities and long term acute care facilities.
• MRI, MRA, PET, CT Scan, SPECT Scan
• Surgical treatment for morbid obesity
• All durable medical equipment (DME) over $750
• Home health care services (Including home hospice)
• Infertility testing and treatment
• Some specialty drugs when delivered in the physician's office, clinic, outpatient or home settings
• All surgeries which may be considered plastic or cosmetic surgery only for repair of accidental injury
• Oral surgeries
• Outpatient Therapy Services for Physical, Occupational and Speech
• Genetic/Molecular Diagnostic Testing – (Genetic testing is covered under the laboratory services benefit, limitations may apply.)
• Chiropractic
• Radiation Therapy
• Acupuncture
• Esophagogastroduodenoscopy (EGD)
• Coronary angiography
• Colonoscopy repeat testing

For a complete listing of the services requiring prior authorization, please visit our website at www.humana.com. See commercial list.

First, your physician, your hospital, you, or your representative, must call us at the phone number printed on your Humana ID card or 1-800-448-6262 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

• enrollee’s name and Plan identification number;
• patient’s name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay.

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 1-800-4HUMANA or 1-800-448-6262. You may also call OPM’s FEHB 3 at 1-(202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 1-800-4HUMANA or 1-800-448-6262. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.  

Precertification is not required for maternity care.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

This plan does not offer out-of-network coverage, except for emergent care situations. If no authorization is received or approved, you will be responsible for all costs of such services.

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 1-800-4-HUMANA.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.

   You or your provider must send the information so that we receive it within 60 days, of our request. We will then decide within 30 more days. 
   
   If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g. coinsurance, and copayments) for the covered care you receive.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: When you see your primary care physician, you pay a copayment of $20 per office visit on the High Option Plan, or a $35 copay on the Standard Option Plan.

Coinsurance is the percentage of our allowance that you must pay for your care.

Example: In our Plan, you pay 50% of charges for infertility services.

You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act. 

After your (copayments and coinsurance) total $8,150 for Self Only, or $16,300 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services.

The maximum annual limitation on cost sharing listed under Self Only of $8,150 for the High and Standard Option plan applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Example Scenario: Your plan has a $8,150 Self Only maximum out-of-pocket limit and a $16,300 Self Plus One or Self and Family maximum out-of-pocket limit. If you or one of your eligible family members has out-of-pocket qualified medical expenses of $8,150 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan. With a Self and Family enrollment out-of-pocket maximum of $16,300, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $16,300 for the calendar year before their qualified medical expenses will begin to be covered in full. 

Be sure to keep accurate records and receipts of your copayments and coinsurance since you are responsible for informing us when you reach the maximum.

If you changed to this plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your prior option to the catastrophic protection limit of your new option.

Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a nonparticipating healthcare provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan. Your health plan must comply with the NSA protections that hold you harmless from unexpected bills.

In addition, your health plan adopts and complies with the surprise billing laws of Florida.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to https://humana.com or contact the health plan at 1-800-4HUMANA.

• Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Professional services of physicians

• In physician’s office
• Office medical consultations
• At home
• Second surgical opinion
• Advance care planning

$20 copay per office visit to your primary care physician

$40 copay per office visit to a specialist

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

• During a hospital stay
• In a skilled nursing facility

• In an urgent care center

$40 copay per visit

$55 copay per visit

Telemedicine (also known as “telehealth,” "virtual visits" or “video visits”) uses information technology and telecommunications to provide virtual clinical care to patients. Patients can interact with Network Primary/Specialty Care providers through video and app technology by using smartphones, tablets, and laptops.

With Humana's telemedicine benefit delivered by Doctor On Demand, you can:

• Connect with a physician from one of Doctor On Demand’s U.S. board-certified doctors
• Immediately see a doctor 24 hours a day, 7 days a week from any location
• Your primary care physician can access your telemedicine visit at your request
• If medically necessary, the telemedicine doctor can send a prescription to a preferred pharmacy

Note: In addition to using Doctor On Demand for telehealth visits, you can talk to other providers to see if they are offering video chat or phone-only visits at normal cost-share.

$20 copay per office visit to your primary care physician

$35 copay per office visit to your primary care physician

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap test
• Pathology
• X-ray
• Non-routine mammogram
• Ultrasound
• Electrocardiogram and EEG
• Coronary angiography (Note: See You need prior plan approval for certain services in Section 3)

Note: See Section 5(c) for some services billed by a facility, such as the outpatient department of a hospital.

Nothing

Nothing

Other tests:

• Genetic counseling and Genetic testing when medically necessary. Genetic testing may require prior authorization (Note: See You need prior plan approval for certain services in Section 3)

$20 copay per office visit to your primary care physician

$40 copay per office visit to a specialist

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

Routine physical every year

The following preventive services are covered at the time interval recommended at each of the links below:

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening.  For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

• Routine mammogram

Nothing

Nothing

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Nothing

Not covered:

• Physical exams and immunizations required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

• Well-child visits, examinations, and other preventive services as described in the bright Fuiture Guidelines provided by the Americam Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org 
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at
  https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at
  https://www.uspreventiveservicestaskforce.org

Note: Any procedure, injection, diagnostic service, laboratory, or X- ray service done in conjunction with a routine examination and is not included in the preventive recommended  listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes
• Delivery
• Postnatal care

Nothing

Facility copay applies for delivery.

Nothing

Facility copay applies for delivery.

Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal
  delivery; see below for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours
  after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay for you or your baby if medically necessary.
• We cover routine nursery care of the newborn
  child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).
• We offer HumanaBeginnings. See Special features in Section 5(h). 

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

Nothing

Nothing

Contraceptive counseling on an annual basis

Nothing

Nothing

A range of voluntary family planning services, limited to:

• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo-Provera)
• Intrauterine devices (IUDs)
• Diaphragms
• Tubal ligation

Note: We cover oral contraceptives under the prescription drug benefit. See Prescription Drugs in Section 5(f).

Voluntary sterilization (See Surgical Procedures Section 5 (b))

Nothing

Nothing

Not Covered:

• Reversal of voluntary surgical sterilization

Infertility is the condition of an individual who is unable to conceive or produce conception during a period of 1 year if the female is age 35 or younger or during a period of 6 months if the female is over the age of 35. For women without male partners or exposure to sperm, infertility is the inability to conceive after six cycles of Artificial Insemination or Intrauterine Insemination performed by a qualified specialist using normal quality donor sperm. These 6 cycles (including donor sperm) are not covered by the plan as a diagnosis of infertility is not established until the cycles have been completed.

50% of charges

50% of charges

Covered benefits including evaluation and treatment:

Females - ovulation evaluation, tubal patency, hormonal evaluation, and cervical factor evaluation.

Males – includes sperm analysis, hormonal analysis, sperm functioning and medical imaging. Treatment would include correction of any defect found in the evaluation of both male and female partners.

Diagnosis and treatment of infertility, such as:

• Artificial insemination:
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Fertility drugs

Note: Self-injectable and oral fertility drugs are covered under the prescription drug benefit (See You need prior plan approval for certain services in Section 3.)

50% coinsurance

50% coinsurance

Iatrogenic infertility

Some of the requirements for coverage:

• One initial prior authorization request is required for the ongoing treatment of iatrogenic infertility preservation
• Limited to enrollees who have been diagnosed with an impairment of fertility by surgery, including:
• transgender reassignment surgery
• radiation
• chemotherapy
• other medical treatment affecting reproductive organs or processes

Note: If an enrollee or family member leaves the Plan, they will no longer have coverage for iatrogenic infertility preservation and will be responsible for storage and thawing cost. In addition, if an enrollee terminates coverage, the former enrollee is responsible for contacting their new carrier to have preservation services taken over. Humana will align their length of preservation coverage with industry standards which currently states reproductive tissue could be kept for over 10 years and remain viable.

50% coinsurance

50% coinsurance

Not covered:

• Assisted reproductive technology (ART) procedures, such as:
  • In vitro fertilization (IVF)
  • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian tranfser (ZIFT)
• Services and supplies related to excluded ART procedures
• Cost of donor sperm
• Cost of donor egg

All charges

All charges

• Testing and treatment, including test and treatment materials

$20 copay per office visit to your primary care physician

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

• Allergy serum
• Allergy injections

Not covered:

• Provocative food testing
• sublingual allergy desensitization

• Chemotherapy and radiation therapy (Note: See You need prior plan approval for certain services in Section 3)

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 41.

Note: Oral Chemo medications covered under the Pharmacy benefit. (See Section 5(f) for details)

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided.  No visit limitations apply. 
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy (See You need prior plan approval for certain services in Section 3).
• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the Prescription Drug benefit. We only cover GHT when we preauthorize the treatment. Your Plan Physician will ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Section 3 under Other services.

Note: Applied Behavior Analysis (ABA) Children with Autism Spectrum Disorder is described in Section 5(e).

$55 copay per office visit to a specialist

• Applied Behavior Analysis (ABA) Children with Autism Spectrum Disorder

$20 copay per office visit to your primary care physician

$40 copay per office visit to a specialist

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

Up to 60 visits per year per condition for the services of each of the following:

• Qualified physical therapists
• Occupational therapists

Note: We only cover therapy when a physician:

• orders the care
• identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• indicates the length of time the services are needed.

See You need prior plan approval for certain services in Section 3.

$55 copay per visit

• Habilitative services, up to 60 visits per year.

$40 copay per office visit to a specialist

$55 copay per office visit to a specialist

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

60 visits per condition per year for the service of the following:

• Speech therapists

Note: See You need prior plan approval for certain services in Section 3.

$55 copay per visit

• Hearing screening performed during a child's preventive care visit, see Section 5(a) - Preventive care, children.

• Cochlear Implants

20% coinsurance

30% coinsurance

Not covered:

• Hearing services that are not shown as covered

• Diagnosis and treatment of diseases of the eye
• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)

$20 copay per office visit to your primary care physician

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

• Screening eye exam to determine the need for vision correction for children through age 17

Note: See Preventive care, children.

Not covered:

• Eye exercises and orthoptics
• Eyeglasses or contact lenses and examinations for them, except as shown above
• Radial keratotomy and other refractive surgery

• Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

$20 copay per office visit to your primary care physician

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, unless primary medical condition requires such care
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy.

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical procedures.  For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

20% coinsurance

30% coinsurance

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Prosthetic replacements except as required by growth or change in medical condition

We cover rental or purchase, of durable medical equipment, at our option , including repair and maintenance of purchased medical equipment. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Insulin pumps and supplies
• Blood glucose monitors
• Communication devices

Note: Communication devices covered for members who have had surgical removal of the larynx or a diagnosis of permanent lack of function of the larynx.

Note: Preauthorization is necessary for items over $750. 

See You need prior plan approval for certain services in Section 3.

20% coinsurance

30% coinsurance

Not covered:

• Equipment such as exercise equipment, air cleaners, heating pads or lights and bed lifts, hearing aids, personnel hygiene equipment.
• Communication devices except for those members who have had surgical removal of the larynx or a diagnosis of permanent lack of function of the larynx.

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.
• Services include intravenous therapy and medications.

See You need prior plan approval for certain services in Section 3.

$40 copay per visit

$55 copay per visit

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family.
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.
• Private duty nurse.

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

See You need prior plan approval for certain services in Section 3.

$55 copay per office visit

Acupuncture – by a licensed acupuncturist for:

• anesthesia
• pain relief

See You need prior plan approval for certain services in Section 3.

$55 copay per office visit

Not covered:

• Naturopathic services
• Hypnotherapy
• Biofeedback

Coverage is provided for:

• Tobacco Cessation, including individual, group and phone counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.

• Childhood obesity screening programs and treatment interventions

Nothing

Nothing

• Diabetes self management training

$20 copay per office visit to your primary care physician

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopin and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Insertion of internal prosthetic devices. See Section 5(a) Orthopedic and prosthetic devices for device coverage information.
• Voluntary sterilization (e.g., Tubal ligation, Vasectomy)
• Treatment of burns
• Surgical treatment for morbid obesity (bariatric surgery). (Note: See You need prior plan approval for certain services in Section 3.) Some of the requirements that must be met before surgery can be authorized are:
  • Patient is 18 years of age or older
  • Body Mass Index of >40, or a Body Mass Index of >35 with associated comorbidity such as:
    • Hypertension
    • Type two diabetes 
    • Life-threatening cardiopulmonary problems
  • Physician's documentation which indicates that you have had unsuccessful attempt(s) with nonoperative medically- supervised weight-reduction program(s)

• Esophagogastroduodenoscopy (EGD) (Note: See You need prior plan approval for certain services in Section 3)
• Colonoscopy repeat testing (Note: See You need prior plan approval for certain services in Section 3)

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot; (See 5(a) Foot care)

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and that is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts;
  • treatment of any physical complications, such as lymphedemas;
  • breast prostheses and surgical bras and replacements (see Orthopedic and Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

• Gender Affirming Surgery performed to change primary and/or secondary sex characteristics
  • Surgical treatment for gender affirmation is limited to the following:
    • For female to male surgery: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy
    • For male to female surgery: penectomy, orchiectomy

Note: You must be 18 years or older to be considered for genital reconstruction surgery. There are pre-surgical requirements for members considering gender affirming surgery including but not limited to: a documented diagnosis of gender dysphoria, 12 months of hormone therapy as appropriate to the individual gender goals, and referral letters from a mental health specialist.

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury (See 5(a) Foot care)
• Any surgical procedure for gender reassignment not listed above

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;
• Surgical correction of congenital defects such as cleft lip, cleft palate or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures;
• Excision of partially or completely impacted teeth;
• Diagnosis and non-dental treatment of temporomandibular joint syndrome (TMJ);
• Other surgical procedures that do not involve the teeth or their supporting structures.

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
• Dental work related to treatment for temporomandibular joint syndrome (TMJ)

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services on page 17. These solid organ transplants are covered. Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney-pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

Nothing

Nothing

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Kostmann’s syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing’s sarcoma
  • Medulloblastoma
  • Multiple myeloma
  • Pineoblastoma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

Nothing

Nothing

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. 

Refer to Other services in Section 3 for prior authorization procedures:

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

Nothing

Nothing

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence. 

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast Cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon Cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MPDs)
  • Non-small cell lung Cancer
  • Ovarian Cancer
  • Prostate Cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia
• Autologous Transplants for
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Aggressive non-Hodgkin lymphoma
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial ovarian cancer
  • Mantle cell (non-Hodgkin lymphoma)
  • Multiple sclerosis
  • Small cell lung Cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

Benefits are available for Allogeneic and Autologous blood or marrow stem cell transplants utilizing a phase two or higher protocol.

National Transplant Program (NTP) - all services are determined and authorized through our transplant department, utilizing our National Transplant Network.

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

See You need prior plan approval for certain services in Section 3.

Nothing

Nothing

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered

Professional services provided in –

• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office

Room and board, such as:

• Ward, semiprivate, intensive care or cardiac care accommodations
• General nursing care
• Private accommodations when a Plan doctor determines it is medically necessary
• Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$400 copay per day for the first five (5) days per admission

$600 copay per day for the first five (5) days per admission

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Not covered:

• Blood and Blood componenets if not replaced by the member
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as phone, television, barber services, guest meals and beds

• Pre-surgical testing
• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service

$400 copay per visit

$500 copay per visit

• Outpatient services, such as: MRI, MRA, CT, PET and SPECT (Note: See You need prior plan approval for certain services in Section 3)

• Voluntary sterilization

• Other outpatient non-surgical care such as mammograms, laboratory tests and X-rays

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

Not covered: 

• Blood and Blood components if not replaced by the member

Extended care benefit:

Up to 100 days per calendar year, including:

• Bed and board
• General nursing care
• Drugs, biologicals, supplies and equipment provided by the facility

Note: Coverage is provided when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan.

$400 copay per day for the first three (3) days per admission

$600 copay per day for the first three (3) days per admission

Not covered: 

• Custodial care

Supportive and palliative care for a terminally ill member is covered in the home or hospice facility. Services include:

• Inpatient care
• Outpatient care
• Bereavement counseling

Note: These services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

See You need prior plan approval for certain services in Section 3.

Nothing

Not covered:

• Independent nursing
• homemaker services

• Hospice coordination
• Education and support services
• Humana At Home Coordination

$50 copay

$50 copay

• Emergency care at a doctor’s office

$20 copay per office visit to your primary care physician

$40 copay per office visit to a specialist

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

• Emergency care at an urgent care center

$55 copay per visit

• Emergency care as an outpatient at a hospital, including doctors’ services

Note: If admitted, hospital copays apply. See Section 5(c) for Inpatient hospital services.

$200 copay per visit

$250 copay per visit

Not covered:

• Elective care or non-emergency care

• Emergency care at a doctor’s office

$20 copay per visit to your primary care physician

$40 copay per visit to a specialist

$35 copay per visit to your primary care physician

$55 copay per visit to a specialist

• Emergency care at an urgent care center

$55 copay per visit

• Emergency care as an outpatient at a hospital, including doctors’ services

$200 copay per visit

$250 copay per visit

Not covered:

• Elective care or non-emergency care
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a
  normal full-term delivery of a baby outside the service area

Professional ambulance service

See Section 5(c) for non-emergency service.

Note: Air ambulance is covered only when point of pick-up is inaccessible by land vehicle; or great distances or other obstacles are involved in getting a patient to the nearest hospital with appropriate facilities when prompt admission is essential.

$50 copay

$50 copay

Telemedicine (also known as “telehealth,” "virtual visits" or “video visits”) uses information technology and telecommunications to provide virtual clinical care to patients. Patients can interact with Network Primary/Specialty Care providers through video and app technology by using smartphones, tablets, and laptops.

With Humana's telemedicine benefit delivered by Doctor On Demand, you can:

•  Connect with a physician from one of Doctor On Demand’s U.S. board-certified doctors
•  Immediately see a doctor 24 hours a day, 7 days a week from any location
•  Your primary care physician can access your telemedicine visit at your request
•  If medically necessary, the telemedicine doctor can send a prescription to a preferred pharmacy

$20 copay per office visit to your primary care physician

$35 copay per office visit to your primary care physician

When we approve a treatment plan, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of substance use disorders including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy

$35 copay per visit

• Outpatient diagnostic tests and services such as: MRI, MRA, CT, PET, and SPECT when provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

Inpatient services provided and billed by a hospital or other covered facility, including residential facilities

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services, including Telemedicine

$400 copay per day for the first five (5) days per admission

$600 copay per day for the first five (5) days per admission

Outpatient services provided and billed by a hospital or other covered facility, including residential facilities

• Services in approved treatment programs, such as partial hospitalization or full-day hospitalization

• Facility-based intensive outpatient treatment

Nothing

Nothing

Applied Behavior Analysis (ABA) Children with Autism Spectrum Disorder

$20 copay per office visit to your primary care physician

$35 copay per office visit to your primary care physician

• Urgent Care
• Physical, Occupational, Speech and Habilitiative therapies for Mental Health (Note: See You need prior plan approval for certain services in Section 3)
• Nutritional Counseling for Eating Disorders
• Telemedicine when using Participating Providers

$20 copay per visit

$35 copay per visit

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

• Drugs and medicines that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Insulin
• Diabetes supplies including testing agents, lancet devices, alcohol swabs, glucose elevating agents, insulin delivery devices and blood glucose monitors
  • Disposable needles and syringes for the administration of covered medications
• Self administered injectable drugs
• Oral fertility drugs
• Oral chemo medications -Your cost share for covered orally administered anticancer medications for the treatment of cancer will not exceed $50 per month supply
• Growth hormone
• Drugs for sexual dysfunction
• Drugs or drug therapies for the treatment of gender dysphoria supported by FDA approved prescribing information and/or clinical treatment guidelines
• Weight loss drugs 

Note: Drugs to treat sexual dysfunction are limited. Contact the Plan for dosage limits. You pay the applicable drug copay up to the dosage limits, and all charges after that.

$10 copay for Level One drugs

$45 copay for Level Two drugs

$65 copay for Level Three drugs

$100 copay for Level Four drugs

25% coinsurance for Level Five drugs (specialty drugs may be limited to a 30-day supply)

2.5 applicable copays for a 90-day supply of prescribed maintenance drugs, when ordered through our mail order program.

$10 copay for Level One drugs

$45 copay for Level Two drugs

$65 copay for Level Three drugs

$100 copay for Level Four drugs

25% coinsurance for Level Five drugs (specialty drugs may be limited to a 30-day supply)

2.5 applicable copays for a 90-day supply of prescribed maintenance drugs, when ordered through our mail-order program.

Contraceptive drugs and devices as listed in the ACA/HRSA site. Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below.

• Women's contraceptive drugs and devices, including the "morning after pill"
• Reimbursement for over-the-counter contraceptives can be submitted
  • For reimbursement for OTC contraceptives, a prescription from your physician and a receipt from an in-network pharmacy will need to be submitted to Humana. Standard formulary coverage, tiering (copayments) and utilization management will apply.

Note: Not all contraceptives are on the ACA drug list at $0 cost share. Please refer to your Rx5 drug list for the appropriate cost share. Some contraceptives are only available through provider administration. Please refer to Section 5(a) for these services.

Nothing

Nothing

• Over-the-counter drugs when prescribed by a physician (only applies to proton pump inhibitors, non-sedating antihistamines and ocular allergy agents)

• Tobacco Cessation drugs

Note: The above over-the-counter drugs and devices approved by the FDA require a written prescription by an approved provider. Some restrictions apply.

Nothing

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Nonprescription medications unless specifically indicated elsewhere

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefits. (See page 36.)

All charges

All charges

Preventive Care medications to promote better health as recommended by ACA.

• Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Pre-natal vitamins for pregnant women
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6
• Statin Medications for ages 40 years old or older: generic forms of atorvastation, lovastatin and simvastatin
• Breast cancer risk reduction medications for women with increased risk for breast cancer
• Colonoscopy bowel preparation medications for Adults age 50 to 75
• Prevention of Human Immunodeficiency virus (HIV) Infection – Pre Exposure Prophylaxis (HIV PreP)
• Preventive vaccines for children and adults as recommended by the Advisory Committee on Immunization Practices (ACIP)

Note: The drugs and supplements listed above are covered without cost-share, even if over-the-counter, are prescribed by a healthcare professional and filled at a network pharmacy.

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to
www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Nothing

Not covered:

• Drugs available without a prescription, or for which there is a non-prescription equivalent available, except as listed above
• Drugs and supplies for cosmetic purposes (such as Rogaine)
• Vitamins, fluoride, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them, except as listed above
• Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
• Drugs to enhance athletic performance
• Medical supplies such as dressings and antiseptics
• Medications considered non-formulary on the Rx5 drug list

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefits. (See page 36.)

All charges

All charges

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

Under the flexible benefits option: we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefit agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

Health Assessment:

Members can benefit from completing an Health Assessment annually and using the information to guide their personal health goals; Health Assessments ask about your medical history, health status, and lifestyle to identify health risks and opportunities to improve health behavior.

Biometric Screenings:

A biometric screening is easy to complete and gives you this true picture of your health. You will not only know your numbers, but you will be able to understand them, so you can take charge of your health. It is an empowering way towards living happier and healthier and being your best.

Visit https://feds.humana.com/ for more information on where members can find HA and biometric screenings.

Once you have taken the Health Assessment, check out MyHumana for resources and information to help you improve your overall health. You will also find shop-and-compare tools to help you choose hospitals and doctors, as well as health encyclopedias and practical information about health conditions, prescription drugs, and other health issues. The site also has video and audio health libraries, discounts and coupons for health-related programs.

You may receive messages by phone, mail or e-mail on topics such as mammograms, immunizations, and more.

Registered nurses offer education and support to mothers throughout pregnancy and the baby's first months.

Nurses provide assistance for those facing a crisis or major medical procedure - includes support for parents during neonatal intensive care.

Registered nurses assist those who are following treatment plans or who need continued guidance in reaching their long-term health goals.

Programs that focus on: asthma, cancer, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, diabetes, depression, chronic kidney disease, end-stage renal disease, cystic fibrosis, hypertension, mental illness, multiple sclerosis, Parkinson's disease, and other conditions.

Humana offers telecommunication devices for the deaf (TDD) and Teletype (TTY) phone lines for the hearing impaired. Call 1-800-432-7482 to access the service.

Humana’s Health Coaching offers you personalized action plans and assistance from certified health coaches. Your health coaches are specially trained experts who will educate, motivate, and support you to address: Weight management, Physical activity, Back care, Nutrition, Stress management, and Tobacco Cessation. With Humana’s health coaching model, our virtual well-being coaching partners offer digital programs that are available 24 hours a day, seven days a week throughout the year. Find out more under “Wellness” in the Health & Wellness section on www.MyHumana.com.

Life, relationships, work, money, legal, family and everyday issues, all can be challenging. Sometimes you need help and guidance to come up with the answers and practical solutions. Your Employee Assistance (EAP) and Work-Life Program is here for you and your family – any day, anytime, as often as you need it. Best of all, this is a completely confidential service at no cost to you. Find out more at login.lifeworks.com or by calling 1-844-261-3286.

Members will receive a 50% discount off every Nutrisystem plan, seven free high-protein shakes, and free shipping on all orders. To get started, sign in to Humana.com/LifestyleDiscounts and select the link to Nutrisystem. If you prefer, call Nutrisystem at 1-866-430-8647.

With nearly 600 locations nationwide, members may choose any in-network provider and receive these discounts: 15% off standard prices or 5% off promotional prices. Extra member value: Special set prices, free Lasik exam, affordable financing options, multiple technologies, 100% bladeless procedures, free enhancements for life on most procedures. To get started, sign in to Humana.com/LifestyleDiscounts and select the link to Lasik. If you prefer, call 1-855-645-2020.

Humana teamed up with ProSmileUSATM to offer up to 70% off teeth whitening. ProSmileUSA specializes in Hi-IntensityTM, competitive strength, professional teeth bleaching. To order a teeth whitening kit, sign in to Humana.com/LifestyleDiscounts and select the link to ProSmileUSA.

Protect yourself with identity monitoring and protection services provided by CyberScout®. This benefit provides expert support to help detect fraud, monitor credit activity, and resolve any identity-related issues. To get started or to review a complete list of services and savings, sign in to Humana.com/LifestyleDiscounts and select CyberScout (MyIDManager.com/LifestyleDiscounts).

You will get on-the-spot discounts of up to 30% when you receive services from the WholeHealth Network providers. Choose from: Chiropractic, Massage therapy, Acupuncture. It’s easy to get your savings from more than 37,000 WholeHealth Network providers. To get started, sign in to Humana.com/LifestyleDiscounts. To find a provider in your area, visit the WholeHealth Choices website at Humana.wholehealthmd.com. If you prefer, call WholeHealth at 1-866-430-8647.

Humana provides you access to the TruHearing® program, which may save you 30%–60% on hearing aids. TruHearing provides hearing solutions for virtually every type of hearing loss, care from a local professional in your area, and a worry-free purchase with a 45-day trial and 3-year warranty. To learn more, visit TruHearing.com today or call 1-888-403-3937.

Humana medical and dental members receive our Vision Discount program at no cost. The program offers access to more than 119,000 vision provider locations (access points) including LensCrafters, Pearle Vision, and Target Optical. To locate a network provider, members can call 1-866-995-9316 or via the following method:

Go to Humana.com > Member Resources > Find a Doctor > Vision care

Humana offers individual Dental and Vision products. Go to Humana.com for more information.

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, call us at 1-800-4HUMANA.

When you must file a claim – such as for services you received outside the Plan’s service area – submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.    

Submit your claims to:   Humana Medical Plan, Inc.
                                          P.O. Box 14602 
                                          Attn: Claims Review 
                                          Lexington, Kentucky 40512-4602

Submit your claims to:  Humana Medical Plan, Inc. at the address listed above
or call us at 1-800-4HUMANA or 1-800-448-6262.

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

We will notify you of our decision within 30 days after we receive your post-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, we will permit a healthcare professional with knowledge of your medical condition to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you.

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at;  Humana Medical Plan, Inc., P.O. Box 14546, Attn: Grievance & Appeals Manager, Lexington, KY 40512-4615

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

e) Include your email address (optional for member), if you would like to receive our decision via email. Please note that by giving us your email, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, Health Insurance 3, 1900 E Street, NW, Washington, DC 20415-3630. 

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

You must tell us if you or a covered family member has coverage under any other health plan. You must also tell us if any treatment you receive may be covered by workers’ compensation or any coverage that pays for injuries regardless of who is at-fault for the injury. Other health plans and injury coverage may be considered “double coverage.”

As a condition of receiving benefits under this plan, you agree to cooperate with our efforts to determine whether other coverage may exist and to assist us and our agents as needed. Failure to cooperate with our efforts may result in delay or denial of benefits under this plan. When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at https://feds.humana.com/.

• If you are a dependent or annuitant on this Plan and you have group health insurance through your employer, your employer is the primary payor and we are the secondary payor.
• When you sustain injuries and are entitled to the payment of healthcare expenses under automobile, property, home owners insurance or any other coverage that pays regardless of fault, that insurance coverage is the primary payor and we are the secondary payor.

For more information on NAIC rules regarding the coordinating of benefits, visit the NAIC website at NAIC.org.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan processes the benefit, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

In the event that we provide benefits for treatment that should have been covered by a primary payor, we shall have the right to be repaid from whoever has received any overpayment from us to the extent that we have provided double coverage.

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.)  For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

Every job-related injury or illness should be reported as soon as possible to your supervisor. Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices. If you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment. If your medical treatment is accepted by the Dept. of Labor Office of Workers’ Compensation (OWCP), the provider will be compensated by OWCP. If your treatment is determined not job-related, we will process your benefit according to the terms of this plan, including use of in-network providers. Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it to your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this plan or by OWCP.

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

By accepting benefits under this plan you agree to the following conditions and limitations on the nature of benefits or benefit payments when another person causes an injury or illness or when you are entitled to recover from any other insurance or source of funds that may be available to pay for the injury or illness.

Humana is entitled to recover the full value of the benefits we have paid or provided in connection with your injury or illness. However, when benefits are otherwise provided by this plan we will cover the cost of treatment that exceeds the amount of the payment you received. You and all covered persons agree to promptly notify us that you have asked anyone other than us to make payment for your injuries and to fully cooperate with our efforts to secure our recovery rights. You and your representative also agree to obtain our consent before releasing any party from liability for payment of medical expenses and before disbursing any funds paid by other parties.

When benefits are provided under the Plan in relation to the illness or injury, Humana may, at its option:

• Subrogate, that is, take over your right to pursue recovery from any other parties, insurance carriers or sources of funds that you may have a right to pursue; or
• Enforce a right to reimbursement from any payment(s) you or your representative may obtain from other parties, settlements or insurance coverage.

Our right to recover the full value of the benefits we have paid or provided for shall take first priority (before any of the rights of any other parties are honored) and are not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned. The amount we are entitled to recovery is not subject to reduction based on attorney fees or costs under the “common fund” or similar rules and is fully enforceable regardless of whether you are “made whole” or compensated for the full amount of damages you may have incurred.

Our recovery rights shall apply only to the extent of the full value of benefits provided for the injury or illness. We will provide benefits to cover the cost of treatment that exceeds amounts that are recoverable other insurance coverage or sources of funds.

If you, a covered person or your representative fails to cooperate with the enforcement of our recovery rights we may delay or deny future benefits until cooperation is provided or we are reimbursed.

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on www.BENEFEDS.com or by phone at 1-877-888-3337, (TTY 1-877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition whether the patient is in a clinical trial or is receiving standard therapy. These costs are covered by this plan.
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care. This plan does not cover these costs.
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.

For more detailed information on “What is Medicare?” and “Should I Enroll in Medicare?” please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to be authorized by your Plan PCP.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 1-800-4HUMANA or at our website: https://feds.humana.com/.

Medicare Coordination of Benefits: Humana will not waive the medical copayments, coinsurance, and deductibles for member when original Medicare is the primary payor. Members must enroll in the Humana Value Plan code associated within the service areas listed on the Value Plan brochure and the Humana Medicare Advantage Plan to receive waivers for medical copayments, coinsurance, and deductibles. See the Value Plan brochure (RI 73-829) for more details.

Please review the following examples which illustrates your cost share if you are enrolled in Medicare Part A and B.  

Benefit Description: Deductible
High Option You Pay Without Medicare:  $0
Standard Option You Pay Without Medicare: $0
High Option With Medicare Parts A & B: $0
Standard Option You Pay With Medicare Parts A & B: $0

Benefit Description: Out-of-Pocket Maximum
High Option You Pay Without Medicare: $8,150 Self Only/$16,300 Self Plus One or Self and Family
Standard Option You Pay Without Medicare: $8,150 Self Only/$16,300 Self Plus One or Self and Family
High Option With Medicare Parts A & B: $8,150 Self Only/$16,300 Self Plus One or Self and Family
Standard Option You Pay With Medicare Parts A & B: $8,150 Self Only/$16,300 Self Plus One or Self and Family

Benefit Description: Part B Premium Reimbursement Offered
High Option You Pay Without Medicare: N/A
Standard Option You Pay Without Medicare: N/A
High Option With Medicare Parts A & B: N/A
Standard Option You Pay With Medicare Parts A & B: N/A

Benefit Description: Primary Care Physician
High Option You Pay Without Medicare: $20
Standard Option You Pay Without Medicare: $35
High Option With Medicare Parts A & B: $20
Standard Option You Pay With Medicare Parts A & B: $35

Benefit Description: Specialist
High Option You Pay Without Medicare: $40
Standard Option You Pay Without Medicare: $55
High Option With Medicare Parts A & B: $40
Standard Option You Pay With Medicare Parts A & B: $55

Benefit Description: Inpatient Hospital
High Option You Pay Without Medicare: $400 copay per day for the first five (5) days per admission
Standard Option You Pay Without Medicare: $600 copay per day for the first five (5) days per admission
High Option With Medicare Parts A & B: $400 copay per day for the first five (5) days per admission
Standard Option You Pay With Medicare Parts A & B: $600 copay per day for the first five (5) days per admission

Benefit Description: Outpatient Hospital
High Option You Pay Without Medicare: $400
Standard Option You Pay Without Medicare: $500
High Option With Medicare Parts A & B: $400
Standard Option You Pay With Medicare Parts A & B: $500

Benefit Description: Incentives Offered
High Option You Pay Without Medicare: N/A
Standard Option You Pay Without Medicare: N/A
High Option With Medicare Parts A & B: N/A
Standard Option You Pay With Medicare Parts A & B: N/A

You can find more information about how our plan coordinates benefits with Medicare by calling 1-800-4HUMANA or visit the Medicare website at https://www.medicare.gov/supplements-other-insurance/how-medicare-works-with-other-insurance.

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE 1-800-633-4227, (TTY 1-877-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). However, we will not waive any of our copayments or coinsurance. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan.

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition whether the patient is in a clinical trial or is receiving standard therapy
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care.
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes are generally covered by the clinical trials. This plan does not cover these costs.

See Section 4, page 21.

See Section 4, page 21.

See Section 4, page 21.

Equipment recognized as such by Medicare Part B, that meets all of the following criteria:

• it can stand repeated use; and
• it is primarily and customarily used to serve a medical purpose rather than being primarily for comfort or convenience; and
• it is usually not useful to a person in the absence of sickness or injury; and
• it is appropriate for home use; and
• it is related to the patient’s physical disorder, and the equipment must be used in the member’s home.

A drug, biological product, device, medical treatment, or procedure is determined to be experimental or investigational if reliable evidence shows it meets one of the following criteria:

• when applied to the circumstances of a particular patient is the subject of ongoing phase I, II or III clinical trials, or
• when applied to the circumstances of a particular patient is under study with written protocol to determine maximum tolerated dose, toxicity, safety, efficacy, or efficacy in comparison to conventional alternatives, or
• is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board as required and defined by the USFDA or Department of Health and Human Services, or
• is not generally accepted by the medical community.

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

The determination as to whether a medical service is required to treat a condition, illness, or injury. In order to meet the standard of medical necessity the service must be consistent with symptoms, diagnosis, or treatment; consistent with good medical practice; and the most appropriate level of service that can be safely provided.

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance using Humana's fee schedule for similar providers in your service area.

You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims. We will evaluate whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at the number printed on your Humana ID card or 1-800-448-6262. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

• $20 copay PCP;
• $40 copay specialist

26

•  $400 copay per day for the first five (5) days per admission

47

• $400 copay per visit
• $200 copay per visit
• Nothing

48

• $20 copay PCP; $40 copay specialist
• $200 copay per visit

52

Regular cost-sharing

54

• $10 copay
• $45 copay
• $65 copay
• $100 copay
• 25% coinsurance
• 2.5 applicable copays

57

Nothing

61

No benefit

62

Nothing after $8,150 for Self Only, or $16,300 for Self Plus One or Self and Family enrollment per year.

21

• $35 copay PCP;
• $55 copay specialist

26

•  $600 copay per day for the first five (5) days per admission

47

• $500 copay per visit
• $250 copay per visit
• Nothing

48

• $35 copay PCP; $55 copay specialist
• $250 copay per visit

52

Regular cost-sharing

54

• $10 copay
• $45 copay
• $65 copay
• $100 copay
• 25% coinsurance
• 2.5 applicable copays

57

Nothing

61

No benefit

62

Nothing after $8,150 for Self Only or $16,300 for Self Plus One or Self and Family enrollment.

21