Important Notice from Humana CoverageFirst/Humana Value Plan About
Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that Humana CoverageFirst/Humana Value Plan prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213, (TTY:  800-325-0778). 

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

• Visit www.medicare.gov for personalized help.
• Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.

This brochure describes the benefits of Humana CoverageFirst and Humana Value Plan under contract (CS 2887) between Humana and the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer Service may be reached at 1-800-4HUMANA, 1-800-448-6262 or through our website: https://feds.humana.com/. This plan is underwritten by Humana Health Plan Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan of Texas, Inc., Humana Insurance Company, Humana Medical Plan, Inc., and Humana Health Plan of Ohio, Inc. The address for the CoverageFirst and the Value Plan administrative office is:

Humana Inc.
500 West Main Street
Louisville, KY 40201

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2022, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2022, and changes are summarized on page 17. Rates are shown at the end of this brochure.

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples:

• Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered family member, “we” means Humana Health Plan Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan of Texas, Inc., Humana Insurance Company, Humana Medical Plan, Inc., and Humana Health Plan of Ohio, Inc.
• We limit acronyms to ones you know.  FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean.
• Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.

Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits Program premium.

OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:

• Do not give your plan identification (ID) number over the phone or to people you do not know, except for your healthcare providers, authorized health benefits plan, or OPM representative.
• Let only the appropriate medical professionals review your medical record or recommend services.
• Avoid using healthcare providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
• Carefully review explanations of benefits (EOBs) statements that you receive from us.
• Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.
• Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
• If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
  • Call the provider and ask for an explanation. There may be an error.
  • If the provider does not resolve the matter, call us at 1-800-4HUMANA and explain the situation.
  • If we do not resolve the issue:

CALL - THE HEALTHCARE FRAUD HOTLINE
1-877-499-7295
   OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/  
The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response time.
You can also write to:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC 20415-1100 

• Do not maintain as a family member on your policy:
•     - Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
      - Your child age 26 or over (unless they are disabled and incapable of self-support prior to age 26)

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 have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).

• Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.
• 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 by your provider for services received. 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 is no longer eligible to use your health insurance coverage.

Humana CoverageFirst/Humana Value Plan complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964.

You can also file a civil rights complaint with the Office of Personnel Management by mail at:

Office of Personnel Management
Healthcare and Insurance
Federal Employee Insurance Operations
Attention:  Assistant Director, FEIO
1900 E Street NW, Suite 3400-S
Washington, D.C. 20415-3610

If you believe that Humana Inc. and its subsidiaries have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.

Multi-Language Interpreter Services

English: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call 1- 800-448-6262, TTY 711.

Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1- 800-448-6262, TTY 711.

Tagalog (Tagalog – Filipino): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-448-6262, TTY 711.

Kreyòl Ayisyen (French Creole): ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1- 800-448-6262, TTY 711.

Français (French): ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1- 800-448-6262, ATS 711.

Português (Portuguese): ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1- 800-448-6262 TTY, 711

Italiano (Italian): ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-448-6262, TTY 711

Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-448-6262, TTY 711.

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies. You can also improve the quality and safety of your own healthcare and that of your family members by learning more about and understanding your risks. Take these simple steps:

1. Ask questions if you have doubts or concerns.

• Ask questions and make sure you understand the answers.
• Choose a doctor with whom you feel comfortable talking.
• Take a relative or friend with you to help you take notes, ask questions and understand answers.

2. Keep and bring a list of all the medications you take.

• Bring the actual medication or give your doctor and pharmacist a list of all the medications and dosage that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
• Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.
• Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
• Make sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than you expected.
• Read the label and patient package insert when you get your medication, including all warnings and instructions.
• Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
• Contact your doctor or pharmacist if you have any questions.
• Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

• Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or Provider’s portal?
• Don’t assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your results.
• Ask what the results mean for your care.

4. Talk to your doctor about which hospital or clinic is best for your health needs.

• Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the healthcare you need.
• Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5. Make sure you understand what will happen if you need surgery.

• Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
• Ask your doctor, “Who will manage my care when I am in the hospital?”
• Ask your surgeon:
  • "Exactly what will you be doing?"
  • "About how long will it take?"
  • "What will happen after surgery?"
  • "How can I expect to feel during recovery?"
• Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

• www.jointcommission.org/speakup.aspx. The Joint Commission’s Speak Up™ patient safety program.
• www.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps healthcare organizations to improve the quality and safety of the care they deliver.
• www.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve the quality of care you receive.
• www.bemedwise.org. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medication.
• www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.
• www.ahqa.org. The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions (“Never Events”)

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a healthcare facility. These conditions and errors are sometimes called “Never Events” or “Serious Reportable Events.”

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen. When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error.

You will not be billed for inpatient services related to treatment of specific hospital acquired conditions or for inpatient services needed to correct Never Events, if you use Humana preferred providers. This policy helps to protect you from preventable medical errors and improve the quality of care you receive.

Coverage information

When you lose benefits

This Plan is a Consumer Driven Health Plan and a Point of Service product. OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Humana holds the following accreditations: The National Committee for Quality Assurance (NCQA). To learn more about this plan’s accreditation(s), please visit the following websites: www.ncqa.gov. We recommend you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your healthcare services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory. We give you a choice of enrollment in a Consumer Driven Health Plan (CDHP) or a Value Plan.

How we pay providers

Participating Providers: We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).

Non-Participating Providers: For services rendered by non-participating physicians, the dollar amount of the deductible or benefit percentage is calculated based on a reimbursement schedule established by us.

When you use Participating Providers

When you use participating providers, you receive the highest level of benefits, with less out-of-pocket expenses. You will not have to submit claim forms. You pay only the copayments, coinsurance, and deductibles described in this brochure.

When you use Non-Participating Providers

When you use a non-participating provider, we will pay benefits at a lower level and you will pay a larger share of the costs. Since non-participating providers have not agreed to accept discounted or negotiated fees as payment in full, they may balance bill you for charges in excess of the allowable amount. You will be responsible for charges in excess of the allowable amount in addition to any applicable deductible or coinsurance. Any amount that you pay to a non-participating provider in excess of your coinsurance (percentage of the allowable fee) will not apply to your out-of-pocket limit or deductible.

General features of our Consumer Driven Health Plan (CDHP)

Our Consumer Driven Health Plan is a comprehensive medical plan. You can see participating or non-participating providers without a referral.

The Plan pays the first $1,000 of covered medical services for each person enrolled. We call this your benefit allowance. While using the $1,000 benefit allowance, you are only responsible for the applicable copayments and coinsurance. The amount the plan deducts from your allowance for a particular service is based on the price Humana has negotiated with the healthcare provider. You do not have to submit receipts for reimbursement. The benefit allowance can only be used to pay for covered medical services from participating providers. Any benefit allowance that remains at the end of the Plan year cannot be “rolled over” or “cashed out.”

The following services do not reduce your $1,000 benefit allowance:

• Preventive Care services are separate and do not apply toward the benefit allowance. The costs of the services are not subject to the deductible.
• Prescription Drug copayments do not apply toward your benefit allowance. You are only responsible for applicable copayments or coinsurance when you use a participating provider. The costs of the services are not subject to the deductible.

Once you spend your $1,000 benefit allowance, you pay for medical services until you meet the deductible. 

The copayment or coinsurance covers services billed as an office visit or consultation. Other services provided in the physician office, such as lab work, X-rays and surgery are subject to the deductible and coinsurance.

Preventive care services

Preventive care services are generally paid as first dollar coverage and are not subject to copayments, deductibles, or annual limits when received from a participating provider.

Annual deductible

The annual deductible of $1,500 for Self Only, or $3,000 for Self Plus One or Self and Family in-network and $3,500 for Self Only, or $7,000 for Self Plus One or Self and Family out-of-network, where applicable, must be met before Plan benefits are paid; not all benefits apply to the deductible, such as preventive care services.

Catastrophic protection

We protect you against catastrophic out-of-pocket expenses for covered services. The IRS limits annual out-of-pocket expenses for covered services, including deductibles and copayments, for participating providers, it cannot exceed $7,000 for Self Only enrollment, and $14,000 for a Self Plus One or Self and Family. For non-participating providers, it cannot exceed $16,300 for Self Only, and $32,600 for a Self Plus One or Self and Family. The out-of-pocket limit for this Plan may differ from the IRS limit, but cannot exceed the amount.

General features of our Value Plan

Our Value Plan is a comprehensive medical plan. You can see participating or non-participating providers without a referral. 

Preventive care services

Preventive care services are generally paid as first dollar coverage and are not subject to copayments, deductibles, or annual limits when received from a participating provider.

Annual deductible

The annual deductible of $1,500 for Self Only, or $3,000 for Self Plus One or Self and Family in-network and $3,500 for Self Only, or $7,000 for Self Plus One or Self and Family out-of-network, where applicable, must be met before Plan benefits are paid; not all benefits apply to the deductible such as preventive care services.

Catastrophic protection

We protect you against catastrophic out-of-pocket expenses for covered services. The IRS limits annual out-of-pocket expenses for covered services, including deductibles and copayments, to no more than $7,000 for Self Only enrollment, and $14,000 for a Self Plus One or Self and Family. For non-participating providers, cannot exceed $16,300 for Self Only, and $32,600 for a Self Plus One or Self and Family. The out-of-pocket limit for this Plan may differ from the IRS limit, but cannot exceed that amount.

Your rights and responsibilities

OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM’s FEHB website (www.opm.gov/healthcare-insurance/) lists the specific types of information that we must make available to you. Some of the required information is listed below:

• Nationally, Humana has been in the healthcare business since 1961.
• Humana is a for profit corporation which is publicly traded on the New York Stock Exchange (NYSE).

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, Humana at https://feds.humana.com/. You can also contact us to request that we mail a copy to you.

If you want more information about us, call 1-800-4HUMANA, or write to the Plan at P.O. Box 14602, Lexington, KY 40512-4602. You may also visit our website at https://feds.humana.com/.

By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit Humana's website at https://feds.humana.com/ to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.

Service Area

To enroll in this Plan you must live in or work in our service areas. This is where our providers practice. Our service areas are:

Arizona, Phoenix – Enrollment Code R6 - Maricopa and Pinal counties

Arizona, Tucson – Enrollment Code R9 - Pima County

Florida, Daytona - Enrollment Code W9 - Flagler and Volusia counties

Florida, Orlando - Enrollment Code X2 - Lake, Orange, Osceola, and Seminole counties

Florida, South Florida – Enrollment code QP – Broward, Dade, Martin, and Palm Beach counties  

Florida, Tampa – Enrollment code MJ – Citrus, Hernando, Hillsborough, Manatee, Pasco, Pinellas, Polk, and Sarasota counties

Georgia, Atlanta – Enrollment code AD – Banks, Barrow, Butts, Cherokee, Clark, Clayton, Cobb, Coweta, DeKalb, Douglas, Fayette, Floyd, Forsyth, Fulton, Gwinett, Hall, Jackson, Lamar, Madison, Newton, Paulding, Polk, Rockdale, Spalding, and Walton counties

Georgia, Columbus – Enrollment code S9 - Muscogee County

Georgia, Macon – Enrollment code LM – Bibb, Bleckley, Crawford, Houston, Jones, Laurens, Peach, Twiggs, and Wilkinson counties

Illinois, Chicago – Enrollment code MW – The Illinois counties of DuPage, Cook, Kane, Kankakee, Kendall, Lake, McHenry and Will. The Indiana counties of Lake, Porter, and LaPorte

Illinois, Central and Northwestern – Enrollment code GB – Boone, Bureau, DeKalb, DeWitt, Fulton, Henderson, Henry, Knox, LaSalle, Lee, Livingston, Marshall, McDonough, McLean, Mercer, Ogle, Peoria, Putnam, Stark, Stephenson, Tazewell, Warren, Whiteside, Winnebago, and Woodford counties

Kansas/Missouri, Kansas City – Enrollment code PH – The Missouri counties of Bates, Cass, Carroll, Clay, Henry, Jackson, Johnson, Lafayette, Platte and Ray. The Kansas counties of Douglas, Johnson, Leavenworth, Miami and Wyandotte

Kentucky, Lexington – Enrollment code 6N – Anderson, Bath, Bourbon, Boyle, Bracken, Clark, Estill, Fayette, Fleming, Franklin, Garrard, Harrison, Jessamine, Madison, Menifee, Mercer, Montgomery, Nicholas, Owen, Powell, Robertson, Scott and Woodford counties

Kentucky, Louisville - Enrollment code TC - The Kentucky counties of Bullitt, Carroll, Green, Hardin, Henry, Jefferson Larue, Meade, Nelson, Marion, Oldham, Shelby, Spencer, Taylor, Trimble, and Washington. The Indiana counties of Clark, Floyd, Harrison, Scott, and Washington

Ohio, Cincinnati - Enrollment Code X3 - The Ohio counties of Adams, Brown, Butler, Clermont, Clinton, Gallia, Hamilton, Highland, Jackson, Lawrence, Pike, Scioto, and Warren; The Indiana counties of Dearborn, Franklin, Ohio, Ripley, Union; Kentucky: Boone, Campbell, Gallatin, Grant, Kenton, and Pendelton

Tennessee, Knoxville – Enrollment code TT- Anderson, Blout, Campbell, Claiborne, Cocke, Grainger, Hamblen, Jefferson, Knox, Loundon, Morgan, Roane, Scott, Sevier, and Union counties; the Tri-City counties of Carter, Greene, Hancock, Hawkins, Johnson, Sullivan, Unicoi, and Washington

Texas, Austin – Enrollment code TV – Bastrop, Bell, Bosque, Burleson, Burnet Caldwell, Coryell, Falls, Hamilton, Hays, Lampasas, Lee, Limestone, McLennan, Milam, Robertson, Travis and Williamson counties

Texas, Houston – Enrollment code T3 - Austin, Brazoria, Chambers, Colorado, Fayette, Fort Bend, Galveston, Harris, Liberty, Montgomery, Waller and Wharton counties

Texas, Corpus Christi – Enrollment code TP – Bee, Brooks, Cameron, DeWitt, Duval, Goliad, Hidalgo, Jim Hogg, Jim Wells, Kenedy, Kleberg, Live Oak, Nueces, Refugio, San Patricio, Starr, Victoria, Willacy and Zapata counties

Texas, San Antonio – Enrollment code TU – Atascosa, Bandera, Bexar, Blanco, Comal, Frio, Gonzales, Guadalupe, Karnes, Kendall, Medina, Uvalde, Webb and Wilson counties

If you or a covered family member visit a non-participating provider outside of our service area, you can utilize your out-of-network benefits. If you move outside of our service area, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Program-wide changes:

• Effective in 2022, premium rates are the same for Non-Postal and Postal employees.

Changes to both the Consumer Driven Health Plan and Value Plan:

• Arizona
• Phoenix, AZ - Enrollment code R6 - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See pages 132)
• Tucson, AZ - Enrollment code R9 - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 132)
• Florida
• Daytona, FL – Enrollment code W9 - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 133)
• Orlando, FL – Enrollment code X2 - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 133)
• South Florida FL – Enrollment code QP (CDHP) - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 133)
• South Florida FL – Enrollment code QP (VP) - Your share of the premium rate will remain the same for Self Only, Self Plus One, and Self and Family. (See page 133)
• Tampa, FL – Enrollment code MJ (CDHP) - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 134)
• Tampa, FL – Enrollment code MJ (VP) - Your share of the premium rate will remain the same for Self Only and Self Plus One. (See page 134)
• Tampa, FL – Enrollment code MJ (VP) - Your share of the premium rate will increase for Self and Family. (See page 134)
• Georgia
• Atlanta, GA – Enrollment code AD (CDHP) – Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 134)
• Atlanta, GA – Enrollment code AD (VP) – Your share of the premium rate will decrease for Self Only, Self Plus One, and Self and Family. (See page 134)
• Columbus, GA - Enrollment code S9 - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 134)
• Macon, GA – Enrollment code LM - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 135)
• Illinois
• Central IL – Enrollment code GB - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 135)
• Chicago, IL – Enrollment code MW (CDHP) - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 135)
• Chicago, IL – Enrollment code MW (VP) - Your share of the premium rate will decrease for Self Only, Self Plus One, and Self and Family. (See page 135)

• Kansas/Missouri
• Kansas City, KS/MO – Enrollment code PH (CDHP) - Your share of the premium rate will decrease for Self Only, Self Plus One, and Self and Family. (See page 136)
• Kansas City, KS/MO – Enrollment code PH (VP) - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 136)
• Kentucky
• Lexington, KY – Enrollment code 6N - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 136)
• Louisville, KY – Enrollment code TC - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 136)
• Ohio
  • Cincinnati, OH – Enrollment code X3 - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 137)
• Tennessee
  • Knoxville, TN - Enrollment code TT - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 137)
• Texas
  • Austin, TX – Enrollment code TV (CDHP) - Your share of the premium rate will decrease for Self Only, Self Plus One, and Self and Family (See page 137)
  • Austin, TX – Enrollment code TV (VP) - Your share of the premium rate will decrease for Self Only and Self Plus One (See page 138)
  • Austin, TX – Enrollment code TV (VP) - Your share of the premium rate will remain the same for Self and Family (See page 138)
  • Corpus Christi, TX – Enrollment code TP (CDHP) - Your share of the premium rate will decrease for Self Only, Self Plus One, and Self and Family. (See page 138)
  • Corpus Christi, TX – Enrollment code TP (VP) - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 138)
  • Houston, TX – Enrollment code T3 - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 138)
  • San Antonio, TX – Enrollment code TU - Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family. (See page 138)

• 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.

Changes to the Consumer Driven Health Plan (CDHP):

• Calendar year deductible: Your in-network calendar year deductible has increased from $1,000 to $1,500 for Self Only enrollment and increased from $2,000 to $3,000 for Self Plus One and Self and Family enrollment.
• Calendar year deductible: Your out-of-network calendar year deductible has increased from $3,000 to $3,500 for Self Only enrollment and increased from $6,000 to $7,000 for Self Plus One and Self and Family enrollment.

Changes to the Value Plan:

• The Value Plan is now being offered in Lexington, KY and Louisville, KY.
• The Medicare Advantage Plan will be available to any eligible retiree that is enrolled as of 1/1/2022 in Medicare Parts A & B and is enrolled in a retiree division of the Value Plan. You will be reimbursed $100 monthly towards your Medicare Part B premium. This Plan will utilize the Medicare Advantage PPO network.
• Calendar year deductible: Your in-network calendar year deductible has increased from $1,000 to $1,500 for Self Only enrollment and increased from $2,000 to $3,000 for Self Plus One and Self and Family enrollment.
• Calendar year deductible: Your out-of-network calendar year deductible has increased from $3,000 to $3,500 for Self Only enrollment and increased from $6,000 to $7,000 for Self Plus One and Self and Family enrollment.

See page 17 for how our benefits changed this year and page 130 for the benefits summary. 

This Plan offers a Consumer Driven Health Plan (CDHP). The CDHP benefit package is described in Section 5. Make sure that you review the benefits that are available under the benefit product in which you are enrolled.

CDHP Section 5, which describes the CDHP benefits, is divided into subsections. Please read important things you should keep in mind at the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about CDHP benefits, contact us at 1-800-4HUMANA or on our website at https://feds.humana.com/.

This CDHP focuses on you, the healthcare consumer, and gives you greater control in how you use your healthcare benefits. With this plan, eligible in-network medical preventive care is covered in full, and you can use the benefit allowance for any covered care. If you use up your benefit allowance, the Traditional Medical Coverage begins after you satisfy your deductible.

Network Availability

The CDHP includes:

Humana contracts with both private office physicians and with physician groups. Referrals are not required for participating providers. The CoverageFirst plan will utilize the National Point of Service (NPOS) network.

Benefit Allowance

Members have a $1,000 in-network benefit allowance to use before they must meet a deductible. Once your benefit allowance has been exhausted, you must satisfy your in-network deductible: $1,500 for Self Only, or $3,000 for Self Plus One or Self and Family. After the deductible has been met, you are only responsible for your copays or coinsurance. 

Pharmacy

Your pharmacy plan is an Rx5 Plan, which allows members access to appropriate drugs used to treat conditions the medical plan covers. See drug levels listed below:

• Level One – preferred generic and lowest-cost generic
• Level Two – non-preferred generic and low-cost generic
• Level Three – preferred brand and higher-cost generic
• Level Four – non-preferred brand and some non-preferred higher-cost generics
• Level Five – most self-administered injectable medications and high-technology drugs that are often newly approved by the U.S. Food and Drug Administration.

Check your pharmacy and drug coverage details at MyHumana.com.

feds.Humana.com

Online tools include:

• Newly hired employees can easily navigate their plan choices
• Ability to view benefits and rates available to you based on service area ZIP code
• Learn “What’s New” about Humana’s plan offerings and other health topics
• Enroll in medical plans online
• Educate yourself about Humana’s health and wellness programs
• Find in-network doctors, hospitals and pharmacies near you
• Search Humana’s Drug List for prescription drugs and their estimated retail prices

Important things you should keep in mind about these benefits:

• Preventive care services listed in this Section are not subject to the deductible.
• The cost of the services does not apply toward your $1,000 benefit allowance.
• For all other covered expenses, please see Section 5. Traditional Medical Coverage Subject to the Deductible.
• 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.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. 
• In-network preventive care is covered at 100% (see page 32) and is not subject to the calendar year deductible. 
• The deductible is $1,500 per person ($3,000 per Self Plus One enrollment, or $3,000 per Self and Family enrollment). The family deductible can be satisfied by one or more family members. The deductible applies to almost all benefits under Traditional medical coverage. You must pay your deductible before your Traditional medical coverage may begin. 
• Under Traditional medical coverage, you are responsible for your coinsurance and copayments for covered expenses. 
• When you use network providers, you are protected by an annual catastrophic maximum on out-of-pocket expenses for covered services. After your coinsurance, copayments and deductibles total $8,150 per person, $16,300 per Self Plus One enrollment or $16,300 per Self and Family enrollment in any calendar year, you do not have to pay any more for covered services from network providers. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out- of-pocket maximum (such as expenses in excess of the Plan’s benefit maximum, or if you use out-of- network providers, amounts in excess of the Plan allowance). 
• In-network benefits apply only when you use a network provider. When a network provider is not available, out-of-network benefits apply. 
• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare. 
• 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.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• A facility copay applies to services that appear in this section but are performed in an ambulatory surgical center or the outpatient department of a hospital.
• The calendar year deductible is:
  • Participating providers – You do not have to meet a deductible until your $1,000 benefit allowance is depleted. The calendar year deductible is: $1,500 for Self Only, ($3,000 for Self Plus One and Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • Non-participating providers – The $1,000 benefit allowance does not apply. The calendar year deductible is $3,500 for Self Only, ($7,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
• After you have satisfied your deductible, your Traditional medical coverage begins.
• Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions. 
• Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
• 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.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• The calendar year deductible is:
  • Participating providers - You do not have to meet a deductible until your $1,000 benefit allowance is depleted. The calendar year deductible is $1,500 for Self Only, ($3,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • Non-participating providers - The $1,000 benefit allowance does not apply. The calendar year deductible is $3,500 for Self Only, ($7,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
• After you have satisfied your deductible, your Traditional medical coverage begins.
• Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions. 
• Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
• The services listed below are for the charges billed by a physician or other healthcare professional for your surgical care. See Section 5(c) for charges associated with a facility (i.e. hospital, surgical center, etc.).
• YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.
• 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.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• The calendar year deductible is:
  • Participating providers – You do not have to meet a deductible until your $1,000 benefit allowance is depleted. The calendar year deductible is $1,500 for Self Only, ($3,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • Non-participating providers – The $1,000 benefit allowance does not apply. The calendar year deductible is $3,500 for Self Only, ($7,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
• After you have satisfied your deductible, your Traditional medical coverage begins.
• Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions. 
• Be sure to read Section 4, Your cost for covered services for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
• The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care.  Any costs associated with the professional charge
  (i.e., physicians, etc.) are in Sections 5(a) or (b).
• YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.
• Observation Care: Your share for hospital observation care that exceeds 24 hours is the same as inpatient hospital care. Observation Care below 24 hours is the same as the Emergency Room benefit/copay.
• 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.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• The calendar year deductible is:
  • Participating providers – You do not have to meet a deductible until your $1,000 benefit allowance is depleted. The calendar year deductible is $1,500 for Self Only, ($3,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • Non-participating providers – The $1,000 benefit allowance does not apply. The calendar year deductible is $3,500 for Self Only, ($7,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
• After you have satisfied your deductible, your Traditional medical coverage begins.
• Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions. 
• Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
• Observation Care: Your share for hospital observation care that exceeds 24 hours is the same as inpatient hospital care. Observation Care below 24 hours is the same as the Emergency Room benefit/copay.
• 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.

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.

What to do in case of emergency:

If a medical emergency requires that an insured person be admitted to a hospital, we must be advised by the hospital of the admission immediately.  We will then review the medical necessity of the admission. If the insured person has been admitted to a non-participating hospital, and it has been determined that the insured person’s condition has stabilized sufficiently to allow the insured person to be transferred safely to a participating hospital, we will request that the insured person and the insured person’s physician approve the transfer.  If the transfer is not approved, the non-participating hospital deductible and copayment amounts will be applied to the benefits payable for any days of hospital confinement beyond the date the insured person’s medical emergency was stabilized.

Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 phone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member must notify the Plan within 48 hours unless it was not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan facilities and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if a delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Copays and coinsurance applies, even after you meet your deductible.
• The calendar year deductible or, for facility care, the inpatient deductible applies to almost all benefits in this Section.
• The calendar year deductible is:
  • Participating providers – You do not have to meet a deductible until your $1,000 benefit allowance is depleted. The calendar year deductible is $1,500 for Self Only, ($3,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • Non-participating providers – The $1,000 benefit allowance does not apply. The calendar year deductible is $3,500 for Self Only, ($7,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
• Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
• YOUR MENTAL HEALTH PROFESSIONAL MUST GET CERTIFICATION FOR SOME MENTAL HEALTH VISITS AND SERVICES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.
• We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.
• OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.
• 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.

Important things you should keep in mind about these benefits:

• We cover prescribed drugs and medications, as described in the chart beginning on the next page.
• Prescription copayments and coinsurance amounts do not apply to the benefit allowance or the deductibles when using participating pharmacies.
• Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies. Prior approval/authorizations must be renewed periodically.
• Federal law prevents the pharmacy from accepting unused medications.
• Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
• 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.

There are important features you should be aware of. These include:

• Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice.
• Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a prescribed maintenance medication. Maintenance medications are drugs that are generally prescribed for the treatment of long term chronic sicknesses or injuries. Members can also fill their maintenance medications for 90 days at a retail pharmacy for their appropriate copayment.
• We use a formulary. We cover non-formulary drugs prescribed by a Plan doctor.
• The Rx5 Plan allows members access to appropriate drugs which are used to treat conditions the medical plan covers. Thousands of drugs have been placed in levels based on their a) efficacy, b) safety, c) possible side effects, d) drug interactions, and e) cost compared to similar drugs. New drugs are continually reviewed for level placement, dispensing limits, step therapy and prior authorization requirements that represent the current clinical judgment of our Pharmacy and Therapeutics Committee. Some medications are considered non-formulary because there are other lower cost therapeutic alternatives available on the formulary.

Level One contains/covers Preferred generic and lowest cost generic drugs.

Level Two contains/covers non-Preferred generic and low cost generic drugs.

Level Three contains/covers Preferred brand and higher cost generic drugs.

Level Four contains/covers non-preferred brand and some non-preferred higher cost generic drugs

Level Five contains specialty drugs and includes most self administered injectable medications and high technology drugs that are often newly approved by the U.S. Food and Drug Administration. For some specialty drugs, see You need prior plan approval for certain services in Section 3.

With Rx5 the member takes on more of the cost share for the drug. In return, members receive access to more drugs to treat their conditions and have more choices, along with their physicians, to decide which drug to take. Members receive letters offering guidance in changing medications to those with a lower copayment. We use internal data to identify members for whom a less expensive prescription drug option may be available. We communicate the information to the member to enable them, along with their physician, to make an informed choice regarding prescription drug copayment options.

• Prior Authorization – Some medications need special monitoring and may require prior authorization. These drugs have different approval criteria based on indication, safety and appropriate use. Prior authorization (PA) requires a physician to obtain pre-approval in order to provide coverage for a drug prescribed to a member. Visit http://feds.humana.com to view the annual drug list for medications that require prior authorization.
• Step Therapy: Step Therapy directs therapy to the most cost-effective and safest drug available to be used prior to moving to a more costly or risky therapy. Step Therapy is an automated process and requires the member to try alternative medications before the more costly medications are considered.
• These are the dispensing limitations. Prescription drugs dispensed at a Plan pharmacy will be dispensed for up to a 30-day supply. You may receive up to a 90-day supply of a prescribed maintenance medication through our mail-order program or at one of our retail pharmacies. Specialty drugs may be limited to a 30-day supply. You must use dispensing limitations as directed, unless provider instructs otherwise.
• Why use generic drugs? Generic medications have the same benefits, ingredients and safety as brand-name medications but without the high dollar cost. With the price of prescription medicine rising, it’s nice to find where you can save money without compromising on quality.
• When you do have to file a claim? For out of network claims, please contact Humana’s customer service for reimbursement.

If there is a national emergency or you are called to active military duty, you may call 1-800-448-6262. A representative will review criteria to determine whether you may obtain more than your normal dispensing amount.

• Non-formulary. Medicine(s) are not in your plan's drug list (which means you pay the full cost of the prescription.) Your doctor can ask Humana to make an exception to cover your non-formulary medicine if he or she believes the alternative covered drugs won't be as effective in treating your health condition and/or would cause a bad reaction.
• A generic equivalent will be dispensed if it is available. When brand name drugs are purchased and a generic is available, you must pay the difference between the brand name and generic cost plus any applicable brand copay, unless the physician writes "dispense as written" on the prescription. The physician must write "dispense as written" on the prescription for you to receive a brand name drug and only pay the brand name copay, if a generic is available.

You can visit our web site at http://feds.humana.com to check the copayment for your prescription drug coverage before you get your prescription filled. You can also find out more about possible drug alternatives and the locations of participating pharmacies.

• Non-participating pharmacy coverage. You may purchase prescribed medications from a non-participating pharmacy. You will pay for your prescriptions the following way:

You pay 100% of the dispensing pharmacy charges and file a claim with Humana. The claim is paid at 60% of charges, after the applicable copay.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary
• If you are enrolled in a Federal Employee Dental Vision Insurance Program (FEDVIP) Dental Plan, your FEHB plan will be primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB plan. See Section 9 Coordinating benefits with Medicare and other coverage.
• Plan dentists must provide or arrange your care.
• The calendar year deductible is:
• Participating providers – You do not have to meet a deductible until your $1,000 benefit allowance is depleted. The calendar year deductible is $1,500 for Self Only, ($3,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section.
• Non-participating providers – The $1,000 benefit allowance does not apply. The calendar year deductible is $3,500 for Self Only, or ($7,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply. 
• After you have satisfied your deductible, your Traditional medical coverage begins.
• Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions. 
• We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for Inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
• Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about Coordinating benefits with Medicare and other coverage, including with Medicare.
• 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.

See page 17 for how our benefits changed this year. Page 131 is the benefits summary. Make sure that you review the benefits that are available under the option in which you are enrolled.

This Plan offers a Value Plan. The Value Plan benefit package is described in Section 5. Make sure that you review the benefits that are available under the option in which you are enrolled.

The Value Plan Section 5 is divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about Value Plan benefits, contact us at 800-4HUMANA or on our website at https://feds.humana.com/.

Network Availability

Humana contracts with both private office physicians and with physician groups. Referrals are not required for participating providers. The Value Plan will utilize the National Point of Service (NPOS) network.

Pharmacy

Your pharmacy plan is an Rx5 Plan, which allows members access to appropriate drugs used to treat conditions the medical plan covers. See drug levels listed below:

• Level One – preferred generic and lowest-cost generic
• Level Two – non-preferred generic and low-cost generic
• Level Three – preferred brand and higher-cost generic
• Level Four – non-preferred brand and some non-preferred higher-cost generics
• Level Five – most self-administered injectable medications and high-technology drugs that are often newly approved by the U.S. Food and Drug Administration.

Check your pharmacy and drug coverage details at MyHumana.com.

feds.Humana.com

Online tools include:

• Newly hired employees can easily navigate their plan choices
• Ability to view benefits and rates available to you based on service area ZIP code
• Learn “What’s New” about Humana’s plan offerings and other health topics
• Enroll in medical plans online
• Educate yourself about Humana’s health and wellness programs
• Find in-network doctors, hospitals and pharmacies near you
• Search Humana’s Drug List for prescription drugs and their estimated retail prices

Medicare Advantage Plan Highlights

If you are a retiree and enroll in the Value Plan and the Medicare Advantage Plan, you will receive a Medicare Part B Premium Reduction.

Medicare Coordination of Benefits: We will reduce the Part B premium that you pay to the Social Security Administration by $100 per month. If you pay your Part B premium on a monthly basis, you will see this dollar amount credited in your Social Security check. If you pay your Part B premium quarterly, you will see an amount equaling three months of reductions credited on your quarterly Part B premium statement. It may take a few months to see these reductions credited to either your Social Security check or premium statement, but you will be reimbursed for any credits you did not receive during this waiting period.

Medicare Advantage Plan Benefits

Benefit Description: Deductible 

You pay No deductible for this Medicare plan.

Benefit Description: Provider visits

• Primary Care Physician (PCP) visit: You pay $0 copayment
• Specialist visit: You pay $0 copayment
• Routine annual physical: You pay $0 copayment
• Virtual doctor visits: You pay $0 copayment
• Outpatient Rehabilitation - physical, occupational or speech/language therapy: You pay $0 copayment
• Urgent care center: You pay $0 copayment

Benefit Description: Hospital services

• Inpatient hospital: You pay $0 copayment
• Inpatient mental health: You pay $0 copayment
• Skilled Nursing Facility: You pay $0 copayment per day for days 1-20; $0 copayment per additional day up to 100 days
• Emergency Room: You pay $0 copayment
• Ambulance: You pay $0 copayment

Benefit Description: Diagnostic Services 

You pay $0 copayment.

Benefit Description: Hearing Aids 

Not covered

Benefit Description: Pharmacy benefits

• 30-day supply: You pay for Tier 1 - $10; Tier 2 - $45; Tier 3 - $65; Tier 4 - $100; Tier 5 - 25%
• 90-day supply at mail order: You pay for Tier 1 - $25; Tier 2 - $112.50; Tier 3 - $162.50; Tier 4 - $250; Tier 5 - 25%

SilverSneakers®

An overall wellness program that may help members improve their health and live the life they want. The program gives members access to exercise equipment, classes, and fun social activities at thousands of locations nationwide.

Note: You must have Medicare Part A and Part B, and Medicare must be primary for you to enroll in the Humana Medicare Advantage Plan. This plan reduces your costs by eliminating your cost sharing for covered medical services. Please see Section 9 in this brochure for additional information on how to enroll in this plan and for details on a reimbursement of $100 of your Medicare Part B premium. You need to retain enrollment in this FEHB plan to be enrolled in the Medicare Advantage Plan.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Copays and coinsurance applies, even after you meet your deductible.
• A facility copay applies to services that appear in this section but are performed in an ambulatory surgical center or the outpatient department of a hospital.
• The calendar year deductible is:
  • Participating providers – The calendar year deductible is $1,500 for Self Only, ($3,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • Non-participating providers – The calendar year deductible is $3,500 for Self Only, ($7,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
• Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
• 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.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Copays and coinsurance applies, even after you meet your deductible.
• The calendar year deductible is:
  • Participating providers - The calendar year deductible is $1,500 for Self Only, or ($3,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • Non-participating providers - The calendar year deductible is $3,500 for Self Only, or ($7,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
• Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
• The services listed below are for the charges billed by a physician or other healthcare professional for your surgical care. See Section 5(c) for charges associated with a facility (i.e. hospital, surgical center, etc.).
• YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.
• 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.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Copays and coinsurance applies, even after you meet your deductible.
• The calendar year deductible is:
  • Participating providers – The calendar year deductible is $1,500 for Self Only, ($3,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • Non-participating providers – The calendar year deductible is $3,500 for Self Only, ($7,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
• Be sure to read Section 4, Your cost for covered services for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
• The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge
  (i.e., physicians, etc.) are in Sections 5(a) or (b).
• YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.
• Observation Care: Your share for hospital observation care that exceeds 24 hours is the same as inpatient hospital care. Observation Care below 24 hours is the same as the Emergency Room benefit/copay.
• 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.

Important things to keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Copays and coinsurance applies, even after you meet your deductible.
• The calendar year deductible is:
  • Participating providers – The calendar year deductible is $1,500 for Self Only, ($3,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • Non-participating providers – The calendar year deductible is $3,500 for Self Only, ($7,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
• Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
• Observation Care: Your share for hospital observation care that exceeds 24 hours is the same as inpatient hospital care. Observation Care below 24 hours is the same as the Emergency Room benefit/copay.
• 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.

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action. 

What to do in case of emergency:

If a medical emergency requires that an insured person be admitted to a hospital, we must be advised by the hospital of the admission immediately. We will then review the medical necessity of the admission. If the insured person has been admitted to a non-participating hospital, and it has been determined that the insured person’s condition has stabilized sufficiently to allow the insured person to be transferred safely to a participating hospital, we will request that the insured person and the insured person’s physician approve the transfer. If the transfer is not approved, the non-participating hospital deductible and copayment amounts will be applied to the benefits payable for any days of hospital confinement beyond the date the insured person’s medical emergency was stabilized.

Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 phone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member must notify the Plan within 48 hours unless it was not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan facilities and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if a delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Copays and coinsurance applies, even after you meet your deductible.
• The calendar year deductible or, for facility care, the inpatient deductible applies to almost all benefits in this Section.
• The calendar year deductible is:
  • Participating providers – The calendar year deductible is $1,500 for Self Only, ($3,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • Non-participating providers – The calendar year deductible is $3,500 for Self Only, ($7,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
• Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
• YOUR MENTAL HEALTH PROFESSIONAL MUST GET CERTIFICATION FOR SOME MENTAL HEALTH VISITS AND SERVICES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.
• We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.
• OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.
• 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.

Important things you should keep in mind about these benefits:

• We cover prescribed drugs and medications, as described in the chart beginning on the next page.
• Prescription copayments and coinsurance amounts do not apply to the deductible when using participating pharmacies.
• Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
• Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies. Prior approval/authorizations must be renewed periodically.
• Federal law prevents the pharmacy from accepting unused medications.
• Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
• 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.

There are important features you should be aware of. These include:

• Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.
• Where you can obtain them. You must fill the prescription at a Plan pharmacy, or by mail for a prescribed maintenance medication. Maintenance medications are drugs that are generally prescribed for the treatment of long term chronic sicknesses or injuries. Members can also fill their maintenance medications for 90 days at a retail pharmacy for their appropriate copayment.
• We use a formulary. We cover non-formulary drugs prescribed by a Plan doctor.
• The Rx5 Plan allows members access to appropriate drugs which are used to treat conditions the medical plan covers. Thousands of drugs have been placed in levels based on their a) efficacy, b) safety, c) possible side effects, d) drug interactions, and e) cost compared to similar drugs. New drugs are continually reviewed for level placement, dispensing limits, step therapy and prior authorization requirements that represent the current clinical judgment of our Pharmacy and Therapeutics Committee. Some medications are considered non-formulary because there are other lower cost therapeutic alternatives available on the formulary.

Level One contains/covers Preferred generic and lowest cost generic drugs.

Level Two contains/covers non-Preferred generic and low cost generic drugs.

Level Three contains/covers Preferred brand and higher cost generic drugs.

Level Four contains/covers non-preferred brand and some non-preferred higher cost generics drugs.

Level Five contains specialty drugs and most self administered injectable medications and high technology drugs that are often newly approved by the U.S. Food and Drug Administration. For some specialty drugs, see You need prior plan approval for certain services in Section 3.

With Rx5 the member takes on more of the cost share for the drug. In return, members receive access to more drugs to treat their conditions and have more choices, along with their physicians, to decide which drug to take. Members receive letters offering guidance in changing medications to those with a lower copayment. We use internal data to identify members for whom a less expensive prescription drug option may be available. We communicate the information to the member to enable them, along with their physician, to make an informed choice regarding prescription drug copayment options.

• Prior Authorization – Some medications need special monitoring and may require prior authorization. These drugs have different approval criteria based on indication, safety and appropriate use. Prior authorization (PA) requires a physician to obtain pre-approval in order to provide coverage for a drug prescribed to a member. Visit feds.humana to view the annual drug list for medications that require prior authorization.
• Step Therapy: Step Therapy directs therapy to the most cost-effective and safest drug available to be used prior to moving to a more costly or risky therapy. Step Therapy is an automated process and requires the member to try alternative medications before the more costly medications are considered.
• These are the dispensing limitations. Prescription drugs dispensed at a Plan pharmacy will be dispensed for up to a 30-day supply. You may receive up to a 90-day supply of a prescribed maintenance medication through our mail-order program or at one of our retail pharmacies. Specialty drugs may be limited to a 30-day supply. You must use dispensing limitations as directed, unless provider instructs otherwise.
• Why use generic drugs? Generic medications have the same benefits, ingredients and safety as brand-name medications but without the high dollar cost. With the price of prescription medicine rising, it’s nice to find where you can save money without compromising on quality.
• When you do have to file a claim? For out of network claims, please contact Humana’s customer service for reimbursement.

If there is a national emergency or you are called to active military duty, you may call 800-448-6262. A representative will review criteria to determine whether you may obtain more than your normal dispensing amount.

• Non-formulary. Medicine(s) are not in your plan's drug list (which means you pay the full cost of the prescription.) Your doctor can ask Humana to make an exception to cover your non-formulary medicine if he or she believes the alternative covered drugs won't be as effective in treating your health condition and/or would cause a bad reaction.
• A generic equivalent will be dispensed if it is available. When brand name drugs are purchased and a generic is available, you must pay the difference between the brand name and generic cost plus any applicable brand copay, unless the physician writes "dispense as written" on the prescription. The physician must write "dispense as written" on the prescription for you to receive a brand name drug and only pay the brand name copay, if a generic is available.

When brand name drugs are purchased and a generic is available, you must pay the difference between the brand name and generic cost plus any applicable brand copay, unless the physician writes "dispense as written" on the prescription. The physician must write "dispense as written" on the prescription for you to receive a brand name drug and only pay the brand name copay, if a generic is available.

You can visit our web site at http://feds.humana.com to check the copayment for your prescription drug coverage before you get your prescription filled. You can also find out more about possible drug alternatives and the locations of participating pharmacies.

• Non-participating pharmacy coverage. You may purchase prescribed medications from a non-participating pharmacy. You will pay for your prescriptions the following way:

You pay 100% of the dispensing pharmacy charges and file a claim with Humana. The claim is paid at 50% of charges, after the applicable copay.

Important things you should keep in mind about these benefits:

• Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary
• If you are enrolled in a Federal Employee Dental Vision Insurance Program (FEDVIP) Dental Plan, your FEHB plan will be primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB plan. See Section 9 Coordinating benefits with Medicare and other coverage.
• Plan dentists must provide or arrange your care.
• The calendar year deductible is:
  • Participating providers – The calendar year deductible is $1,500 for Self Only, ($3,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • Non-participating providers – The calendar year deductible is $3,500 for Self Only, ($7,000 for Self Plus One or Self and Family.) The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
• We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for Inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
• Be sure to read Section 4, Your cost for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about Coordinating benefits with Medicare and other coverage, including with Medicare.
• 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.

For more information regarding these programs, call customer service at the number on the back of your ID card.

The benefits on this page are not insurance or insured benefits, nor part of the FEHB contract and premium; they are not eligible as part of the FEHB disputed claim process. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. This program is subject to change at any time and not available where prohibited by law. For additional information, contact us at 1-800-4-HUMANA or visit our website at http://feds.humana.com.

Humana’s Lifestyle Discount Program is designed to help you achieve lifelong well-being with valuable discounts and exclusive deals on popular health and wellness services. As a Humana member, you have access to this valuable program (program eligibility varies based on your service area).

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3 You need prior Plan approval for certain services.

We do not cover the following:

• Services, drugs, or supplies you receive while you are not enrolled in this Plan.
• Services, drugs, or supplies that are not medically necessary.
• Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.
• Experimental or investigational procedures, treatments, drugs or devices (See specifics regarding transplants).
• Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.
• Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
• Services, drugs, or supplies you receive without charge while in active military service.
• Services or supplies we are prohibited from covering under the Federal Law.

This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received). See Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval), including urgent care claims procedures. When you see Plan providers, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or deductible.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly.  Check with the provider. 

If you need to file the claim, here is the process:

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes. For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan’s customer service representative at the phone number found on your enrollment card, plan brochure, or plan website.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs or supplies have already been provided). In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your request, please contact our Customer Service Department by writing Humana Claims Office, P.O. Box 14546, Lexington KY 40512-4601 or calling 1-800-4HUMANA or 1-800-448-6262.

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or their subordinate, who made the initial decision.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at
1-800-523-0023. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s Health Insurance 3 at 1-(202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not  make decisions about plan eligibility issues. For example, we do not determine whether you or a dependent is covered under this plan. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.

Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.

• Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at https://feds.humana.com/.
• If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
• Members have a $1,000 in-network benefit allowance to use before they must meet a deductible. Once your benefit allowance has been exhausted, you must satisfy your in-network deductible: $1,500 for Self Only, or $3,000 for Self Plus One or Self and Family. After the deductible has been met, you are only responsible for your copays or coinsurance.

• Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at https://feds.humana.com/.
• If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
• After the $1,500 for Self Only, or $3,000 for Self Plus One or Self and Family in-network deductible has been met, you are only responsible for your copays or coinsurance.