Professional services of physicians

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

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

• In an urgent care center

$55 copay per visit

• During a hospital stay
• In a skilled nursing facility

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

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

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

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

$35 copay per visit

Tests, such as:

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

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

Nothing

Other tests:

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

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

Routine physical every year

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

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

• Routine mammogram – covered for women

Nothing

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

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

Nothing

Not covered:

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

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

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

Complete maternity (obstetrical) care, such as:

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

Nothing

Facility copay applies to delivery

Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

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

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

Note: We offer HumanaBeginnings. See Special features in Section 5(h). 

Nothing

• Contraceptive counseling on an annual basis

A range of voluntary family planning services, limited to:

• Voluntary sterilization (e.g., tubal ligation, vasectomy) (See Surgical procedures Section 5(b))
• Surgically implanted contraceptives
• Contraceptive devices
• Injectable contraceptive drugs (such as Depo-Provera)
• Intrauterine devices (IUDs)
• Diaphragms

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

Not covered:

• Reversal of voluntary surgical sterilization

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

Covered benefits including evaluation and treatment:

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

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

Diagnosis and treatment of infertility, such as:

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

Note: We cover Injectable fertility drugs under medical benefits and fertility drugs under the prescription drug benefit (See You need prior plan approval for certain services in Section 3.)

50% of charges

Not covered:

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

• Testing and treatment, including materials

$35 copay per office visit to your primary care physician

$55 copay per office visit to a specialist

• Allergy serum
• Allergy injections

Not covered:

• Provocative food testing 
• Sublingual allergy desensitization

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 38.

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

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

Note: Growth hormone is covered under the Prescription Drug benefit.

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that GHT is medically necessary. Your Plan Physician will ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Section 3 under Other services under You need prior Plan approval for certain services on page 17.

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

$55 copay per office visit to a specialist

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

• Qualified physical therapists
• Occupational therapists

Note: We only cover therapy when a physician:

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

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

$55 copay per office visit to a specialist

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

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

• Speech therapists

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

$55 copay per office visit to a specialist

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

• Cochlear implants
  • Note: For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices

30% coinsurance

Not covered:

• Hearing services that are not shown as covered

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

$35 per office visit to your primary care physician

$55 per office visit to a specialist

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

Note: See Preventive care, children for eye exams for children.

Not covered:

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

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

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$35 per office visit to your primary care physician

$55 per office visit to a specialist

Not covered:

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

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

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

30% coinsurance

Not covered:

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

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

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

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

Note: Preauthorization is necessary for items over $750. See You need prior plan approval for certain services in Section 3.

Note: Call customer service at 1-800-4HUMANA as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

30% coinsurance

Not covered:

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

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

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

$55 copay per visit

Not covered:

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

• Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

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

$55 per office visit to a specialist

Acupuncture – by a licensed acupuncturist for:

• anesthesia
• pain relief

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

$55 per office visit to a specialist

Not covered:

• Naturopathic services
• Hypnotherapy
• Biofeedback

Coverage is provided for:

• Tobacco Cessation programs, including individual/group/telephone counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence
• Childhood obesity education

Nothing for counseling for up to two quit attempts per year.

Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

• Diabetes self management training

$35 per office visit to your primary care physician

$55 per office visit to a specialist

A comprehensive range of services, such as:

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

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

Nothing

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot. (See Foot care)

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and that is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts;
  • treatment of any physical complications, such as lymphedemas;
  • breast prostheses and surgical bras and replacements (see Section 5(a) Orthopedic and Prosthetic devices)

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

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

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

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury (Note: See You need prior plan approval for certain services in Section 3)
• Any surgical procedure for gender reassignment not listed above

Oral surgical procedures, limited to:

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

Not covered:

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

These solid organ transplants are covered. Solid organ transplants are limited to:

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

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

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

Nothing

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

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

Nothing

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

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

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

Nothing

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocols. 

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

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

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

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

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

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

Nothing

Not covered:

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

Professional services provided in –

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

Room and board, such as:

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

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

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

Other hospital services and supplies, such as:

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

Not covered:

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

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

$500 copay per visit

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

• Other outpatient non-surgical care such as mammograms

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

Not covered:

• Blood and blood components not replaced by the member

Extended care benefit:

Up to 100 days per calendar year, including:

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

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

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

Not covered:

• Custodial care

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

• Inpatient care
• Outpatient care
• Bereavement counseling

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

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

Note: Personal Nurse provides the following end-of-life support:

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

Not covered:

• Independent nursing
• Homemaker services

Personal Nurse provides the following end-of-life support:

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

$50 copay

• Emergency care at a doctor’s office

$35 copay per visit to your primary care physician

$55 copay per visit to a specialist

• Emergency care at an urgent care center

$55 copay per visit

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

Note: We waive the ER copay if you are admitted to the hospital.

$250 copay per visit

Not covered:

• Elective care or non-emergency care

• Emergency care at a doctor’s office

$35 copay per visit to a primary care physician

$55 copay per visit to a specialist

• Emergency care at an urgent care center

$55 copay per visit

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

Note: We waive the ER copay if you are admitted to the hospital.

$250 copay per visit

Not covered:

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

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

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

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

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

$35 copay per visit

Professional ambulance service when medically appropriate

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

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

$50 copay

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

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

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

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

$35 copay per visit

• Outpatient diagnostic tests when provided and billed by a licensed mental health and use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

Nothing

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

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

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

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

• Services in approved treatment programs, such as residential treatment, partial hospitalization, full-day hospitalization or facility-based intensive outpatient treatment

Nothing

Applied Behavior Analysis (ABA) Therapy for Autism Spectrum Disorder

$35 copay per office visit to your primary care physician

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

$35 copay per visit

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

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

Note: Blood Glucose Monitors are also covered under Durable Medical Equipment. (See Section 5(a), page 35.)

Note: Your cost share for covered orally administered anticancer medications for the treatment of cancer will not exceed $50 per month supply.

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

$10 copay for Level One drugs

$45 copay for Level Two drugs

$65 copay for Level Three drugs

$100 copay for Level Four drugs

25% coinsurance for Level Five drugs

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

• Women's contraceptive drugs and devices including the "morning after pill"
• Tobacco Cessation drugs

Note: The above over-the-counter drugs and devices approved by the FDA for contraception or to treat tobacco dependence require a written prescription by an approved provider. Some restrictions apply.

Not covered:

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

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefits. (See page 35.)

All charges

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

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

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

Nothing

Not covered:

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

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefits. (See page 35.)

Professional services of physicians

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

$50 copay per office visit to your primary care physician

$70 copay per office visit to a specialist

• In an urgent care center

$70 copay per visit

• During a hospital stay
• In a skilled nursing facility

Nothing

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

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

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

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

$50 copay per visit

Tests, such as:

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

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

Nothing

Other tests:

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

$50 copay per office visit to your primary care physician

$70 copay per office visit to a specialist

Routine physical every year

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

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

Nothing

• Routine mammogram – covered for women

Nothing

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

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

Nothing

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams or travel.

• Immunizations, boosters, and medications for travel or work related exposure.

All charges

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

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

Nothing

Complete maternity (obstetrical) care, such as:

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

Nothing

Facility copay applies to delivery

Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

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

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

Note: We offer HumanaBeginnings. See Special features in Section 5(h).

Nothing

• Contraceptive counseling on an annual basis

A range of voluntary family planning services, limited to:

• Surgically implanted contraceptives
• Contraceptive devices
• Injectable contraceptive drugs (such as Depo-Provera)
• Intrauterine devices (IUDs)
• Diaphragms
• Voluntary sterilization (e.g., tubal ligation, vasectomy) (See Surgical procedures, Section 5(b))

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

Nothing

Not covered:

• Reversal of voluntary surgical sterilization

All charges

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

Covered benefits including evaluation and treatment:

• Females - ovulation evaluation, tubal patency, hormonal evaluation, and cervical factor evaluation.
• Males – includes sperm analysis, hormonal analysis, sperm functioning and medical imaging. Treatment would include correction of any defect found in the evaluation of both male and female partners.

Diagnosis and treatment of infertility, such as:

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

Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit (See You need prior plan approval for certain services in Section 3.)

50% of charges

Not covered:

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

All charges

• Testing and treatment, including test and treatment materials

$50 copay per office visit to your primary care physician

$70 copay per office visit to a specialist

• Allergy serum
• Allergy injection

Nothing

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

All charges

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 72.

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

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided. No visit limitations apply.
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)

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

Note: Growth hormone is covered under the Prescription Drug benefit.

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that GHT is medically necessary. Your Plan Physician will ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Section 3, Other services under You need prior Plan approval for certain services on page 17.

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

$70 copay per office visit to a specialist

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

• Qualified physical therapists
• Occupational therapists

Note: We only cover therapy when a physician:

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

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

$70 copay per office visit to a specialist

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

All charges

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

• Speech therapists

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

$70 copay per office visit to a specialist

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

Nothing

• Cochlear implants
  • Note: For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices

50% coinsurance

Not covered:

• Hearing services that are not shown as covered

All charges

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

$50 copay per office visit to your primary care physician

$70 copay per office visit to a specialist

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

Note: See Preventive care, children for eye exams for children.

Nothing

Not covered:

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

All charges

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

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$50 copay per office visit to your primary care physician

$70 copay per office visit to a specialist

Not covered:

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

All charges

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

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

50% of charges

Not covered:

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

All charges

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

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

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

Note: Preauthorization is necessary for items over $750. See You need prior plan approval for certain services in Section 3.

Note: Call customer service at 1-800-4HUMANA as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

50% of charges

Not covered:

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

All charges

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

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

$70 copay per visit

Not covered:

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

All charges

• Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

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

$70 copay per office visit to a specialist

Acupuncture – by a licensed acupuncturist for:

• anesthesia
• pain relief

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

$70 per office visit to a specialist

Not covered:

• Naturopathic services
• Hypnotherapy
• Biofeedback

All charges

Coverage is provided for:

• Tobacco Cessation programs, including individual/group/telephone counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence
• Childhood obesity education

Nothing for counseling for up to two quit attempts per year.

Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

• Diabetes self management training

$50 per office visit to your primary care physician

$70 per office visit to a specialist

A comprehensive range of services, such as:

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

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

Nothing

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot. (See Foot care)

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
• the condition produced a major effect on the member’s appearance an
• the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and that is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
• Surgery to produce a symmetrical appearance of breasts;
• Treatment of any physical complications, such as lymphedemas;
• Breast prostheses and surgical bras and replacements (see Section 5(a) Orthopedic and Prosthetic devices)

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

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

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

Nothing

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury (Note: See You need prior plan approval for certain services in Section 3)
• Any surgical procedure for gender reassignment not listed above

All charges

Oral surgical procedures, limited to:

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

Nothing

Not covered:

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

All charges

These solid organ transplants are covered. Solid organ transplants are limited to:

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

Nothing

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

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

Nothing

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

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

Nothing

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

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

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

Nothing

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocols.

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

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

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

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

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

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

Nothing

Not covered:

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

All charges

Professional services provided in –

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

Nothing

Room and board, such as:

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

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

$900 copay per day for the first five (5) days per admission

Other hospital services and supplies, such as:

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

Nothing

Not covered:

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

All charges

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

$700 copay per visit

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

$300 copay per visit

• Other outpatient non-surgical care such as mammograms

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

Nothing

Not covered:

• Blood and blood components not replaced by the member

All charges

Extended care benefit:

Up to 100 days per calendar year, including:

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

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

$900 copay per day for the first three (3) days per admission

Not covered:

• Custodial care

All charges

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

• Inpatient care
• Outpatient care
• Bereavement counseling

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

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

Note: Personal Nurse provides the following end-of-life support:

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

Nothing

Not covered:

• Independent nursing
• Homemaker services

All charges

Personal Nurse provides the following end-of-life support:

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

Nothing

Local professional ambulance service when medically appropriate

$50 copay

• Emergency care at a doctor’s office

$50 copay per visit to your primary care physician

$70 copay per visit to a specialist

• Emergency care at an urgent care center

$70 copay per visit

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

Note: We waive the ER copay if you are admitted to the hospital.

$325 copay per visit

Not covered:

• Elective care or non-emergency care

All charges

• Emergency care at a doctor’s office

$50 copay per visit to your primary care physician

$70 copay per visit to a specialist

• Emergency care at an urgent care center

$70 copay per visit

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

Note: We waive the ER copay if you are admitted to the hospital.

$325 copay per visit

Not covered:

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

All charges

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

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

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

   

  ary, the telemedicine doctor can send a prescription to a preferred pharmacy

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

$50 copay per visit

Professional ambulance service when medically appropriate

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

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

$50 copay

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

Your cost-sharing responsibilities are no greater than for other illnesses or conditions

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

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

$50 copay per visit

• Outpatient diagnostic tests when provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

Nothing

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

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

$900 copay per day for the first five (5) days per admission

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

• Services in approved treatment programs, such as residential treatment, partial hospitalization, full-day hospitalization or facility-based intensive outpatient treatment

Nothing

Applied Behavior Analysis (ABA) Therapy for Autism Spectrum Disorder

$50 copay per office visit to your primary care physician

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

$50 copay per visit

Services that are not part of a preauthorized approved treatment plan

All charges

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

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

Note: Blood Glucose Monitors are also covered under Durable Medical Equipment. (See Section 5(a), page 68.)

Note: Your cost share for covered orally administered anticancer medications for the treatment of cancer will not exceed $50 per month supply

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

$10 copay for Level One drugs

$45 copay for Level Two drugs

$65 copay for Level Three drugs

$100 copay for Level Four drugs

25% coinsurance for Level Five drugs

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

• Women's contraceptive drugs and devices including the "morning after pill"
• Tobacco Cessation drugs

Note: The above over-the-counter drugs and devices approved by the FDA for contraception or to treat tobacco dependence require a written prescription by an approved provider. Some restrictions apply.

Not covered:

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

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefits. (See page 69.)

Nothing

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

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

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

Nothing

Not covered:

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

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefits. (See page 69)

All charges

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

Nothing

We have no other dental benefits.

All charges

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

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

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

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

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

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

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

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