Humana High Deductible Health Plan

https://feds.humana.com/

Customer Service 1-800-4HUMANA

2022

A High Deductible Health Plan (HDHP)

IMPORTANT

• Rates: Back Cover

• Changes for 2022: Page 17

• Summary of Benefits: Page 93

This plan’s health coverage qualifies as minimum essential coverage

and meets the minimum value standard for the benefits it provides. See

page 8 for details. This plan is accredited. See page 13.

Serving:

The following metropolitan areas – Phoenix and Tucson, Arizona;

Daytona, Orlando, Tampa and South Florida, Florida; Atlanta,

Columbus and Macon, Georgia; Chicago, Illinois; Central Illinois;

Kansas City, Kansas/Missouri; Cincinnati, Ohio; Austin, Corpus

Christi, Houston and San Antonio, Texas; Knoxville, Tennessee.

Enrollment in this plan is limited. You must live or work in our

geographic service area to enroll. See page 15 for requirements.

Enrollment codes for this Plan can be found in the Rate Information section.

High Deductible Health Plan is a new offering for 2022.

RI 73-908

Important Notice from Humana High Deductible Health Plan About

Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that Humana High Deductible Health 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).

Table of Contents

Table of Contents ..........................................................................................................................................................................1

Introduction ...................................................................................................................................................................................3

Plain Language ..............................................................................................................................................................................3

Stop Healthcare Fraud! .................................................................................................................................................................3

Discrimination is Against the Law ................................................................................................................................................4

Preventing Medical Mistakes ........................................................................................................................................................5

FEHB Facts ...................................................................................................................................................................................8

Coverage information .........................................................................................................................................................8

• No pre-existing condition limitation ...............................................................................................................................8

• Minimum essential coverage (MEC) ..............................................................................................................................8

• Minimum value standard ................................................................................................................................................8

• Where you can get information about enrolling in the FEHB Program .........................................................................8

• Types of coverage available for you and your family ....................................................................................................8

• Family member coverage ...............................................................................................................................................9

• Children’s Equity Act ...................................................................................................................................................10

• When benefits and premiums start ...............................................................................................................................10

• When you retire ............................................................................................................................................................10

When you lose benefits .....................................................................................................................................................11

• When FEHB coverage ends ..........................................................................................................................................11

• Upon divorce .................................................................................................................................................................11

• Temporary Continuation of Coverage (TCC) ...............................................................................................................11

• Converting to individual coverage ................................................................................................................................11

• Health Insurance Marketplace ......................................................................................................................................12

Section 1. How This Plan Works ................................................................................................................................................13

How we pay providers ......................................................................................................................................................13

General features of our High Deductible Health Plan (HDHP) ........................................................................................13

Your rights and responsibilities .........................................................................................................................................15

Your medical and claims records are confidential ............................................................................................................15

Service Area ......................................................................................................................................................................15

Section 2. Changes for 2022 .......................................................................................................................................................17

Program-wide changes: .....................................................................................................................................................17

High Deductible Health Plan: ...........................................................................................................................................17

Section 3. How You Get Care .....................................................................................................................................................18

Identification cards ............................................................................................................................................................18

Where you get covered care ..............................................................................................................................................18

• Plan providers .....................................................................................................................................................18

• Plan facilities ......................................................................................................................................................18

What you must do to get covered care ..............................................................................................................................18

• Primary care ........................................................................................................................................................18

• Specialty care ......................................................................................................................................................19

• Hospital care .......................................................................................................................................................19

• If you are hospitalized when your enrollment begins .........................................................................................19

You need prior Plan approval for certain services ............................................................................................................19

• Inpatient hospital admission ...............................................................................................................................20

• Other services .....................................................................................................................................................20

How to request precertification for an admission or get prior authorization for Other services ......................................20

1 2022 Humana High Deductible Health Plan Table of Contents

• Non-urgent care claims .......................................................................................................................................21

• Urgent care claims ..............................................................................................................................................21

• Concurrent care claims .......................................................................................................................................21

The Federal Flexible Spending Account Program - FSAFEDS ..............................................................................22

• Emergency inpatient admission ..........................................................................................................................22

• Maternity care .....................................................................................................................................................22

• If your treatment needs to be extended ...............................................................................................................22

What happens when you do not follow the precertification rules when using non-network facilities .............................22

Circumstances beyond our control ....................................................................................................................................22

If you disagree with our pre-service claim decision .........................................................................................................22

• To reconsider a non-urgent care claim ................................................................................................................22

• To reconsider an urgent care claim .....................................................................................................................23

• To file an appeal with OPM ................................................................................................................................23

Section 4. Your Cost for Covered Services .................................................................................................................................24

Cost-sharing ......................................................................................................................................................................24

Coinsurance .......................................................................................................................................................................24

Deductible .........................................................................................................................................................................24

Differences between our Plan allowance and the bill .......................................................................................................24

Your catastrophic protection out-of-pocket maximum .....................................................................................................24

Carryover ..........................................................................................................................................................................25

When Government facilities bill us ..................................................................................................................................25

Section 5. High Deductible Health Plan Benefits .......................................................................................................................26

Non-FEHB benefits Available to Plan members .........................................................................................................................75

Section 6. General Exclusions – Services, Drugs and Supplies We Do not Cover .....................................................................76

Section 7. Filing a Claim for Covered Services .........................................................................................................................77

Section 8. The Disputed Claims Process .....................................................................................................................................79

Section 9. Coordinating Benefits with Medicare and Other Coverage .......................................................................................82

When you have other health coverage ..............................................................................................................................82

• TRICARE and CHAMPVA ................................................................................................................................82

• Workers’ Compensation ......................................................................................................................................82

• Medicaid .............................................................................................................................................................82

When other Government agencies are responsible for your care .....................................................................................82

When others are responsible for injuries ...........................................................................................................................83

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage ..........................................83

Clinical trials .....................................................................................................................................................................83

When you have Medicare .................................................................................................................................................84

• The Original Medicare Plan (Part A or Part B) ..................................................................................................84

• Tell us about your Medicare coverage ................................................................................................................85

• Medicare Advantage (Part C) .............................................................................................................................85

• Medicare prescription drug coverage (Part D) ...................................................................................................86

Section 10. Definitions of Terms We Use in This Brochure .......................................................................................................88

Index ............................................................................................................................................................................................91

Summary of Benefits for the HDHP - 2022 ................................................................................................................................93

2022 Rate Information for Humana High Deductible Health Plan .............................................................................................95

2 2022 Humana High Deductible Health Plan Table of Contents

Introduction

This brochure describes the benefits of Humana High Deductible Health 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 High Deductible Health 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.

Plain Language

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.

Stop Healthcare Fraud!

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.

3 2022 Humana High Deductible Health Plan Introduction/Plain Language/Advisory

•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.

Discrimination is Against the Law

Humana High Deductible Health 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

4 2022 Humana High Deductible Health Plan Introduction/Plain Language/Advisory

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.

Preventing Medical Mistakes

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.

5 2022 Humana High Deductible Health Plan Introduction/Plain Language/Advisory

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.

6 2022 Humana High Deductible Health Plan Introduction/Plain Language/Advisory

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.

7 2022 Humana High Deductible Health Plan Introduction/Plain Language/Advisory

FEHB Facts

Coverage information

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

solely because you had the condition before you enrolled.

• No pre-existing

condition

limitation

Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal

Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-

Shared-Responsibility-Provision for more information on the individual requirement for MEC.

• Minimum

essential

coverage (MEC)

Our health coverage meets the minimum value standard of 60% established by the ACA. This

means that we provide benefits to cover at least 60% of the total allowed costs of essential health

benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are

determined as explained in this brochure.

• Minimum value

standard

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

• Information on the FEHB Program and plans available to you

• A health plan comparison tool

• A list of agencies that participate in Employee Express

• A link to Employee Express

• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you brochures

for other plans, and other materials you need to make an informed decision about your FEHB

coverage. These materials tell you:

• When you may change your enrollment

• How you can cover your family members

• What happens when you transfer to another Federal agency, go on leave without pay, enter

military service, or retire

• What happens when your enrollment ends

• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your

enrollment status without information from your employing or retirement office. For information

on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact Humana directly for address

updates and questions about your benefit coverage.

• Where you can

get information

about enrolling

in the FEHB

Program

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one

eligible family member. Self and Family coverage is for the enrollee and one or more eligible

family members. Family members include your spouse and your dependent children under age

26, including any foster children authorized for coverage by your employing agency or

retirement office. Under certain circumstances, you may also continue coverage for a disabled

child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family

enrollment if you marry, give birth, or add a child to your family. You may change your

enrollment 31 days before to 60 days after that event.

• Types of

coverage

available for

you and your

family

8 2022 Humana High Deductible Health Plan FEHB Facts

The Self Plus One or Self and Family enrollment begins on the first day of the pay period in

which the child is born or becomes an eligible family member. When you change to Self Plus

One or Self and Family because you marry, the change is effective on the first day of the pay

period that begins after your employing office receives your enrollment form. Benefits will not

be available to your spouse until you are married. A carrier may request that an enrollee verify

the eligibility of any or all family members listed as covered under the enrollee’s FEHB

enrollment.

Contact your carrier to obtain a Certificate of Creditable Coverage (COCC) or to add a

dependent when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or

Self and Family or to add a newborn if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer

eligible to receive benefits, nor will we. Please tell us immediately of changes in family member

status, including your marriage, divorce, annulment, or when your child reaches age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be

enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child -

outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB

Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the

FEHB website at www.opm.gov/healthcare-insurance/life-events. If you need assistance, please

contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement

office.

Family members covered under your Self and Family enrollment are your spouse (including

your spouse by valid common-law marriage from a state that recognizes common-law

marriages) and children as described in the chart below. A Self Plus One enrollment covers you

and your spouse, or one other eligible family member as described in the chart below.

Natural children, adopted children, and stepchildren

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

birthday.

Foster children

Coverage: Foster children are eligible for coverage until their 26th birthday if you provide

documentation of your regular and substantial support of the child and sign a certification stating

that your foster child meets all the requirements. Contact your human resources office or

retirement system for additional information.

Children incapable of self-support

Coverage: Children who are incapable of self-support because of a mental or physical disability

that began before age 26 are eligible to continue coverage. Contact your human resources office

or retirement system for additional information.

Married children

Coverage: Married children (but NOT their spouse or their own children) are covered until their

26th birthday.

Children with or eligible for employer-provided health insurance

Coverage: Children who are eligible for or have their own employer-provided health insurance

are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered

portion of the mother's maternity stay.

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

• Family member

coverage

9 2022 Humana High Deductible Health Plan FEHB Facts

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of

2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in

the FEHB Program, if you are an employee subject to a court or administrative order requiring

you to provide health benefits for your child(ren).

If this law applies to you, you must enroll for Self Plus One or Self and Family coverage in a

health plan that provides full benefits in the area where your children live or provide

documentation to your employing office that you have obtained other health benefits coverage

for your children. If you do not do so, your employing office will enroll you involuntarily as

follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or

Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as

determined by OPM;

• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the

area where your children live, your employing office will change your enrollment to Self

Plus One or Self and Family, as appropriate, in the same option of the same plan; or

• If you are enrolled in an HMO that does not serve the area where the children live, your

employing office will change your enrollment to Self Plus One or Self and Family, as

appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in

the order who is still eligible under the FEHB Program, you cannot cancel your enrollment,

change to Self Only, or change to a plan that does not serve the area in which your children live,

unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child

still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if

eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not

serve the area in which your children live as long as the court/administrative order is in

effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies

more than one child. Contact your employing office for further information.

• Children’s

Equity Act

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season,

your coverage begins on the first day of your first pay period that starts on or after January 1. If

you changed plans or plan options during Open Season and you receive care between

January 1 and the effective date of coverage under your new plan or option, your claims

will be processed according to the 2022 benefits of your prior plan or option. If you have

met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the

prior plan or option, you will not pay cost-sharing for services covered between January 1 and

the effective date of coverage under your new plan or option. However, if your prior plan left the

FEHB Program at the end of the year, you are covered under that plan’s 2021 benefits until the

effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin

on January 1. If you joined at any other time during the year, your employing office will tell you

the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e. you have

separated from Federal service) and premiums are not paid, you will be responsible for all

benefits paid during the period in which premiums were not paid. You may be billed for services

received directly from your provider. You may be prosecuted for fraud for knowingly using

health insurance benefits for which you have not paid premiums. It is your responsibility to

know when you or a family member are no longer eligible to use your health insurance

coverage.

• When benefits

and premiums

start

When you retire, you can usually stay in the FEHB Program. Generally, you must have been

enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet

this requirement, you may be eligible for other forms of coverage, such as Temporary

Continuation of Coverage (TCC).

• When you retire

10 2022 Humana High Deductible Health Plan FEHB Facts

When you lose benefits

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

• Your enrollment ends, unless you cancel your enrollment; or

• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or

other institution for care or treatment on the 31

day of the temporary extension is entitled to

continuation of the benefits of the Plan during the continuance of the confinement but not

beyond the 60

day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC),

or a conversion policy (a non-FEHB individual policy.)

• When FEHB

coverage ends

If you are divorced from a Federal employee, or an annuitant, you may not continue to get

benefits under your former spouse’s enrollment. This is the case even when the court has

ordered your former spouse to provide health coverage to you. However, you may be eligible

for your own FEHB coverage under either the spouse equity law or Temporary Continuation of

Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-

spouse’s employing or retirement office to get additional information about your coverage

choices. You can also visit OPM’s website at www.opm.gov/healthcare-insurance/healthcare/

plan-information/. A carrier may request that an enrollee verify the eligibility of any or all family

members listed as covered under the enrollee’s FEHB enrollment.

• Upon divorce

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer

qualify as a family member, you may be eligible for Temporary Continuation of Coverage

(TCC). The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. For

example, you can receive TCC if you are not able to continue your FEHB enrollment after you

retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn

26, etc.

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

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement

office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where,

depending on your income, you could be eligible for a new kind of tax credit that lowers your

monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium,

deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if

you qualify for coverage under another group health plan (such as your spouse’s plan), you may

be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program

coverage.

• Temporary

Continuation of

Coverage

(TCC)

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

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or

did not pay your premium, you cannot convert);

• You decided not to receive coverage under TCC or the spouse equity law; or

• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to

convert. You must contact us in writing within 31 days after you receive this notice. However, if

you are a family member who is losing coverage, the employing or retirement office will not

notify you. You must contact us in writing within 31 days after you are no longer eligible for

coverage.

• Converting to

individual

coverage

11 2022 Humana High Deductible Health Plan FEHB Facts

Your benefits and rates will differ from those under the FEHB Program; however, you will not

have to answer questions about your health, a waiting period will not be imposed and your

coverage will not be limited due to pre-existing conditions. When you contact us, we will assist

you in obtaining information about health benefits coverage inside or outside the Affordable

Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage,

please contact us at 1-800-4HUMANA or visit www.HealthCare.gov

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace,

please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health

and Human Services that provides up-to-date information on the Marketplace.

• Health

Insurance

Marketplace

12 2022 Humana High Deductible Health Plan FEHB Facts

Section 1. How This Plan Works

This plan is a High Deductible Health Plan. 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.

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 based on a maximum allowable fee schedule. They will

not bill you and you will not have to file claim forms.

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 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 High Deductible Health Plan (HDHP)

HDHPs have higher annual deductibles and annual out-of-pocket maximum limits than other types of FEHB plans. FEHB

Program HDHPs also offer health saving accounts or health reimbursement arrangements. Please see below for more

information about these savings features. Our High Deductible Health Plan is a comprehensive medical plan. You can see

participating or non-participating providers without a referral.

An HDHP is a health plan product that provides traditional healthcare coverage and a tax-advantaged way to help you build

savings for future medical needs. An HDHP with an HSA or HRA is designed to give greater flexibility and discretion over

how you use your healthcare benefits. As an informed consumer, you decide how to utilize your plan coverage with a high

deductible and out-of-pocket expenses limited by catastrophic protection. And you decide how to spend the dollars in your

HSA. You have:

• An HSA in which the Plan will automatically deposit $50 per month/Self Only or $100 per month/Self Plus One or

$100 per month/Self and Family.

• The ability to make voluntary contributions to your HSA of up to $3,000/Self Only or $6,000/Self Plus One or $6,000/Self

and Family per year. If you are age 55 or older, you may also make a catch-up contribution of up to $1,000 for 2022.

Our Plan offers services through a National POS-Open Access provider (NPOS) network.

You have access to NPOS providers inside and outside of your home network. When you use an NPOS provider in your

home network, you are only responsible for the deductible and coinsurance for covered charges. When you use an NPOS

provider that is outside your home network, Humana will pay a benefits based on a contracted rate, negotiated amount or a

billed charge. You are still only responsible for the deductible and coinsurance for covered charges. If you expect that you or

a dependent will be residing outside of your home network for a temporary period of time, please contact Humana for special

assistance.

13 2022 Humana High Deductible Health Plan Section 1

To find NPOS providers, use the provider search tool on the https://feds.humana.com/ website or call Humana at

1-800-4HUMANA. When you phone for an appointment, please remember to verify that the physician is still an NPOS

provider. Humana providers are required to meet licensure and certification standards established by State and Federal

authorities, however, inclusion in the network does not represent a guarantee of professional performance nor does it

constitute medical advice.

You always have the right to choose an NPOS provider or a non-NPOS provider for medical treatment. When you see a

provider not in the NPOS network, Humana will pay at the non-NPOS level and you will pay a higher percentage of the cost.

HDHP benefits apply only when you use an NPOS provider. Provider networks may be more extensive in some areas than

others. We cannot guarantee the availability of every specialty in all areas. If no NPOS provider is available, or you do not

use an NPOS provider, the standard non-HDHP benefits apply. However, if the services are rendered at an NPOS hospital,

we will pay up to the Plan allowable for services of radiologists, anesthesiologists, emergency room physicians, hospitalists,

neonatologists and pathologists who are not preferred providers at the preferred provider rate. You will be responsible for the

difference between the plan allowance and the billed amount. In addition, providers outside the United States will be paid at

the NPOS level of benefits.

Preventive care services

Preventive care services are generally covered with no cost sharing and are not subject to deductibles or annual limits when

received from a network provider.

Annual deductible

The annual deductible of $3,000 for Self Only, or $6,000 for Self Plus One or Self and Family in-network and $9,000 for Self

Only, or $18,000 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 services.

Health Savings Account (HSA)

You are eligible for an HSA if you are enrolled in an HDHP, not covered by any other health plan that is not an HDHP

(including a spouse’s health plan, excluding specific injury insurance and accident, disability, dental care, vision care, or

long-term care coverage), not enrolled in Medicare, not have received VA (except for veterans with a service-connected

disability) or Indian Health Service (IHS) benefits within the last three months, not covered by your own or your spouse's

flexible spending account (FSA), and are not claimed as a dependent on someone else’s tax return.

•You may use the money in your HSA to pay all or a portion of your annual deductible, coinsurance, or other out-of-pocket

costs that meet the IRS definition of a qualified medical expense.

•Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even

if they are not covered by an HDHP.

•You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income

tax and, if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.

•For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a

portion of the health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to

your HSA up to an allowable amount determined by IRS rules. Your HSA dollars earn tax-free interest.

•You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable – you may

take the HSA with you if you leave the Federal government or switch to another plan.

14 2022 Humana High Deductible Health Plan Section 1

Health Reimbursement Arrangement (HRA) under HDHP

If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement

Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.

•An HRA does not earn interest.

•An HRA is not portable if you leave the Federal government or switch to another plan.

Catastrophic protection

We protect you against catastrophic out-of-pocket expenses for covered services. The annual IRS limits out-of-pocket

expenses for covered services, including deductibles and coinsurance, for participating providers, 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, it cannot exceed

$21,000 for Self Only, and $42,000 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. 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 our 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 BV - Maricopa and Pinal counties

Arizona, Tucson – Enrollment Code BY - Pima County

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

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

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

Florida, Tampa – Enrollment code A4 – Citrus, Hernando, Hillsborough, Manatee, Pasco, Pinellas, Polk, and Sarasota

counties

15 2022 Humana High Deductible Health Plan Section 1

Georgia, Atlanta – Enrollment code AR – 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 B2 - Muscogee County

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

counties

Illinois, Central and Northwestern – Enrollment code AW – 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

Illinois, Chicago – Enrollment code BB – The Illinois counties of DuPage, Cook, Kane, Kankakee, Kendall, Lake, McHenry

and Will. The Indiana counties of Lake, Porter, and LaPorte

Kansas/Missouri, Kansas City – Enrollment code BK – 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

Ohio, Cincinnati - Enrollment Code DT - 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 ER - 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 AN – Bastrop, Bell, Bosque, Burleson, Burnet Caldwell, Coryell, Falls, Hamilton, Hays,

Lampasas, Lee, Limestone, McLennan, Milam, Robertson, Travis and Williamson counties

Texas, Corpus Christi – Enrollment code DX – 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, Houston – Enrollment code CG - Austin, Brazoria, Chambers, Colorado, Fayette, Fort Bend, Galveston, Harris,

Liberty, Montgomery, Waller and Wharton counties

Texas, San Antonio – Enrollment code FD – 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.

16 2022 Humana High Deductible Health Plan Section 1

Section 2. Changes for 2022

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.

High Deductible Health Plan:

A new High Deductible Health Plan is being offered for the 2022 Open Season.

17 2022 Humana High Deductible Health Plan Section 2

Section 3. How You Get Care

We will send you an identification (ID) card when you enroll. You should carry your ID

card with you at all times. You must show it whenever you receive services from a Plan

provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use

your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment

confirmation (for annuitants), or your electronic enrollment system (such as Employee

Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your

enrollment, or if you need replacement cards, call us at 1-800-4HUMANA or

1-800-448-6262 or write to the Plan at P.O. Box 14602, Lexington, KY 40512-4602. You

may also request replacement cards through our website https://feds.humana.com/.

Identification cards

You can get care from any “Plan provider” or “Plan facilities.” You will only pay

deductibles and/or coinsurance, and you will not have to file claims. You can also get care

from non-Plan providers, but it will cost you more.

Where you get covered

care

Plan providers are physicians and other healthcare professionals in our service area that

we contract with to provide covered services to our members. We credential Plan

providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is

also on our website at https://feds.humana.com/.

This plan recognizes that transsexual, transgender, and gender-nonconforming members

require health care delivered by healthcare providers experienced in transgender health.

While gender reassignment surgeons (benefit details found in Section 5(b)) and hormone

therapy providers (benefit details found in Section 5(f)) play important roles in preventive

care, you should see a primary care provider familiar with your overall health care needs.

Benefits described in this brochure are available to all members meeting medical necessity

guidelines.

• Plan providers

Plan facilities are hospitals and other facilities in our service area that we contract with to

provide covered services to our members. We list these in the provider directory, which

we update periodically. The list is also on our website at https://feds.humana.com/.

• Plan facilities

FEHB Carriers must have clauses in their in-network (participating) providers agreements.

These clauses provide that, for a service that is a covered benefit in the plan brochure or

for services determined not medically necessary, the in-network provider agrees to hold

the covered individual harmless (and may not bill) for the difference between the billed

charge and the in network contracted amount. If an in-network provider bills you for

covered services over your normal cost share (deductible, copay, coinsurance) contact

Humana to enforce the terms of its provider contract.

Balance Billing

Protection

You do not have to select a primary care physician and may self refer. To obtain the

highest level of coverage, however, a member must seek care from a participating

provider. Some care requires you or your provider to obtain prior authorization.

What you must do to get

covered care

Your primary care physician can be a general practitioner, family practitioner, internist, or

pediatrician. Your primary care physician will provide most of your healthcare.

If you want to change primary care physicians or if your pharmacy care physician leaves

the Plan call us. We will help you select a new one.

• Primary care

18 2022 Humana High Deductible Health Plan Section 3

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

• Mental health providers

• Vision care providers

• OB/GYN providers for your annual well-woman exam

• Another doctor your primary care physician has designated to provide patient care

when he or she is not available.

Here are things you should know about specialty care:

If you have a chronic and disabling condition and lose access to your specialist because

we:

• terminate our contract with your specialist for other than cause;

• drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in

another FEHB program plan; or

• reduce our service area and you enroll in another FEHB plan;

you may be able to continue seeing your specialist for up to 90 days after you receive

notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your

specialist based on the above circumstances, you can continue to see your specialist until

the end of your postpartum care and continue to receive participating provider benefits,

even if it is beyond the 90 days.

• Specialty care

Your Plan primary care physician or specialist will make necessary hospital arrangements

and supervise your care. This includes admission to a skilled nursing or other type of

facility.

• Hospital care

We pay for covered services from the effective date of your enrollment. However, if you

are in the hospital when your enrollment in our Plan begins, call our customer service

department immediately at 1-800-426-2173. If you are new to the FEHB Program, we will

arrange for you to receive care and provide benefits for your covered services while you

are in the hospital beginning on the effective date of your coverage.

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

stay until:

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

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

• the 92

day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan

terminates participation in the FEHB Program in whole or in part, or if OPM orders an

enrollment change, this continuation of coverage provision does not apply. In such cases,

the hospitalized family member’s benefits under the new plan begin on the effective date

of enrollment.

• If you are hospitalized

when your enrollment

begins

Since we do not have a primary care physician requirement and we allow you to use non-

Plan providers, you need to obtain our approval before you receive certain services. The

pre-service claim approval processes for inpatient hospital admissions (called

precertification) and for other services, are detailed in this Section. A pre-service claim is

any claim in whole or in part, that requires approval from us in advance of obtaining

medical care of services. In other words, a pre-service claim for benefits (1) requires

precertification, prior approval or a referral and (2) will result in a denial or reduction of

benefits if you do not obtain precertification, prior approval or a referral.

You need prior Plan

approval for certain

services

19 2022 Humana High Deductible Health Plan Section 3

Precertification is the process by which – prior to your inpatient hospital admission – we

evaluate the medical necessity of your proposed stay and the number of days required to

treat your condition.

• Inpatient hospital

admission

Your primary care physician has authority to refer you for most services. For certain

services, however, your physician must obtain prior approval from us. Before giving

approval, we consider if the service is covered, medically necessary, and follows generally

accepted medical practice. You must obtain prior authorization for:

• Organ/tissue transplants

• All elective medical and surgical hospitalizations (Including Inpatient Hospice)

• Non-emergent admissions for mental health, skilled nursing, acute rehabilitation

facilities and long term acute care facilities

• MRI, MRA, PET, CT Scan, and SPECT Scan

• Surgical treatment for morbid obesity

• All durable medical equipment (DME) over $750

• Home healthcare services (Including Home Hospice)

• Infertility testing and treatment

• Some specialty drugs when delivered in the physician's office, clinic, outpatient or

home setting

• All surgeries which may be considered plastic or cosmetic surgery only for repair of

accidental injury

• Oral surgeries

• Outpatient Therapy Services for Physical, Occupational and Speech

• Genetic/Molecular Diagnostic Testing – (Genetic testing is covered under the

laboratory services benefit, limitations may apply)

• Chiropractic

• Radiation Therapy

• Acupuncture

• Esophagogastroduodenoscopy (EGD)

• Coronary angiography

• Colonoscopy repeat testing

For a complete list of service requiring authorization, please visit our website www.

humana.com.

• Other services

First, your physician, your hospital, you, or your representative must call us at

1-800-4HUMANA before admission or services requiring prior authorization are

rendered.

Next, provide the following information:

• enrollee’s name and Plan identification number;

• patient’s name, birth date, identification number and phone number;

• reason for hospitalization, proposed treatment, or surgery;

• name and phone number of admitting physician;

• name of hospital or facility; and

• number of days requested for hospital stay.

How to request

precertification for an

admission or get prior

authorization for Other

services

20 2022 Humana High Deductible Health Plan Section 3

For non-urgent care claims, we will tell the physician and/or hospital the number of

approved inpatient days, or the care that we approve for other services that must have

prior authorization. We will make our decision within 15 days of receipt of the pre-service

claim. If matters beyond our control require an extension of time, we may take up to an

additional 15 days for review and we will notify you of the need for an extension of time

before the end of the original 15-day period. Our notice will include the circumstances

underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you,

our notice will describe the specific information required and we will allow you up to 60

days from the receipt of the notice to provide the information.

• Non-urgent care

claims

If you have an urgent care claim (i.e., when waiting for the regular time limit for your

medical care or treatment could seriously jeopardize your life, health, or ability to regain

maximum function, or in the opinion of a physician with knowledge of your medical

condition, would subject you to severe pain that cannot be adequately managed without

this care or treatment), we will expedite our review and notify you of our decision within

72 hours. If you request that we review your claim as an urgent care claim, we will review

the documentation you provide and decide whether or not it is an urgent care claim by

applying the judgment of a prudent layperson that possesses an average knowledge of

health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we

receive the claim to let you know what information we need to complete our review of the

claim. You will then have up to 48 hours from the receipt of this notice to provide the

necessary information. We will make our decision on the claim within 48 hours of (1) the

time we received the additional information or (2) the end of the time frame you received

the notice to provide the additional information, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with

written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us

and OPM. Please let us know that you would like a simultaneous review of your urgent

care claim by OPM either in writing at the time you appeal our initial decision, or by

calling us at 1-800-4HUMANA or 1-800-448-6262. You may also call OPM’s Health

Insurance 3 at 1-(202) 606-0755 between 8 a.m. and 5 p.m. Eastern Time to ask for the

simultaneous review. We will cooperate with OPM so they can quickly review your claim

on appeal. In addition, if you did not indicate that your claim was a claim for urgent

care, call us at 1-800-4HUMANA or 1-800-448-6262. If it is determined that your claim is

an urgent care claim, we will expedite our review (if we have not yet responded to your

claim).

• Urgent care claims

A concurrent care claim involves care provided over a period of time or over a number of

treatments. We will treat any reduction or termination of our pre-approved course of

treatment before the end of the approved period of time or number of treatments as an

appealable decision. This does not include reduction or termination due to benefit changes

or if your enrollment ends. If we believe a reduction or termination is warranted, we will

allow you sufficient time to appeal and obtain a decision from us before the reduction or

termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the

expiration of the approved time period and this is also an urgent care claim, we will make

a decision within 24 hours after we receive the claim.

• Concurrent care

claims

21 2022 Humana High Deductible Health Plan Section 3

• HealthCare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare

expenses (such as deductibles, physician prescribed over-the-counter drugs and

medications, vision and dental expenses, and much more) for you and your tax

dependents, including adult children (through the end of the calendar year in which

they turn 26).

• FSAFEDS offers paperless reimbursement for your HCFSA through a number of

FEHB and FEDVIP plans. This means that when you or your provider files claims

with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your

eligible out-of-pocket expenses based on the claim information it receives from your

plan.

• The Federal Flexible

Spending Account

Program - FSAFEDS

If you have an emergency admission due to a condition that you reasonably believe puts

your life in danger or could cause serious damage to bodily function, you, your

representative, the physician, or the hospital must phone us within two business days

following the day of the emergency admission, even if you have been discharged from the

hospital.

• Emergency inpatient

admission

Precertification is not required for maternity care. • Maternity care

If you request an extension of an ongoing course of treatment at least 24 hours prior to the

expiration of the approved time period and this is also an urgent care claim, we will make

a decision within 24 hours after we receive the claim.

• If your treatment

needs to be extended

You are responsible for the precertification rules when using non-network healthcare

providers. If preauthorization is required but not obtained, benefits will be reduced by

$500.

What happens when you

do not follow the

precertification rules

when using non-network

facilities

Under certain extraordinary circumstances, such as natural disasters, we may have to

delay your services or we may be unable to provide them. In that case, we will make all

reasonable efforts to provide you with the necessary care.

Circumstances beyond

our control

If you have a pre-service claim and you do not agree with our decision regarding

precertification of an inpatient admission or prior approval of other services, you may

request a review in accord with the procedures detailed below.

If you have already received the service, supply, or treatment, then you have a post-

service claim and must follow the entire disputed claims process detailed in Section 8.

If you disagree with our

pre-service claim decision

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial

decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this

brochure.

In the case of a pre-service claim and subject to a request for additional information, we

have 30 days from the date we receive your written request for reconsideration to

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to

give you the care or grant your request for prior approval for a service, drug, or

supply; or

2. Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of

our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of

the date the information was due. We will base our decision on the information we

already have. We will write to you with our decision.

3. Write to you and maintain our denial.

• To reconsider a non-

urgent care claim

22 2022 Humana High Deductible Health Plan Section 3

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial

decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the

disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72

hours after receipt of your reconsideration request. We will expedite the review process,

which allows oral or written requests for appeals and the exchange of information by

phone, electronic mail, facsimile, or other expeditious methods.

• To reconsider an

urgent care claim

After we reconsider your pre-service claim, if you do not agree with our decision, you

may ask OPM to review it by following Step 3 of the disputed claims process detailed in

Section 8 of this brochure.

• To file an appeal with

OPM

23 2022 Humana High Deductible Health Plan Section 3

Section 4. Your Cost for Covered Services

This is what you will pay out-of-pocket for covered care:

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g. deductible

and coinsurance) for the covered care you receive.

Cost-sharing

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

care. Coinsurance does not begin until you have met your calendar year deductible.

Participating providers example: You pay 50% of charges for in-network infertility

services under the HDHP.

Non-participating providers example: You pay 40% of charges for out-of-network

infertility services under the HDHP.

Coinsurance

A deductible is a fixed expense you must incur for certain covered services and supplies

before we start paying benefits for them. Deductible and out-of-pocket limits for

participating and non-participating benefits are calculated separately.

Participating providers – If you use participating providers, the calendar year deductible is

$3,000 for Self Only. The deductible for Self Plus One or Self and Family coverage is

$6,000.

Non-participating providers – If you use non-participating providers, the calendar year

deductible of $9,000 for Self Only must be met. The deductible for Self Plus One or Self

and Family coverage is $18,000.

Note: If you change plans during Open Season, you do not have to start a new deductible

under your prior plan between January 1 and the effective date of your new plan. If you

change plans at another time during the year, you must begin a new deductible under your

new plan.

Deductible

Participating providers – have agreed to accept a negotiated payment from us; you are

only responsible for your coinsurance. You never have to pay the difference between the

plan allowance and the billed amount.

Non-participating providers – You will be responsible for any difference between the

amount non-participating providers charge and our allowance, in addition to the

applicable coinsurance amounts.

You should also see section Important Notice About Surprise Billing – Know Your Rights

below that describes your protections against surprise billing under the No Surprises Act.

Differences between our

Plan allowance and the

bill

Out-of-pocket maximums are the amount of out-of-pocket expenses that a Self Only, Self

Plus One or a Self and Family will have to pay in a plan year. Out -of-pocket maximums

apply on a calendar year basis only. The non-participating maximum out-of-pocket

expense limits exclude expenses for covered organ transplants.

Participating providers – After your (deductibles and coinsurance) total $7,000 for Self

Only, or $14,000 for a Self Plus One or Self and Family enrollment in any calendar year,

you do not have to pay any more for covered services.

Non-participating providers – After your (deductibles and coinsurance) total $21,000 for

Self Only, or $42,000 for a Self Plus One or Self and Family enrollment in any calendar

year, you do not have to pay any more for covered services.

The maximum annual limitation on cost sharing listed under Self Only of $7,000 for

participating providers and $14,000 for non-participating providers applies to each

individual, regardless of whether the individual is enrolled in Self Only, Self Plus

One, or Self and Family.

Your catastrophic

protection out-of-pocket

maximum

24 2022 Humana High Deductible Health Plan Section 4

Example Scenario: Your plan has a $7,000 Self Only maximum out-of-pocket limit and a

$14,000 Self Plus One or Self and Family maximum out-of-pocket limit. If you or one of

your eligible family members has out-of-pocket qualified medical expenses of $7,000 or

more for the calendar year, any remaining qualified medical expenses for that individual

will be covered fully by your health plan. With a Self and Family enrollment out-of-

pocket maximum of $14,000, a second family member, or an aggregate of other eligible

family members, will continue to accrue out-of-pocket qualified medical expenses up to a

maximum of $7,000 for the calendar year before their qualified medical expenses will

begin to be covered in full.

Be sure to keep accurate records and receipts of your coinsurance since you are

responsible for informing us when you reach the maximum.

If you changed to this plan during Open Season from a plan with a catastrophic protection

benefit and the effective date of the change was after January 1, any expenses that would

have applied to that plan’s catastrophic protection benefit during the prior year will be

covered by your prior plan if they are for care you received in January before your

effective date of coverage in this Plan. If you have already met your prior plan’s

catastrophic protection benefit level in full, it will continue to apply until the effective date

of your coverage in this Plan. If you have not met this expense level in full, your prior

plan will first apply your covered out-of-pocket expenses until the prior year’s

catastrophic level is reached and then apply the catastrophic protection benefit to covered

out-of-pocket expenses incurred from that point until the effective date of your coverage

in this Plan. Your prior plan will pay these covered expenses according to this year’s

benefits; benefit changes are effective January 1.

Carryover

Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian

Health Services are entitled to seek reimbursement from us for certain services and

supplies they provide to you or a family member. They may not seek more than their

governing laws allow. You may be responsible to pay for certain services and charges.

Contact the government facility directly for more information.

When Government

facilities bill us

The No Surprises Act (NSA) is a federal law that provides you with protections against

“surprise billing” and “balance billing” under certain circumstances. A surprise bill is an

unexpected bill you receive from a nonparticipating healthcare provider, facility, or air

ambulance service for healthcare. Surprise bills can happen when you receive emergency

care – when you have little or no say in the facility or provider from whom you receive

care. They can also happen when you receive non-emergency services at participating

facilities, but you receive some care from nonparticipating providers.

Balance billing happens when you receive a bill from the nonparticipating provider,

facility, or air ambulance service for the difference between the nonparticipating

provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from

unexpected bills.

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

Arizona, Florida, Georgia, Illinois, Kansas, Kentucky, Ohio, Tennessee, and Texas.

For specific information on surprise billing, the rights and protections you have, and your

responsibilities go to https://humana.com or contact the health plan at 1-800-4HUMANA.

Important Notice About

Surprise Billing – Know

Your Rights

25 2022 Humana High Deductible Health Plan Section 4

Section 5. High Deductible Health Plan Benefits

HDHP

See page 17 for how our benefits changed this year and page 93 is the benefits summary.

Section 5. High Deductible Health Plan Benefits Overview ......................................................................................................28

Section 5. Savings - HSAs and HRAs ........................................................................................................................................31

Section 5. Preventive Care ..........................................................................................................................................................36

Preventive care, adult ........................................................................................................................................................36

Preventive care, children ...................................................................................................................................................37

Section 5. Traditional Medical Coverage Subject to the Deductible ..........................................................................................38

• Deductible before Traditional medical coverage begins ..............................................................................................38

Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals ..............................39

Diagnostic and treatment services .....................................................................................................................................39

Telehealth services ............................................................................................................................................................40

Lab, X-ray and other diagnostic tests ................................................................................................................................40

Maternity care ...................................................................................................................................................................41

Family planning ................................................................................................................................................................41

Infertility services .............................................................................................................................................................42

Allergy care .......................................................................................................................................................................43

Treatment therapies ...........................................................................................................................................................43

Physical, occupational and cardiac therapies ....................................................................................................................44

Speech therapy ..................................................................................................................................................................44

Hearing services (testing, treatment, and supplies) ...........................................................................................................44

Vision services (testing, treatment, and supplies) .............................................................................................................45

Foot care ............................................................................................................................................................................45

Orthopedic and prosthetic devices ....................................................................................................................................45

Durable medical equipment (DME) ..................................................................................................................................46

Home health services ........................................................................................................................................................47

Chiropractic .......................................................................................................................................................................47

Alternative treatments .......................................................................................................................................................47

Educational classes and programs .....................................................................................................................................48

Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals ..........................49

Surgical procedures ...........................................................................................................................................................49

Reconstructive surgery ......................................................................................................................................................50

Oral and maxillofacial surgery ..........................................................................................................................................51

Organ/tissue transplants ....................................................................................................................................................52

Anesthesia .........................................................................................................................................................................57

Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services .......................................................58

Inpatient hospital ...............................................................................................................................................................58

Outpatient hospital or ambulatory surgical center ............................................................................................................59

Extended care benefits/Skilled nursing care facility benefits ...........................................................................................60

Hospice care ......................................................................................................................................................................60

End of life care ..................................................................................................................................................................60

Ambulance ........................................................................................................................................................................60

Section 5(d). Emergency Services/Accidents .............................................................................................................................61

Emergency within our service area ...................................................................................................................................62

Ambulance ........................................................................................................................................................................63

Section 5(e). Mental Health and Substance Use Disorder Benefits ............................................................................................64

Professional services .........................................................................................................................................................64

26 2022 Humana High Deductible Health Plan HDHP Section 5

HDHP

Diagnostics ........................................................................................................................................................................65

Inpatient hospital or other covered facility .......................................................................................................................65

Outpatient hospital or other covered facility .....................................................................................................................65

Applied behavior analysis (ABA) therapy ........................................................................................................................66

Section 5(f). Prescription Drug Benefits .....................................................................................................................................67

Covered medications and supplies ....................................................................................................................................69

Preventive care medications ..............................................................................................................................................70

Section 5(g). Dental Benefits ......................................................................................................................................................72

Accidental injury benefit ...................................................................................................................................................72

Dental benefits ..................................................................................................................................................................72

Section 5(h). Wellness and Other Special Features .....................................................................................................................73

Flexible benefits option .....................................................................................................................................................73

Wellness Benefit ................................................................................................................................................................73

MyHumana(Humana.com) ...............................................................................................................................................73

Wellness Reminders ..........................................................................................................................................................73

Humana Pharmacy ............................................................................................................................................................73

HumanaBeginnings® ........................................................................................................................................................74

Case Management .............................................................................................................................................................74

Transplant Management ....................................................................................................................................................74

Maximize Your Benefit (MYB) ........................................................................................................................................74

Personal Nurse® ...............................................................................................................................................................74

Chronic Condition Management .......................................................................................................................................74

Services for deaf and hearing impaired .............................................................................................................................74

Humana Health Coaching .................................................................................................................................................74

Employee Assistance Program (EAP) ...............................................................................................................................74

Summary of Benefits for the HDHP - 2022 ................................................................................................................................93

27 2022 Humana High Deductible Health Plan HDHP Section 5

Section 5. High Deductible Health Plan Benefits Overview

HDHP

This Plan offers a High Deductible Health Plan (HDHP). The HDHP benefit package is described in this section.

Make sure that you review the benefits that are available under the option in which you are enrolled.

The HDHP Section 5, which describes the HDHP benefits is divided into subsections. Please read

Important things you

should keep in mind about these benefits

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 HDHP benefits, contact us at 1-800-4HUMANA or on our website at https://feds.humana.com/.

Our HDHP option provides comprehensive healthcare coverage for high-cost medical events and a tax-advantaged way to

help you build savings for future medical expenses. The Plan gives you greater control over how you use your healthcare

benefits.

When you enroll in this HDHP, we establish either a Health Savings Account (HSA) or a Health Reimbursement

Arrangement (HRA) for you. We automatically pass through a portion of the total health Plan premium to your HSA or credit

an equal amount to your HRA based upon your eligibility. Your full annual HRA credit will be available on your effective

date of enrollment.

With this Plan, preventive care is covered in full. As you receive other non-preventive medical care, you must meet the Plan’s

deductible before we pay benefits according to the benefits described on page 38. You can choose to use funds available in

your HSA to make payments toward the deductible or you can pay toward your deductible entirely out-of-pocket, allowing

your savings to continue to grow.

This HDHP includes five key components: preventive care; traditional medical coverage healthcare that is subject to the

deductible; savings; catastrophic protection for out-of-pocket expenses; and health education resources and account

management tools.

•Preventive care

The Plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.

g., mammograms), routine prenatal and well-child care, child and adult immunizations, tobacco cessation programs, obesity

weight loss programs, disease management and wellness programs. These services are covered at 100% if you use a network

provider and the services are described in Section 5 -

Preventive care

You do not have to meet the deductible before using

these services.

•Traditional medical coverage

After you have paid the Plan’s deductible, we pay benefits under traditional medical coverage described in Section 5. The

Plan typically pays 90% after deductible for in-network and 60% after deductible for out-of-network care.

Covered services include:

•Medical services and supplies provided by physicians and other healthcare professionals

•Surgical and anesthesia services provided by physicians and other healthcare professionals

•Hospital services; other facility or ambulance services

•Emergency services/accidents

•Mental health and substance use disorder benefits

•Prescription drug benefits

Savings

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses

(see page 31 for more details).

28 2022 Humana High Deductible Health Plan HDHP Section 5 Overview

HDHP

•Health Savings Accounts (HSAs)

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone

else’s tax return, have not received VA (except for veterans with a service-connected disability) and/or Indian Health Services

(IHS) benefits within the last three months or do not have other health insurance coverage other than another High

Deductible Health Plan. In 2022, for each month you are eligible for an HSA premium pass through, we will contribute to

your HSA $50 per month for a Self Only enrollment or $100 per month for a Self Plus One enrollment or $100 per month for

a Self and Family enrollment. In addition to our monthly contribution, you have the option to make additional tax-free

contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $3,600 for an

individual and $7,200 for a family. See maximum contribution information on page 32. You can use funds in your HSA to

help pay your health plan deductible. You own your HSA, so the funds can go with you if you change plans or employment.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution

payments are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the

flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don’t deplete your

HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future

expenses.

HSA features include:

•Your HSA is administered by Humana

•Your contributions to the HSA are tax deductible

•Your HSA earns tax-free interest.

•You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents (see IRS

publication 502 for a complete list of eligible expenses)

•Your unused HSA funds and interest accumulate from year to year

•It’s portable - the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire

•When you need it, funds up to the actual HSA balance are available.

Important consideration if you want to participate in a HealthCare Flexible Spending Account (HCFSA): If you are

enrolled in this HDHP with a Health Savings Account (HSA), and start or become covered by a HCFSA healthcare flexible

spending account (such as FSAFEDS offers – see Section 11), this HDHP cannot continue to contribute to your HSA.

Similarly, you cannot contribute to an HSA if your spouse enrolls in an HCFSA. Instead, when you inform us of your

coverage in an HCFSA, we will establish an HRA for you.

•Health Reimbursement Arrangements (HRA)

If you are not eligible for an HSA, for example, you are enrolled in Medicare or have another health plan, we will administer

and provide an HRA instead. You must notify us that you are ineligible for an HSA.

In 2022, we will give you an HRA credit of $50 per month for a Self Only enrollment or $100 per month for a Self Plus One

enrollment or $100 per month for a Self and Family enrollment. You can use funds in your HRA to help pay your health plan

deductible and/or for certain expenses that don’t count toward the deductible.

HRA features include:

•For our HDHP option, the HRA is administered by Humana.

•Entire HRA credit (prorated from your effective date to the end of the plan year) is available from your effective date of

enrollment.

•Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP.

•Unused credits carryover from year to year.

•HRA credit does not earn interest.

•HRA credit is forfeited if you leave Federal employment or switch health insurance plans.

29 2022 Humana High Deductible Health Plan HDHP Section 5 Overview

HDHP

•An HRA does not affect your ability to participate in an FSAFEDS HealthCare Flexible Spending Account (HCFSA).

However, you must meet FSAFEDS eligibility requirements.

•Catastrophic protection for out-of-pocket expenses

When you use network providers, your annual maximum for out-of-pocket expenses (deductibles and coinsurance) for

covered services is limited to $7,000 per person or $14,000 per Self Plus One enrollment or, $14,000 Self and Family

enrollment. 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 allowable amount or benefit

maximum). Refer to Section 4 -

Your catastrophic protection out-of-pocket maximum

and HDHP Section 5 -

Traditional

medical coverage subject to the deductible for more details

•Health education resources and account management tools

HDHP Section 5(i) describes the health education resources and account management tools available to you to help you

manage your healthcare and your healthcare dollars.

Network Availability

Humana contracts with both private office physicians and with physician groups. Referrals are not required for participating

providers. The HDHP will utilize the National POS-Open Access 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

30 2022 Humana High Deductible Health Plan HDHP Section 5 Overview

Section 5. Savings - HSAs and HRAs

HDHP

Feature Comparison Health Savings Account (HSA) Health Reimbursement

Arrangement (HRA)

Provided when you are ineligible

for an HSA

The Plan will establish an HSA for you

with UMB Bank, this HDHP’s fiduciary

(an administrator, trustee or custodian

as defined by Federal tax code and

approved by IRS.)

UMB Bank is the HRA fiduciary for

this Plan.

Administrator

Set-up fee is paid by the HDHP.

No administrative fee charged by the

fiduciary.

None Fees

You must:

• Enroll in this HDHP

• Have no other health insurance

coverage (does not apply to specific

injury, accident, disability, dental,

vision or long-term care coverage)

• Not be enrolled in Medicare

• Not be claimed as a dependent on

someone else’s tax return

• Not have received VA (except for

veterans with a service-connected

disability) and/or Indian Health

Service (IHS) benefits in the last

three months

• Complete and return all banking

paperwork

You must enroll in this HDHP.

Eligibility is determined on the first day

of the month following your effective

day of enrollment and will be prorated

for length of enrollment.

Eligibility

If you are eligible for HSA

contributions, a portion of your monthly

health plan premium is deposited to

your HSA each month. Premium pass

through contributions are based on the

effective date of your enrollment in the

HDHP.

Note: If your effective date in the

HDHP is after the 1st of the month, the

earliest your HSA will be established is

the 1st of the following month.

In addition, you may establish pre-tax

HSA deductions from your paycheck to

fund your HSA up to IRS limits using

the same method that you use to

establish other deductions (i.e.,

Employee Express, MyPay, etc.).

Eligibility for the annual credit will be

determined on the first day of the month

and will be prorated for length of

enrollment. The entire amount of your

HRA will be available to you upon your

enrollment.

Funding

31 2022 Humana High Deductible Health Plan HDHP Section 5 Savings - HSAs and HRAs

HDHP

For 2022, a monthly premium pass

through of $50 will be made by the

HDHP directly into your HSA each

month.

For 2022, your HRA annual credit is

$50 (prorated for mid-year enrollment).

Self Only enrollment

For 2022, a monthly premium pass

through of $100 will be made by the

HDHP directly into your HSA each

month.

For 2022, your HRA annual credit is

$100 (prorated for mid-year

enrollment).

Self Plus One enrollment

For 2022, a monthly premium pass

through of $100 will be made by the

HDHP directly into your HSA each

month.

For 2022, your HRA annual credit is

$100 (prorated for mid-year

enrollment).

Self and Family enrollment

The maximum that can be contributed

to your HSA is an annual combination

of HDHP premium pass through and

enrollee contribution funds, which

when combined, do not exceed the

maximum contribution amount set by

the IRS of $3,600 for an individual and

$7,200 for a family.

If you enroll during Open Season, you

are eligible to fund your account up to

the maximum contribution limit set by

the IRS. To determine the amount you

may contribute, subtract the amount the

Plan will contribute to your account for

the year from the maximum allowable

contribution.

You are eligible to contribute up to the

IRS limit for partial year coverage as

long as you maintain your HDHP

enrollment for 12 months following the

last month of the year of your first year

of eligibility. To determine the amount

you may contribute, take the IRS limit

and subtract the amount the Plan will

contribute to your account for the year.

If you do not meet the 12 month

requirement, the maximum contribution

amount is reduced by 1/12 for any

month you were ineligible to contribute

to an HSA. If you exceed the maximum

contribution amount, a portion of your

tax reduction is lost and a 10% penalty

is imposed. There is an exception for

death or disability.

You may rollover funds you have in

other HSAs to this HDHP HSA

(rollover funds do not affect your

annual maximum contribution under

this HDHP).

The full HRA credit will be available,

subject to proration, on the effective

date of enrollment. The HRA does not

earn interest.

Contributions/credits

32 2022 Humana High Deductible Health Plan HDHP Section 5 Savings - HSAs and HRAs

HDHP

HSAs earn tax-free interest (does not

affect your annual maximum

contribution).

Catch-up contribution discussed on

page 35.

You may make an annual maximum

contribution of $3,650.

You cannot contribute to the HRA. Self Only enrollment

You may make an annual maximum

contribution of $7,300.

You cannot contribute to the HRA. Self Plus One enrollment

You may make an annual maximum

contribution of $7,300.

You cannot contribute to the HRA. Self and Family enrollment

You can access your HSA by the

following methods:

• Debit card

• Withdrawal form

• Checks

For qualified medical expenses under

your HDHP, you will be automatically

reimbursed when claims are submitted

through the HDHP. For expenses not

covered by the HDHP, such as

orthodontia, a reimbursement form will

be sent to you upon your request.

Access Funds

You can pay the out-of-pocket expenses

for yourself, your spouse or your

dependents (even if they are not

covered by the HDHP) from the funds

available in your HSA.

You can pay the out-of-pocket expenses

for qualified medical expenses for

individuals covered under the HDHP.

Distributions/withdrawals

• Medical

See IRS Publication 502 for a list of

eligible medical expenses.

Non-reimbursed qualified medical

expenses are allowable if they occur

after the effective date of your

enrollment in this Plan.

See

Availability of funds

below for

information on when funds are

available in the HRA.

See IRS Publication 502 for a list of

eligible medical expenses. Physician

prescribed over-the-counter drugs and

Medicare premiums are also

reimbursable. Most other types of

medical insurance premiums are not

reimbursable.

If you are under age 65, withdrawal of

funds for non-medical expenses will

create a 20% income tax penalty in

addition to any other income taxes you

may owe on the withdrawn funds.

When you turn age 65, distributions can

be used for any reason without being

subject to the 20% penalty, however

they will be subject to ordinary income

tax.

Not applicable – distributions will not

be made for anything other than non-

reimbursed qualified medical expenses.

• Non-medical

33 2022 Humana High Deductible Health Plan HDHP Section 5 Savings - HSAs and HRAs

HDHP

Funds are not available for withdrawal

until all the following steps are

completed:

• Your enrollment in this HDHP is

effective (effective date is

determined by your agency in

accord with the event permitting the

enrollment change).

• The HDHP receives record of your

enrollment and initially establishes

your HSA account with the

fiduciary by providing information

it must furnish and by contributing

the minimum amount required to

establish an HSA.

The fiduciary sends you HSA

paperwork for you to complete and the

fiduciary receives the completed

paperwork back from you.

The entire amount of your HRA will be

available to you upon your enrollment

in the HDHP.

Availability of funds

FEHB enrollee. HDHP. Account owner

You can take this account with you

when you change plans, separate or

retire.

If you do not enroll in another HDHP,

you can no longer contribute to your

HSA. See page 31 for HSA eligibility.

If you retire and remain in this HDHP,

you may continue to use and

accumulate credits in your HRA.

If you terminate employment or change

health plans, only eligible expenses

incurred while covered under the

HDHP will be eligible for

reimbursement subject to timely filing

requirements. Unused funds are

forfeited.

Portable

Yes, accumulates without a maximum

cap.

Yes, accumulates without a maximum

cap.

Annual rollover

If you have and HSA

All contributions are aggregated and cannot exceed the maximum contribution amount set

by the IRS. You may contribute your own money to your account through payroll

deductions, or you may make lump sum contributions at any time, in any amount not to

exceed an annual maximum limit. If you contribute, you can claim the total amount you

contributed for the year as a tax deduction when you file your income taxes. Your own

HSA contributions are either tax-deductible or pre-tax (if made by payroll deduction). You

receive tax advantages in any case. To determine the amount you may contribute, subtract

the amount the Plan will contribute to your account for the year from the maximum

contribution amount set by the IRS. You have until April 15 of the following year to make

HSA contributions for the current year.

If you newly enroll in an HDHP during Open Season and your effective data is after

January 1st or you otherwise have partial year coverage, you are eligible to fund your

account up to the maximum contribution limit set by the IRS as long as you maintain your

HDHP enrollment for 12 months following the last month of the year of your first year of

eligibility. If you do not meet this requirement, a portion of your tax reduction is lost and a

10% penalty is imposed. There is an exception for death or disability.

Contributions

34 2022 Humana High Deductible Health Plan HDHP Section 5 Savings - HSAs and HRAs

HDHP

If you are age 55 or older, the IRS permits you to make additional “catch-up”

contributions to your HSA. The allowable catch-up contribution is $1,000. Contributions

must stop once an individual is enrolled in Medicare. Additional details are available on

the U.S. Department of Treasury website at www.treasury.gov/resource-center/faqs/Taxes/

Pages/Health-Savings-Accounts.aspx.

Catch-up contributions

If you have not named beneficiary and you are married, your HSA becomes your spouse’s;

otherwise, your HSA becomes part of your taxable estate.

If you die

You can pay for “qualified medical expenses,” as defined by IRS Code 213(d). These

expenses include, but are not limited to, medical plan deductibles, diagnostic services

covered by your plan, long-term care premiums, health insurance premiums if you are

receiving Federal unemployment compensation, physician prescribed over-the-counter

drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to pay Medicare premiums or to

purchase health insurance other than a Medigap policy. You may not, however, continue to

make contributions to your HSA once you are enrolled in Medicare.

For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by

calling

1-800-829-3676, or visit the IRS website at www.irs.gov and click on “Forms and

Publications.”

Note: Although physician prescribed over-the-counter drugs are not listed in the

publication, they are reimbursable from your HSA. Also, insurance premiums are

reimbursable under limited circumstances.

Qualified expenses

You may withdraw money from your HSA for items other than qualified health expenses,

but it will be subject to income tax and if you are under 65 years old, an additional 20%

penalty tax on the amount withdrawn.

Non-qualified expenses

You will receive a periodic statement that shows the “premium pass through”,

withdrawals, and interest earned on your account. In addition, you will receive an

Explanation of Payment statement when you withdraw money from your HSA.

Tracking your HSA

balance

There is not a minimum reimbursement requirement. Minimum

reimbursements from

your HSA

IF you have an HRA

If you don’t qualify for an HSA when you enroll in this HDHP, or later become ineligible

for an HSA, we will establish an HRA for you. If you are enrolled in Medicare, you are

ineligible for an HSA and we will establish an HRA for you. You must tell us if you

become ineligible to contribute to an HSA.

Why an HRA is

established

Please review the chart on page 31 which details the differences between an HRA and an

HSA. The major differences are:

• you cannot make contributions to an HRA

• funds are forfeited if you leave the HDHP

• an HRA does not earn interest

HRAs can only pay for qualified medical expenses, such as deductibles and coinsurance

expenses, for individuals covered by the HDHP. FEHB law does not permit qualified

medical expenses to include 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.

How an HRA differs

35 2022 Humana High Deductible Health Plan HDHP Section 5 Savings - HSAs and HRAs

Section 5. Preventive Care

HDHP

Important things you should keep in mind about these benefits:

•Preventive care services listed in this Section are not subject to the deductible.

•You must use providers that are part of our network.

•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.

Benefit Description You pay

Note: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it

does not apply.

Preventive care, adult HDHP

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

Participating: Nothing (No deductible)

Non-participating: 40% of our plan allowance and any difference

between our allowance and the billed amount

• Routine mammogram – covered for women Participating: Nothing (No deductible)

Non-participating: 40% of our plan allowance and any difference

between our allowance and the billed amount

Preventive care, adult - continued on next page

36 2022 Humana High Deductible Health Plan HDHP Section 5 Preventive care

HDHP

Benefit Description You pay

Preventive care, adult (cont.) HDHP

• Adult immunizations endorsed by the Centers for

Disease Control and Prevention (CDC): based on

the Advisory Committee on Immunization

Practices (ACIP) schedule.

Participating: Nothing (No deductible)

Non-participating: 40% of our plan allowance and any difference

between our allowance and the billed amount

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 coinsurance and

deductible.

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

Preventive care, children HDHP

• 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/

• 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: When receiving these services from a

participating provider, it is not necessary to first meet

your deductible.

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 coinsurance and

deductible.

Participating: Nothing (No deductible)

Non-participating: 40% of our plan allowance and any difference

between our allowance and the billed amount

37 2022 Humana High Deductible Health Plan HDHP Section 5 Preventive care

Section 5. Traditional Medical Coverage Subject to the Deductible

HDHP

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 36) and is not subject to the calendar year

deductible.

•The deductible is $3,000 per person ($6,000 per Self Plus One enrollment, or $6,000 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 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 and deductibles total $7,000 per

person, $14,000 per Self Plus One enrollment or $14,000 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.

Benefit Description You pay

After the calendar year deductible…

Deductible before Traditional medical

coverage begins

HDHP

The deductible applies to almost all benefits in this

Section. In the You pay column, we say “No

deductible” when it does not apply. When you receive

covered services from network providers, you are

responsible for paying the allowable charges until you

meet the deductible.

100% of allowable charges until you meet the deductible of

$3,000 per person, $6,000 per Self Plus One enrollment or $6,000

per Self and Family enrollment.

After you meet the deductible, we pay the allowable

charge (less your coinsurance) until you meet the

annual catastrophic out-of- pocket maximum.

In-network: After you meet the deductible, you pay the indicated

coinsurance for covered services.

Out-of-network: After you meet the deductible, you pay the

indicated coinsurance based on our Plan allowance and any

difference between our allowance and the billed amount.

38 2022 Humana High Deductible Health Plan HDHP Section 5 Traditional Medical Coverage

Section 5(a). Medical Services and Supplies Provided by Physicians and Other

Healthcare Professionals

HDHP

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 – The calendar year deductible is $3,000 for Self Only, or $6,000 for Self

Plus One or Self and Family. We added “(No deductible)” to show when the calendar year

deductible does not apply.

- Non-participating providers – The calendar year deductible is $9,000 for Self Only, or $18,000

for Self Plus One or Self and Family. We added “(No deductible)” to show when the calendar

year deductible does not apply.

•After you have satisfied your deductible, coverage begins for traditional medical services.

•Under your Traditional medical coverage, you will be responsible for your coinsurance amounts 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.

Benefit Description You pay

After the calendar year deductible...

Note: The calendar year deductible applies to almost all benefits in this Section.

We say “(No deductible)” when it does not apply.

Diagnostic and treatment services HDHP

Professional services of physicians

• In physician’s office

• Office medical consultations

• At home

• Second surgical opinion

• Advance care planning

Participating: 10% coinsurance after deductible per

office visit to a primary care physician or specialist

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

• In an urgent care center Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

• During a hospital stay

• In a skilled nursing facility

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

39 2022 Humana High Deductible Health Plan HDHP Section 5(a)

HDHP

Benefit Description You pay

After the calendar year deductible...

Telehealth services HDHP

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.

10% coinsurance after deductible

Lab, X-ray and other diagnostic tests HDHP

Tests, such as:

• Blood tests

• Urinalysis

• Non-routine pap tests

• Pathology

• X-rays

• Non-routine mammograms

• 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.

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Other tests:

• Genetic counseling and Genetic testing when medically

necessary. (Note: See

You need prior plan approval for certain

services

in Section 3)

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

40 2022 Humana High Deductible Health Plan HDHP Section 5(a)

HDHP

Benefit Description You pay

After the calendar year deductible...

Maternity care HDHP

Complete maternity (obstetrical) care, such as:

• Prenatal care

• Screening for gestational diabetes for pregnant women

• Delivery

• Postnatal care

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see page 22

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).

Participating: Nothing

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Facility coinsurance and deductible applies to

delivery

Breastfeeding support, supplies and counseling for each birth Participating: Nothing

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Family planning HDHP

Contraceptive counseling on an annual basis Nothing

A range of voluntary family planning services, limited to:

• Voluntary sterilization (See

Surgical procedures,

Section 5(b))

• Surgically implanted contraceptives

• Injectable contraceptive drugs (such as Depo-Provera)

• Intrauterine devices (IUDs)

• Diaphragms

Participating: Nothing (no deductible)

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Family planning - continued on next page

41 2022 Humana High Deductible Health Plan HDHP Section 5(a)

HDHP

Benefit Description You pay

After the calendar year deductible...

Family planning (cont.) HDHP

Note: We cover oral contraceptives under the prescription drug

benefit.

Participating: Nothing (no deductible)

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Not covered:

•

Reversal of voluntary surgical sterilization

All charges

Infertility services HDHP

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 Self-Injectable and oral fertility drugs under the

prescription drug benefit (See

You need prior plan approval for

certain services

in Section 3).

Participating: 50% of charges

Non-participating: 40% up to $5,000 limit per plan

year, of our plan allowance and any difference

between our allowance and the billed amount

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

42 2022 Humana High Deductible Health Plan HDHP Section 5(a)

HDHP

Benefit Description You pay

After the calendar year deductible...

Allergy care HDHP

Testing and treatment Participating: 10% coinsurance after deductible per

office visit to a primary care physician or specialist

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Allergy injection Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Allergy serum Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Not covered:

•

Provocative food testing

•

Sublingual allergy desensitization

All charges

Treatment therapies HDHP

• Chemotherapy and radiation therapy (Note: See

You need prior

plan approval for certain services

in Section 3)

Note: High dose chemotherapy in association with autologous

bone marrow transplants is limited to those transplants listed

under

Organ/Tissue Transplants

on page 52.

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 the 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

Other services

under

You

need prior Plan approval for certain services

on page 19.

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Treatment therapies - continued on next page

43 2022 Humana High Deductible Health Plan HDHP Section 5(a)

HDHP

Benefit Description You pay

After the calendar year deductible...

Treatment therapies (cont.) HDHP

Note: Applied Behavior Analysis (ABA) children with Autism

Spectrum Disorder is described in Section 5(e).

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Physical, occupational and cardiac therapies HDHP

60 visits per condition per year 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

Section 3.

Participating: 10% coinsurance after deductible per

visit to a specialist

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Not covered:

•

Long-term rehabilitative therapy

•

Exercise programs

All charges

Speech therapy HDHP

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

• Speech therapists

Note: See

You need prior plan approval for certain services

Section 3.

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Hearing services (testing, treatment, and supplies) HDHP

• For treatment related to illness or injury, including evaluation

and diagnostic hearing tests performed by an M.D., D.O., or

audiologist

• Cochlear implants

- Note: For benefits for the devices, see Section 5(a)

Orthopedic and prosthetic devices

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

• Hearing screening performed during a child's preventive care

visit, see Section 5(a) -

Preventive care, children

Participating: Nothing

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Not covered:

•

Hearing services that are not shown as covered

All charges

44 2022 Humana High Deductible Health Plan HDHP Section 5(a)

HDHP

Benefit Description You pay

After the calendar year deductible...

Vision services (testing, treatment, and supplies) HDHP

• Diagnosis and treatment of diseases of the eye Participating: 10% coinsurance after deductible per

office visit to a primary care physician or specialist

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

• Eye exam to determine the need for vision correction for

children through age 17 (see

Preventive care, children

)

Participating: Nothing

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

• One pair of eyeglasses or contact lenses to correct an

impairment directly caused by accidental ocular injury or

intraocular surgery (such as for cataracts)

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Not covered:

•

Eyeglasses or contact lenses except as shown above

•

Eye exercises and orthoptics

•

Radial keratotomy and other refractive surgery

All charges

Foot care HDHP

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.

Participating: 10% coinsurance after deductible per

office visit to a primary care physician or specialist

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Not covered:

•

Cutting, trimming or removal of corns, calluses, or the free

edge of toenails, and similar routine treatment of conditions of

the foot, except as stated above

•

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

Orthopedic and prosthetic devices HDHP

• 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.

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Orthopedic and prosthetic devices - continued on next page

45 2022 Humana High Deductible Health Plan HDHP Section 5(a)

HDHP

Benefit Description You pay

After the calendar year deductible...

Orthopedic and prosthetic devices (cont.) HDHP

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

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Not covered:

•

Orthopedic and corrective shoes, heel pads and heel cups,

c orsets, trusses

•

Arch supports, foot orthotics except for diabetes and hammer

toe

•

Elastic stockings, support hose, and other supportive devices

not custom made

•

Prosthetic replacements except as required by growth or change

in medical condition, or in the case where the medically

necessary repair exceeds the cost replacement or normal wear

and tear renders the device nonfunctional and non-repairable

All charges

Durable medical equipment (DME) HDHP

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 are covered when there has been

surgical removal of the larynx or a diagnosis of permanent lack of

function of the larynx, additional criteria may need to be met.

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.

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Durable medical equipment (DME) - continued on next page

46 2022 Humana High Deductible Health Plan HDHP Section 5(a)

HDHP

Benefit Description You pay

After the calendar year deductible...

Durable medical equipment (DME) (cont.) HDHP

Not covered:

•

Equipment such as exercise equipment, air cleaners, heating

pads or lights and bed lifts, hearing aids, personnel hygiene

equipment

•

Communication devices, except after surgical removal of the

larynx or a diagnosis of permanent lack of function of the

larynx, additional criteria may need to be met.

All charges

Home health services HDHP

• 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

Section 3.

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

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

Chiropractic HDHP

• 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

Section 3.

Participating: 10% coinsurance after deductible per

office visit to a specialist

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Alternative treatments HDHP

Acupuncture – by a licensed acupuncturist for:

• anesthesia

• pain relief

Note: See

You need prior plan approval for certain services

Section 3.

Participating: 10% coinsurance after deductible per

office visit to a specialist

Non-participating: 20% of our plan allowance and

any difference between our allowance and the billed

amount

Not covered:

•

Naturopathic services

•

Hypnotherapy

•

Biofeedback

All charges

47 2022 Humana High Deductible Health Plan HDHP Section 5(a)

HDHP

Benefit Description You pay

After the calendar year deductible...

Educational classes and programs HDHP

Coverage is provided for:

• Tobacco Cessation program, including individual, group, phone

counseling, over-the-counter (OTC) and prescription drugs

approved by the FDA to treat tobacco dependence

• Childhood obesity education

Participating: Nothing for counseling for up to two

(2) quit attempts per year with up to four (4) tobacco

cessation counseling sessions per quit attempt

Nothing for OTC and prescription drugs approved by

the FDA to treat tobacco dependence

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

• Diabetes self management training Participating: 10% coinsurance after deductible per

office visit to a primary care physician or specialist

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

48 2022 Humana High Deductible Health Plan HDHP Section 5(a)

Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other

Healthcare Professionals

HDHP

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 - The calendar year deductible is $3,000 for Self Only, or $6,000 for Self

Plus One or Self and Family. We added “(No deductible)” to show when the calendar year

deductible does not apply.

- Non-participating providers - The calendar year deductible is $9,000 for Self Only, or $18,000 for

Self Plus One or Self and Family. We added “(No deductible)” to show when the calendar year

deductible does not apply.

•The calendar year deductible applies to all benefits in this Section.

•After you have satisfied your deductible, coverage begins for Traditional medical services.

•Under your Traditional medical coverage, you will be responsible for your coinsurance amounts for

eligible medical expenses and prescriptions.

•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.

Benefit Description You pay

After the calendar year deductible...

Note: The calendar year deductible applies to almost all benefits in this Section.

We say “(No deductible)” when it does not apply.

Surgical procedures HDHP

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 amblyopia and strabismus

• Endoscopy procedures

• Biopsy procedures

• Removal of tumors and cysts

• Correction of congenital anomalies (see

Reconstructive surgery

)

• Insertion of internal prosthetic devices. See Section 5(a)

Orthopedic and prosthetic devices for device coverage

information

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Surgical procedures - continued on next page

49 2022 Humana High Deductible Health Plan HDHP Section 5(b)

HDHP

Benefit Description You pay

After the calendar year deductible...

Surgical procedures (cont.) HDHP

• Treatment of burns

• Voluntary sterilization (e.g., Tubal ligation, Vasectomy)

• Surgical treatment for morbid obesity (bariatric surgery). (Note:

See

You need prior plan approval for certain services

.) Some of

the requirements that must be met before surgery can be

authorized are:

- Patient is 18 years of age or older

- Body Mass Index of >40, or a Body Mass Index of >35 with

associated comorbidity such as:

• Hypertension

• Type two diabetes

• Life-threatening cardiopulmonary problems

- Physician's documentation which indicates that you have had

unsuccessful attempt(s) with nonoperative medically

supervised weight-reduction program(s)

• Esophagogastroduodenoscopy (EGD) (Note: See You need prior

plan approval for certain services in Section 3)

• Colonoscopy repeat testing (Note: See You need prior plan

approval for certain services in Section 3)

Note: Generally, we pay for internal prostheses (devices) according

to where the procedure is done. For example, we pay Hospital

benefits for a pacemaker and Surgery benefits for insertion of the

pacemaker.

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Not covered:

•

Reversal of voluntary sterilization

•

Radial keratotomy and other refractive surgery

•

Routine treatment of conditions of the foot: (See Foot care in

Section 5(a))

All charges

Reconstructive surgery HDHP

• 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 toes.

• All stages of breast reconstruction surgery following a

mastectomy, such as:

- surgery to produce a symmetrical appearance of breasts;

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Reconstructive surgery - continued on next page

50 2022 Humana High Deductible Health Plan HDHP Section 5(b)

HDHP

Benefit Description You pay

After the calendar year deductible...

Reconstructive surgery (cont.) HDHP

- treatment of any physical complications, such as

lymphedemas;

- breast prostheses and surgical bras and replacements (see

Orthopedic and Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the

procedure performed on an inpatient basis and remain in the

hospital up to 48 hours after the procedure.

• Gender 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.

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

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

injur y (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 and maxillofacial surgery HDHP

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;

• Surgical correction of 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; and

• Other surgical procedures that do not involve the teeth or their

supporting structures.

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Oral and maxillofacial surgery - continued on next page

51 2022 Humana High Deductible Health Plan HDHP Section 5(b)

HDHP

Benefit Description You pay

After the calendar year deductible...

Oral and maxillofacial surgery (cont.) HDHP

Not covered:

•

Procedures that involve the teeth or their supporting structures

(such as the periodontal membrane, gingiva, and alveolar bone)

•

Oral implants and transplants

•

Dental work related to treatment of temporomandibular joint

syndrome (TMJ)

All charges

Organ/tissue transplants HDHP

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

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Non-participating transplant services do not apply

toward the maximum out-of-pocket expense limit.

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)

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Non-participating transplant services do not apply

toward the maximum out-of-pocket expense limit.

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)

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Non-participating transplant services do not apply

toward the maximum out-of-pocket expense limit.

Organ/tissue transplants - continued on next page

52 2022 Humana High Deductible Health Plan HDHP Section 5(b)

HDHP

Benefit Description You pay

After the calendar year deductible...

Organ/tissue transplants (cont.) HDHP

- 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

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Non-participating transplant services do not apply

toward the maximum out-of-pocket expense limit.

Organ/tissue transplants - continued on next page

53 2022 Humana High Deductible Health Plan HDHP Section 5(b)

HDHP

Benefit Description You pay

After the calendar year deductible...

Organ/tissue transplants (cont.) HDHP

- Pineoblastoma

- Testicular, Mediastinal, Retroperitoneal, and Ovarian germ

cell tumors

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Non-participating transplant services do not apply

toward the maximum out-of-pocket expense limit.

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

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Non-participating transplant services do not apply

toward the maximum out-of-pocket expense limit.

Organ/tissue transplants - continued on next page

54 2022 Humana High Deductible Health Plan HDHP Section 5(b)

HDHP

Benefit Description You pay

After the calendar year deductible...

Organ/tissue transplants (cont.) HDHP

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 protocol.

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

- Myeloproliferative disorders (MPDs)

- Non-small cell lung cancer

- Ovarian cancer

- Prostate cancer

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Non-participating transplant services do not apply

toward the maximum out-of-pocket expense limit.

Organ/tissue transplants - continued on next page

55 2022 Humana High Deductible Health Plan HDHP Section 5(b)

HDHP

Benefit Description You pay

After the calendar year deductible...

Organ/tissue transplants (cont.) HDHP

- 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

Section 3.

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Non-participating transplant services do not apply

toward the maximum out-of-pocket expense limit.

Not covered:

•

Donor screening tests and donor search expenses, except as

shown above

•

Implants of artificial organs

•

Transplants not listed as covered

All charges

56 2022 Humana High Deductible Health Plan HDHP Section 5(b)

HDHP

Benefit Description You pay

After the calendar year deductible...

Anesthesia HDHP

Professional services provided in –

• Hospital (inpatient)

• Hospital outpatient department

• Skilled nursing facility

• Ambulatory surgical center

• Office

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

57 2022 Humana High Deductible Health Plan HDHP Section 5(b)

Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance

Services

HDHP

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 – The calendar year deductible is $3,000 for Self Only, or $6,000 for Self

Plus One or Self and Family. We added “(No deductible)” to show when the calendar year

deductible does not apply.

- Non-participating providers – The calendar year deductible is $9,000 for Self Only, or $18,000

for Self Plus One or Self and Family. We added “(No deductible)” to show when the calendar

year deductible does not apply.

•The calendar year deductible applies to almost all benefits in this Section.

•After you have satisfied your deductible, your Traditional coverage begins.

•Under your Traditional medical coverage, you will be responsible for your coinsurance amounts 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.

•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.

Benefit Description You pay

After the calendar year deductible...

Note: The calendar year deductible applies to almost all benefits in this Section.

We say “(No deductible)” when it does not apply.

Inpatient hospital HDHP

Room and board, such as:

• Ward, semiprivate, or intensive care accommodations

• General nursing care

• 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.

Other hospital services and supplies, such as:

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Inpatient hospital - continued on next page

58 2022 Humana High Deductible Health Plan HDHP Section 5(c)

HDHP

Benefit Description You pay

After the calendar year deductible...

Inpatient hospital (cont.) HDHP

• 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

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Not covered:

•

Custodial care

•

Non-covered facilities, such as nursing homes, schools

•

Personal comfort items, such as phone, television, barber

services, guest meals and beds

•

Blood and blood components if not replaced

All charges

Outpatient hospital or ambulatory surgical center HDHP

• 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

• Pre-surgical testing

• Dressings, casts, and sterile tray services

• Medical supplies, including oxygen

• Anesthetics and anesthesia service

• Outpatient Hospital Services such as: MRI, MRA, CAT, PET,

and SPECT both at a Hospital and Free Standing Facility (Note:

See

You need prior plan approval for certain services

in Section

• Other outpatient non-surgical care such as mammograms,

laboratory tests and X-rays

Note: We cover hospital services and supplies related to dental

procedures when necessitated by a non-dental physical

impairment. We do not cover the dental procedures.

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Not covered:

•

Blood and Bloo d derivatives no t replaced by the member.

All charges

59 2022 Humana High Deductible Health Plan HDHP Section 5(c)

HDHP

Benefit Description You pay

After the calendar year deductible...

Extended care benefits/Skilled nursing care facility

benefits

HDHP

Extended care benefit:

Up to 60 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.

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Not covered:

•

Custodial care

All charges

Hospice care HDHP

Supportive and palliative care for a terminally ill member is

covered in the home or hospice facility. Includes:

• Inpatient and outpatient services and supplies

Note: These services must be described in a Hospice Care

program that has been approved by us.

See

You need prior plan approval for certain services

in Section 3.

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and

any difference between our allowance and the billed

amount

Not covered:

•

Independent nursing; homemaker services

All charges

End of life care HDHP

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

• Hospice coordination

• Education and support services

• Humana At Home Coordination

Nothing

Ambulance HDHP

Local professional ambulance service when medically appropriate 10% coinsurance after deductible

60 2022 Humana High Deductible Health Plan HDHP Section 5(c)

Section 5(d). Emergency Services/Accidents

HDHP

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 – The calendar year deductible is $3,000 for Self Only, or $6,000 for Self

Plus One or Self and Family. We added “(No deductible)” to show when the calendar year

deductible does not apply.

- Non-participating providers – The calendar year deductible is $9,000 for Self Only, or $18,000

for Self Plus One or Self and Family. 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 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.

•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

amount 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.

61 2022 Humana High Deductible Health Plan HDHP Section 5(d)

HDHP

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.

Benefit Description You pay

After the calendar year deductible...

Note: The calendar year deductible applies to almost all benefits in this Section.

We say “(No deductible)” when it does not apply.

Emergency within our service area HDHP

• Emergency care at a doctor’s office 10% coinsurance after deductible at a primary care

physician’s office or specialist's office

• Emergency care at an urgent care center 10% coinsurance after deductible

• Emergency care as an outpatient at a hospital, including

doctors’ services

10% coinsurance after deductible

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

Emergency outside our service area HDHP

• Emergency care at a doctor’s office 10% coinsurance after deductible at a primary care

physician’s office or specialist’s office

• Emergency care at an urgent care center 10% coinsurance after deductible

• Emergency care as an outpatient at a hospital, including

doctors’ services

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

10% coinsurance after deductible per visit

Emergency outside our service area - continued on next page

62 2022 Humana High Deductible Health Plan HDHP Section 5(d)

HDHP

Benefit Description You pay

After the calendar year deductible...

Emergency outside our service area (cont.) HDHP

Not covered:

•

Elective care or non-emergency care and follow-up care

recommended by non-Plan providers that has not been

approved by the Plan or provided by Plan providers

•

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

Telehealth services HDHP

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.

10% coinsurance after deductible per visit

Ambulance HDHP

Professional ambulance service when medically appropriate

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

10% coinsurance after deductible

Not covered:

•

Air ambulance

All charges

63 2022 Humana High Deductible Health Plan HDHP Section 5(d)

Section 5(e). Mental Health and Substance Use Disorder Benefits

HDHP

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.

•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 $3,000 for Self Only, or $6,000 for Self

Plus One or Self and Family. We added “(No deductible)” to show when the calendar year

deductible does not apply.

- Non-participating providers – The calendar year deductible is $9,000 for Self Only, or $18,000

for Self Plus One or Self and Family. 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.

Benefit Description You pay

After the calendar year deductible...

Note: The calendar year deductible applies to almost all benefits in this Section.

We say “(No deductible)” when it does not apply.

Professional services HDHP

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

Participating: 10% coinsurance after deductible per visit

to a primary care physician

Non-participating: 40% of our plan allowance and any

difference between our allowance and the billed amount

Professional services - continued on next page

64 2022 Humana High Deductible Health Plan HDHP Section 5(e)

HDHP

Benefit Description You pay

After the calendar year deductible...

Professional services (cont.) HDHP

• 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

Participating: 10% coinsurance after deductible per visit

to a primary care physician

Non-participating: 40% of our plan allowance and any

difference between our allowance and the billed amount

Diagnostics HDHP

• Outpatient diagnostic tests 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

• Outpatient services, such as: MRI, MRA, CT, PET, and

SPECT

• Other outpatient non-surgical services

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and any

difference between our allowance and the billed amount

Inpatient hospital or other covered facility HDHP

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

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and any

difference between our allowance and the billed amount

Outpatient hospital or other covered facility HDHP

Outpatient services provided and billed by a hospital or other

covered facility

• Services in approved treatment programs, such as partial

hospitalization or full-day hospitalization

Participating: 10% coinsurance after deductible

Non-participating: 40% of our plan allowance and any

difference between our allowance and the billed amount

• Facility-based intensive outpatient treatment Participating: Nothing

Non-participating: 40% of our plan allowance and any

difference between our allowance and the billed amount

Telemedicine (also known as “telehealth” or “video visits”)

uses information technology and telecommunications to

provide virtual clinical care to patients. Patients can interact

with providers through video and app technology by using

smartphones, tablets, and laptops.

10% coinsurance after deductible

Outpatient hospital or other covered facility - continued on next page

65 2022 Humana High Deductible Health Plan HDHP Section 5(e)

HDHP

Benefit Description You pay

After the calendar year deductible...

Outpatient hospital or other covered facility (cont.) HDHP

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

10% coinsurance after deductible

Applied behavior analysis (ABA) therapy HDHP

Applied behavior analysis (ABA) therapy for Autism Spectrum

Disorder

Participating: 10% coinsurance after deductible per visit

to a primary care physician

Non-participating: 40% of our plan allowance and any

difference between our allowance and the billed amount

Other Services HDHP

• Urgent Care

• Physical, Occupational, Speech and Habilitative therapies for

Mental Health (Note: See

You need prior plan approval for

certain services

in Section 3)

10% coinsurance after deductible to a primary care

physician

Non-participating: 40% of our plan allowance and any

difference between our allowance and the billed amount

66 2022 Humana High Deductible Health Plan HDHP Section 5(e)

Section 5(f). Prescription Drug Benefits

HDHP

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 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 coinsurance.

•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.

67 2022 Humana High Deductible Health Plan HDHP Section 5(f)

HDHP

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 cost share. 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 cost share.

•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 they believe 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 coinsurance, 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 coinsurance, if a generic is available.

You can visit our web site at http://feds.humana.com to check the cost share 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 70% of

charges after deductible.

68 2022 Humana High Deductible Health Plan HDHP Section 5(f)

HDHP

Benefit Description You pay

Note: The calendar year deductible applies to almost all benefits in this Section.

We say “(No deductible)” when it does not apply.

Covered medications and supplies HDHP

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

• Oral chemo medications

• Growth hormone

• Drugs for sexual dysfunction

• Drugs or drug therapies for the treatment of gender dysphoria

supported by FDA approved prescribing information and/or

clinical treatment guidelines

• Weight loss drugs

Note: Blood Glucose Monitors are also covered under Durable

Medical Equipment. (See Section 5(a), page 46.)

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 coinsurance up

to the dosage limits, and all charges after that.

At participating pharmacies:

10% coinsurance after deductible for Level One

drugs

10% coinsurance after deductible for Level Two

drugs

10% coinsurance after deductible for Level Three

drugs

10% coinsurance after deductible for Level Four

drugs

25% coinsurance for Level Five drugs (specialty

drugs may be limited to a 30-day supply)

10% coinsurance after deductible for a 90-day supply

of prescribed maintenance drugs when ordered

through our mail-order program

At non-participating pharmacies:

You pay 100% of the dispensing pharmacy charges

and file a claim with Humana. The claim would be

reimbursed at 70% of Humana’s out of network

pharmacy rate, after the applicable deductible.

• 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 require a written prescription by an approved provider.

Some restrictions apply.

Nothing

Not covered:

•

Drugs and supplies for cosmetic purposes

•

Drugs to enhance athletic performance

•

Drugs obtained at a non-Plan pharmacy; except for out-of-area

emergencies

•

Nonprescription medications/medicines

All charges

Covered medications and supplies - continued on next page

69 2022 Humana High Deductible Health Plan HDHP Section 5(f)

HDHP

Benefit Description You pay

Covered medications and supplies (cont.) HDHP

Not covered (cont.)

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 48.)

All charges

Preventive care medications HDHP

The following are covered:

• 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 old and older generic

forms of 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 towww.uspreventiveservicestaskforce.org/

BrowseRec/Index/browse-recommendation

Nothing

Not covered:

•

Drugs available without a prescription, or for which there is a

non-prescription equivalent available, except as listed above

•

Drugs and supplies for cosmetic purposes (such as Rogaine)

•

Vitamins, nutrients and food supplements not listed as a

covered benefit even if a physician prescribes or administers

them, except as listed above

•

Drugs to enhance athletic performance

•

Medical supplies such as dressings and antiseptics

All charges

Preventive care medications - continued on next page

70 2022 Humana High Deductible Health Plan HDHP Section 5(f)

HDHP

Benefit Description You pay

Preventive care medications (cont.) HDHP

Not covered (cont.)

Note: Over-the-counter and appropriate prescription drugs

approved by the FDA to treat tobacco dependence are covered

under the Toba cco Cessation program benefits . (See page 48)

All charges

71 2022 Humana High Deductible Health Plan HDHP Section 5(f)

Section 5(g). Dental Benefits

HDHP

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 $3,000 for Self Only, or $6,000 for Self

Plus One or Self and Family.

- Non-participating providers – The calendar year deductible is $9,000 for Self Only, or $18,000

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 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.

Benefit Desription You Pay

Accidental injury benefit HDHP

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.

10% coinsurance after deductible

Dental benefits HDHP

We have no other dental benefits.

All charges

72 2022 Humana High Deductible Health Plan HDHP Section 5(g)

Section 5(h). Wellness and Other Special Features

HDHP

Feature Description

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

services.

• We may identify medically appropriate alternatives to regular contract benefits as a

less costly alternative. If we identify a less costly alternative, we will ask you to sign

an alternative benefit agreement that will include all of the following terms in addition

to other terms as necessary. Until you sign and return the agreement regular contract

benefits will continue.

• Alternative benefits will be made available for a limited time period and are subject to

our ongoing review. You must cooperate with the review process.

• By approving an alternative benefit, we do not guarantee you will get it in the future.

• The decision to offer an alternative benefit is solely ours, and except as expressly

provided in the agreement, we may withdraw it at any time and resume regular

contract benefits.

• If you sign the agreement, we will provide the agreed-upon alternative benefits for the

stated time period (unless circumstances change). You may request an extension of the

time period, but regular contract benefits will resume if we do not approve your

request.

• Our decision to offer or withdraw alternative benefits is not subject to OPM review

under the disputed claims process. However, if at the time we make a decision

regarding alternative benefits, we also decide that regular contract benefits are not

payable, then you may dispute our regular contract benefits decision under the OPM

disputed claim process (see Section 8).

Flexible benefits option

Health Assessment:

Members can benefit from completing an Health Assessment annually and using the

information to guide their personal health goals; Health Assessments ask about your

medical history, health status, and lifestyle to identify health risks and opportunities to

improve health behavior.

Biometric Screenings:

A biometric screening is easy to complete and gives you this true picture of your health.

You’ll not only know your numbers, but you’ll be able to understand them, so you can

take charge of your health. It’s an empowering way towards living happier and

healthier…and being your best.

For more information, visit our website, https://feds.humana.com/.

Wellness Benefit

Once you've taken your Health Assessment, check out MyHumana for resources and

information to help you improve your overall health. You'll also find shop-and-compare

tools to help you choose hospitals and doctors, as well as health encyclopedias and

practical information about health conditions, prescription drugs, and other health

issues. The site also has video and audio health libraries, discounts and coupons for

health-related programs.

Humana(Humana.

com)

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

immunizations, and more.

Wellness Reminders

Humana Pharmacy, a prescription home delivery service, is a wholly owned subsidiary of

Humana that gives members convenience, savings, guidance, and excellent Customer

Service. Humana Pharmacy is a fast and easy alternative to retail pharmacies. Depending

on your location and benefits, you may be able to use Humana Pharmacy.

Humana Pharmacy

73 2022 Humana High Deductible Health Plan HDHP Section 5(h)

HDHP

Feature Description

Registered nurses offer education and support to mothers throughout pregnancy and the

baby's first months.

Humana

Beginnings

Nurses provide assistance for those facing a crisis or major medical procedure - includes

support for parents during neonatal intensive care.

Case Management

This specialized team helps transplant recipients coordinate benefits, facilitate services,

and follow their treatment plans.

Transplant Management

The Maximize Your Benefit (MYB) program, available to Humana members, offers

guidance in helping you control the rising cost of prescription drugs with information

about generics, lower cost alternatives and prescription home delivery service.

Maximize Your Benefit

(MYB)

Registered nurses assist those who are following treatment plans or who need continued

guidance in reaching their long-term health goals.

Personal Nurse

Programs that focus on: asthma, cancer, chronic obstructive pulmonary disease,

congestive heart failure, coronary artery disease, diabetes, depression, chronic kidney

disease, end-stage renal disease, cystic fibrosis, hypertension, mental illness, multiple

sclerosis, Parkinson's disease, and other conditions.

Chronic

Condition Management

Humana offers telecommunication devices for the deaf (TDD) and Teletype (TTY) phone

lines for the hearing impaired. Call 1-800-432-7482 to access the service.

Services for deaf and

hearing impaired

Humana’s Health Coaching offers you personalized action plans and assistance

from certified health coaches. Your health coaches are specially trained experts who will

educate, motivate, and support you to address: Weight management, Physical activity,

Back care, Nutrition, Stress management, and Tobacco Cessation. With Humana’s health

coaching model, our virtual well-being coaching partners offer digital programs that are

available 24 hours a day, seven days a week throughout the year. Find out more under

“Wellness” in the Health & Wellness section on www.MyHumana.com.

Humana Health

Coaching

Life, relationships, work, money, legal, family and everyday issues, all can be challenging.

Sometimes you need help and guidance to come up with the answers and practical

solutions. Your Employee Assistance (EAP) any day, anytime, as often as you need

it. Best of all, this is a completely confidential service at no cost to you. Find out more at

www.humana.com/eap or by calling 1-866-440-6556.

Employee Assistance

Program (EAP)

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

74 2022 Humana High Deductible Health Plan HDHP Section 5(h)

Non-FEHB benefits Available to Plan members

The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about

them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket

maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow their guidelines. For

additional information contact the Plan at, 1-800-4-HUMANA or visit their website at https://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).

Members will receive a 50% discount off every Nutrisystem plan, seven free high-protein shakes, and

free shipping on all orders. To get started, sign in to Humana.com/LifestyleDiscounts and select the

link to Nutrisystem. If you prefer, call Nutrisystem at 1-866-430-8647.

Weight loss

With nearly 600 locations nationwide, members may choose any in-network provider and receive these

discounts: 15% off standard prices or 5% off promotional prices. Extra member value: Special set

prices, free Lasik exam, affordable financing options, multiple technologies, 100% bladeless

procedures, free enhancements for life on most procedures. To get started, sign in to Humana.com/

LifestyleDiscounts and select the link to Lasik. If you prefer, call 1-855-645-2020.

Lasik

Humana teamed up with ProSmileUSATM to offer up to 70% off teeth whitening. ProSmileUSA

specializes in Hi-IntensityTM, competitive strength, professional teeth bleaching. To order a teeth

whitening kit, sign in to Humana.com/LifestyleDiscounts and select the link to ProSmileUSA.

Teeth

whitening

Protect yourself with identity monitoring and protection services provided by CyberScout®. This

benefit provides expert support to help detect fraud, monitor credit activity, and resolve any identity-

related issues. To get started or to review a complete list of services and savings, sign in to Humana.

com/LifestyleDiscounts and select CyberScout (MyIDManager.com/LifestyleDiscounts).

Identity

monitoring

and

protection

services

You’ll get on-the-spot discounts of up to 30% when you receive services from the WholeHealth

Network providers. Choose from: Chiropractic, Massage therapy, Acupuncture. It’s easy to get your

savings from more than 37,000 WholeHealth Network providers. To get started, sign in to Humana.

com/LifestyleDiscounts. To find a provider in your area, visit the WholeHealth Choices website at

Humana.wholehealthmd.com. If you prefer, call WholeHealth at 1-866-430-8647.

Alternative

medicine

Humana provides you access to the TruHearing® program, which may save you 30%–60% on hearing

aids. TruHearing provides hearing solutions for virtually every type of hearing loss, care from a local

professional in your area, and a worry-free purchase with a 45-day trial and 3-year warranty. To learn

more, visit TruHearing.com today or call 1-888-403-3937.

Hearing aids

Humana medical and dental members receive our Vision Discount program at no cost. The program

offers access to more than 119,000 vision provider locations (access points) including LensCrafters,

Pearle Vision, and Target Optical. To locate a network provider, members can call 1-866-995-9316 or

via the following method:

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

Vision

Discount

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

Individual

Plans

75 2022 Humana High Deductible Health Plan Section 5 Non-FEHB Benefits Available to Plan members

Section 6. General Exclusions – Services, Drugs and Supplies We Do not Cover

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 -

When 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 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.

76 2022 Humana High Deductible Health Plan Section 6

Section 7. Filing a Claim for Covered Services

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 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:

In most cases, providers and facilities file claims for you. Provider must file on the form

CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For

claims questions and assistance, call us at 1-800-4HUMANA or 1-800-448-6262.

When you must file a claim – such as for services you received outside the Plan’s service

area – submit it on the CMS-1500 or a claim form that includes the information shown

below. Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number and ID number

• Name and address of the provider or facility that provided the service or supply

• Dates you received the services or supplies

• Diagnosis

• Type of each service or supply

• The charge for each service or supply

• A copy of the explanation of benefits, payments, or denial from any primary payor –

such as the Medicare Summary Notice (MSN)

• Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not

acceptable substitutes for itemized bills.

Submit your claims to: Humana Claims Office

P.O. Box 14601

Lexington, Kentucky 40512-4601

Medical and hospital

benefits

Submit your claims to: Humana Claims Office at the address listed above

or call us at 1-800-4HUMANA or 1-800-448-6262.

Prescription drugs and

other supplies or services

Send us all of the documents for your claim as soon as possible. You must submit the

claim by December 31 of the year after the year you received the service, unless timely

filing was prevented by administrative operations of Government or legal incapacity,

provided the claim was submitted as soon as reasonably possible.

Deadline for filing your

claim

We will notify you of our decision within 30 days after we receive your post-

service claim. If matters beyond our control require an extension of time, we may take up

to an additional 15 days for review and we will notify you before the expiration of the

original 30-day period. Our notice will include the circumstances underlying the request

for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you,

our notice will describe the specific information required and we will allow you up to 60

days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the

disputed claims process detailed in Section 8 of this brochure.

Post-service claims

procedures

77 2022 Humana High Deductible Health Plan Section 7

You may designate an authorized representative to act on your behalf for filing a claim or

to appeal claims decisions to us. For urgent care claims, we will permit a healthcare

professional with knowledge of your medical condition to act as your authorized

representative without your express consent. For the purposes of this section, we are also

referring to your authorized representative when we refer to you.

Authorized

Representative

If you live in a county where at least 10 percent of the population is literate only in a non-

English language (as determined by the Secretary of Health and Human Services), we will

provide language assistance in that non-English language. You can request a copy of your

Explanation of Benefits (EOB) statement, related correspondence, oral language services

(such as phone customer assistance), and help with filing claims and appeals (including

external reviews) in the applicable non-English language. The English versions of your

EOBs and related correspondence will include information in the non-English language

about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an

adverse benefit determination will include information sufficient to identify the claim

involved (including the date of service, the healthcare provider, and the claim amount, if

applicable), and a statement describing the availability, upon request, of the diagnosis and

procedure codes.

Notice Requirements

78 2022 Humana High Deductible Health Plan Section 7

Section 8. The Disputed Claims 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.

Step Description

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

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

b) Send your request to us at: Humana Claims Office, Attn: Grievance and Appeals, P.O. Box 14546,

Lexington, KY 40512-4601; and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit

provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills,

medical records, and explanation of benefits (EOB) forms.

e) Include your email address (optional for member), if you would like to receive our decision via

email. Please note that by giving us your email, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered,

relied upon, or generated by us or at our direction in connection with your claim and any new rationale for

our claim decision. We will provide you with this information sufficiently in advance of the date that we are

required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond

to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time

to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that

new evidence or rationale at the OPM review stage described in step 4.

79 2022 Humana High Deductible Health Plan Section 8

Step Description

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

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information

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

then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the date the information

was due. We will base our decision on the information we already have. We will write to you with our

decision.

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

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or

• 120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or

• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal

Employee Insurance Operations, Health Insurance 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this

brochure;

• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical

records, and explanation of benefits (EOB) forms;

• Copies of all letters you sent to us about the claim;

• Copies of all letters we sent to you about the claim; and

• Your daytime phone number and the best time to call.

• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing

your email address, you may receive OPM’s decision more quickly.

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

which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your

representative, such as medical providers, must include a copy of your specific written consent with the

review request. However, for urgent care claims, a healthcare professional with knowledge of your medical

condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because

of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to

decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other

administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you

must file the suit against OPM in Federal court by December 31 of the third year after the year in which you

received the disputed services, drugs, or supplies or from the year in which you were denied precertification

or prior approval. This is the only deadline that may not be extended.

80 2022 Humana High Deductible Health Plan Section 8

OPM may disclose the information it collects during the review process to support their disputed claim

decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law

governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record

that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the

amount of benefits in dispute.

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.

81 2022 Humana High Deductible Health Plan Section 8

Section 9. Coordinating Benefits with Medicare and Other Coverage

You must tell us if you or a covered family member has coverage under any other

health plan or has automobile insurance that pays healthcare expenses without

regard to fault. This is called “double coverage”.

When you have double coverage, one plan normally pays its benefits in full as the

primary payor and the other plan pays a reduced benefit as the secondary payor. We,

like other insurers, determine which coverage is primary according to the National

Association of Insurance Commissioners’ (NAIC) guidelines. For more information

on NAIC rules regarding the coordinating of benefits, visit our website at https://

feds.humana.com/.

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

When we are the secondary payor, we will determine our allowance. After the

primary plan pays, we will pay what is left of our allowance, up to our regular

benefit. We will not pay more than our allowance.

When you have other health

coverage

TRICARE is the healthcare program for eligible dependents of military persons,

and retirees of the military. TRICARE includes the CHAMPUS

program. CHAMPVA provides health coverage to disabled Veterans and their

eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay

first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have

questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an

annuitant or former spouse, you can suspend your FEHB coverage to enroll in one

of these programs, eliminating your FEHB premium. (OPM does not contribute to

any applicable plan premiums.) For information on suspending your FEHB

enrollment, contact your retirement office. If you later want to re-enroll in the

FEHB Program, generally you may do so only at the next Open Season unless you

involuntarily lose coverage under TRICARE or CHAMPVA.

• TRICARE and CHAMPVA

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness

or injury that the Office of Workers’ Compensation Programs (OWCP) or a

similar federal or state agency determines they must provide; or

• OWCP or similar agency pays for through a third-party injury settlement or

other similar proceeding that is based on a claim you filed under OWCP or

similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we

will cover your care. You must use our providers.

• Workers’ Compensation

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

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored

program of medical assistance: If you are an annuitant or former spouse, you can

suspend your FEHB coverage to enroll in one of these state programs, eliminating

your FEHB premium. For information on suspending your FEHB enrollment,

contact your retirement office. If you later want to re-enroll in the FEHB Program,

generally you may do so only at the next Open Season unless you involuntarily lose

coverage under the state program.

• Medicaid

We do not cover services and supplies when a local, state, or federal government

agency directly or indirectly pays for them.

When other Government

agencies are responsible for

your care

82 2022 Humana High Deductible Health Plan Section 9

By accepting benefits under this plan you agree to the following conditions and

limitations on the nature of benefits or benefit payments when another person

causes an injury or illness or when you are entitled to recover from any other

insurance or source of funds that may be available to pay for the injury or illness.

Humana is entitled to recover the full value of the benefits we have paid or provided

in connection with your injury or illness. However, when benefits are otherwise

provided by this plan we will cover the cost of treatment that exceeds the amount of

the payment you received. You and all covered persons agree to promptly notify us

that you have asked anyone other than us to make payment for your injuries and to

fully cooperate with our efforts to secure our recovery rights. You and your

representative also agree to obtain our consent before releasing any party from

liability for payment of medical expenses and before disbursing any funds paid by

other parties.

When benefits are provided under the Plan in relation to the illness or injury,

Humana may, at its option:

• Subrogate, that is, take over your right to pursue recovery from any other

parties, insurance carriers or sources of funds that you may have a right to

pursue; or

• Enforce a right to reimbursement from any payment(s) you or your

representative may obtain from other parties, settlements or insurance coverage.

Our right to recover the full value of the benefits we have paid or provided for shall

take first priority (before any of the rights of any other parties are honored) and are

not impacted by how the judgment, settlement, or other recovery is characterized,

designated, or apportioned. The amount we are entitled to recovery is not subject to

reduction based on attorney fees or costs under the “common fund” or similar rules

and is fully enforceable regardless of whether you are “made whole” or

compensated for the full amount of damages you may have incurred.

Our recovery rights shall apply only to the extent of the full value of benefits

provided for the injury or illness. We will provide benefits to cover the cost of

treatment that exceeds amounts that are recoverable other insurance coverage or

sources of funds.

If you, a covered person or your representative fails to cooperate with the

enforcement of our recovery rights we may delay or deny future benefits until

cooperation is provided or we are reimbursed.

When others are responsible

for injuries

Some FEHB plans already cover some dental and vision services. When you are

covered by more than one vision/dental plan, coverage provided under your FEHB

plan remains as your primary coverage. FEDVIP coverage pays secondary to that

coverage. When you enroll in a dental and/or vision plan on www.BENEFEDS.

com or by phone at 1-877-888-3337, TTY (1-877-889-5680), you will be asked to

provide information on your FEHB plan so that your plans can coordinate

benefits. Providing your FEHB information may reduce your out-of-pocket cost.

When you have Federal

Employees Dental and Vision

Insurance Plan (FEDVIP)

coverage

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical

trial that is conducted in relation to the prevention, detection, or treatment of cancer

or other life-threatening disease or condition and is either Federally funded;

conducted under an investigational new drug application reviewed by the Food and

Drug Administration; or is a drug trial that is exempt from the requirement of an

investigational new drug application.

If you are a participant in a clinical trial, this health plan will provide related care as

follows, if it is not provided by the clinical trial:

Clinical trials

83 2022 Humana High Deductible Health Plan Section 9

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-

rays and scans, and hospitalizations related to treating the patient’s condition,

whether the patient is in a clinical trial or is receiving standard therapy.

• Extra care costs – costs related to taking part in a clinical trial such as additional

tests that a patient may need as part of the trial, but not as part of the patient’s

routine care.

• Research costs – costs related to conducting the clinical trial such as research

physician and nurse time, analysis of results, and clinical tests performed only

for research purposes. These costs are generally covered by the clinical

trials. This plan does not cover these costs.

For more detailed information on “What is Medicare?” and “Should I Enroll in

Medicare?” please contact Medicare at 800-MEDICARE (1-800-633-4227), (TTY

1-877-486-2048) or atwww.medicare.gov.

When you have Medicare

The Original Medicare Plan (Original Medicare) is available everywhere in the

United States. It is the way everyone used to get Medicare benefits and is the way

most people get their Medicare Part A and Part B benefits now. You may go to any

doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan

pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to

Medicare for members with Medicare Part B, when Medicare is primary. This is

true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to

follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan – You will probably

not need to file a claim form when you have both our Plan and the Original

Medicare Plan.

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

When Original Medicare is the primary payor, Medicare processes your claim first.

In most cases, your claim will be coordinated automatically and we will then

provide secondary benefits for covered charges. To find out if you need to do

something to file your claim, call us at 1-800-4HUMANA or 1-800-448-6262 or

visit our website: http://feds.humana.com/.

Humana will not waive the medical copayments, coinsurance, and deductibles for

member when original Medicare is the primary payor. Members must enroll in the

Humana Value Plan code associated within the service areas listed on the Value Plan

brochure and the Humana Medicare Advantage Plan to receive waivers for medical

copayments, coinsurance, and deductibles. See the Value Plan brochure (RI 73-829)

for more details.

Please review the following table it illustrates your cost share if you are enrolled in

Medicare Part A and B. Members must use providers who accept Medicare’s

assignment.

Benefit Description: Deductible

You pay without Medicare: $3,000 Self Only/$6,000 Self Plus One or Self

and Family

You pay with Medicare Parts A and B (primary): $3,000 Self Only/$6,000 Self Plus

One or Self and Family

• The Original Medicare Plan

(Part A or Part B)

84 2022 Humana High Deductible Health Plan Section 9

Benefit Description: Out of Pocket Maximum

You pay without Medicare: $7,000 Self Only/$14,000 Self Plus One or Self and

Family

You pay with Medicare Parts A and B (primary): $7,000 Self Only/$14,000 Self

Plus One or Self and Family

Benefit Description: Primary Care Physician

You pay without Medicare: 10% coinsurance after deductible

You pay with Medicare Parts A and B (primary): 10% coinsurance after deductible

Benefit Description: Specialist

You pay without Medicare: 10% coinsurance after deductible

You pay with Medicare Parts A and B (primary): 10% coinsurance after deductible

Benefit Description: In-Patient Hospital

You pay without Medicare: 10% coinsurance after deductible

You pay with Medicare Parts A and B (primary): 10% coinsurance after deductible

Benefit Description: Out-Patient Hospital

You pay without Medicare: 10% coinsurance after deductible

You pay with Medicare Parts A and B (primary): 10% coinsurance after deductible

You can find more information about how our plan coordinates benefits with

Medicare by calling 1-800-4HUMANA or visit the Medicare website at https://

www.medicare.gov/supplements-other-insurance/how-medicare-works-with-other-

insurance.

You must tell us if you or a covered family member has Medicare coverage, and let

us obtain information about services denied or paid under Medicare if we ask. You

must also tell us about other coverage you or your covered family members may

have, as this coverage may affect the primary/secondary status of this Plan and

Medicare.

• Tell us about your Medicare

coverage

If you are eligible for Medicare, you may choose to enroll in and get your Medicare

benefits from a Medicare Advantage plan. These are private healthcare choices (like

HMOs and regional PPOs) in some areas of the country. To learn more about

Medicare Advantage plans, contact Medicare at 1-800-MEDICARE

(1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

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

you:

This Plan and another plan’s Medicare Advantage plan: You may enroll in

another plan’s Medicare Advantage plan and also remain enrolled in our FEHB

plan. We will still provide benefits when your Medicare Advantage plan is primary,

even out of the Medicare Advantage plan’s network and/or service area (if you use

our Plan providers). However, we will not waive any of our coinsurance or

deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to

know whether you are in the Original Medicare Plan or in a Medicare Advantage

plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are

an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a

Medicare Advantage plan, eliminating your FEHB premium. (OPM does not

contribute to your Medicare Advantage plan premium.) For information on

suspending your FEHB enrollment, contact your retirement office. If you later want

to re-enroll in the FEHB Program, generally you may do so only at the next Open

Season unless you involuntarily lose coverage or move out of the Medicare

Advantage plan’s service area.

• Medicare Advantage

(Part C)

85 2022 Humana High Deductible Health Plan Section 9

When we are the primary payor, we process the claim first. If you enroll in

Medicare Part D and we are the secondary payor, we will review claims for your

prescription drug costs that are not covered by Medicare Part D and consider them

for payment under the FEHB plan.

• Medicare prescription drug

coverage (Part D)

86 2022 Humana High Deductible Health Plan Section 9

Medicare always makes the final determination as to whether they are the primary payor. The following chart illustrates

whether Medicare or this Plan should be the primary payor for you according to your employment status and other factors

determined by Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can

administer these requirements correctly. (Having coverage under more than two health plans may change the order of

benefits determined on this chart.)

Primary Payor Chart

A. When you - or your covered spouse - are age 65 or over and have Medicare and you... The primary payor for the

individual with Medicare is...

Medicare This Plan

1) Have FEHB coverage on your own as an active employee

2) Have FEHB coverage on your own as an annuitant or through your spouse who is an

annuitant

3) Have FEHB through your spouse who is an active employee

4) Are a reemployed annuitant with the Federal government and your position is excluded from

the FEHB (your employing office will know if this is the case) and you are not covered under

FEHB through your spouse under #3 above

5) Are a reemployed annuitant with the Federal government and your position is not excluded

from the FEHB (your employing office will know if this is the case) and...

• 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

6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired

under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and

you are not covered under FEHB through your spouse under #3 above

7) Are enrolled in Part B only, regardless of your employment status

for Part B

services

for other

services

8) Are a Federal employee receiving Workers' Compensation

9) Are a Federal employee receiving disability benefits for six months or more

B. When you or a covered family member...

1) Have Medicare solely based on end stage renal disease (ESRD) and...

• 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

2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...

• 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

3) Have Temporary Continuation of Coverage (TCC) and...

• 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)

C. When either you or a covered family member are eligible for Medicare solely due to

disability and you...

1) Have FEHB coverage on your own as an active employee or through a family member who

is an active employee

2) Have FEHB coverage on your own as an annuitant or through a family member who is an

annuitant

D. When you are covered under the FEHB Spouse Equity provision as a former spouse

*Workers' Compensation is primary for claims related to your condition under Workers' Compensation.

87 2022 Humana High Deductible Health Plan Section 9

Section 10. Definitions of Terms We Use in This Brochure

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on

the effective date of their enrollment and ends on December 31 of the same year.

Calendar year

Your calendar year deductible is $3,000 for Self Only, $6,000 for Self Plus One or $6,000 for

Self and Family enrollment for In-Network services OR $9,000 for Self only, $18,000 for Self

Plus One or $18,000 for Self and Family enrollment for Out-of-Network services. In-network

and out-of-network deductibles do not cross apply and will need to be met separately for

traditional benefits to begin.

Calendar year

deductible

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is

conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening

disease or condition and is either Federally funded; conducted under an investigational new drug

application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from

the requirement of an investigational new drug application.

• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and

scans, and hospitalizations related to treating the patient's condition whether the patient is in

a clinical trial or is receiving standard therapy

• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a

patient may need as part of the trial, but not as part of the patient's routine care

• Research costs - costs related to conducting the clinical trial such as research physician and

nurse time, analysis of results, and clinical tests performed only for research purposes are

generally covered by the clinical trials. This plan does not cover these costs.

Clinical Trials Cost