Humana Health Plan of Texas, Inc.

https://feds.humana.com/

Customer Service 1-800-4HUMANA

2021

A Health Maintenance Organization

(High, Standard and Basic Option)

IMPORTANT

• Rates: Back Cover

• Changes for 2021: Page 15

• Summary of Benefits: Page 85

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: Austin, Corpus Christi, Houston and San Antonio areas

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

geographic service area to enroll. See page 14 for requirements.

Enrollment codes for this Plan:

Austin:

UU1 High Option Self Only

UU3 High Option Self Plus One

UU2 High Option Self and Family

UU4 Standard Option Self Only

UU6 Standard Option Self Plus One

UU5 Standard Option Self and Family

QY1 Basic Option Self Only

QY3 Basic Option Self Plus One

QY2 Basic Option Self and Family

Corpus Christi:

UC1 High Option Self Only

UC3 High Option Self Plus One

UC2 High Option Self and Family

UC4 Standard Option Self Only

UC6 Starndard Option Self Plus One

UC5 Standard Option Self and Family

Q21 Basic Option Self Only

Q23 Basic Option Self Plus One

Q22 Basic Option Self and Family

Houston:

EW1 High Option Self Only

EW3 High Option Self Plus One

EW2 High Option Self and Family

EW4 Standard Option Self Only

EW6 Standard Option Self Plus One

EW5 Standard Option Self and Family

Q61 Basic Option Self Only

Q63 Basic Option Self Plus One

Q62 Basic Option Self and Family

San Antonio:

UR1 High Option Self Only

UR3 High Option Self Plus One

UR2 High Option Self and Family

UR4 Standard Option Self Only

UR6 Standard Option Self Plus One

UR5 Standard Option Self and Family

QX1 Basic Option Self Only

QX3 Basic Option Self Plus One

QX2 Basic Option Self and Family

RI 73-070

Important Notice from Humana Health Plan of Texas, Inc. About

Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that Humana Health Plan of Texas, Inc. 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 Credible 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 Humana 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 1-800-772-1213 , (TTY 1- 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 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048).

Table of Contents

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

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

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

Stop Health Care Fraud! ...............................................................................................................................................................3

Discrimination is Against the Law ................................................................................................................................................5

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

General features of our High, Standard and Basic Options ..............................................................................................13

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

Your rights and responsibilities .........................................................................................................................................13

Service Area ......................................................................................................................................................................14

Section 2. Changes for 2021 .......................................................................................................................................................15

Changes to the High, Standard and Basic Options: ..........................................................................................................15

Section 3. How You Get Care .....................................................................................................................................................16

Identification cards ............................................................................................................................................................16

Where you get covered care ..............................................................................................................................................16

• Plan providers .....................................................................................................................................................16

• Plan facilities ......................................................................................................................................................16

What you must do to get covered care ..............................................................................................................................16

• Primary care ........................................................................................................................................................16

• Specialty care ......................................................................................................................................................16

• Hospital care .......................................................................................................................................................17

If you are hospitalized when your enrollment begins .......................................................................................................17

You need prior Plan approval for certain services ............................................................................................................17

• Inpatient hospital admission ...............................................................................................................................18

• Other services .....................................................................................................................................................18

How to request precertification for an admission or get prior authorization for Other services ......................................18

• Non-urgent care claims .......................................................................................................................................19

• Urgent care claims ..............................................................................................................................................19

1 2021 Humana Health Plan of Texas, Inc. Table of Contents

• Concurrent care claims .......................................................................................................................................19

The Federal Flexible Spending Account Program - FSAFEDS ..............................................................................20

• Emergency inpatient admission ..........................................................................................................................20

• Maternity care .....................................................................................................................................................20

• If your treatment needs to be extended ...............................................................................................................20

What happens when you do not follow the precertification rules when using non-network facilities .............................20

If you disagree with our pre-service claim decision .........................................................................................................20

• To reconsider a non-urgent care claim ................................................................................................................20

• To reconsider an urgent care claim .....................................................................................................................20

• To file an appeal with OPM ................................................................................................................................21

Section 4. Your Cost for Covered Services .................................................................................................................................22

Cost-sharing ......................................................................................................................................................................22

Copayments .......................................................................................................................................................................22

Deductible .........................................................................................................................................................................22

Coinsurance .......................................................................................................................................................................22

Carryover ..........................................................................................................................................................................22

Your catastrophic protection out-of-pocket maximum .....................................................................................................22

When Government facilities bill us ..................................................................................................................................23

Section 5. High, Standard and Basic Option Benefits ................................................................................................................24

Non-FEHB Benefits Available to Plan members ........................................................................................................................65

Section 6. General Exclusions – Services, Drugs and Supplies We Do not Cover .....................................................................66

Section 7. Filing a Claim for Covered Services .........................................................................................................................67

Section 8. The Disputed Claims Process .....................................................................................................................................69

Section 9. Coordinating Benefits with Medicare and Other Coverage .......................................................................................72

When you have other health coverage or coverage for injuries ........................................................................................72

• TRICARE and CHAMPVA ................................................................................................................................72

• Workers' Compensation ......................................................................................................................................72

• Medicaid .............................................................................................................................................................73

When other government agencies are responsible for your care ......................................................................................73

When others are responsible for injuries ...........................................................................................................................73

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage ..........................................73

Clinical trials .....................................................................................................................................................................74

When you have Medicare .................................................................................................................................................74

• The Original Medicare Plan (Part A or Part B) ..................................................................................................74

• Tell us about your Medicare coverage ................................................................................................................75

• Medicare Advantage (Part C) .............................................................................................................................76

• Medicare prescription drug coverage (Part D) ...................................................................................................76

Section 10. Definitions of Terms We Use in This Brochure .......................................................................................................78

Index ............................................................................................................................................................................................81

Summary of Benefits for the High Option of Humana Health Plan of Texas - 2021 .................................................................85

Summary of Benefits for the Standard Option of Humana Health Plan of Texas - 2021 ...........................................................86

Summary of Benefits for the Basic Option of Humana Health Plan of Texas - 2021 ................................................................87

2021 Rate Information for Humana Health Plan of Texas ..........................................................................................................88

2 2021 Humana Health Plan of Texas, Inc. Table of Contents

Introduction

This brochure describes the benefits of Humana Health Plan of Texas, Inc. under contract (CS 1895) with 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/. The addresses for the

Humana Health Plan of Texas, Inc. administrative offices are:

In San Antonio:

Humana Health Plan of Texas, Inc.

8431 Fredericksburg Rd.

San Antonio, TX 78222

In Austin:

Humana Health Plan of Texas, Inc.

1221 South Mopac, Suite 20

Austin, TX 78746

In Corpus Christi:

Humana Health Plan of Texas, Inc.

802 N. Carancahua, Suite 170

Corpus Christi, TX 78470

In Houston:

Humana Health Plan of Texas, Inc.

9 Greenway Plaza, Suite 2000, 20th Floor

Houston, TX 77046

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, 2021 unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2021, and changes are

summarized on page 15. 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 of Texas, 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 Health Care Fraud!

Fraud increases the cost of health care 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 health care

providers, authorized health benefits plan, or OPM representative.

•Let only the appropriate medical professionals review your medical record or recommend services.

•Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to

get it paid.

3 2021 Humana Health Plan of Texas, Inc. Introduction/Plain Language/Advisory

•Carefully review explanations of benefits (EOBs) statements that you receive from us.

•Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.

•Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.

•If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or

misrepresented any information, do the following:

- Call the provider and ask for an explanation. There may be an error.

- If the provider does not resolve the matter, call us at 1-800-4HUMANA and explain the situation.

- If we do not resolve the issue:

CALL - THE HEALTH CARE 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 he/she was 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.

4 2021 Humana Health Plan of Texas, Inc. Introduction/Plain Language/Advisory

Discrimination is Against the Law

Humana Health Plan of Texas, Inc. complies with all applicable Federal civil rights laws, including Title VII of the Civil

Rights Act of 1964.

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

Office of Personnel Management

Healthcare and Insurance

Federal Employee Insurance Operations

Attention: Assistant Director, FEIO

1900 E Street NW, Suite 3400-S

Washington, D.C. 20415-3610

If you believe that Humana Inc. and its subsidiaries have failed to provide these services or discriminated in another way on

the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Discrimination Grievances:

P.O. Box 14618, Lexington, KY 40512-4618.

Multi-Language Interpreter Services

English: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call

1-800-448-6262, TTY 711.

Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame

al 1-800-448-6262, TTY 711.

Tagalog (Tagalog – Filipino): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng

tulong sa wika nang walang bayad. Tumawag sa 1-800-448-6262, TTY 711.

Kreyòl Ayisyen (French Creole): ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou.

Rele 1-800-448-6262, TTY 711.

Français (French): ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement.

Appelez le 1-800-448-6262, ATS 711.

Português (Portuguese): ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para

1-800-448-6262, TTY 711.

Italiano (Italian): ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica

gratuiti. Chiamare il numero 1-800-448-6262, TTY 711.

Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur

Verfügung. Rufnummer: 1-800-448-6262, TTY 711.

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 health care 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.

5 2021 Humana Health Plan of Texas, Inc. Introduction/Plain Language/Advisory

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 medicine if it looks different than

you expected.

•Read the label and patient package insert when you get your medication, including all warnings and instructions.

•Know how to use your medication. Especially note the times and conditions when your medication should and should not

be taken.

•Contact your doctor or pharmacist if you have any questions.

•Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing

from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

•Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or

Provider’s portal?

•Do not 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 health care 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 health care organizations to improve

the quality and safety of the care they deliver.

6 2021 Humana Health Plan of Texas, Inc. Introduction/Plain Language/Advisory

•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 health care 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 health care professionals working

to improve patient safety.

Preventable Healthcare Acquired Conditions ("Never Events")

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries,

infections, or other serious conditions that occur during the course of your stay. Although some of these complications may

not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had

taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences

for patients, can indicate a significant problem in the safety and credibility of a health care 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 2021 Humana Health Plan of Texas, Inc. 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.

• Where you can

get information

about enrolling

in the FEHB

Program

Self Only coverage is for you alone. Self Plus One coverage is for you and one eligible family

member. Self and Family coverage is for you, and one eligible family member, or 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 2021 Humana Health Plan of Texas, Inc. 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.

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/heathcare-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 a

valid common law marriage) and children as described in the chart below. A Self Plus One

enrollment covers you and your spouse, or one other and one eligible family member as

described in the chart below.

ChildrenCoverage

Natural children, adopted children, and

stepchildren

Natural, adopted children and stepchildren are

covered until their 26

birthday.

Foster children Foster children are eligible for coverage until

their 26

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 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 Married children (but NOT their spouse or

their own children) are covered until their 26

birthday.

Children with or eligible for employer-

provided health insurance

Children who are eligible for or have their own

employer-provided health insurance are

covered until their 26

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 2021 Humana Health Plan of Texas, Inc. 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 in 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 2021 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 2020 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 2021 Humana Health Plan of Texas, Inc. 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 assistance with enrolling in a conversion

policy (a non-FEHB individual policy).

• When FEHB

coverage ends

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

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

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

FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage

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

employing or retirement office to get 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 2021 Humana Health Plan of Texas, Inc. 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 customer service on the back of your ID card or visit www.HealthCare.gov.

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

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

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

• Health

Insurance

Marketplace

12 2021 Humana Health Plan of Texas, Inc. FEHB Facts

Section 1. How This Plan Works

This Plan is a health maintenance organization (HMO). OPM requires that FEHB plans be accredited to validate that plan

operations and/or care management meet nationally recognized standards. Humana holds the following accreditation: The

National Committee for Quality Assurance (NCQA). To learn more about this plan's accreditation, please visit the following

websites: www.ncqa.gov.

We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers

coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us

for a copy of our most recent provider directory. We give you a choice of enrollment in a High Option, a Standard Option, or

a Basic Option.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in

addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any

course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the

copayments and coinsurance described in this brochure. When you receive emergency services from non-Plan providers, you

may have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You

cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or

other provider will be available and/or remain under contract with us.

General features of our High, Standard and Basic Options

How we pay providers

We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan

providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments or

coinsurance, deductibles, and non-covered services and supplies).

Who provides my health care?

Humana Health Plan of Texas offers members an extensive choice of primary care physicians. Humana contracts with both

private office physicians and with physician groups. You should expect to receive specialty care from providers within

Humana's HMO network. Referrals are required for all specialty services except mental health, vision exam and annual well

woman exam.

Catastrophic protection

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

covered services, including deductibles and copayments, cannot exceed $8,150 for Self Only enrollment, and $16,300 for a

Self Plus One or Self and Family.

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 health care business since 1961.

•Locally, Humana Health Plan of Texas has been in existence since 1984.

•Humana is a for profit corporation which is publicly traded on the New York Stock Exchange (NYSE).

13 2021 Humana Health Plan of Texas, Inc. Section 1

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, OPM's FEHB website (www.opm.gov//

healthcare-insurance/). You can also contact us to request that we mail a copy to you.

If you want more information about us, call 1-800-4HUMANA, or write to the Plan at Humana Claims Office, P.O. Box

14603, Lexington, KY 40512-4603. 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 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 area. This is where our providers practice. Our service area is:

Austin: The Texas counties of Bastrop, Bell, Bosque, Coryell, Falls, Hays, Limestone, McLennan, Travis and Williamson.

Corpus Christi: The Texas counties of Bee, Jim Wells, Kleberg, Nueces, Refugio and San Patricio.

Houston: The Texas counties of Austin, Brazoria, Chambers, Colorado, Fayette, Fort Bend, Galveston, Harris, Liberty,

Montgomery, Waller, and Wharton.

San Antonio: The Texas counties of Atascosa, Bexar, Blanco, Comal, Frio, Guadalupe, Karnes, Kendall, Medina and Wilson

and Zip codes 78003 and 78063 in Bandera County.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will

pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the

services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live

out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service

plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait

until Open Season to change plans. Contact your employing or retirement office.

14 2021 Humana Health Plan of Texas, Inc. Section 1

Section 2. Changes for 2021

Changes to the High, Standard and Basic Options:

•Austin, TX – High Option, Enrollment code UU - Your share of the non-Postal premium will increase for Self Only, Self

Plus One, and Self and Family. (See page 88)

•Austin, TX – Standard Option, Enrollment code UU - Your share of the non-Postal premium will decrease for Self Only,

Self Plus One, and Self and Family. (See page 88)

•Austin, TX – Enrollment code QY - Your share of the non-Postal premium will increase for Self Only, Self Plus

One, and Self and Family. (See page 88)

•Corpus Christi, TX – Enrollment code UC - Your share of the non-Postal premium will increase for Self Only, Self Plus

One, and Self and Family. (See page 89)

•Corpus Christi, TX – Enrollment code Q2 - Your share of the non-Postal premium will increase for Self Only, Self Plus

One, and Self and Family. (See page 89)

•Houston, TX - Enrollment code EW - Your share of the non-Postal premium will increase for Self Only, Self Plus

One, and Self and Family. (See page 89)

•Houston, TX - Enrollment code Q6 - Your share of the non-Postal premium will increase for Self Only, Self Plus

One, and Self and Family. (See page 89)

•San Antonio, TX – Enrollment code QX - Your share of the non-Postal premium will increase for Self Only, Self Plus

One, and Self and Family. (See page 90)

•San Antonio, TX – Enrollment code UR - Your share of the non-Postal premium will increase for Self Only, Self Plus

One, and Self and Family. (See page 90)

•San Antonio, TX – Enrollment code UR - Your share of the non-Postal premium will increase for Self Only, Self Plus One,

and Self and Family. (See page 90)

•San Antonio, TX – Enrollment code QX - Your share of the non-Postal premium will increase for Self Only, Self Plus One,

and Self and Family. (See page 90)

•Your coverage for Preventive care medications is changing:

- The Plan will no longer include coverage for the following medications:

- Liquid iron supplements for children age 6 months to 1 year.

- Vitamin D supplements (prescription strength) 400 and 1,000 units for members 65 or older.

- The Plan will now cover the following medications at no cost to members (See page 60):

- 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).

15 2021 Humana Health Plan of Texas, Inc. 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 us at

P.O. Box 14603, Lexington, KY 40512-4603. You may also request replacement cards through

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

Identification cards

You get care from "Plan providers" and "Plan facilities." You will only pay copayments or

coinsurance, and you will not have to file claims.

Where you get

covered care

Plan providers are physicians and other health care 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/.

• 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

It depends on the type of care you need. First, you and each family member must choose a

primary care physician. This decision is important since your primary care physician provides or

arranges for most of your health care. You may choose your primary care physician from our

Provider Directory or our website, or you may call us for assistance.

What you must do

to get covered care

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

pediatrician. Your primary care physician will provide most of your health care, or give you a

referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan,

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

• Primary care

Your primary care physician will refer you to a specialist for needed care. When you receive a

referral from your primary care physician, you must return to your primary care physician after

the consultation, unless your primary care physician authorized a certain number of visits

without additional referrals. The primary care physician must provide or authorize follow-up

care. Do not go to the specialist for your return visit unless your primary care physician gives

you a referral. However, you may see the following providers without a referral:

• Mental health providers

• Vision care providers

• OB/GYN providers

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

or she is not available.

• Specialty care

16 2021 Humana Health Plan of Texas, Inc. Section 3

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

• If you need to see a specialist frequently because of a chronic, complex, or serious medical

condition, your primary care physician will develop a treatment plan that allows you to see

your specialist for a certain number of visits without additional referrals. Your primary care

physician will use our criteria when creating your treatment plan (the physician may have to

get an authorization or approval beforehand).

• If you are seeing a specialist when you enroll in our Plan, talk to your primary care

physician. Your primary care physician will decide what treatment you need. If he or she

decides to refer you to a specialist, ask if you can see your current specialist. If your current

specialist does not participate with us, you must receive treatment from a specialist who

does. Generally, we will not pay for you to see a specialist who does not participate with our

Plan.

• If you are seeing a specialist and your specialist leaves the Plan, call your primary care

physician, who will arrange for you to see another specialist. You may receive services from

your current specialist until we can make arrangements for you to see someone else.

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 third trimester of pregnancy and you lose access to your specialist based on the

above circumstances, you can continue to see your specialist until the end of your postpartum

care, even if it is beyond the 90 days.

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

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

• 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 1-800-4HUMANA (1-800-448-6262). 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 your primary care physician arranges most referrals to specialists and inpatient

hospitalization, the pre-service claim approval process only applies to care shown under

Other

services

You need prior Plan

approval for certain

services

17 2021 Humana Health Plan of Texas, Inc. 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. Some of the services requiring prior authorization are listed below (a complete listing

of services requiring prior authorization can be found at www.humana.com. See commercial

list):

• Organ/tissue transplants

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

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

and long term acute care facilities.

• MRI, MRA, PET, CT Scan, SPECT Scan

• Surgical treatment for morbid obesity

• All durable medical equipment (DME) over $750

• Home health care services (Including Home Hospice)

• Infertility testing and treatment

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

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.)

• Radiation Therapy

• Chiropractic

• Acupuncture

• Transgender surgery

• Esophagogastroduodenoscopy (EGD)

• Coronary angiography

• Colonoscopy repeat testing

• Other services

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

printed on your Humana ID card 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

18 2021 Humana Health Plan of Texas, Inc. 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 to provide the required information. We will make our

decision on the claim within 48 hours of (1) the time we received the additional information or

(2) the end of the time frame, whichever is earlier.

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

or electronic notification within three days of oral notification.

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

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

by OPM either in writing at the time you appeal our initial decision, or by calling us

at 1-800-4HUMANA or 1-800-448-6262. You may also call OPM’s FEHB 3 at (1-202)

606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will

cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not

indicate that your claim was a claim for urgent care, call us at 1-800-4HUMANA or

1-800-448-6262. If it is determined that your claim is an urgent care claim, we will expedite our

review (if we have not yet responded to your claim).

• 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

19 2021 Humana Health Plan of Texas, Inc. Section 3

• Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket health care

expenses (such as copayments, 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

This plan does not offer out-of-network coverage, except for emergent care situations. If no

authorization is received or approved, you will be responsible for all costs of such services.

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 health care 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

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.

• To reconsider

an urgent care

claim

20 2021 Humana Health Plan of Texas, Inc. Section 3

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

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

oral or written requests for appeals and the exchange of information by phone, electronic mail,

facsimile, or other expeditious methods.

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

OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this

brochure.

• To file an appeal

with OPM

21 2021 Humana Health Plan of Texas, Inc. 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,

coinsurance, and copayments) for the covered care you receive.

Cost-sharing

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

when you receive certain services.

Example: When you see your primary care physician, you pay a copayment of $20 per

office visit with the High Option, $35 with the Standard Option or a $50 with the Basic

Option.

Copayments

We do not have a deductible. Deductible

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

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

Coinsurance

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

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

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

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

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

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

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

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

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

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

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

benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of

covered expenses already accumulated toward the catastrophic out-of-pocket limit of

your old option to the catastrophic protection limit of your new option.

Carryover

With the High, Standard and Basic Option plan, after your out-of-pocket expenses,

including any applicable deductibles, copayments and coinsurance total $8,150 for Self

Only, or $16,300 for a Self Plus One or Self and Family enrollment in any calendar year,

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

The maximum annual limitation

on cost sharing listed under Self Only of $8,150 for the High, Standard and Basic

Option plan applies to each individual, regardless of whether the individual is

enrolled in Self Only, Self Plus One, or Self and Family.

Example Scenario: Your plan has a $8,150 Self Only maximum out-of-pocket limit and a

$16,300 Self Plus One or Self and Family maximum out-of-pocket limit. If you or one of

your eligible family members has out-of-pocket qualified medical expenses of $8,150 or

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

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

pocket maximum of $16,300, a second family member, or an aggregate of other eligible

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

maximum of $16,300 for the calendar year before their qualified medical expenses will

begin to be covered in full.

Be sure to keep accurate records and receipts of your copayments and coinsurance to

ensure the plan’s calculation of your out-of-pocket maximum is reflected accurately.

Your catastrophic

protection out-of-pocket

maximum

22 2021 Humana Health Plan of Texas, Inc. Section 4

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

23 2021 Humana Health Plan of Texas, Inc. Section 4

Section 5. High, Standard and Basic Option Benefits

High, Standard and Basic Option

See page 15 for how our benefits changed this year. Pages 85, 86 and 87 are a benefits summary of each option. Make sure

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

Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals ............................27

Diagnostic and treatment services .....................................................................................................................................27

Telehealth services ............................................................................................................................................................27

Lab, X-ray and other diagnostic tests ................................................................................................................................28

Preventive care, adult ........................................................................................................................................................28

Preventive care, children ...................................................................................................................................................29

Maternity care ...................................................................................................................................................................30

Family planning ................................................................................................................................................................31

Infertility services .............................................................................................................................................................31

Allergy care .......................................................................................................................................................................32

Treatment therapies ...........................................................................................................................................................32

Physical, occupational and cardiac therapies ....................................................................................................................33

Speech therapy ..................................................................................................................................................................34

Hearing services (testing, treatment, and supplies) ...........................................................................................................34

Vision services (testing, treatment, and supplies) .............................................................................................................34

Foot care ............................................................................................................................................................................34

Orthopedic and prosthetic devices ....................................................................................................................................35

Durable medical equipment (DME) ..................................................................................................................................35

Home health services ........................................................................................................................................................36

Chiropractic .......................................................................................................................................................................37

Alternative treatments .......................................................................................................................................................37

Educational classes and programs .....................................................................................................................................37

Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals ........................38

Surgical procedures ...........................................................................................................................................................38

Reconstructive surgery ......................................................................................................................................................39

Oral and maxillofacial surgery ..........................................................................................................................................40

Organ/tissue transplants ....................................................................................................................................................41

Anesthesia .........................................................................................................................................................................46

Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services .......................................................47

Inpatient hospital ...............................................................................................................................................................47

Outpatient hospital or ambulatory surgical center ............................................................................................................48

Extended care benefits/Skilled nursing care facility benefits ...........................................................................................49

Hospice care ......................................................................................................................................................................49

End of life care ..................................................................................................................................................................49

Ambulance ........................................................................................................................................................................50

Section 5(d). Emergency Services/Accidents .............................................................................................................................51

Emergency within our service area ...................................................................................................................................52

Emergency outside our service area ..................................................................................................................................52

Ambulance ........................................................................................................................................................................52

Section 5(e). Mental Health and Substance Use Disorder Benefits ............................................................................................54

Professional services .........................................................................................................................................................54

Diagnostics ........................................................................................................................................................................55

Inpatient hospital or other covered facility .......................................................................................................................55

Outpatient hospital or other covered facility .....................................................................................................................55

24 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5

High, Standard and Basic Option

Applied behavior analysis (ABA) therapy ........................................................................................................................55

Not covered .......................................................................................................................................................................56

Section 5(f). Prescription Drug Benefits .....................................................................................................................................57

Covered medications and supplies ....................................................................................................................................58

Preventive care medications ..............................................................................................................................................60

Section 5(g). Dental Benefits ......................................................................................................................................................62

Accidental injury benefit ...................................................................................................................................................62

Dental benefits ..................................................................................................................................................................62

Section 5(h). Wellness and Other Special Features .....................................................................................................................63

Flexible benefits option .....................................................................................................................................................63

Wellness Benefit ................................................................................................................................................................63

MyHumana(Humana.com) ...............................................................................................................................................63

Wellness Reminders ..........................................................................................................................................................63

Humana Pharmacy ............................................................................................................................................................64

HumanaBeginnings® ........................................................................................................................................................64

Case Management .............................................................................................................................................................64

Transplant Management ....................................................................................................................................................64

Maximize Your Benefit (MYB) ........................................................................................................................................64

Personal Nurse® ...............................................................................................................................................................64

Chronic Condition Management .......................................................................................................................................64

Services for deaf and hearing impaired .............................................................................................................................64

Humana Health Coaching .................................................................................................................................................64

Employee Assistance Program (EAP) ...............................................................................................................................64

Summary of Benefits for the High Option of Humana Health Plan of Texas - 2021 .................................................................85

Summary of Benefits for the Standard Option of Humana Health Plan of Texas - 2021 ...........................................................86

Summary of Benefits for the Basic Option of Humana Health Plan of Texas - 2021 ................................................................87

25 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5

Section 5. High, Standard and Basic Option Benefits Overview

This Plan offers a High, Standard and Basic Option. All benefit packages are described in Section 5. Make sure that you

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

The High, Standard and Basic Option Section 5 is divided into subsections. Please read important things you should keep in

mind at the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the

following subsections. To obtain claim forms, claims filing advice, or more information about High, Standard and Basic

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

Network Availability

Humana contracts with both private office physicians and with physician groups. Referrals are required for participating

providers. The HMO plans will utilize the HMO Premier 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

26 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Benefits

Overview Section 5

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

Health Care Professionals

High, Standard and Basic Option

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.

•Plan physicians must provide or arrange your care.

•A facility copay applies to services that appear in this section but are performed in an ambulatory

surgical center or the outpatient department of a hospital.

•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.

Benefit Description You pay

Diagnostic and treatment services High Option Standard Option Basic Option

Professional services of physicians

• In physician’s office

• Office medical consultations

• At home

• Second surgical opinion

• Advance care planning

$20 copay per office

visit to your primary

care physician

$40 copay per office

visit to a specialist

$35 copay per office

visit to your primary

care physician

$55 copay per office

visit to a specialist

$50 copay per office

visit to your primary

care physician

$70 copay per office

visit to a specialist

• During a hospital stay

• In a skilled nursing facility

Nothing Nothing Nothing

• In an urgent care center $40 copay per visit $55 copay per visit $70 copay per visit

Telehealth services High Option Standard Option Basic Option

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.

With Humana's telemedicine benefit delivered by

Doctor On Demand, you can:

• Connect with a physician from one of Doctor On

Demand’s U.S. board-certified doctors

• Immediately see a doctor 24 hours a day, 7 days

a week from any location

• Your primary care physician can access your

telemedicine visit at your request

• If medically necessary, the telemedicine doctor

can send a prescription to a preferred pharmacy

$20 copay per office

visit to your primary

care physician

$35 copay per office

visit to your primary

care physician

$50 copay per office

visit to your primary

care physician

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.

27 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(a)

High, Standard and Basic Option

Benefit Description You pay

Lab, X-ray and other diagnostic tests High Option Standard Option Basic Option

Tests, such as:

• Blood tests

• Urinalysis

• Non-routine pap tests

• Pathology

• X-rays

• Non-routine mammograms

• CAT Scans/MRI (See

You need prior plan

approval for certain services

in Section 3.)

• Ultrasound

• Electrocardiogram and EEG

• Coronary angiography (Note: See

You need

prior plan approval for certain services

Section 3)

Nothing if you

receive these

services during your

office visit;

otherwise:

$20 copay per office

visit to your primary

care physician

$40 copay per office

visit to a specialist

Nothing if you

receive these

services during your

office visit;

otherwise:

$35 copay per office

visit to your primary

care physician

$55 copay per office

visit to a specialist

Nothing if you

receive these

services during your

office visit;

otherwise:

$50 copay per office

visit to your primary

care physician

$70 copay per office

visit to a specialist

Other tests:

• Genetic counseling and Genetic testing when

medically necessary. (Note: See

You need prior

plan approval for certain services

in Section 3)

$20 copay per office

visit to your primary

care physician

$40 copay per office

visit to a specialist

$35 copay per office

visit to your primary

care physician

$55 copay per office

visit to a specialist

$50 copay per office

visit to your primary

care physician

$70 copay per office

visit to a specialist

Preventive care, adult High Option Standard Option Basic Option

Annual routine physical

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

Nothing Nothing Nothing

Preventive care, adult - continued on next page

28 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(a)

High, Standard and Basic Option

Benefit Description You pay

Preventive care, adult (cont.) High Option Standard Option Basic Option

• 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/

Nothing Nothing Nothing

• Routine mammogram – covered for women Nothing Nothing Nothing

• Adult immunizations endorsed by the Centers

for Disease Control and Prevention (CDC):

based on the Advisory Committee on

Immunization Practices (ACIP) schedule.

Nothing Nothing Nothing

Note: Any procedure, injection, diagnostic service,

laboratory, or X-ray service done in conjunction

with a routine examination and is not included in

the preventive recommended listing of services

will be subject to the applicable member

copayments, coinsurance, and deductible.

Nothing Nothing Nothing

Not covered:

•

Physical exams required for obtaining or

continuing employment or insurance, attending

schools or camp, athletic exams, or travel.

•

Immunizations, boosters, and medications for

travel or work-related exposure.

All charges All charges All charges

Preventive care, children High Option Standard Option Basic Option

• Well-child visits, examinations, and other

preventive services as described in the Bright

Future Guidelines provided by the American

Academy of Pediatrics. For a complete list of the

American Academy of Pediatrics Bright Futures

Guidelines go to https://brightfutures.aap.org

• Immunizations such as DTaP, Polio, Measles,

Mumps, and Rubella (MMR), and Varicella. For

a complete list of immunizations go to the

Centers for Disease Control (CDC) website at

https://www.cdc.gov/vaccines/schedules/index.

html

• You can also find a complete list of preventive

care services recommended under the U.S.

Preventive Services Task Force (USPSTF)

online at

https://www.uspreventiveservicestaskforce.org

Nothing Nothing Nothing

Preventive care, children - continued on next page

29 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(a)

High, Standard and Basic Option

Benefit Description You pay

Preventive care, children (cont.) High Option Standard Option Basic Option

Note: Any procedure, injection, diagnostic service,

laboratory, or X-ray service done in conjunction

with a routine examination and is not included in

the preventive recommended listing of services

will be subject to the applicable member

copayments, coinsurance, and deductible.

Nothing Nothing Nothing

Maternity care High Option Standard Option Basic Option

Complete maternity (obstetrical) care, such as:

• Prenatal care

• Screening for gestational diabetes for pregnant

women

• Delivery

• Postnatal care

Nothing

Facility copay

applies to Delivery

Nothing

Facility copay

applies to Delivery

Nothing

Facility copay

applies to Delivery

Breastfeeding support, supplies and counseling for

each birth

Nothing Nothing Nothing

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal

delivery; see below for other circumstances,

such as extended stays for you or your baby.

• You may remain in the hospital up to 48 hours

after a vaginal delivery and 96 hours after a

cesarean delivery. We will extend your inpatient

stay for you or your baby if medically necessary.

• We cover routine nursery care of the newborn

child during the covered portion of the mother's

maternity stay. We will cover other care of an

infant who requires non-routine treatment only if

we cover the infant under a Self Plus One or Self

and Family enrollment. Surgical benefits, not

maternity benefits, apply to circumcision.

• We pay hospitalization and surgeon services for

non-maternity care the same as for illness and

injury.

• Hospital services are covered under Section 5(c)

and Surgical benefits Section 5(b).

• We offer Humana

Beginnings.

See

Special

features

in Section 5(h).

Note: When a newborn requires definitive

treatment during or after the mother's

confinement, the newborn is considered a patient

in his or her own right. If the newborn is eligible

for coverage, regular medical or surgical benefits

apply rather than maternity benefits.

30 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(a)

High, Standard and Basic Option

Benefit Description You pay

Family planning High Option Standard Option Basic Option

• Contraceptive counseling on an annual basis

A range of voluntary family planning services,

limited to:

• Voluntary sterilization (See

Surgical procedures

Section 5 (b))

• Surgically implanted contraceptives

• Contraceptive devices

• Injectable contraceptive drugs (such as Depo-

Provera)

• Intrauterine devices (IUDs)

• Diaphragms

Note: We cover oral contraceptives under the

prescription drug benefit. See

Prescription drug

benefits

Section 5(f).

Nothing Nothing Nothing

Not covered:

•

Reversal of voluntary surgical sterilization

All charges All charges All charges

Infertility services High Option Standard Option Basic Option

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)

50% of charges 50% of charges 50% of charges

Infertility services - continued on next page

31 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(a)

High, Standard and Basic Option

Benefit Description You pay

Infertility services (cont.) High Option Standard Option Basic Option

- Intracervical insemination (ICI)

- Intrauterine insemination (IUI)

• Fertility drugs

Note: Self-injectable and oral fertility drugs are

covered under the prescription drug benefit (See

You need prior plan approval for certain services

Section 3.)

50% of charges 50% of charges 50% of charges

Not covered:

•

Assisted reproductive technology (ART)

procedures, such as:

In vitro fertilization (IVF)

Embryo transfer, gamete intra-fallopian

transfer (GIFT) and zygote intra-fallopian

tranfser (ZIFT

•

Services and supplies related to excluded ART

procedures

•

Cost of donor sperm

•

Cost of donor egg

All charges All charges All charges

Allergy care High Option Standard Option Basic Option

• Testing and treatment $20 copay per office

visit to your primary

care physician

$40 copay per office

visit to a specialist

$35 copay per office

visit to your primary

care physician

$55 copay per office

visit to a specialist

$50 copay per office

visit to your primary

care physician

$70 copay per office

visit to a specialist

• Allergy serum

• Allergy injections

Nothing Nothing Nothing

Not covered:

•

Provocative food testing

•

sublingual allergy desensitization

All charges All charges All charges

Treatment therapies High Option Standard Option Basic Option

• Chemotherapy and radiation therapy (Note: See

You need prior plan approval for certain services

in Section 3)

Note: High dose chemotherapy in association with

autologous bone marrow transplants is limited to

those transplants listed under Organ/Tissue

Transplants on page 41.

• Respiratory and inhalation therapy

• Cardiac rehabilitation following qualifying

event/condition is provided. No visit limitations

apply.

$40 copay per office

visit to a specialist

$55 copay per office

visit to a specialist

$70 copay per office

visit to a specialist

Treatment therapies - continued on next page

32 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(a)

High, Standard and Basic Option

Benefit Description You pay

Treatment therapies (cont.) High Option Standard Option Basic Option

• Dialysis – hemodialysis and peritoneal dialysis

• Intravenous (IV)/Infusion Therapy – Home IV

and antibiotic therapy (See

You need prior plan

approval for certain services

in Section 3).

• Growth hormone therapy (GHT)

Oral Chemo medications covered under the

Pharmacy benefit. (See Section 5(f) for details).

$40 copay per office

visit to a specialist

$55 copay per office

visit to a specialist

$70 copay per office

visit to a specialist

Note: Growth hormone is covered under the

Prescription Drug benefit. We only cover GHT

when we preauthorize the treatment. Your Plan

Physician will ask us to authorize GHT before you

begin treatment. We will only cover GHT services

and related services and supplies that we determine

are medically necessary. See Section 3 under

Other

services

Note: Applied Behavior Analysis (ABA) Children

with Autism Spectrum Disorder is described in

Section 5(e).

• Applied Behavior Analysis (ABA) Children with

Autism Spectrum Disorder

$20 copay per office

visit to your primary

care physician

$40 copay per office

visit to a specialist

$35 copay per office

visit to your primary

care physician

$55 copay per office

visit to a specialist

$50 copay per office

visit to your primary

care physician

$70 copay per office

visit to a specialist

Physical, occupational and cardiac

therapies

High Option Standard Option Basic Option

Up to 60 visits per year per condition for the

services of each of the following:

• Qualified physical therapists

• Occupational therapists

Note: We only cover therapy when a physician:

• orders the care

• identifies the specific professional skills the

patient requires and the medical necessity for

skilled services; and

• indicates the length of time the services are

needed.

Note: See

You need prior plan approval for certain

services

in Section 3.

$40 copay per visit $55 copay per visit $70 copay per visit

• Habilitative services up to 60 vists per year $40 copay per office

visit to a specialist

$55 copay per office

visit to a specialist

$70 copay per office

visit to a specialist

Not covered:

•

Long-term rehabilitative therapy

•

Exercise programs

All charges All charges All charges

33 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(a)

High, Standard and Basic Option

Benefit Description You pay

Speech therapy High Option Standard Option Basic Option

60 visits per condition per year for the service of

the following:

• Speech therapists

Note: See

You need prior plan approval for certain

services

in Section 3.

$40 copay per visit $55 copay per visit $70 copay per visit

Hearing services (testing, treatment, and

supplies)

High Option Standard Option Basic Option

• Hearing testing for children through age 17, as

shown in

Preventive care, children

• Hearing treatment related to illness or injury

including evaluation and a diagnostic hearing

tests performed by an M.D., D.O., or audiologist

Nothing Nothing Nothing

• Cochlear Implants20% coinsurance30% coinsurance50% coinsurance

Not covered:

•

Hearing aids, testing and examinations except

for those listed above.

All charges All charges All charges

Vision services (testing, treatment, and

supplies)

High Option Standard Option Basic Option

• Diagnosis and treatment of diseases of the eye

• Annual eye refractions (to provide a written lens

prescription for eyeglasses)

• One pair of eyeglasses or contact lenses to

correct an impairment directly caused by

accidental ocular injury or intraocular surgery

(such as for cataracts)

$20 copay per office

visit to your primary

care physician

$40 copay per office

visit to a specialist

$35 copay per office

visit to your primary

care physician

$55 copay per office

visit to a specialist

$50 copay per office

visit to your primary

care physician

$70 copay per office

visit to a specialist

• Eye exam to determine the need for vision

correction for children through age 17 (see

Preventive care

)

Nothing Nothing Nothing

Not covered:

•

Eyeglasses or contact lenses, except as shown

above

•

Eye exercises and orthoptics

•

Radial keratotomy and other refractive surgery

All charges All charges All charges

Foot care High Option Standard Option Basic Option

• 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.

$20 copay per office

visit to your primary

care physician

$40 copay per office

visit to a specialist

$35 copay per office

visit to your primary

care physician

$55 copay per office

visit to a specialist

$50 copay per office

visit to your primary

care physician

$70 copay per office

visit to a specialist

Foot care - continued on next page

34 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(a)

High, Standard and Basic Option

Benefit Description You pay

Foot care (cont.) High Option Standard Option Basic Option

Not covered:

•

Cutting, trimming or removal of corns, calluses,

or the free edge of toenails, and similar routine

treatment of conditions of the foot, unless

primary medical condition requires such care

•

Treatment of weak, strained or flat feet or

bunions or spurs; and of any instability,

imbalance or subluxation of the foot (unless the

treatment is by open cutting surgery)

All charges All charges All charges

Orthopedic and prosthetic devices High Option Standard Option Basic Option

• Artificial limbs and eyes

• Prosthetic sleeve or sock

• Externally worn breast prostheses and surgical

bras, including necessary replacements,

following a mastectomy

• Corrective orthopedic appliances for non-dental

treatment of temporomandibular joint (TMJ)

pain dysfunction syndrome

• Internal prosthetic devices, such as artificial

joints, pacemakers, cochlear implants, and

surgically implanted breast implant following

mastectomy.

Note: For information on the professional charges

for the surgery to insert an implant, see Section 5

(b)

Surgical procedures

. For information on the

hospital and/or ambulatory surgery center benefits,

see Section 5(c)

Services provided by a hospital or

other facility, and ambulance services

20% coinsurance30% coinsurance50% coinsurance

Not covered:

•

Orthopedic and corrective shoes, arch

supports, heel pads and heel cups

•

Lumbosacral supports

•

Corsets, trusses, elastic stockings, support hose,

and other supportive devices

•

Prosthetic replacements except as required by

growth or change in medical condition

All charges All charges All charges

Durable medical equipment (DME) High Option Standard Option Basic Option

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

20% coinsurance30% coinsurance50% coinsurance

Durable medical equipment (DME) - continued on next page

35 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(a)

High, Standard and Basic Option

Benefit Description You pay

Durable medical equipment (DME)

(cont.)

High Option Standard Option Basic Option

• Wheelchairs

• Crutches

• Walkers

• Insulin pumps and supplies

• Blood glucose monitors

• Communication devices

Note: Communication devices covered for

members who have had surgical removal of the

larynx or a diagnosis of permanent lack of function

of the larynx.

Note: Preauthorization is necessary for items over

$750. See

You need prior plan approval for certain

services

in Section 3.

20% coinsurance30% coinsurance50% coinsurance

Not covered:

•

Equipment such as exercise equipment, air

cleaners, heating pads or lights and bed lifts,

hearing aids, personnel hygiene equipment.

•

Communication devices except for those

members who have had surgical removal of the

larynx or a diagnosis of permanent lack of

function of the larynx.

All charges All charges All charges

Home health services High Option Standard Option Basic Option

• Home health care ordered by a Plan physician

and provided by a registered nurse (R.N.),

licensed practical nurse (L.P.N.), licensed

vocational nurse (L.V.N.), or home health aide.

• Services include intravenous therapy and

medications.

See

You need prior plan approval for certain

services

in Section 3.

$40 copay per visit$55 copay per visit$70 copay per visit

Not covered:

•

Nursing care requested by, or for the

convenience of, the patient or the patient’s

family.

•

Home care primarily for personal assistance that

does not include a medical component and is not

diagnostic, therapeutic, or rehabilitative.

•

Private duty nurse.

All charges All charges All charges

36 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(a)

High, Standard and Basic Option

Benefit Description You pay

Chiropractic High Option Standard Option Basic Option

• Spinal manipulations, adjustments and

modalities limited to a combined maximum of

20 visits per year

See

You need prior plan approval for certain

services

in Section 3.

$40 copay per visit $55 copay per visit $70 copay per visit

Alternative treatments High Option Standard Option Basic Option

Acupuncture – by a licensed acupuncturist for:

• anesthesia

• pain relief

See

You need prior plan approval for certain

services

in Section 3.

$40 copay per visit $55 copay per visit $70 copay per visit

Not covered:

•

Naturopathic services

•

Hypnotherapy

• Biofeedback

All charges All charges All charges

Educational classes and programs High Option Standard Option Basic Option

Coverage is provided for:

• Tobacco Cessation program benefits, including

individual, group and phone counseling, over-

the-counter (OTC) and prescription drugs

approved by the FDA to treat tobacco

dependence

• Childhood obesity education

Nothing Nothing Nothing

• Diabetes self management training $20 copay per office

visit to your primary

care physician

$40 copay per office

visit to a specialist

$35 copay per office

visit to your primary

care physician

$55 copay per office

visit to a specialist

$50 copay per office

visit to your primary

care physician

$70 copay per office

visit to a specialist

37 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(a)

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

Health Care Professionals

High, Standard and Basic Option

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.

•Plan physicians must provide or arrange your care.

•Be sure to read Section 4,

Your cost for covered services

, for valuable information about how cost-

sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with

Medicare.

•The services listed below are for the charges billed by a physician or other health care professional

for your surgical care. See Section 5(c) for charges associated with the 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.

Benefit Description You pay

Surgical procedures High Option Standard Option Basic Option

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.

• Voluntary sterilization (e.g., Tubal ligation,

Vasectomy)

• Treatment of burns

• Surgical treatment for morbid obesity

(bariatric surgery). (Note: See

You need prior

plan approval for certain services

in Section

3). Some of the requirements that must be

met before surgery can be authorized are:

- Patient is 18 years of age or older

- Body Mass Index of >40, or a Body Mass

Index of >35 with associated comorbidity

such as:

• Hypertension

Nothing Nothing Nothing

Surgical procedures - continued on next page

38 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(b)

High, Standard and Basic Option

Benefit Description You pay

Surgical procedures (cont.) High Option Standard Option Basic Option

• 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)

• Surgical treatment for gender reassignment

is limited to the following (Note: See

You

need prior plan approval for certain services

in Section 3):

- For female to male surgery: mastectomy,

hysterectomy, vaginectomy, salpingo-

oophorectomy

- For male to female surgery: penectomy,

orchiectomy

• Esophagogastroduodenoscopy (EGD) (Note:

See

You need prior plan approval for certain

services

in Section 3)

• Colonoscopy repeat testing (Note: See

You

need prior plan approval for certain services

in Section 3)

Note: Generally, we pay for internal prostheses

(devices) according to where the procedure is

done. For example, we pay Hospital benefits

for a pacemaker and Surgery benefits for

insertion of the pacemaker.

Nothing Nothing Nothing

Not covered:

•

Reversal of voluntary sterilization

•

Routine treatment of conditions of the foot;

(See 5(a) Foot Care)

All charges All charges All charges

Reconstructive surgery High Option Standard Option Basic Option

• Surgery to correct a functional defect

• Surgery to correct a condition caused by

injury or illness if:

- the condition produced a major effect on

the member’s appearance and

- the condition can reasonably be expected

to be corrected by such surgery

• Surgery to correct a condition that existed at

or from birth and that is a significant

deviation from the common form or norm.

Examples of congenital anomalies

are: protruding ear deformities; cleft lip;

cleft palate; birth marks; webbed fingers and

webbed toes.

Nothing Nothing Nothing

Reconstructive surgery - continued on next page

39 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(b)

High, Standard and Basic Option

Benefit Description You pay

Reconstructive surgery (cont.) High Option Standard Option Basic Option

• All stages of breast reconstruction surgery

following a mastectomy, such as:

- surgery to produce a symmetrical

appearance of breasts;

- treatment of any physical complications,

such as lymphedemas;

- breast prostheses and surgical bras and

replacements (see

Orthopedic and

Prosthetic devices

)

Note: If you need a mastectomy, you may

choose to have the procedure performed on an

inpatient basis and remain in the hospital up to

48 hours after the procedure.

Nothing Nothing Nothing

Not covered:

•

Cosmetic surgery – any surgical procedure

(or any portion of a procedure) performed

primarily to improve physical appearance

through change in bodily form, except repair

of accidental injury (Note: See You need

prior plan approval for certain services in

Section 3)

All charges All charges All charges

Oral and maxillofacial surgery High Option Standard Option Basic Option

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial

bones;

• Surgical correction of congenital defects

such as cleft lip or cleft palate or severe

functional malocclusion;

• Removal of stones from salivary ducts;

• Excision of leukoplakia or malignancies;

• Excision of cysts and incision of abscesses

when done as independent procedures;

• Excision of partially or completely impacted

teeth;

• Diagnosis and treatment specifically directed

toward medical and functional disorders of

the temporomandibular joint (TMJ).

• Other surgical procedures that do not involve

the teeth or their supporting structures

Nothing Nothing Nothing

Oral and maxillofacial surgery - continued on next page

40 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(b)

High, Standard and Basic Option

Benefit Description You pay

Oral and maxillofacial surgery (cont.) High Option Standard Option Basic Option

Not covered:

•

Oral implants and transplants

•

Procedures that involve the teeth or their

supporting structures (such as the

periodontal membrane, gingival, and

alveolar bone)

•

Dental work related to treatment of

temporomandibular joint syndrome (TMJ)

All charges All charges All charges

Organ/tissue transplants High Option Standard Option Basic Option

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

Nothing Nothing Nothing

These tandem blood or marrow stem cell

transplants for covered transplants are

subject to medical necessity review by the

Plan. Refer to

Other services

in Section 3 for

prior authorization procedures.

• Autologous tandem transplants for

- AL Amyloidosis

- Multiple myeloma (de novo and treated)

- Recurrent germ cell tumors (including

testicular cancer)

Nothing Nothing Nothing

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as

indicated below.

• Allogeneic transplants for

Nothing Nothing Nothing

Organ/tissue transplants - continued on next page

41 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(b)

High, Standard and Basic Option

Benefit Description You pay

Organ/tissue transplants (cont.) High Option Standard Option Basic Option

- Acute lymphocytic or non-lymphocytic

(i.e., myelogenous) leukemia

- Acute myeloid leukemia

- Advanced Hodgkin’s lymphoma with

recurrence (relapsed)

- Advanced Myeloproliferative Disorders

(MPDs)

- Advanced neuroblastoma

- Advanced non-Hodgkin’s lymphoma with

recurrence (relapsed)

- Amyloidosis

- Chronic lymphocytic leukemia/small

lymphocytic lymphoma (CLL/SLL)

- Hemoglobinopathy

- Infantile malignant osteopetrosis

- Kostmann’s syndrome

- Leukocyte adhesion deficiencies

- Marrow failure and related disorders (i.e.,

Fanconi’s, Paroxysmal Nocturnal

Hemoglobinuria, Pure Red Cell Aplasia)

- Mucolipidosis (e.g., Gaucher’s disease,

metachromatic leukodystrophy,

adrenoleukodystrophy)

- Mucopolysaccharidosis (e.g., Hunter’s

syndrome, Hurler’s syndrome,

Sanfillippo’s syndrome, Maroteaux-Lamy

syndrome variants)

- Myelodysplasia/Myelodysplastic

syndromes

- Paroxysmal Nocturnal Hemoglobinuria

- Phagocytic/Hemophagocytic deficiency

diseases (e.g., Wiskott-Aldrich syndrome)

- Severe combined immunodeficiency

- Severe or very severe aplastic anemia

- Sickle cell anemia

- X-linked lymphoproliferative syndrome

• Autologous transplants for

- Acute lymphocytic or nonlymphocytic

(i.e., myelogenous) leukemia

- Advanced Hodgkin’s lymphoma with

recurrence (relapsed)

- Advanced non-Hodgkin’s lymphoma with

recurrence (relapsed)

- Amyloidosis

Nothing Nothing Nothing

Organ/tissue transplants - continued on next page

42 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(b)

High, Standard and Basic Option

Benefit Description You pay

Organ/tissue transplants (cont.) High Option Standard Option Basic Option

- Breast Cancer

- Ependymoblastoma

- Epithelial ovarian cancer

- Ewing’s sarcoma

- Medulloblastoma

- Multiple myeloma

- Pineoblastoma

- Neuroblastoma

- Testicular, Mediastinal, Retroperitoneal,

and Ovarian germ cell tumors

Nothing Nothing Nothing

Mini-transplants performed in a clinical

trial setting (non-myeloablative, reduced

intensity conditioning or RIC) for members

with a diagnosis listed below are subject to

medical necessity review by the Plan.

Refer to

Other services

in Section 3 for prior

authorization procedures:

• Allogeneic transplants for

- Acute lymphocytic or non-lymphocytic (i.

e., myelogenous) leukemia

- Acute myeloid leukemia

- Advanced Hodgkin’s lymphoma with

recurrence (relapsed)

- Advanced Myeloproliferative Disorders

(MPDs)

- Advanced non-Hodgkin’s lymphoma with

recurrence (relapsed)

- Amyloidosis

- Chronic lymphocytic leukemia/small

lymphocytic lymphoma (CLL/SLL)

- Hemoglobinopathy

- Marrow failure and related disorders (i.e.,

Fanconi’s, PNH, Pure Red Cell Aplasia)

- Myelodysplasia/Myelodysplastic

syndromes

- Paroxysmal Nocturnal Hemoglobinuria

- Severe combined immunodeficiency

- Severe or very severe aplastic anemia

• Autologous transplants for

- Acute lymphocytic or nonlymphocytic (i.

e., myelogenous) leukemia

- Advanced Hodgkin’s lymphoma with

recurrence (relapsed)

Nothing Nothing Nothing

Organ/tissue transplants - continued on next page

43 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(b)

High, Standard and Basic Option

Benefit Description You pay

Organ/tissue transplants (cont.) High Option Standard Option Basic Option

- Advanced non-Hodgkin’s lymphoma with

recurrence (relapsed)

- Amyloidosis

- Neuroblastoma

Nothing Nothing Nothing

These blood or marrow stem cell transplants

are covered only in a National Cancer Institute

or National Institutes of health approved

clinical trial or a Plan-designated center of

excellence and if approved by the Plan’s

medical director in accordance with the Plan’s

protocols.

If you are a participant in a clinical trial, the

Plan will provide benefits for related routine

care that is medically necessary (such as doctor

visits, lab tests, X-rays and scans, and

hospitalization related to treating the patient’s

condition) if it is not provided by the clinical

trial. Section 9 has additional information on

costs related to clinical trials. We encourage

you to contact the Plan to discuss specific

services if you participate in a clinical trial.

• Allogeneic transplants for

- Advanced Hodgkin’s lymphoma

- Advanced non-Hodgkin’s lymphoma

- Beta Thalassemia Major

- Chronic inflammatory demyelination

polyneuropathy (CIDP)

- Early stage (indolent or non-advanced)

small cell lymphocytic lymphoma

- Multiple myeloma

- Multiple sclerosis

- Sickle Cell anemia

• Mini-transplants (non-myeloablative

allogeneic, reduced intensity conditioning or

RIC) for

- Acute lymphocytic or non-lymphocytic (i.

e., myelogenous) leukemia

- Advanced Hodgkin’s lymphoma

- Advanced non-Hodgkin’s lymphoma

- Breast cancer

- Chronic lymphocytic leukemia

- Chronic lymphocytic lymphoma/small

lymphocytic lymphoma (CLL/SLL)

- Chronic myelogenous leukemia

- Colon cancer

Nothing Nothing Nothing

Organ/tissue transplants - continued on next page

44 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(b)

High, Standard and Basic Option

Benefit Description You pay

Organ/tissue transplants (cont.) High Option Standard Option Basic Option

- Early stage (indolent or non-advanced)

small cell lymphocytic lymphoma

- Multiple myeloma

- Multiple sclerosis

- Myelodysplasia/Myelodysplastic

syndromes

- Myeloproliferative disorders (MPDs)

- Non-small cell lung cancer

- Ovarian cancer

- Prostate cancer

- Renal cell carcinoma

- Sarcomas

- Sickle cell anemia

• Autologous Transplants for

- Advanced childhood kidney cancers

- Advanced Ewing sarcoma

- Advanced Hodgkin’s lymphoma

- Advanced non-Hodgkin’s lymphomas

- 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.

Nothing Nothing Nothing

National Transplant Program (NTP) - all

services are determined and authorized through

our transplant department, utilizing our

National Transplant Network.

Organ/tissue transplants - continued on next page

45 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(b)

High, Standard and Basic Option

Benefit Description You pay

Organ/tissue transplants (cont.) High Option Standard Option Basic Option

Note: We cover related medical and hospital

expenses of the donor when we cover the

recipient. We cover donor testing for the actual

solid organ donor or up to four bone marrow/

stem cell transplant donors in addition to the

testing of family members.

Note: See

You need prior plan approval for

certain services

in Section 3.

Not covered:

•

Donor screening tests and donor search

expenses, except as shown above

•

Implants of artificial organs

•

Transplants not listed as covered

All charges All charges All charges

Anesthesia High Option Standard Option Basic Option

Professional services provided in –

• Hospital (inpatient)

• Hospital outpatient department

• Skilled nursing facility

• Ambulatory surgical center

• Office

Nothing Nothing Nothing

46 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(b)

Section 5(c). Services Provided by a Hospital or

Other Facility, and Ambulance Services

High, Standard and Basic Option

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.

•Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

•Be sure to read Section 4, Your cost for covered services for valuable information about how cost-

sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with

Medicare.

•The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center)

or ambulance service for your surgery or care. Any costs associated with the professional charge

(i.e., physicians, etc.) are in Sections 5(a) or (b).

•YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please

refer to Section 3 to be sure which services require precertification.

•Observation Care: Your share for hospital observation care that exceeds 24 hours is the same as

inpatient hospital care. Observation Care below 24 hours is the same as the Emergency Room

benefit/copay.

Benefit Description You pay

Inpatient hospital High Option Standard Option Basic Option

Room and board, such as:

• Ward, semiprivate, intensive care or cardiac

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.

$400 copay per day

for the first three (3)

days per admission

$600 copay per day

for the first three (3)

days per admission

$900 copay per day

for the first three (3)

days per admission

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other

treatment rooms

• Prescribed drugs and medications

• Diagnostic laboratory tests and X-rays

• Dressings, splints, casts, and sterile tray

services

• Medical supplies and equipment, including

oxygen

• Anesthetics, including nurse anesthetist

services

• Take-home items

• Medical supplies, appliances, medical

equipment, and any covered items billed by

a hospital for use at home

Nothing Nothing Nothing

Inpatient hospital - continued on next page

47 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(c)

High, Standard and Basic Option

Benefit Description You pay

Inpatient hospital (cont.) High Option Standard Option Basic Option

Not covered:

•

Blood or blood components if not replaced

by the member

•

Non-covered facilities, such as nursing

homes

•

Personal comfort items, such as phone,

television, barber services, guest meals and

beds

All charges All charges All charges

Outpatient hospital or ambulatory

surgical center

High Option Standard Option Basic Option

• Pre-surgical testing

• Operating, recovery, and other treatment

rooms

• Prescribed drugs and medications

• Diagnostic laboratory tests, X-rays, and

pathology services

• Administration of blood, blood plasma, and

other biologicals

• Dressings, casts, and sterile tray services

• Medical supplies, including oxygen

• Anesthetics and anesthesia service

$400 copay per visit $500 copay per visit $700 copay per visit

• Outpatient services, such as: MRI, MRA,

CT, PET, and SPECT

(Note: See

You need prior plan approval for

certain services

in Section 3)

$200 copay per visit $250 copay per visit $300 copay per visit

• Voluntary sterilization Nothing Nothing Nothing

• 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.

Nothing Nothing Nothing

Not Covered:

•

Blood and blood components if not replaced

by the member

All charges All charges All charges

48 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(c)

High, Standard and Basic Option

Benefit Description You pay

Extended care benefits/Skilled nursing

care facility benefits

High Option Standard Option Basic Option

Extended care benefit:

Up to 100 days per calendar year, including

• Bed and board

• General nursing care

• Drugs, biologicals, supplies and equipment

provided by the facility

Note: Coverage is provided when full-time

skilled nursing care is necessary and

confinement in a skilled nursing facility is

medically appropriate as determined by a Plan

doctor and approved by the Plan.

$400 copay per day

for the first three (3)

days per admission

$600 copay per day

for the first three (3)

days per admission

$900 copay per day

for the first three (3)

days per admission

Not covered:

•

Custodial care

All charges All charges All charges

Hospice care High Option Standard Option Basic Option

Supportive and palliative care for a terminally

ill member is covered in the home or hospice

facility. Services include:

• Inpatient care

• Outpatient care

• Bereavement counseling

Note: These services are provided under the

direction of a Plan doctor who certifies that the

patient is in the terminal stages of illness, with

a life expectancy of approximately six months

or less.

See

You need prior plan approval for certain

services

in Section 3.

Nothing Nothing Nothing

Not covered:

•

Independent nursing, homemaker services

All charges All charges All charges

End of life care High Option Standard Option Basic Option

Personal Nurse provides the following end-of-

life support:

• Hospice coordination

• Education and support services

• Humana At Home Coordination

Nothing Nothing Nothing

49 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(c)

High, Standard and Basic Option

Benefit Description You pay

Ambulance High Option Standard Option Basic Option

Local professional ambulance service when

ordered or authorized by a Plan doctor

$50 copay $50 copay $50 copay

50 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(c)

Section 5(d). Emergency Services/Accidents

High, Standard and Basic Option

Here are some 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.

•Be sure to read Section 4,

Your cost for covered services,

for valuable information about how cost-

sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with

Medicare.

•Observation Care: Your share for hospital observation care that exceeds 24 hours is the same as

inpatient hospital care. Observation Care below 24 hours is the same as the Emergency Room

benefit/copay.

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:

Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme

emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 phone system) or go

to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they

can notify the Plan. You or a family member must notify the Plan within 48 hours unless it was not reasonably possible to do

so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your

admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan

facilities and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically

feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if 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.

51 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(d)

High, Standard and Basic Option

Benefit Description You pay

Emergency within our service area High Option Standard Option Basic Option

• Emergency care at a doctor’s office $20 copay per office

visit to your primary

care physician

$40 copay per office

visit to a specialist

$35 copay per office

visit to your primary

care physician

$55 copay per office

visit to a specialist

$50 copay per office

visit to your primary

care physician

$70 copay per office

visit to a specialist

• Emergency care at an urgent care center $40 copay per visit $55 copay per visit $70 copay per visit

• Emergency care as an outpatient at a

hospital, including doctors’ services

Note: If admitted, hospital copays apply. See

Section 5(c) for

Inpatient hospital

services.

$200 copay per visit $250 copay per visit $325 copay per visit

Not covered:

•

Elective care or non-emergency care

All charges All charges All charges

Emergency outside our service area High Option Standard Option Basic Option

• Emergency care as an outpatient at a

hospital, including doctors’ services

Note: If admitted, hospital copays apply. See

Section 5(c) for

Inpatient hospital

services.

$200 copay per visit

Note: copay is waived

if admitted

$250 copay per visit

Note: copay is waived

if admitted

$325 copay per visit

Note: copay is waived

if admitted

• Emergency care at a doctor’s office $20 copay per office

visit to a primary care

physician

$40 copay per office

visit to a specialist

$35 copay per office

visit to a primary care

physician

$55 copay per office

visit to a specialist

$50 copay per office

visit to a primary care

physician

$70 copay per office

visit to a specialist

• Emergency care at an urgent care center $40 copay per visit $55 copay per visit $70 copay per visit

Not covered:

•

Elective care or non-emergency care

•

Emergency care provided outside the service

area if the need for care could have been

foreseen before leaving the service area

•

Medical and hospital costs resulting from a

normal full-term delivery of a baby outside

the service area

All charges All charges All charges

Ambulance High Option Standard Option Basic Option

Professional ambulance service

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

service.

Note: Air ambulance is covered only when

point of pick-up is inaccessible by land vehicle;

or great distances or other obstacles are

involved in getting a patient to the nearest

hospital with appropriate facilities when

prompt admission is essential.

$50 copay $50 copay $50 copay

52 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(d)

High, Standard and Basic Option

Benefit Description You pay

Telehealth services High Option Standard Option Basic Option

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.

With Humana's telemedicine benefit delivered

by Doctor On Demand, you can:

• Connect with a physician from one of Doctor

On Demand’s U.S. board-certified doctors

• Immediately see a doctor 24 hours a day, 7

days a week from any location

• Your primary care physician can access your

telemedicine visit at your request

• If medically necessary, the telemedicine

doctor can send a prescription to a preferred

pharmacy

$20 copay per office

visit to your primary

care physician

$35 copay per office

visit to your primary

care physician

$50 copay per office

visit to your primary

care physician

53 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(d)

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

High, Standard and Basic Option

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.

•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.

Benefit Description You pay

Professional services High Option Standard Option Basic Option

When we approve a treatment plan, we cover

professional services by licensed professional

mental health and substance use disorder

treatment practitioners when acting within the

scope of their license, such as psychiatrists,

psychologists, clinical social workers, licensed

professional counselors, or marriage and family

therapists.

Your cost-sharing

responsibilities are no

greater than for other

illnesses or

conditions.

Your cost-sharing

responsibilities are no

greater than for other

illnesses or

conditions.

Your cost-sharing

responsibilities are no

greater than for other

illnesses or

conditions.

Diagnosis and treatment of psychiatric

conditions, mental illness, or mental

disorders. Services include:

• Diagnostic evaluation

• Crisis intervention and stabilization for acute

episodes

• Medication evaluation and management

(pharmacotherapy)

• Psychological and neuropsychological

testing necessary to determine the

appropriate psychiatric treatment

• Treatment and counseling (including

individual or group therapy visits)

• Diagnosis and treatment of alcoholism and

drug use, including detoxification, treatment

and counseling

• Professional charges for intensive outpatient

treatment in a providers office or other

professional setting

• Electroconvulsive therapy

$20 copay per visit $35 copay per visit $50 copay per visit

54 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(e)

High, Standard and Basic Option

Benefit Description You pay

Diagnostics High Option Standard Option Basic Option

• Outpatient diagnostic tests and services such

as: MRI, MRA, CT, PET, and SPECT when

provided and billed by a licensed mental

health and substance use disorder treatment

practitioner

Outpatient diagnostic tests provided and

billed by a laboratory, hospital or other

covered facility

• Inpatient diagnostic tests provided and billed

by a hospital or other covered facility

Nothing Nothing Nothing

Inpatient hospital or other covered

facility

High Option Standard Option Basic Option

Inpatient services provided and billed by a

hospital or other covered facility, including

residential facilities

• Room and board, such as semiprivate or

intensive accommodations, general nursing

care, meals and special diets, and other

hospital services, including Telemedicine

$400 copay per day

for the first three (3)

days per admission

$600 copay per day

for the first three (3)

days per admission

$900 copay per day

for the first three (3)

days per admission

Outpatient hospital or other covered

facility

High Option Standard Option Basic Option

Outpatient services provided and billed by a

hospital or other covered facility, including

residential facilities

• Services in approved treatment programs,

such as partial hospitalization or full-day

hospitalization

Nothing Nothing Nothing

• Facility-based intensive outpatient treatment Nothing Nothing Nothing

Applied behavior analysis (ABA)

therapy

High Option Standard Option Basic Option

Applied Behavior Analysis (ABA) Therapy for

Autism Spectrum Disorder

$20 copay per office

visit to your primary

care physician

$35 copay per office

visit to your primary

care physician

$50 copay per office

visit to your primary

care physician

Other Services High Option Standard Option Basic Option

• Urgent Care

• Physical, Occupational, Speech and

Habilitative therapies for Mental

Health (Note: See

You need prior plan

approval for certain services

in Section 3)

• Nutritional Counseling for Eating Disorders

• Telemedicine when using Participating

Providers

$20 copay per visit $35 copay per visit $50 copay per visit

55 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(e)

High, Standard and Basic Option

Benefit Description You pay

Not covered High Option Standard Option Basic Option

Services that are not part of a preauthorized

approved treatment plan

All charges All charges All charges

56 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(e)

Section 5(f). Prescription Drug Benefits

High, Standard and Basic Option

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.

•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.

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

•Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/certified providers

with prescriptive authority prescribing within their scope of practice must prescribe your medication.

•Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a prescribed maintenance

medication. Maintenance medications are drugs that are generally prescribed for the treatment of long term chronic

sicknesses or injuries. Members can also fill their maintenance medications for 90 days at a retail pharmacy for their

appropriate copayment.

•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.

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

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

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

Level Five includes most self administered injectable medications and high technology drugs that are often newly approved

by the U.S. Food and Drug Administration (specialty drugs may be limited to a 30-day supply). For some specialty drugs, see

You need prior plan approval for certain services

in Section 3.

With Rx5 the member takes on more of the cost share for the drug. In return, members receive access to more drugs to treat

their conditions and have more choices, along with their physicians, to decide which drug to take. Members receive letters

offering guidance in changing medications to those with a lower copayment. We use internal data to identify members for

whom a less expensive prescription drug option may be available. We communicate the information to the member to enable

them, along with their physician, to make an informed choice regarding prescription drug copayment options.

•Prior Authorization: Some medications need special monitoring and may require prior authorization. These drugs have

different approval criteria based on indication, safety and appropriate use. Prior authorization (PA) requires a physician to

obtain pre-approval in order to provide coverage for a drug prescribed to a member.

•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.

57 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(f)

High, Standard and Basic Option

•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. 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 for the prescription).

Your doctor can ask Humana to make an exception to cover your non-formulary medicine if he or she believes the

alternative covered drugs won't be as effective in treating your health condition and/or would cause a bad reaction.

When brand name drugs are purchased and a generic is available, you must pay the difference between the brand name and

generic cost plus any applicable brand copay, unless the physician writes "dispense as written" on the prescription. The

physician must write "dispense as written" on the prescription for you to receive a brand name drug and only pay the brand

name copay, if a generic is available.

You can visit our web site at http://feds.humana.com to check the copayment for your prescription drug coverage before you

get your prescription filled. You can also find out more about possible drug alternatives and the locations of participating

pharmacies.

Benefit Description You pay

Covered medications and supplies High Option Standard Option Basic Option

We cover the following medications and

supplies prescribed by a licensed physician and

obtained from a Plan pharmacy or through our

mail order program:

• Drugs and medicines that by Federal law of

the United States require a physician’s

prescription for their purchase, except those

listed as Not covered.

• Insulin

• Diabetes supplies including testing agents,

lancet devices, alcohol swabs, glucose

elevating agents, insulin delivery devices

and blood glucose monitors

- Disposable needles and syringes for the

administration of covered medications

• Self administered injectable drugs

• Oral fertility drugs

• Oral chemo medications - Your cost share

for covered orally administered anticancer

medications for the treatment of cancer will

not exceed $50 per month supply

• Growth hormones

• Drugs for sexual dysfunction

$10 copay for Level

One drugs

$45 copay for Level

Two drugs

$65 copay for Level

Three drugs

$100 copay for Level

Four drugs

25% coinsurance for

Level Five

drugs (specialty drugs

may be limited to a

30-day supply)

2.5 applicable copays

for a 90-day supply of

prescribed

maintenance drugs,

when ordered through

our mail-order

program

$10 copay for Level

One drugs

$45 copay for Level

Two drugs

$65 copay for Level

Three drugs

$100 copay for Level

Four drugs

25% coinsurance for

Level Five

drugs (specialty drugs

may be limited to a

30-day supply)

2.5 applicable copays

for a 90-day supply of

prescribed

maintenance drugs,

when ordered through

our mail-order

program

$10 copay for Level

One drugs

$45 copay for Level

Two drugs

$65 copay for Level

Three drugs

$100 copay for Level

Four drugs

25% coinsurance for

Level Five

drugs (specialty drugs

may be limited to a

30-day supply)

2.5 applicable copays

for a 90-day supply of

prescribed

maintenance drugs,

when ordered through

our mail-order

program

Covered medications and supplies - continued on next page

58 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(f)

High, Standard and Basic Option

Benefit Description You pay

Covered medications and supplies

(cont.)

High Option Standard Option Basic Option

• Weight loss drugs

Note: Drugs to treat sexual dysfunction are

limited. Contact the Plan for dosage limits. You

pay the applicable drug copay up to the dosage

limits, and all charges after that.

$10 copay for Level

One drugs

$45 copay for Level

Two drugs

$65 copay for Level

Three drugs

$100 copay for Level

Four drugs

25% coinsurance for

Level Five

drugs (specialty drugs

may be limited to a

30-day supply)

2.5 applicable copays

for a 90-day supply of

prescribed

maintenance drugs,

when ordered through

our mail-order

program

$10 copay for Level

One drugs

$45 copay for Level

Two drugs

$65 copay for Level

Three drugs

$100 copay for Level

Four drugs

25% coinsurance for

Level Five

drugs (specialty drugs

may be limited to a

30-day supply)

2.5 applicable copays

for a 90-day supply of

prescribed

maintenance drugs,

when ordered through

our mail-order

program

$10 copay for Level

One drugs

$45 copay for Level

Two drugs

$65 copay for Level

Three drugs

$100 copay for Level

Four drugs

25% coinsurance for

Level Five

drugs (specialty drugs

may be limited to a

30-day supply)

2.5 applicable copays

for a 90-day supply of

prescribed

maintenance drugs,

when ordered through

our mail-order

program

• 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 Nothing Nothing

Not covered:

•

Drugs and supplies for cosmetic purposes

•

Drugs to enhance athletic performance

•

Drugs obtained at a non-Plan pharmacy;

except for out-of- area emergencies

•

Nonprescription medications medicines

Note: Over-the-counter and appropriate

prescription drugs approved by the FDA to

treat tobacco dependence are covered under the

Tobacco Cessation program benefits . (See page

37)

All charges All charges All charges

59 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(f)

High, Standard and Basic Option

Benefit Description You pay

Preventive care medications High Option Standard Option Basic Option

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

• Pre-natal vitamins for pregnant women

• Fluoride tablets, solution (not toothpaste,

rinses) for children age 0-6

• Statin Medications for ages 40 years old or

older: generic forms of 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 health care

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 health care

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-recommendations.

Nothing Nothing Nothing

Not covered:

•

Drugs available without a prescription, or for

which there is a non-prescription equivalent

available, except as listed above

•

Drugs and supplies for cosmetic purposes

(such as Rogaine)

•

Vitamins, fluoride, nutrients and food

supplements not listed as a covered benefit

even if a physician prescribes or administers

them, except as listed above

All charges All charges All charges

Preventive care medications - continued on next page

60 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(f)

High, Standard and Basic Option

Benefit Description You pay

Preventive care medications (cont.) High Option Standard Option Basic Option

•

Drugs obtained at a non-Plan pharmacy

except for out-of-area emergencies

•

Drugs to enhance athletic performance

•

Medical supplies such as dressings and

a ntiseptics

•

Medications considered non-formulary on

the Rx5 drug list

Note: Over-the-counter and prescription drugs

approved by the FDA to treat tobacco

dependence are covered under the Tobacco

Cessation program benefits. (See page 37)

All charges All charges All charges

61 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(f)

Section 5(g). Dental Benefits

High, Standard and Basic Option

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.

•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 other coverage, including with

Medicare.

Benefit Desription You Pay

Accidental injury benefit High Option Standard Option Basic Option

We cover restorative services and supplies

necessary to promptly repair (but not replace)

sound natural teeth. The need for these services

must result from an accidental injury.

Nothing Nothing Nothing

Dental benefits High Option Standard Option Basic Option

We have no other dental benefits.

All charges All charges All charges

62 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(g)

Section 5(h). Wellness and Other Special Features

High, Standard and Basic Option

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 benefits 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 will not only know your numbers, but you will be able to understand them, so you

can take charge of your health. It is an empowering way towards living happier and

healthier…and being your best.

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

biometric screenings.

Wellness Benefit

Once you have taken the Health Assessment, check out MyHumana for resources and

information to help you improve your overall health. You will also find shop-and-compare

tools to help you choose hospitals and doctors, as well as health encyclopedias and

practical information about health conditions, prescription drugs, and other health

issues. The site also has video and audio health libraries, discounts and coupons for

health-related programs.

Humana(Humana.

com)

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

immunizations, and more.

Wellness Reminders

63 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option Section 5(h)

High, Standard and Basic Option

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

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.

64 2021 Humana Health Plan of Texas, Inc. High, Standard and Basic Option 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 us at, 1-800-4-HUMANA or visit the website at http://feds.humana.com.

Humana health plans offer its members a broad array of treatment options because we

understand that healthcare decisions reflect our members’ personal philosophies and priorities.

We meet the needs of our members by offering discounts on complementary and alternative

medicine (CAM) services that include chiropractic care, acupuncture, massage therapy, and

weight management services. Discounts and access to more than 20,000 providers are available

at no additional cost. The discounts are designed to enhance the role and care of conventional

medicine. Please note that CAM services are not insurance products through the health benefits

plan. Therefore, there is no need for referrals or pre-certifications - but members should talk

with their primary care provider about any treatments they are considering.

Members may select a provider through MyHumana, their personal password-protected Web

page on Humana’s website, www.humana.com, (>Coverage Benefits & Savings Center), or call

the toll-free customer service number on the back of their ID card for provider selection

assistance. The Humana ID card should be presented when services are received in order to

obtain the specified discount.

Complementary

and Alternative

Medicine (CAM)

discount program

Vision Discount - Humana medical members receive our Vision Discount program at no cost.

The program offers access to more than 108,000 vision provider locations, comprised of over

62,000 independent and 46,000 retail locations including LensCrafters, Pearle Vision, and Target

Optical.

Discount members can locate a network provider via the following methods:

• Go to Humana.com > find a doctor > provider search > select vision

• Call 1-866-995-9316

Our members present their member ID card to the provider at the time of service to receive their

savings. Members can also access a printable discount card that can be presented at the time of

service. There are no claims to file, no deductibles to meet, and no waiting for reimbursement.

Savings are applied directly to the member’s purchase.

procedures to correct vision problems, such as nearsightedness, farsightedness, and astigmatism.

Through agreements at more than 200 laser centers across the United States, Truvision can offer

the laser procedure for less than $1,000 per eye.

Services include: Phone screening; Comprehensive eye exam; Lasik procedure on an FDA-

approved excimer laser; Postoperative care; Retreatment warranty. Members can contact our

member services to schedule a preoperative exam, determine price, find a laser location, or

receive additional information about Lasik services.

Vision discount

programs

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

information.

Humana Individual

Plans

65 2021 Humana Health Plan of Texas, Inc. 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

You need prior Plan approval for certain services .

We do not cover the following:

•Care by non-Plan providers except for authorized referrals or emergencies (see

Emergency services/accidents

•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.

66 2021 Humana Health Plan of Texas, Inc. 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 copayment or coinsurance.

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 Health Plan of Texas

Attn: Claims Review

P.O. Box 14603

Lexington, Kentucky 40512-4603

Medical and hospital

benefits

Submit your claims to: Humana Health Plan of Texas 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

67 2021 Humana Health Plan of Texas, Inc. 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 health care

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 health care provider, and the claim amount, if

applicable), and a statement describing the availability, upon request, of the diagnosis and

procedure codes.

Notice Requirements

68 2021 Humana Health Plan of Texas, Inc. 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 (FEHB) 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

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 Plan of Texas, ATTN: Member Grievance

P.O. Box 14546, Lexington KY 40512-4614 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 health care 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

his/her 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 Health Plan of Texas, ATTN: Member Grievance 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.

69 2021 Humana Health Plan of Texas, Inc. 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, FEHB 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 health care 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.

70 2021 Humana Health Plan of Texas, Inc. 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 FEHB 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.

71 2021 Humana Health Plan of Texas, Inc. 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. You must also tell us if any treatment you receive may be covered by workers

compensation or any coverage that pays for injuries regardless of who is at-fault for the

injury. Other health plans and injury coverage may be considered double coverage.

As a condition of receiving benefits under this plan, you agree to cooperate with our

efforts to determine whether other coverage may exist and to assist us and our agents as

needed. Failure to cooperate with our efforts may result in delay or denial of benefits

under this plan. When you have double coverage, one plan normally pays its benefits in

full as the primary payor and the other plan pays a reduced benefit as the secondary

payor. We, like other insurers, determine which coverage is primary according to the

National Association of Insurance Commissioners’ (NAIC) guidelines. For more

information on NAIC rules regarding the coordinating of benefits, visit our website at

http://feds.humana.com.

• If you are a dependent or annuitant on this Plan and you have group health insurance

through your employer, your employer is the primary payor and we are the secondary

payor.

• When you sustain injuries and are entitled to the payment of health care expenses

under automobile, property, home owners insurance or any other coverage that pays

regardless of fault, that insurance coverage is the primary payor and we are the

secondary payor.

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.

In the event that we provide benefits for treatment that should have been covered by a

primary payor, we shall have the right to be repaid from whoever has received any

overpayment from us to the extent that we have provided double coverage.

When you have other

health coverage or

coverage for injuries

TRICARE is the health care 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 should be covered under any other workers compensation policy or that the

Office of Workers Compensation Programs (OWCP) or a similar federal or state

agency determines they must provide; or

• OWCP or a workers compensation carrier 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.

• Workers'

Compensation

72 2021 Humana Health Plan of Texas, Inc. Section 9

• Once OWCP pays its maximum benefits for your treatment, we will cover your care.

You must use our providers.

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

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. 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

73 2021 Humana Health Plan of Texas, Inc. Section 9

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial

that is conducted in relation to the prevention, detection, or treatment of cancer or other

life-threatening disease or condition and is either Federally funded; conducted under an

investigational new drug application reviewed by the Food and Drug Administration; or is

a drug trial that is exempt from the requirement of an investigational new drug

application.

If you are a participant in a clinical trial, this health plan will provide related care as

follows, if it is not provided by the clinical trial:

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays

and scans, and hospitalizations related to treating the patient’s condition, whether the

patient is in a clinical trial or is receiving standard therapy.

• 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.

Clinical trials

When you have Medicare

For more detailed information on “What is Medicare?” and “Should I Enroll in

Medicare?” please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY

1-877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United

States. It is the way everyone used to get Medicare benefits and is the way most people

get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or

hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay

your share.

All physicians and other providers are required by law to file claims directly to Medicare

for members with Medicare Part B, when Medicare is primary. This is true whether or not

they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow

the rules in this brochure for us to cover your care. Your care must continue to be

authorized by your Plan PCP.

Claims process when you have the Original Medicare Plan – You will probably not

need to file a claim form when you have both our Plan and the Original Medicare Plan.

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

When Original Medicare is the primary payor, Medicare processes your claim first. In

most cases, your claim will be coordinated automatically and we will then provide

secondary benefits for covered charges. To find out if you need to do something to file

your claim, contact us at 1-800-4HUMANA or at our website: http://feds.humana.com.

We waive some costs if the original Medicare Plan is your primary payor. We will

waive some out-of-pocket costs as follows:

• Medical services and supplies provided by physicians and other health care

professionals.

Please review the following table it illustrates your cost share if you are enrolled in

Medicare Part A and B. If you purchase Medicare Part B, your provider is in our network

and participates in Medicare, then we waive some costs because Medicare will be the

primary payor.

• The Original

Medicare Plan (Part

A or Part B)

74 2021 Humana Health Plan of Texas, Inc. Section 9

Benefit

Description

You pay

without

Medicare

You pay

without

Medicare

You pay

without

Medicare

You pay

with

Medicare

Part A

and B

You pay

with

Medicare

Part A

and B

You pay

with

Medicare

Part A

and B

Benefit

Description

High

Option

Standard

Option

Basic

Option

High

Option

Standard

Option

Basic

Option

Deductible

$0 $0 $0 $0 $0 $0

Out of

Pocket

Maximum

$8,150

Self Only/

$16,300

Self Plus

One or

Self and

Family

$8,150

Self Only/

$16,300

Self Plus

One or

Self and

Family

$8,150

Self Only/

$16,300

Self Plus

One or

Self and

Family

$8,150

Self Only/

$16,300

Self Plus

One or

Self and

Family

$8,150

Self Only/

$16,300

Self Plus

One or

Self and

Family

$8,150

Self Only/

$16,300

Self Plus

One or

Self and

Family

Part B

Premium

Reimbur-

sement

Offered

NANANANANANA

Primary

Care

Physician

$20 $35$50$0$0$0

Specialist$40$55$70$0$0$0

Inpatient

Hospital

$400

copay per

day for the

first three

(3) days

per

admission

$600

copay per

day for the

first three

(3) days

per

admission

$900

copay per

day for the

first three

(3) days

per

admission

$0$0$0

Outpatient

Hospital

$400$500$700$0$0$0

Incentives

offered

NANANANANANA

You can find more information about how our plan coordinates benefits with Medicare on

the CMS web site at https://www.medicare.gov/supplements-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 your 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

75 2021 Humana Health Plan of Texas, Inc. Section 9

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 health care choices (like

HMOs and regional PPOs) in some areas of the country. To learn more Medicare

Advantage plans, contact Medicare at 1-800-MEDICARE (1-800-486-2048), (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 our Medicare Advantage plan: You may enroll in our Medicare

Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits

when your Medicare Advantage plan is primary. We will not waive any of the

copayments, 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. For information

about Medicare Advantage plans offered in your area call 1-866-836-5079.

This Plan and another plan’s Medicare Advantage plan: You may enroll in another

plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still

provide benefits when your Medicare Advantage plan is primary, even out of the Medicare

Advantage plan’s network and/or service area (if you use our Plan providers). However,

we will not waive any of our copayments or coinsurance. If you enroll in a Medicare

Advantage plan, tell us. We will need to know whether you are in the Original Medicare

Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with

Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an

annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare

Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your

Medicare Advantage plan premium.) For information on suspending your FEHB

enrollment, contact your retirement 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)

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

76 2021 Humana Health Plan of Texas, Inc. 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 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.

77 2021 Humana Health Plan of Texas, Inc. 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

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