Columbia Part B Giveback HMO H5619-081 Key Selling Points $52 - PDF document

Columbia Part B Giveback HMO H5619-081 Key Selling Points • $52 Part B Giveback • Strong Network • No Referrals Supplemental Benefits • TruHearing • SilverSneakers • HumanaFirst Nursing Hotline • Go365 Rewards Benefits 2017 2018 $0 Premium $6,700 MOOP: N/A Plan Deductible: $450/Day for Days 1 thru 4 Inpatient Cost Share $0 (days 1-20); $167/day (days 21-100) SNF PCP Copay $15 $45 Spec Copay $400 at ASC or $450 Outpatient Hospital Outpatient Surgery $400 at Free-Standing or $450 Outpatient Hospital Advanced Imaging $300 Ded on Tier 3, 4 & 5 $5/$15/$47/$100/27% Part D Benefit 1 ***For Agent Use Only. Not for Public Distribution. Humana Confidential***

Charleston $0 HMO H5619-084 Key Selling Points • $0 Premium • Strong Network • No Referrals • SilverSneakers Supplemental Benefits • SilverSneakers • HumanaFirst Nursing Hotline • Go365 Rewards • Vision – Exam & $100 Eyewear allowance • Enhanced Nutrition Therapy Benefits 2017 2018 $0 Premium MOOP: $6,700 N/A Plan Deductible: Inpatient Cost Share $450/Day for Days 1 thru 4 $0 (days 1-20); $167/day (days 21-100) SNF $15 PCP Copay Spec Copay $50 $400 at ASC or $450 Outpatient Hospital Setting Outpatient Surgery $400 at ASC or $450 Outpatient Hospital Setting Advanced Imaging $250 Ded on Tier 3, 4 & 5 $6/$15/$47/$100/28% Part D Benefit 2 ***For Agent Use Only. Not for Public Distribution. Humana Confidential***

Upstate HMO H5619-086 (formerly H2012-100) Key Selling Points • No referrals • Strong Network • $5 PCP Copay • Rich Supplemental Benefits • York County expansion • Combined Segments Supplemental Benefits • Dental • Vision – Exam & $100 Eyewear • TruHearing • OTC - $50/Quarter • WellDine Meal Program • SilverSneakers • HumanaFirst Nursing Hotline • Go365 Rewards Benefits 2017 2018 Premium $0 $0 MOOP: $6,700 $5,900 Plan Deductible: N/A N/A Inpatient Cost Share $345/day for Days 1-5 $360/day for Days 1-5 $0 (days 1-20); $160/day $0 (days 1-20); $167/day SNF (days 21-100) (days 21-100) PCP Copay $5 / $15 $5 Spec Copay $45 $45 $295 at ASC or $345 $310 at ASC or $360 Outpatient Surgery Outpatient Hospital Outpatient Hospital $295 at Free-Standing or $310 at Free-Standing or Advanced Imaging $345 Outpatient Hospital $360 Outpatient Hospital $400 Ded on Tier 4 & 5 $195 Ded on Tier 3, 4 & 5 Part D Benefit $7/$17/$47/$97/25% $4/$12/$47/$100/29% 3 ***For Agent Use Only. Not for Public Distribution. Humana Confidential***

Preferred PDP S5884-134 Key Selling Points • Low monthly premium • $0 copay on Tier 1 & 2 for 90 day supply through Humana Pharmacy after meeting deductible • Retail Preferred Cost- Sharing at Walmart, Walgreens & Sam’s Club Plan Premium $26.60 (Full LIS - $3.60) Deductible $405* Preferred Standard Tier 1 $0 $2 Initial Coverage Limit Tier 2 $1 $3 $3,750 Tier 3 20% 25% Tier 4 35% 37% Tier 5 25% 25% Generic 44% Co-Insurance Coverage Gap Brand 35% Co-Insurance True Out of Pocket $5,000 Member pays the greater of $3.35 for Catastrophic Coverage Generic/Preferred multi-source drugs and $8.35 for all other drugs; or 5% co-insurance *Deductible applies to all tiers. Please refer to the Summary of Benefits and EOC for full explanation of benefits. 4 ***For Agent Use Only. Not for Public Distribution. Humana Confidential***