Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

Coverage Period: Beginning on or after 01/01/2021

HUMANA INSURANCE COMPANY: GN 19 LFP CANOPY RX5 Coverage for: Individual +Family | Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage by calling 1-866-4ASSIST
(427-7478). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-866-4ASSIST (427-7478) to request a copy.

Important Questions Answers Why This Matters:

Generally, you must pay all of the costs from providers up to the deductible
amount before this plan begins to pay. If you have other family members on
What is the overall Network: $5,000 Individual / $10,000 Family. Non- the plan, each family member must meet their own individual deductible until
deductible? network: $20,000 Individual / $40,000 Family. the total amount of deductible expenses paid by all family members meets the
overall family deductible.
This plan covers some items and services even if you haven’t yet met the
Are there services Network Providers: Yes. Preventive, Certain Office Visits, deductible amount. But a copayment or coinsurance may apply. For example,
covered before you Urgent Care, Prescription Drugs and Certain therapies. this plan covers certain preventive services without cost-sharing and before
meet your deductible? Non-Network Providers: Yes. Prescription Drugs you meet your deductible. See a list of covered preventive services at
https://www.healthcare.gov/coverage/preventive-care-benefits/.
Is there other
deductibles for No. You don't have to meet deductibles for specific services.
specific services?
The out-of-pocket limit is the most you could pay in a year for covered
What is the out-of- For Network Providers: $7,900 Individual / $15,800
services. If you have other family members in this plan, they have to meet
pocket limit for this Family. For Non-network providers: $31,600 Individual /
their own out-of-pocket limits until the overall family out-of-pocket limit has
plan? $63,200 Family.
been met.
Premiums, balance-billing charges, health care this plan
What is not included doesn’t cover, penalties, Non-network transplant, non- Even though you pay these expenses, they don’t count toward the out-of-
in the out-of-pocket network immune effector cell therapy non-network pocket limit.
limit? prescription drugs, non-network specialty drugs.
This plan uses a network provider. You will pay less if you use a provider in
the plan’s network. You will pay the most if you use an out-of-pocket limit
Will you pay less if Yes. See www.humana.com/directories or call 1-866- provider, and you might receive a bill from a provider for the difference
you use a network 4ASSIST (427-7478) for a list of network providers. between the provider’s charge and what your plan pays (balance-billing). Be
provider?
aware, your network provider might use an out-of-network provider for some
services (such as lab work). Check with your provider before you get services.
Do you need a referral No. You can see the specialist you choose without a referral.
to see a specialist?
M11302020
Page 1 of 9
 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Non-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)

Preferred network provider

virtual visit: No charge

Network providers virtual visit: Primary care visit:

Primary care visit to treat $20 copay/visit; deductible 50% coinsurance
None
an injury or illness does not apply Virtual visit:
50% coinsurance
Primary care visit:
If you visit a health care $20 copay/visit; deductible
provider’s office or does not apply
clinic

$80 copay/visit; deductible

Specialist visit 50% coinsurance None
does not apply

You may have to pay for services that aren’t

Preventive
preventive. Ask your provider if the services
care/screening/ No charge 50% coinsurance
needed are preventive. Then check what your
Immunization
plan will pay for.

Diagnostic test (x-ray,

50% coinsurance 50% coinsurance None
blood work)
If you have a test
Imaging (CT/PET scans, Preauthorization may be required - If not
50% coinsurance 50% coinsurance
MRIs) obtained, penalty will be 50%.

M11302020 Page 2 of 9
 Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Non-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)

30% coinsurance after

$5 copay/prescription;
$5 copay/prescription;
deductible does not apply
deductible does not apply
Level 1 – (Retail)
(Retail)
Preferred/lowest cost
30% coinsurance after
generics drugs $12.50 copay/prescription;
$12.50 copay/prescription;
deductible does not apply
deductible does not apply
(Mail Order)
(Mail Order)
30 day supply
Preauthorization may be required - if not
If you need drugs to obtained, penalty will 100% of the cost of the
30% coinsurance after
treat your illness or $20 copay/prescription; drug.
$20 copay/prescription;
condition deductible does not apply (Retail)
deductible does not apply
(Retail) 90 day supply
Level 2 – Low cost (Retail)
More information about Preauthorization may be required - if not
generics drugs 30% coinsurance after
prescription drug $50 copay/prescription; obtained, penalty will 100% of the cost of the
$50 copay/prescription;
coverage is available at deductible does not apply drug.
deductible does not apply
https://www.humana.com/ (Mail Order) (Mail Order)
(Mail Order)
2021-Rx5 Non-network cost sharing does not count
toward the out-of-pocket limit.
30% coinsurance after
$50 copay/prescription;
$50 copay/prescription;
deductible does not apply
deductible does not apply
Level 3 – Preferred (Retail)
(Retail)
brand-name drugs and
30% coinsurance after
higher cost generic drugs $125 copay/prescription;
$125 copay/prescription;
deductible does not apply
deductible does not apply
(Mail Order)
(Mail Order)

M11302020 Page 3 of 9
 Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Non-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)

30% coinsurance after

$100 copay/prescription;
$100 copay/prescription;
deductible does not apply
deductible does not apply
Level 4 – Non-preferred (Retail)
(Retail)
brand-name drugs and
30% coinsurance after
high-cost generic drugs $250 copay/prescription;
$250 copay/prescription;
deductible does not apply
deductible does not apply
(Mail Order)
(Mail Order)

Preferred specialty pharmacy 30 day supply

Level 5 – Highest- $450 copay/prescription; Preauthorization may be required - if not
30%coinsurance after
cost/high technology deductible does not apply
$500 copay/prescription obtained, member is responsible for 100% of
drugs and specialty Network specialty pharmacy
deductible does not apply the cost of the drug.
drugs $500 copay/prescription;
deductible does not apply

Facility fee (e.g.,

Preauthorization may be required - if not
ambulatory surgery 50% coinsurance 50% coinsurance
obtained, penalty will be 50%.
If you have outpatient center)
surgery
Physician/surgeon fees 50% coinsurance 50% coinsurance None

50% coinsurance after

Emergency room care 50% coinsurance None
network deductible

If you need immediate Emergency medical 50% coinsurance after

50% coinsurance None
medical attention transportation network deductible
Cost sharing may vary and may be subject to
Urgent care $100 copay/visit; deductible 50% coinsurance deductible and coinsurance based on service
does not apply performed.
If you have a hospital Facility fee (e.g., hospital Preauthorization may be required - if not
50% coinsurance
stay room) 50% coinsurance obtained, penalty will be 50%

M11302020 Page 4 of 9
 Common What You Will Pay Limitations, Exceptions, & Other Important
Services You May Need Network Provider Non-Network Provider
Medical Event Information
(You will pay the least) (You will pay the most)

Physician/surgeon fees 50% coinsurance 50% coinsurance None

Therapy:
$20 copay/visit; deductible
does not apply
If you need mental Outpatient services 50% coinsurance None
health, behavioral Other outpatient non-surgical
health, or substance services:
abuse services 50% coinsurance

Preauthorization may be required - if not

Inpatient services 50% coinsurance 50% coinsurance
obtained, penalty will be 50%.

Cost-sharing does not apply for preventive

Office visits No charge 50% coinsurance
services

Depending on the type of services, a

Childbirth/delivery
50% coinsurance 50% coinsurance copayment, coinsurance or deductible may
If you are pregnant professional services
apply.

Maternity care may include tests and services

Childbirth/delivery facility
50% coinsurance 50% coinsurance described elsewhere in the SBC (i.e.
services
ultrasound).

M11302020 Page 5 of 9
 Common Limitations, Exceptions, & Other Important
Services You May Need What You Will Pay
Medical Event Information
100 visit per year
Home health care 50% coinsurance 50% coinsurance Preauthorization may be required - if not
obtained, penalty will be 50%.
Therapies:
Physical, occupational,
Physical, occupational,
cognitive, speech and Preauthorization may be required - if not
cognitive, speech and
Rehabilitation services audiology therapy: obtained, penalty will be 50%.
audiology therapy
$20 copay/visit; Physical, occupational, speech, cognitive and
50% coinsurance
deductible does not apply. audiology therapy 40 visits per year.

Therapies:
Physical, occupational,
Physical, occupational, Preauthorization may be required - if not
If you need help speech and audiology
Habilitation services speech and audiology obtained, penalty will be 50%.
recovering or have therapy: $20 copay/visit;
therapy 50% coinsurance Physical, occupational, speech, and audiology
other special health deductible does not apply.
therapy 40 visits per year.
needs

60 days per year. Preauthorization may be

Skilled nursing care 50% coinsurance 50% coinsurance
required - if not obtained, penalty will be 50%.

Excludes vehicle and home modifications,

Durable medical exercise, and bathroom equipment
50% coinsurance 50% coinsurance
equipment
Preauthorization may be required - if not
obtained, penalty will be 50%.
Preauthorization may be required - if not
Hospice services 50% coinsurance 50% coinsurance
obtained, penalty will be 50%.
Children’s eye exam Not Covered Not Covered None
If your child needs
Children’s glasses Not Covered Not Covered None
dental or eye care
Children’s dental check-up Not Covered Not Covered None

M11302020 Page 6 of 9
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Bariatric Surgery • Hearing Aids • Private Duty Nursing
• Child Dental Check-Up • Infertility Treatment • Routine eye care (Adult)
• Child Eye Exam • Long Term Care • Routine Foot Care
• Child Glasses • Non-emergency care when traveling outside the • Weight Loss Programs
U.S., when traveling outside the U.S. more than
6 consecutive months in a year

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.
• Manipulations – 20 visits per year

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is:
• www.humana.com or 1-866-4ASSIST (427-7478).
• For group health coverage subject to ERISA, you may also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA
(3272) or www.dol.gov/ebsa/healthreform.
• For non-federal governmental group health plans, you may also contact the Department of Health and Human Services, Center for Consumer Information and
Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov.
• If your coverage is a church plan, church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals
should contact their State insurance regulator regarding their possible rights to continuation coverage under State law.

Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information
about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or
assistance, contact.
• www.humana.com or 1-866-4ASSIST (427-7478).
• Department of Labor Employee Benefits Security Administration: 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.

M11302020 Page 7 of 9
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit

Does this plan meet Minimum Value Standards? Yes.

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-866-4ASSIST (427-7478). (TTY: 711).

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

M11302020
Page 8 of 9
About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)

 The plan’s overall deductible $5,000  The plan’s overall deductible $5,000  The plan’s overall deductible $5,000
 Specialist copayment $80  Specialist copayment $80  Specialist copayment $80
 Hospital (facility) coinsurance 50%  Hospital (facility) coinsurance 50%  Hospital (facility) coinsurance 50%
 Other coinsurance 50%  Other coinsurance 50%  Other coinsurance 50%

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $5,000 Deductibles $100 Deductibles $1,800
Copayments $0 Copayments $1,600 Copayments $300
Coinsurance $2,900 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $20 Limits or exclusions $0 Limits or exclusions $0
The total Peg would pay is $7,920 The total Joe would pay is $1,700 The total Mia would pay is $2,100

M11302020 The plan would be responsible for the other costs of these EXAMPLE covered services. Page 9 of 9
Important! ________________________________________________
At Humana, it is important you are treated fairly. Language assistance services, free of charge,
Humana Inc. and its subsidiaries do not discriminate or exclude are available to you. 1-866-427-7478 (TTY: 711)
people because of their race, color, national origin, age, disability, Español (Spanish): Llame al número arriba indicado para recibir
sex, sexual orientation, gender, gender identity, ancestry, marital VHUYLFLRVJUDWXLWRVGHDVLVWHQFLDbOLQJ¾¯VWLFD
status or religion. Discrimination is against the law. Humana and its 籗넓⚥俒 (Chinese) 丸䩧♳꬗涸ꨶ鑨贫焺⽰〳栽䖤⯝顥铃鎊䴂⸔剪⹡
subsidiaries comply with applicable Federal Civil Rights laws. If you 7L̹QJ9ĹW9LHWQDPHVH;LQJ͇LV͋ÓĹQWKR̛LWU¬QÓ¤\Ó̽QĶQÓɟ͝F
believe that you have been discriminated against by Humana or its F£FGͅFKY͟K͑WU͝QJ¶QQJͩPL̿QSK¯
묻펂 (Korean) 줂욚펆펂힎풞컪찒큲읊짩픊엲졂퓒픦쩖옪헒킻킪폲 
subsidiaries, there are ways to get help.
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• You may file a complaint, also known as a grievance:
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Discrimination Grievances, P.O. Box 14618, ƺǝǛǛǔǒǓ5XVVLDQƹǘǑnjǘǗǒǜǏǙǘǗǘǖǏǚǝǝǔNJǑNJǗǗǘǖǝnjǥǢǏ
Lexington, KY 40512-4618 ǡǜǘNjǥǙǘǕǝǡǒǜǦNjǏǛǙǕNJǜǗǥǏǝǛǕǝǍǒbǙǏǚǏnjǘǎNJ
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use a TTY, call 711. UHVHYZDVªYLVªGSRXODQJNLbJUDWLV
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of Health and Human Services, Office for Civil Rights electronically JUDWXLWHPHQWGHVVHUYLFHVGȇDLGHOLQJXLVWLTXH
through their Complaint Portal, available at Polski (Polish):$E\VNRU]\VWDÉ]EH]SĄDWQHMSRPRF\MÛ]\NRZHMSURV]Û
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, ]DG]ZRQLÉSRGZ\ľHMSRGDQ\QXPHU
or at U.S. Department of Health and Human Services, 3RUWXJX¬V3RUWXJXHVH Ligue para o número acima indicado para
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200 Independence Avenue, SW, Room 509F, HHH Building,
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Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).
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Complaint forms are available at
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• California residents: You may also call California Department of 傈劤铂 (Japanese) 搀俱‫ך‬鎉铂佄䴂‫؟‬٦‫׀׾أؽ‬銲劄‫ך‬㜥さ‫כ‬ծ♳鎸‫ך‬殢〾‫ֶדת‬
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a grievance. ƖNJ1ƱǢ )DUVL
Auxiliary aids and services, free of charge, are available to you. DžƗLJƘŦƳ3ƱǯƷBǶǢG1ƱǯǍƱƳFƱŦƗ'1*1ǶǑƳƖDZƱƳ2*ȂƘǵNjƷƶǢƱƗ1/Ì'LJƳ
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opportunity to participate.
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