MEDICARE ADVANTAGE PLANS

Select the market(s) below to view their Market HighlightsVIRGINIA

MA/MAPD PLANS

Humana offers a wide range of affordable plans and a broad network of healthcare providers nationwide to meet the unique needs of your clients. Many plans come with low or no monthly plan premium, plus health-boosting benefits that aim to help your clients achieve their best health.

VAHK7GUEN

DSNP AND VALUE PLUS PLANS

DSNP AND VALUE PLUS PLANS

VIRGINIA

PRESCRIPTION DRUG PLANS

PDP PLANS

Humana offers affordable prescription drug plans that meet the unique needs of your clients. Our vast network includes mail-order pharmacies like Humana Pharmacy, which offers mail-order copays as low as $0 on generic drugs in many regions. In-store copays as low as $1 on certain generic drugs at Walmart, Sam’s Club, and Walmart Neighborhood Markets, which are preferred cost sharing pharmacies.

VIRGINIA

LOCAL SUPPORT

VIRGINIA

LOCAL SUPPORT

Humana now offers two new resources, Broker Relationship Managers (BRM) and Broker Relationship Executives (BRE), in addition to your local market offices. BRMs have been deployed in markets across the country to offer on-the-ground assistance, BREs to provide sales support telephonically and electronically. We encourage you to contact these resources or simply contact Humana Agent Support at 1-800-309-3163.

MEDICARE ADVANTAGE PLANS

MARKET HIGHLIGHTS• New LPPO with $0 plan premium available

in Central VA: Lynchburg, Martinsville, and selected surrounding counties

• New Value Plus LPPO plan designed with dual eligibles in mind, available in Lynchburg and selected surrounding counties

• Improved Charlottesville HMO plan: Reduced plan premium, PCP copay, and Rx deductible

• No referrals needed

• All MAPD plans offer preferred mail order 90-day Rx Tier 1, 2 for $0 copay through Humana Pharmacy

NETWORK HIGHLIGHTS• Some in-network hospitals include: Sentara

Martha Jefferson Hospital (All Plans), University of Virginia (All Plans) and Centra Health System (PPO & PFFS Plans)

• Some in-network providers include: Central VA Family Practice; Medical Associates of Central Virginia

• All PPO plans use Humana’s Nationwide ChoiceCare PPO Network

MARKET SERVICE AREAAlbemarle, Amherst, Appomattox, Bedford City, Campbell, Charlottesville City, Danville City, Henry, Lynchburg City, Martinsville City, Pittsylvania

VIRGINIA CENTRAL VIRGINIA

NEW

Plan Name Humana Gold Plus (HMO) HumanaChoice (PPO) HumanaChoice (Regional PPO)

Plan Number H5619-041-000 H5216-148-000 R1390-002-000

Plan Highlights$29 plan premium; $5 PCP copay; $215 Rx deductible (Charlottesville HMO)

$0 plan premium; newly available in select counties in Central VA

$74 plan premium; $0 OON deductible; IN & OON cost share are equal (available in all VA counties)

Premium $29 $0 $74

PCP $5 $0 $15

Specialist $45 $45 $50

Referrals Required No No No

Inpatient Hospital $345 per day Days 1-5 $345 per day Days 1-4 $360 per day Days 1-5

Max Out-of-Pocket $6,700 In-network $6,700 In-network $6,700 In-network

Rx Deductible $215 tiers 4-5 $265 tiers 4-5 $360 tiers 4-5

Rx Preferred

$2/$8/$45/$95/29%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$4/$12/$47/$100/28%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$99/26%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

Key Extra Benefits Hearing, Fitness, OTC allowance $30/Quarter

Hearing, Fitness, OTC allowance $30/Quarter

Vision, Hearing, Fitness, OTC allowance $25/Quarter

Market Service Area Albemarle, Charlottesville CityAmherst, Appomattox, Campbell, Danville City, Henry, Lynchburg City, Martinsville City, Pittsylvania

Statewide in North Carolina, Virginia

VIRGINIA | CENTRAL VIRGINIA MA/MAPD PLANS

NEW

Plan Name Humana Gold Choice (PFFS) Humana Gold Choice (PFFS) HumanaChoice (PPO)

Plan Number H8145-003-000 H8145-004-000 H5216-152-000

Plan Highlights$66 plan premium; $15 PCP copay, $45 Spec copay (see service areas for counties)

$77 plan premium; $15 PCP copay; $45 Spec copay (see service areas for counties)

$0 plan premium; $3,400 MOOP; $500 copay inpatient hospital; Niche plan for those not needing Rx benefits

Premium $66 $77 $0

PCP $15 $15 $10

Specialist $45 $45 $35

Referrals Required No No No

Inpatient Hospital $345 per day Days 1-5 $345 per day Days 1-5 $500 per admission

Max Out-of-Pocket $6,700 In-network $6,700 In-network $3,400 In-network

Rx Deductible $160 tiers 3-5 $160 tiers 3-5 No Coverage

Rx Preferred

$5/$15/$47/$99/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$99/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

No Coverage

Key Extra Benefits Hearing, Fitness Hearing, Fitness Hearing, Fitness, OTC allowance $30/Quarter

Market Service Area Amherst, Appomattox PittsylvaniaAmherst, Appomattox, Campbell, Danville City, Henry, Lynchburg City, Martinsville City, Pittsylvania

VIRGINIA | CENTRAL VIRGINIA MA/MAPD PLANS

Plan Name HumanaChoice (Regional PPO)

Plan Number R1390-001-000

Plan Highlights$0 plan premium, $3400 MOOP, $695 IP copay, Niche plan for those not needing Rx benefits (available in all VA counties)

Premium $0

PCP $10

Specialist $35

Referrals Required No

Inpatient Hospital $695 per admission

Max Out-of-Pocket $3,400 In-network

Rx Deductible No Coverage

Rx Preferred No Coverage

Key Extra Benefits Vision, Hearing, Fitness, OTC allowance $30/Quarter

Market Service Area Statewide in North Carolina, Virginia

VIRGINIA | CENTRAL VIRGINIA MA/MAPD PLANS

MEDICARE ADVANTAGE PLANS

MARKET HIGHLIGHTS• Two new LPPO plans with $0 plan premium

(Winchester and Fredericksburg, and some surrounding counties)

• No referrals needed

• All MAPD plans offer preferred mail order 90-day Rx Tier 1, 2 for $0 copay through Humana Pharmacy

• $0 deductible out-of-network on LPPO MAPD plans

• $160 Rx deductible on HMO plan; $265 Rx deductible Tier 4 & 5 on LPPO MAPD plan

NETWORK HIGHLIGHTS• Privia Medical Group: $0 PCP copay on HMO

• Some in-network providers include: Valley Health, Mary Washington Healthcare, Virginia Hospital Center, UVA/Novant, Reston Hospital Center and Sentara Northern VA Medical Center

• All PPO plans use Humana’s Nationwide ChoiceCare PPO Network

MARKET SERVICE AREAAccomack, Alexandria City, Arlington, Clarke, Culpeper, Essex, Falls Church City, Fauquier, Frederick, Fredericksburg City, King George, Loudoun, Manassas City, Manassas Park City, Northampton, Northumberland, Page, Prince William, Rappahannock, Richmond, Shenandoah, Spotsylvania, Stafford, Warren, Westmoreland, Winchester City

VIRGINIA NORTHERN VIRGINIA

NEW NEW

Plan Name Humana Gold Plus (HMO) HumanaChoice (PPO) HumanaChoice (PPO)

Plan Number H5619-047-000 H5216-150-000 H5216-151-000

Plan Highlights$0 plan premium; $0-$15 PCP copay ($0 copay for Privia-affiliated PCPs); $160 Rx deductible Tier 4&5 only

$0 plan premium; $265 Rx deductible Tier 4&5 only

$0 plan premium; $265 Rx deductible Tier 4&5 only

Premium $0 $0 $0

PCP $15 $15 $15

Specialist $40 $45 $45

Referrals Required No No No

Inpatient Hospital $295 per day Days 1-6 $345 per day Days 1-4 $345 per day Days 1-4

Max Out-of-Pocket $6,700 In-network $6,700 In-network $6,700 In-network

Rx Deductible $160 tiers 4-5 $265 tiers 4-5 $265 tiers 4-5

Rx Preferred

$2/$8/$45/$95/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$4/$12/$47/$100/28%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$4/$12/$47/$100/28%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

Key Extra Benefits Dental, Vision, Hearing, Fitness, OTC allowance $30/Quarter

Hearing, Fitness, OTC allowance $30/Quarter

Hearing, Fitness, OTC allowance $30/Quarter

Market Service AreaAlexandria City, Arlington, Falls Church City, Fauquier, Loudoun, Manassas City, Manassas Park City, Prince William

Frederick, Shenandoah, Winchester City

Fredericksburg City, Spotsylvania, Stafford

VIRGINIA | NORTHERN VIRGINIA MA/MAPD PLANS

Plan Name HumanaChoice (PPO) HumanaChoice (PPO) HumanaChoice (Regional PPO)

Plan Number H5216-026-000 H5216-025-000 R1390-002-000

Plan Highlights$49 plan premium; $0 OON deductible; $265 Rx deductible Tier 4&5 only; $699-$999 copays on hearing aids

$69 plan premium; $0 OON deductible; $265 Rx deductible Tier 4&5 only; $699-$999 copays on hearing aids

$74 plan premium; $0 OON deductible; IN & OON cost share are equal

Premium $49 $69 $74

PCP $15 $15 $15

Specialist $45 $45 $50

Referrals Required No No No

Inpatient Hospital $345 per day Days 1-5 $345 per day Days 1-5 $360 per day Days 1-5

Max Out-of-Pocket $6,700 In-network $6,700 In-network $6,700 In-network

Rx Deductible $265 tiers 4-5 $265 tiers 4-5 $360 tiers 4-5

Rx Preferred

$4/$12/$47/$100/28%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$4/$12/$47/$100/28%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$99/26%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

Key Extra Benefits Hearing, Fitness, OTC allowance $30/Quarter

Hearing, Fitness, OTC allowance $30/Quarter

Vision, Hearing, Fitness, OTC allowance $25/Quarter

Market Service AreaAlexandria City, Arlington, Clarke, Falls Church City, Loudoun, Manassas City, Manassas Park City, Prince William

Accomack, Essex, Fauquier, Fredericksburg City, King George, Northampton, Northumberland, Page, Rappahannock, Richmond, Spotsylvania, Stafford, Warren, Westmoreland

Statewide in North Carolina, Virginia

VIRGINIA | NORTHERN VIRGINIA MA/MAPD PLANS

NEW

Plan Name Humana Gold Choice (PFFS) Humana Gold Choice (PFFS) HumanaChoice (PPO)

Plan Number H8145-003-000 H8145-004-000 H5216-152-000

Plan Highlights$66 plan premium; $15 PCP copay, $45 Spec copay (see service areas for counties)

$77 plan premium; $15 PCP copay; $45 Spec copay (see service areas for counties)

$0 plan premium; $3,400 MOOP; $500 copay inpatient hospital; Niche plan for those not needing Rx benefits

Premium $66 $77 $0

PCP $15 $15 $10

Specialist $45 $45 $35

Referrals Required No No No

Inpatient Hospital $345 per day Days 1-5 $345 per day Days 1-5 $500 per admission

Max Out-of-Pocket $6,700 In-network $6,700 In-network $3,400 In-network

Rx Deductible $160 tiers 3-5 $160 tiers 3-5 No Coverage

Rx Preferred

$5/$15/$47/$99/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$99/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

No Coverage

Key Extra Benefits Hearing, Fitness Hearing, Fitness Hearing, Fitness, OTC allowance $30/Quarter

Market Service Area Essex, Northumberland, Richmond

Alexandria City, Falls Church City, Fredericksburg City, King George, Loudoun, Northampton, Page, Rappahannock, Spotsylvania, Stafford, Westmoreland

Prince William, Loudoun, Arlington, Spotsylvania, Alexandria City, Stafford, Frederick, Fauquier, Shenandoah, Accomack, Warren, Page, Winchester City, Westmoreland, among others

VIRGINIA | NORTHERN VIRGINIA MA/MAPD PLANS

Plan Name HumanaChoice (Regional PPO) Humana Gold Choice (PFFS)

Plan Number R1390-001-000 H8145-042-000

Plan Highlights$0 plan premium; $3,400 MOOP; $695 copay inpatient hospital; Niche plan for those not needing Rx benefits

$29 plan premium; can be paired with stand alone PDP plan

Premium $0 $29

PCP $10 $15

Specialist $35 $45

Referrals Required No No

Inpatient Hospital $695 per admission $345 per day Days 1-5

Max Out-of-Pocket $3,400 In-network $6,700 In-network

Rx Deductible No Coverage No Coverage

Rx Preferred No Coverage No Coverage

Key Extra Benefits Vision, Hearing, Fitness, OTC allowance $30/Quarter

Hearing, Fitness, OTC allowance $30/Quarter

Market Service Area Statewide in North Carolina, Virginia Essex, Northumberland, Richmond

VIRGINIA | NORTHERN VIRGINIA MA/MAPD PLANS

MEDICARE ADVANTAGE PLANS

MARKET HIGHLIGHTS• $0 plan premium; $0 PCP copay; $3,400 MOOP

on Core HMO plan

• Transportation benefit included on most HMO plans

• Year round selling opportunity CSNP (Diabetes, Cardiovascular Disease and Chronic Heart Condition)

• New supplemental benefit for food insecurity on Value Plus Plan in Henrico County and Richmond City

• All MAPD plans offer preferred mail order 90-day Rx Tier 1,2 for $0 copay through Humana Pharmacy

• No referrals needed

NETWORK HIGHLIGHTS• Some in-network hospitals include: Bon

Secours and HCA Health Systems

• 4 JenCare locations: Downtown Richmond, Mechanicsville, Southside-Hull St, and Petersburg-Colonial Heights

• Some in-network providers include: OrthoVirginia, Commonwealth Primary Care and Virginia Physicians, Inc.

• All PPO plans use Humana’s Nationwide ChoiceCare PPO Network

MARKET SERVICE AREAAmelia, Caroline, Chesterfield, Colonial Heights City, Cumberland, Dinwiddie, Goochland, Hanover, Henrico, Hopewell City, King And Queen, Louisa, New Kent, Petersburg City, Powhatan, Prince George, Richmond City, Sussex

VIRGINIA RICHMOND

Plan Name Humana Gold Plus (HMO) Humana Gold Plus (HMO) Humana Gold Plus - Diabetes and Heart (HMO SNP)

Plan Number H6622-004-000 H5619-044-000 H5619-046-000

Plan Highlights$0 plan premium, $3400 MOOP, $0 PCP copay, $30 Spec copay, $100 Rx deductible Tier 4 & 5 only, $99-$399 copay on hearing aids

$13 plan premium; $10 PCP copay; $40 Spec copay; $265 Rx deductible Tier 4 & 5 only; $699-$999 copays on hearing aids

$0 plan premium; $0 PCP copay; $45 Spec copay; $150 Rx deductible Tier 4 & 5 only; $499 - $799 copay on hearing aids

Premium $0 $13 $0

PCP $0 $10 $0

Specialist $30 $40 $45

Referrals Required No No No

Inpatient Hospital $275 per day Days 1-6 $295 per day Days 1-6 $275 per day Days 1-6

Max Out-of-Pocket $3,400 In-network $6,700 In-network $6,700 In-network

Rx Deductible $100 tiers 4-5 $265 tiers 4-5 $150 tiers 4-5

Rx Preferred

$2/$8/$45/$95/31%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$4/$12/$47/$100/28%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$4/$12/$47/$100/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

Key Extra BenefitsDental, Vision, Hearing, Fitness, OTC allowance $75/Quarter, Transportation

Hearing, Fitness, OTC allowance $30/Quarter

Dental, Vision, Hearing, Fitness, OTC allowance $50/Quarter, Transportation

Market Service AreaChesterfield, Colonial Heights City, Dinwiddie, Hanover, Henrico, Hopewell City, Petersburg City, Richmond City

Chesterfield, Colonial Heights City, Dinwiddie, Goochland, Hanover, Henrico, Hopewell City, Louisa, Petersburg City, Powhatan, Richmond City

Chesterfield, Colonial Heights City, Hanover, Henrico, Hopewell City, Petersburg City, Richmond City

VIRGINIA | RICHMOND MA/MAPD PLANS

Plan Name HumanaChoice (PPO) HumanaChoice (Regional PPO) Humana Gold Choice (PFFS)

Plan Number H5216-146-000 R1390-002-000 H8145-003-000

Plan Highlights$53 plan premium; $10 PCP copay; $40 Spec copay; $160 Rx deductible Tier 4 & 5 only; $699-$999 copays on hearing aids

$74 plan premium; $0 OON deductible; IN & OON cost share are equal

$66 plan premium; $15 PCP copay, $45 Spec copay (see service areas for counties)

Premium $53 $74 $66

PCP $10 $15 $15

Specialist $40 $50 $45

Referrals Required No No No

Inpatient Hospital $295 per day Days 1-6 $360 per day Days 1-5 $345 per day Days 1-5

Max Out-of-Pocket $6,700 In-network $6,700 In-network $6,700 In-network

Rx Deductible $160 tiers 4-5 $360 tiers 4-5 $160 tiers 3-5

Rx Preferred

$4/$12/$47/$100/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$99/26%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$99/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

Key Extra Benefits Hearing, Fitness, OTC allowance $30/Quarter

Vision, Hearing, Fitness, OTC allowance $25/Quarter Hearing, Fitness

Market Service Area Richmond Marketwide Statewide in North Carolina, Virginia

Chesterfield, Goochland, Hanover, Henrico, Petersburg City, Powhatan, Richmond City

VIRGINIA | RICHMOND MA/MAPD PLANS

NEW

Plan Name HumanaChoice (PPO) HumanaChoice (Regional PPO) Humana Gold Choice (PFFS)

Plan Number H5216-152-000 R1390-001-000 H8145-042-000

Plan Highlights$0 plan premium; $3,400 MOOP; $500 copay inpatient hospital; Niche plan for those not needing Rx benefits

$0 plan premium; $3,400 MOOP; $695 copay inpatient hospital; Niche plan for those not needing Rx benefits

$29 plan premium; can be paired with stand alone PDP plan

Premium $0 $0 $29

PCP $10 $10 $15

Specialist $35 $35 $45

Referrals Required No No No

Inpatient Hospital $500 per admission $695 per admission $345 per day Days 1-5

Max Out-of-Pocket $3,400 In-network $3,400 In-network $6,700 In-network

Rx Deductible No Coverage No Coverage No Coverage

Rx Preferred No Coverage No Coverage No Coverage

Key Extra Benefits Hearing, Fitness, OTC allowance $30/Quarter

Vision, Hearing, Fitness, OTC allowance $30/Quarter

Hearing, Fitness, OTC allowance $30/Quarter

Market Service Area Richmond Marketwide Statewide in North Carolina, Virginia

Chesterfield, Goochland, Hanover, Henrico, Petersburg City, Powhatan, Richmond City

VIRGINIA | RICHMOND MA/MAPD PLANS

MEDICARE ADVANTAGE PLANS

MARKET HIGHLIGHTS• New high benefit HMO plan in Roanoke and

surrounding counties. $0 copay for PCP, SPC and IPH

• HMO with $0 plan premium available in Roanoke and some surrounding counties with $3,400 MOOP and $0 PCP copay

• Niche MA Only plan is a good fit for veterans

• All MAPD plans offer preferred mail order 90-day Rx Tier 1, 2 for $0 copay through Humana Pharmacy

• No referrals needed

• HMO plan has $160 Rx deductible only on Tiers 4 & 5; LPPO MAPD plan has $215 Rx deductible only on Tiers 4 & 5

NETWORK HIGHLIGHTS• Some in-network hospitals include: Carilion

and HCA Lewis Gale

• All PPO plans use Humana’s Nationwide ChoiceCare PPO Network

MARKET SERVICE AREABedford, Bland, Botetourt, Craig, Floyd, Franklin, Montgomery, Pulaski, Radford, Roanoke, Roanoke City, Salem

VIRGINIA ROANOKE

NEW

Plan Name Humana Gold Plus (HMO) Humana Gold Plus (HMO) Humana Gold Plus (HMO)

Plan Number H5619-042-001 H5377-001-000 H5619-042-002

Plan Highlights$0 plan premium; $0 PCP copay; $35 Spec copay; $160 Rx deductible Tier 4 & 5 only; $699-$999 copay on hearing aids

$125 plan premium; $0 PCP copay; $0 Spec copay; $190 Rx deductible Tier 3,4,5

$13 plan premium; $0 PCP copay; $45 Spec copay; $160 Rx deductible Tier 4 & 5 only; $699-$999 copay on hearing aids

Premium $0 $125 $13

PCP $0 $0 $0

Specialist $35 $0 $45

Referrals Required No No No

Inpatient Hospital $275 per day Days 1-6 $0 per admission $275 per day Days 1-6

Max Out-of-Pocket $3,400 In-network $6,700 In-network $6,700 In-network

Rx Deductible $160 tiers 4-5 $190 tiers 3-5 $160 tiers 4-5

Rx Preferred

$2/$8/$45/$95/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$4/$12/$47/$99/29%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$2/$8/$45/$95/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

Key Extra Benefits Vision, Hearing, Fitness, OTC allowance $30/Quarter

Vision, Hearing, Fitness, OTC allowance $75/Quarter, Transportation

Vision, Hearing, Fitness, OTC allowance $30/Quarter

Market Service Area Franklin, Roanoke, Roanoke City, Salem

Botetourt, Craig, Floyd, Franklin, Montgomery, Pulaski, Radford, Roanoke, Roanoke City, Salem

Botetourt, Craig, Floyd, Montgomery, Pulaski, Radford

VIRGINIA | ROANOKE MA/MAPD PLANS

Plan Name HumanaChoice (PPO) HumanaChoice (Regional PPO) Humana Gold Choice (PFFS)

Plan Number H5216-027-000 R1390-002-000 H8145-003-000

Plan Highlights$69 plan premium; $500 OON deductible; $10 PCP copay; $45 Spec copay; $215 Rx deductible Tier 4 & 5 only

$74 plan premium; $0 OON deductible; IN & OON cost share are equal

$66 plan premium; $15 PCP copay, $45 Spec copay (see service areas for counties)

Premium $69 $74 $66

PCP $10 $15 $15

Specialist $45 $50 $45

Referrals Required No No No

Inpatient Hospital $345 per day Days 1-5 $360 per day Days 1-5 $345 per day Days 1-5

Max Out-of-Pocket $6,700 In-network $6,700 In-network $6,700 In-network

Rx Deductible $215 tiers 4-5 $360 tiers 4-5 $160 tiers 3-5

Rx Preferred

$4/$12/$47/$100/29%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$99/26%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$99/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

Key Extra Benefits Vision, Hearing, Fitness, OTC allowance $30/Quarter

Vision, Hearing, Fitness, OTC allowance $25/Quarter Hearing, Fitness

Market Service Area Roanoke Marketwide Statewide in North Carolina, Virginia

Bedford, Bland, Botetourt, Craig, Floyd, Pulaski, Radford, Roanoke, Roanoke City, Salem

VIRGINIA | ROANOKE MA/MAPD PLANS

NEW

Plan Name HumanaChoice (PPO) HumanaChoice (Regional PPO) Humana Gold Choice (PFFS)

Plan Number H5216-152-000 R1390-001-000 H8145-042-000

Plan Highlights$0 plan premium; $3,400 MOOP; $500 copay inpatient hospital; Niche plan for those not needing Rx benefits

$0 plan premium; $3,400 MOOP; $695 copay inpatient hospital; Niche plan for those not needing Rx benefits

$29 plan premium; can be paired with stand alone PDP plan

Premium $0 $0 $29

PCP $10 $10 $15

Specialist $35 $35 $45

Referrals Required No No No

Inpatient Hospital $500 per admission $695 per admission $345 per day Days 1-5

Max Out-of-Pocket $3,400 In-network $3,400 In-network $6,700 In-network

Rx Deductible No Coverage No Coverage No Coverage

Rx Preferred No Coverage No Coverage No Coverage

Key Extra Benefits Hearing, Fitness, OTC allowance $30/Quarter

Vision, Hearing, Fitness, OTC allowance $30/Quarter

Hearing, Fitness, OTC allowance $30/Quarter

Market Service Area Roanoke Marketwide Statewide in North Carolina, Virginia

Bedford, Bland, Botetourt, Craig, Floyd, Radford, Roanoke, Roanoke City, Salem

VIRGINIA | ROANOKE MA/MAPD PLANS

MEDICARE ADVANTAGE PLANS

MARKET HIGHLIGHTS• $0 Rx deductible on HMO plans with $29 plan

premium and $95 plan premium

• No referrals needed

• All MAPD plans offer preferred mail order 90-day Rx Tier 1, 2 for $0 copay through Humana Pharmacy

• $0 PCP copay on HMO plans with $29 plan premium and $95 plan premium

• HMO available with $0 plan premium, $5 PCP copay and $50 Rx deductible on Tiers 4 and 5

NETWORK HIGHLIGHTS• Some in-network providers include: Holston

Medical Group

• Some in-network hospitals include: Ballad Health (Wellmont and Mountain States), LifePoint

• All PPO plans use Humana’s Nationwide ChoiceCare PPO Network

MARKET SERVICE AREABristol, Buchanan, Dickenson, Grayson, Lee, Norton City, Russell, Scott, Smyth, Tazewell, Washington, Wise, Wythe

VIRGINIA SOUTHWEST VIRGINIA

Plan Name Humana Gold Plus (HMO) Humana Gold Plus (HMO) Humana Gold Plus (HMO)

Plan Number H5619-095-000 H5619-091-000 H5619-090-000

Plan Highlights$0 plan premium; $5 PCP copay; $45 Spec copay; $50 Rx deductible Tier 4&5 only; $399-$699 copay on hearing aids

$29 plan premium; $0 PCP copay; $35 Spec copay; $0 Rx deductible; $399-$699 copay on hearing aids

$95 plan premium; $0 PCP copay; $35 Spec copay; $0 copay inpatient hospital; $0 Rx deductible; $399-$699 copay on hearing aids

Premium $0 $29 $95

PCP $5 $0 $0

Specialist $45 $35 $35

Referrals Required No No No

Inpatient Hospital $295 per day Days 1-6 $245 per day Days 1-6 $0 per admission

Max Out-of-Pocket $6,700 In-network $5,900 In-network $5,400 In-network

Rx Deductible $50 tiers 4-5 No Deductible No Deductible

Rx Preferred

$7/$17/$47/$100/32%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$97/33%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$3/$10/$47/$97/33%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

Key Extra Benefits Vision, Hearing, Fitness, OTC allowance $25/Quarter

Dental, Vision, Hearing, Fitness, OTC allowance $25/Quarter

Dental, Vision, Hearing, Fitness, OTC allowance $30/Quarter

Market Service Area Southwest Virginia Marketwide Southwest Virginia Marketwide Southwest Virginia Marketwide

VIRGINIA | SOUTHWEST VIRGINIA MA/MAPD PLANS

Plan Name HumanaChoice (PPO) HumanaChoice (Regional PPO) Humana Gold Choice (PFFS)

Plan Number H5216-100-000 R1390-002-000 H8145-091-000

Plan Highlights$59 plan premium; $15 PCP copay; $35 Spec copay; $0 Rx deductible; $399-$699 copay on hearing aids

$74 plan premium; $0 OON deductible; IN & OON cost share are equal

$90 plan premium; $15 PCP copay, $40 Spec copay; $415 Rx deductible

Premium $59 $74 $90

PCP $15 $15 $15

Specialist $35 $50 $40

Referrals Required No No No

Inpatient Hospital $265 per day Days 1-7 $360 per day Days 1-5 $295 per day Days 1-6

Max Out-of-Pocket $6,700 In-network $6,700 In-network $6,700 In-network

Rx Deductible No Deductible $360 tiers 4-5 $415 tiers 4-5

Rx Preferred

$7/$17/$47/$97/33%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$99/26%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$7/$17/$47/$100/25%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

Key Extra Benefits Vision, Hearing, Fitness, OTC allowance $25/Quarter

Vision, Hearing, Fitness, OTC allowance $25/Quarter

Vision, Hearing, OTC allowance $10/Month

Market Service Area Southwest Virginia Marketwide Statewide in North Carolina, Virginia

Bristol, Buchanan, Dickenson, Grayson, Lee, Russell, Smyth, Tazewell, Washington, Wise, Wythe

VIRGINIA | SOUTHWEST VIRGINIA MA/MAPD PLANS

Plan Name HumanaChoice (Regional PPO) Humana Gold Choice (PFFS)

Plan Number R1390-001-000 H8145-108-000

Plan Highlights$0 plan premium; $3,400 MOOP; $695 copay inpatient hospital; Niche plan for those not needing Rx benefits

$0 plan premium; $15 PCP copay, $40 Spec copay; may be paired with stand alone PDP plan

Premium $0 $0

PCP $10 $15

Specialist $35 $40

Referrals Required No No

Inpatient Hospital $695 per admission $295 per day Days 1-6

Max Out-of-Pocket $3,400 In-network $6,700 In-network

Rx Deductible No Coverage No Coverage

Rx Preferred No Coverage No Coverage

Key Extra Benefits Vision, Hearing, Fitness, OTC allowance $30/Quarter

Vision, Fitness, OTC allowance $25/Quarter

Market Service Area Statewide in North Carolina, Virginia

Bristol, Buchanan, Dickenson, Grayson, Lee, Russell, Smyth, Tazewell, Washington, Wise, Wythe

VIRGINIA | SOUTHWEST VIRGINIA MA/MAPD PLANS

MEDICARE ADVANTAGE PLANS

MARKET HIGHLIGHTS• $0 plan premium; $0 PCP copay; $3,400 MOOP

on Core HMO plan

• Transportation benefit included on most HMO plans

• Year round selling opportunity CSNP (Diabetes, Cardiovascular Disease and Chronic Heart Condition)

• All MAPD plans offer preferred mail order 90-day Rx Tier 1, 2 for $0 copay through Humana Pharmacy

• No referrals needed

NETWORK HIGHLIGHTS• Some in-network hospitals include: Sentara,

Riverside, Bon Secours and Chesapeake Regional

• 4 JenCare locations: Virginia Beach, Norfolk, Portsmouth and Newport News

• Some in-network providers include: TPMG and FirstCare

• All PPO plans use Humana’s Nationwide ChoiceCare PPO Network

MARKET SERVICE AREAChesapeake City, Franklin City, Gloucester, Hampton City, Isle Of Wight, James City, Newport News City, Norfolk City, Poquoson City, Portsmouth City, Southampton, Suffolk City, Surry, Virginia Beach City, Williamsburg City, York

VIRGINIA TIDEWATER

Plan Name Humana Gold Plus (HMO) Humana Gold Plus (HMO) Humana Gold Plus - Diabetes and Heart (HMO SNP)

Plan Number H5619-045-000 H6622-005-000 H5619-046-000

Plan Highlights$0 plan premium; $0 PCP copay; $40 Spec copay; $160 Rx deductible Tier 4 & 5 only; $699-$999 copays on hearing aids

$0 plan premium, $3400 MOOP, $0 PCP copay, $30 Spec copay, $100 RX deductible Tier 4 & 5 only, $99-$399 copay on hearing aids

$0 plan premium; $0 PCP copay; $45 Spec copay; $150 Rx deductible Tier 4 & 5 only; $499 - $799 copay on hearing aids

Premium $0 $0 $0

PCP $0 $0 $0

Specialist $40 $30 $45

Referrals Required No No No

Inpatient Hospital $295 per day Days 1-6 $275 per day Days 1-6 $275 per day Days 1-6

Max Out-of-Pocket $6,700 In-network $3,400 In-network $6,700 In-network

Rx Deductible $160 tiers 4-5 $100 tiers 4-5 $150 tiers 4-5

Rx Preferred

$4/$12/$47/$100/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$2/$8/$45/$95/31%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$4/$12/$47/$100/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

Key Extra Benefits Dental, Hearing, Fitness, OTC allowance $30/Quarter

Dental, Vision, Hearing, Fitness, OTC allowance $200/Quarter, Transportation

Dental, Vision, Hearing, Fitness, OTC allowance $50/Quarter, Transportation

Market Service Area

Chesapeake City, Hampton City, Isle Of Wight, James City, Newport News City, Norfolk City, Poquoson City, Portsmouth City, Suffolk City, Virginia Beach City, Williamsburg City, York

Chesapeake City, Hampton City, Newport News City, Norfolk City, Portsmouth City, Suffolk City, Virginia Beach City

Chesapeake City, Hampton City, Newport News City, Norfolk City, Portsmouth City, Virginia Beach City

VIRGINIA | TIDEWATER MA/MAPD PLANS

Plan Name HumanaChoice (PPO) HumanaChoice (Regional PPO) Humana Gold Choice (PFFS)

Plan Number H5216-144-000 R1390-002-000 H8145-003-000

Plan Highlights$55 plan premium; $10 PCP copay; $40 Spec copay; $265 Rx deductible Tier 4 & 5 only; $699-$999 copays on hearing aids

$74 plan premium; $0 OON deductible; IN & OON cost share are equal

$66 plan premium; $15 PCP copay, $45 Spec copay (see service areas for counties)

Premium $55 $74 $66

PCP $10 $15 $15

Specialist $40 $50 $45

Referrals Required No No No

Inpatient Hospital $295 per day Days 1-6 $360 per day Days 1-5 $345 per day Days 1-5

Max Out-of-Pocket $6,700 In-network $6,700 In-network $6,700 In-network

Rx Deductible $265 tiers 4-5 $360 tiers 4-5 $160 tiers 3-5

Rx Preferred

$4/$12/$47/$100/28%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$99/26%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$99/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

Key Extra Benefits Vision, Hearing, Fitness, OTC allowance $30/Quarter

Vision, Hearing, Fitness, OTC allowance $25/Quarter Hearing, Fitness

Market Service Area Tidewater Marketwide Statewide in North Carolina, Virginia

Chesapeake City, Gloucester, Hampton City, Isle Of Wight, Newport News City, Norfolk City, Portsmouth City, Southampton, Suffolk City, Virginia Beach City, Williamsburg City, York

VIRGINIA | TIDEWATER MA/MAPD PLANS

NEW

Plan Name HumanaChoice (PPO) HumanaChoice (Regional PPO) Humana Gold Choice (PFFS)

Plan Number H5216-152-000 R1390-001-000 H8145-042-000

Plan Highlights$0 plan premium; $3,400 MOOP; $500 copay inpatient hospital; Niche plan for those not needing Rx benefits

$0 plan premium; $3,400 MOOP; $695 copay inpatient hospital; Niche plan for those not needing Rx benefits

$29 plan premium; can be paired with stand alone PDP plan

Premium $0 $0 $29

PCP $10 $10 $15

Specialist $35 $35 $45

Referrals Required No No No

Inpatient Hospital $500 per admission $695 per admission $345 per day Days 1-5

Max Out-of-Pocket $3,400 In-network $3,400 In-network $6,700 In-network

Rx Deductible No Coverage No Coverage No Coverage

Rx Preferred No Coverage No Coverage No Coverage

Key Extra Benefits Hearing, Fitness, OTC allowance $30/Quarter

Vision, Hearing, Fitness, OTC allowance $30/Quarter

Hearing, Fitness, OTC allowance $30/Quarter

Market Service Area Tidewater Marketwide Statewide in North Carolina, Virginia

Chesapeake City, Gloucester, Hampton City, Isle Of Wight, Newport News City, Norfolk City, Portsmouth City, Southampton, Suffolk City, Virginia Beach City, Williamsburg City, York

VIRGINIA | TIDEWATER MA/MAPD PLANS

MEDICARE ADVANTAGE PLANS

MARKET HIGHLIGHTS• Select rural counties offering PFFS and/or RPPO

plans

• RPPO MAPD and MA Only plans in all VA counties • PFFS MAPD and MA Only plans available in

select VA counties

• LPPO MA Only plan available in most VA counties

• Only the PFFS MA Only plan can be paired with a stand-alone PDP plan

NETWORK HIGHLIGHTS• RPPO and LPPO plans in this area are passive

in design having no OON deductibles or co-insurance

• PFFS plans are networked, have $750 OON deductible, but are passive after deductible (IN = OON cost share)

• All PPO plans use Humana’s Nationwide ChoiceCare PPO Network

MARKET SERVICE AREAAlleghany, Augusta, Bath, Brunswick, Buckingham, Buena Vista City, Carroll, Charles City, Charlotte, Covington City, Emporia City, Fairfax, Fairfax City, Fluvanna, Galax City, Giles, Greene, Greensville, Halifax, Harrisonburg City, Highland, King William, Lancaster, Lexington City, Lunenburg, Madison, Mathews, Mecklenburg, Middlesex, Nelson, Nottoway, Orange, Patrick, Prince Edward, Rockbridge, Rockingham, Staunton City, Waynesboro City

VIRGINIA VIRGINIA OUTSTATE

Plan Name HumanaChoice (Regional PPO) Humana Gold Choice (PFFS) Humana Gold Choice (PFFS)

Plan Number R1390-002-000 H8145-003-000 H8145-004-000

Plan Highlights$74 plan premium; $0 OON deductible; IN & OON cost share are equal

$66 plan premium; $15 PCP copay, $45 Spec copay (see service areas for counties)

$77 plan premium; $15 PCP copay; $45 Spec copay (see service areas for counties)

Premium $74 $66 $77

PCP $15 $15 $15

Specialist $50 $45 $45

Referrals Required No No No

Inpatient Hospital $360 per day Days 1-5 $345 per day Days 1-5 $345 per day Days 1-5

Max Out-of-Pocket $6,700 In-network $6,700 In-network $6,700 In-network

Rx Deductible $360 tiers 4-5 $160 tiers 3-5 $160 tiers 3-5

Rx Preferred

$5/$15/$47/$99/26%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$99/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

$5/$15/$47/$99/30%; $0 copay for tiers 1 & 2 through mail order for a 90 day supply from Humana Pharmacy

Key Extra Benefits Vision, Hearing, Fitness, OTC allowance $25/Quarter Hearing, Fitness Hearing, Fitness

Market Service Area Statewide in North Carolina, Virginia

Halifax, Lancaster, Middlesex, Nottoway, Prince Edward

Bath, Brunswick, Carroll, Emporia City, Galax City, Greensville, Harrisonburg City, Highland, Mecklenburg, Patrick, Rockingham

VIRGINIA | VIRGINIA OUTSTATE MA/MAPD PLANS

Plan Name HumanaChoice (Regional PPO) Humana Gold Choice (PFFS)

Plan Number R1390-001-000 H8145-042-000

Plan Highlights$0 plan premium; $3,400 MOOP; $695 copay inpatient hospital; Niche plan for those not needing Rx benefits

$29 plan premium; can be paired with stand alone PDP plan

Premium $0 $29

PCP $10 $15

Specialist $35 $45

Referrals Required No No

Inpatient Hospital $695 per admission $345 per day Days 1-5

Max Out-of-Pocket $3,400 In-network $6,700 In-network

Rx Deductible No Coverage No Coverage

Rx Preferred No Coverage No Coverage

Key Extra Benefits Vision, Hearing, Fitness, OTC allowance $30/Quarter

Hearing, Fitness, OTC allowance $30/Quarter

Market Service Area Statewide in North Carolina, Virginia

Brunswick, Buckingham, Carroll, Emporia City, Galax City, Giles, Greensville, Lancaster, Middlesex, Nottoway, Orange, Patrick, Prince Edward

VIRGINIA | VIRGINIA OUTSTATE MA/MAPD PLANS

DSNP AND VALUE PLUS PLANS

DUAL-ELIGIBLE SPECIAL NEEDS PLANS (DSNP)Humana’s DSNPs offer beneficiaries who qualify for both Medicare and Medicaid with $0 or low cost copays for many medical and pharmacy services, as well as rich supplemental benefits like dental coverage, eye exams and glasses, over-the-counter allowance, hearing aids, and more. DSNPs allow year-round enrollment. Eligible members must meet Medicaid requirements to enroll in these plans.

VALUE PLUS PLANSA Value Plus Plan is a Medicare Advantage plan offered by Humana with those eligible for both Medicare and Medicaid in mind, but since it’s a Medicare Advantage plan, it’s available to anyone with Medicare.

Dual-Eligible Medicare and Medicaid beneficiaries will receive $0 or low cost copays for many medical and pharmacy services, as well as rich supplemental benefits like dental coverage,

eye exams and glasses, over-the-counter allowance, hearing aids, and more. Dual eligibles may enroll in this plan year-round. Unlike a DSNP, if a beneficiary loses Medicaid status, they are not required to change health plans – they will keep this plan, but will lose their Medicaid benefits.

Value Plus Plans also appeal to Medicare beneficiaries who are familiar with Original Medicare benefits and cost sharing, who also desire pharmacy coverage and rich supplemental benefits.

VIRGINIA

VIRGINIA DSNP AND VALUE PLUS PLANS BENEFIT OVERVIEW

Plan Name Humana Value Plus (HMO)Plan Number H6622-041-000

Plan Highlights Lean medical and Rx benefits with rich supplemental benefits, designed with dual eligibles in mind yet available to all

Vision Annual exam and $200 credit every year for eyewear or contact lenses including fittings

Hearing $0 annual exams, fittings and TruHearing advanced level hearing aids plus 48 batteries

OTC Allowance OTC $300/Quarter for select health and wellness products

Transportation Up to 36 one-way trips to approved locations and fitness centers per year

Current Service Area

Accomack, Albemarle, Alexandria City, Alleghany, Amelia, Appomattox, Arlington, Augusta, Bath, Bland, Botetourt, Brunswick, Buckingham, Buena Vista City, Caroline, Carroll, Charles City, Charlotte, Charlottesville City, Clarke, Covington City, Craig, Cumberland, Danville City, Emporia City, Essex, Falls Church City, Fauquier, Floyd, Fluvanna, Franklin, Franklin City, Fredericksburg City, Galax City, Giles, Gloucester, Goochland, Greene, Greensville, Halifax, Harrisonburg City, Henry, Highland, Isle Of Wight, James City, King And Queen, King George, King William, Lancaster, Lexington City, Loudoun, Louisa, Lunenburg, Madison, Manassas City, Manassas Park City, Martinsville City, Mathews, Mecklenburg, Middlesex, Montgomery, Nelson, New Kent, Northampton, Northumberland, Nottoway, Orange, Page, Patrick, Pittsylvania, Powhatan, Prince George, Prince William, Pulaski, Radford, Rappahannock, Richmond, Roanoke, Roanoke City, Rockbridge, Rockingham, Salem, Southampton, Spotsylvania, Stafford, Staunton City, Surry, Sussex, Warren, Waynesboro City, Westmoreland, Williamsburg City, Wythe, York

VIRGINIA DSNP AND VALUE PLUS PLANS BENEFIT OVERVIEW

Plan Name Humana Value Plus (HMO)Plan Number H6622-050-001

Plan Highlights Lean medical and Rx benefits with rich supplemental benefits, designed with dual eligibles in mind yet availableto all

Dental $0 copayment covers: exams, x-rays, cleanings, fillings, and extractions

Vision Annual exam and $200 credit every year for eyewear or contact lenses including fittings

Hearing $0 annual exams, fittings and TruHearing advanced level hearing aids plus 48 batteries

OTC Allowance OTC $300/Quarter for select health and wellness products

Transportation Up to 36 one-way trips to approved locations and fitness centers per year

Meals on Wheels 2 meals per day, 5 days a week up to 130 meals for members referred by a provider for food access

Current Service Area Henrico, Richmond City

VIRGINIA DSNP AND VALUE PLUS PLANS BENEFIT OVERVIEW

Plan Name Humana Value Plus (HMO)Plan Number H6622-050-002

Plan Highlights Lean medical and Rx benefits with rich supplemental benefits, designed with dual eligibles in mind yet available to all

Dental $0 copayment covers: exams, x-rays, cleanings, fillings, and extractions

Vision Annual exam and $200 credit every year for eyewear or contact lenses including fittings

Hearing $0 annual exams, fittings and TruHearing advanced level hearing aids plus 48 batteries

OTC Allowance OTC $300/Quarter for select health and wellness products

Transportation Up to 36 one-way trips to approved locations and fitness centers per year

Current Service Area Chesapeake City, Chesterfield, Colonial Heights City, Dinwiddie, Hampton City, Hanover, Hopewell City, Newport News City, Norfolk City, Petersburg City, Poquoson City, Portsmouth City, Suffolk City, Virginia Beach City

VIRGINIA DSNP AND VALUE PLUS PLANS BENEFIT OVERVIEW

NEW

Plan Name Humana Value Plus (PPO)Plan Number H5216-149-000

Plan Highlights Lean medical and Rx benefits with rich supplemental benefits, designed with dual eligibles in mind yet available to all

Vision Annual exam and $100 credit every year for eyeglasses or contact lenses. OON coverage available. Some restrictions apply if benefits received Out-of-Network

Hearing $0 annual exam, fittings and TruHearing advanced level hearing aids plus 48 batteries

OTC Allowance OTC $300/Quarter for select health and wellness products

Transportation Up to 12 one-way trips to approved locations and fitness centers per year

Current Service Area Amherst, Appomattox, Bedford, Campbell, Frederick, Lynchburg City, Shenandoah, Winchester City

VIRGINIA DSNP AND VALUE PLUS PLANS BENEFIT OVERVIEW

NEW

Plan Name Humana Value Plus (PPO)Plan Number H5216-181-000

Plan Highlights Lean medical and Rx benefits with rich supplemental benefits, designed with dual eligibles in mind yet available to all

Dental $2,000 annually; $0 copayment covers: exams, x-rays, cleanings, fillings, crowns, extractions, dentures

Vision $40 maximum benefit coverage for routine exam

Hearing $0 annual exam, fittings and TruHearing advanced level hearing aids plus 48 batteries

OTC Allowance OTC $100/Month for select health and wellness products

Transportation Up to 12 one-way trips to approved locations and fitness centers per year

Current Service Area Bristol, Buchanan, Dickenson, Grayson, Lee, Norton City, Russell, Scott, Smyth, Tazewell, Washington, Wise, Wythe

Plan Name Humana Preferred Rx Plan (PDP) Humana Walmart Rx Plan (PDP)

Plan Number S5884-132-000 S5884-153-000

Plan HighlightsPairs well for members with Extra Help (LIS). Tier 1 & Tier 2 mail-order copays are $0 at Humana Pharmacy for 90-day supply.

Retail copays as low as $1. Tier 1 mail-order copays are as low as $0 at Humana Pharmacy for 90-day supply.

Premium TBD TBD

Rx Deductible $415 all tiers $415 tiers 3-5

Preferred Retail 30-day Supply No Coverage $1/$4/20%/35%/25%

Standard Retail 30-day Supply $0/$1/25%/37%/25% $10/$20/25%/50%/25%

Preferred Mail 90-day Supply $0 copay for tiers 1 & 2 $0 copay for tier 1, $8 copay for

tier 2

Market Service Area Virginia Statewide Virginia Statewide

VIRGINIA PDP PLANS

LOCAL SUPPORT

VIRGINIA

Jennifer MeyerBroker Relationship Manager (540) 676-3060                                                                  jmeyer1@humana.com

Christopher Rosa BieserBroker Relationship Executive (800) 572-6517cbieser@humana.com

Local Market Office(800) 350-7213