Questions and answers about the Humana Group Medicare Advantage PPO plan

How is the Humana Group Medicare Advantage PPO plan offered through the Board different from other Medicare Advantage plans?

The Humana Group Medicare Advantage PPO plan is a group Medicare Advantage plan, which is very different from individual Medicare Advantage plans available in your local market. There are $0 copays for many types of healthcare services, such as preventive care and primary doctor’s office visits, and no annual deductible.

While Humana has one of the largest PPO networks, the Board has secured a passive PPO plan, which means you can go to any provider that accepts Medicare and will bill Humana. Humana will reimburse that provider at 100% of the Medicare-allowed amount. Another notable difference is that the plan’s prescription drug formulary has significantly more prescription drug options than the standard individual formulary.

Do I have to use a network doctor, specialist, or hospital to receive benefits under the plan?

While Humana offers a large national network of contracted providers, under the plan you can use any provider who accepts Medicare and agrees to bill Humana. Your plan coverage remains the same, even if you receive care from an out-of-network provider.

What if my physician accepts Medicare but isn’t in the Humana network?

If your physician accepts Medicare but isn’t in the Humana network, you should ask that they bill Humana directly. The reimbursement will be no less than what Medicare allows. You can call the Humana Customer Care team at 855-273-0021 (TTY: 711) and a Humana representative can call your provider to explain how your plan works and confirm the provider will submit claims to Humana.

Does Humana have to approve care or services from my doctor before I receive benefits?

Certain medical services and procedures or medications may need advance approval from Humana — called prior authorization. Your provider typically handles the prior authorization process on your behalf; however, you are responsible for making sure it gets done.

How do I know what services require prior authorization?

The best way to find out if a service or medication requires prior authorization is to call the Humana Customer Care team at 855-273-0021 (TTY: 711). It is your provider’s responsibility to obtain prior authorizations.

What if I have one or more chronic medical conditions and need ongoing outpatient treatment or frequent hospital stays?

The designated Customer Care Team at Humana can help you navigate complex care issues and treatment.

How can I find out if my medications are covered under the plan?

The formulary is the list of drugs covered by the plan. The plan formulary includes four tiers: Tier 1 — Generic or Preferred Generic; Tier 2 — Preferred Brand; Tier 3 — Non-Preferred; and Tier 4 — Specialty.

Are diabetic monitoring supplies covered under the plan?

The plan helps cover the cost for a variety of diabetic glucose testing supplies. The following meters, along with their test strips and lancets, are the preferred meters covered with $0 copayment for you through CenterWell Pharmacy: CenterWell TRUE METRIX AIR, by Trividia Health; Accu-Chek Guide Me, by Roche Diabetes Care; and Accu-Chek Guide, by Roche Diabetes Care.

Will I have separate ID cards for medical and prescription coverage?

You will have one Humana ID card, which you will receive approximately 10-14 days after you enroll in the plan.

You can also use your Humana ID card for dental, vision, and hearing aid benefits.

Does the plan cover mental health services?

The Humana plan includes benefits for mental health services provided on an inpatient basis, as well as outpatient mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental healthcare professional as allowed under applicable state laws. Plan copayments apply. For details, contact the Customer Care team at Humana.

Will I have coverage during international travel?

The Humana Group Medicare Advantage PPO plan includes worldwide benefits for emergencies. If you have an emergency outside of the U.S. and its territories, you will be responsible for paying for the services rendered upfront. You must then submit a claim, including proof of payment, itemized bill, physician order (if applicable), and medical records, to Humana for reimbursement. For details, view the Evidence of Coverage (EOC) under Coverage and Documents on the Humana Board of Pensions website. 

For 2024 and 2025, you also have access to International SOS services when traveling abroad.

Do I have to use a dentist in the Humana Dental Medicare Network?

In-network dentists have agreed to provide covered services at contracted rates. If you use an in-network dentist, you cannot be billed for charges that exceed the negotiated fee schedule, but you will still be responsible for paying your coinsurance.

Out-of-network dentists have not agreed to provide services at contracted fees. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions, and the provider may bill you for any amount greater than the payment made by Humana.

How do I locate in-network dentists?

Contact Humana’s Customer Care team at 855-273-0021 (TTY: 711) to locate network dentists. You may also go to humana.com, click the Find Care button, scroll down, and click Find a dentist. Enter your ZIP code and select preferred distance from the Distance drop-down menu. For Select a lookup method, choose All Dental Networks, then select HumanaDental Medicare.

Is there a network I have to use for vision services?

EyeMed Insight is the in-network provider for the routine vision benefit that is included with the Humana Group Medicare Advantage PPO plan. This benefit includes a routine vision exam with refraction (up to one per year) and a combined annual benefit for contact lenses and glasses (lenses and frames). Contact the Humana Customer Care team for more details and to locate an EyeMed Insight provider.

Are hearing aids covered?

The Humana Group Medicare Advantage PPO plan covers one routine hearing exam per year as well as part of your cost for hearing aids, up to one per ear per year, prescribed by an audiologist. To receive this benefit, you must use a TruHearing provider. Contact the Humana Customer Care team for more details and to locate a TruHearing provider.

How do I get more details about what’s covered?

View the Evidence of Coverage (EOC) for current and future year information as available. The EOC gives you details about your Medicare and prescription drug coverage for the plan year. You can also view a copy on the Humana Board of Pensions website under Coverage and Documents.

If you would like the EOC mailed to you, contact the Humana Customer Care team.

Will I receive explanation of benefits statements?

You will receive an explanation of benefits (EOB) statement if a claim is denied. All other claims will be listed on your SmartSummary from Humana. The SmartSummary is a personalized benefits statement you receive after each month you’ve had a claim processed. You can also log in to your MyHumana account and see your past SmartSummary statements anytime.

What is Go365 by Humana?

Go365 is a wellness program that rewards you for completing eligible healthy activities, like walking or getting your Annual Wellness Visit. You track the activities you complete to earn rewards that can be redeemed for gift cards from retailers like Albertsons, CVS, Home Depot, Petco, and Walmart.

If you enroll in the Humana Group Medicare Advantage PPO plan, you are automatically enrolled for the Go365 wellness program, and can participate online at MyHumana.com or by filling out and mailing in paper forms. For details about the program and how to participate, contact the Customer Care team at Humana.