Humana
Humana Medical Insurance
The NEW Medicare Advantage PPO & Prescription Drug Plan is now optional for Harris County Retirees and/or their spouses who are 65 years or older.
Harris County has a custom group Medicare Advantage Passive PPO plan. This is not the same as plans marketed to individuals during annual open enrollment on TV. This PPO plan has the exact same benefits in and out-of-network. So, whether you use an in-network provider or an out-of-network provider, the member’s cost share is the same. The provider simply needs to participate in Medicare and agree to bill to Humana.
Enrollment Requirements for Humana Medicare Advantage
- Members must have Part A and be enrolled in Part B
- Member must have a U.S. residential address for purposes of enrollment. A PO Box is not accepted for purposes of enrollment. Once enrolled, you may receive mail from Humana at a PO Box.
- Members must reside in the U.S. at least 6 months out of the year
- Members must have their Medicare Beneficiary Identification (MBI) number
Plan Costs
Switching to the Humana Medicare Advantage plan may result in premium savings for retirees who cover Medicare-eligible spouses.
Please refer to your Open Enrollment worksheet to review your monthly premiums.
| IN & OUT-OF-NETWORK | |
|---|---|
| YOU PAY | |
| Annual Deductible, per individual | $100 (combined in and out-of-network) |
| Maximum Out-of-Pocket, per individual | $100 |
| Primary Care Office Visit | $0 after combined annual deductible |
| Specialist Office Visit | $0 after combined annual deductible |
| Virtual Care Visit | $0 |
| Urgent Care Center | $0 |
| Emergency Room | $0 |
| Inpatient Hospital Care | $0 after combined annual deductible |
| Outpatient Hospital Services | $0 after combined annual deductible |
Please refer to your Humana Welcome Kit for a comprehensive list of services, limitations and exclusions.
Humana Medicare Advantage RX Plan
Humana’s Group Plus Formulary offers the most extensive employer coverage and covers most drugs. Your plan has a 4-Tier structure. Tier 1 = Preferred Generic, Tier 2 = Preferred Brand, Tier 3 = Non-Preferred Drugs and Tier 4 = Specialty Drugs. Tier 4 is defined by CMS as high-cost medications that treat rare, complex and chronic health conditions.
| 30-DAY STANDARD RETAIL/MAIL ORDER (from $0 to Catastrophic) |
90-DAY STANDARD RETAIL/MAIL ORDER (from $0 to Catastrophic) |
|
|---|---|---|
| Tier 1 – Generic or Preferred Generic | 25% $5 min / $50 max | 25% $10 min / $100 max |
| Tier 2 – Preferred Brand | 30% $25 min / $150 max | 30% $50 min / $300 max |
| Tier 3 – Non-Preferred Drug | 35% $50 min / $250 max | 35% $100 min / $500 max |
| Tier 4 – Specialty Drug | 30% $75 min / $350 max | N/A |
| 30-Day Standard Cost Sharing from Catastrophic to Unlimited | $0 | $0 |
| Part D Maximum Out-of-Pocket | $2,100 | $2,100 |
FAQs
Does the plan require me to have a referral to see a specialist?
No, the plan does not require referrals. You are welcome to see any provider who accepts Medicare and is willing to bill Humana. Please be aware that there are some specialties where it is more common for the physician’s office to require you to have a referral, in order to be seen. Some examples are endocrinologists, neurologists and cardiologists. If a provider requests a referral that is at their office’s discretion; this Humana plan does not require referrals.
What happens when I travel?
Retirees have access to the same level of benefits throughout Humana’s service area, which includes all 50 states, Puerto Rico and U.S. Territories. When traveling outside Humana’s service area, retirees have worldwide emergency care subject to a $100 deductible, 20% coinsurance and a $25,000 maximum benefit. Please refer to the Evidence of Coverage for additional details.
What does this plan cover?
All Medicare-covered services are covered by this plan. Humana’s Medicare Advantage plan follows all Medicare guidelines to determine medical necessity. In addition to Medicare covered services, Medicare Advantage plans are also allowed to add on services. As examples, Humana offers Well Dine and Go365. Well Dine provides up to 28 flash-frozen meals delivered to your home upon discharge from the hospital or a skilled nursing facility. Go365 is a wellness program where a person can earn rewards through different wellness activities, for example getting an annual physical.
What is Part A, Part B, Part C & Part D?
Parts A and B are called Original Medicare. Part A and Part B is what you sign up for with Social Security. Most people do not have to pay for Part A but everyone is required to pay for Medicare Part B.
Medicare Part A is hospital insurance. It helps pay for inpatient care in a hospital or skilled nursing facility. It also pays for some home healthcare and hospice care.
Medicare Part B is medical insurance. Part B helps cover medically necessary doctors’ services, outpatient care and other medical services and supplies. Part B also covers some preventive services.
Medicare Part C, commonly called Medicare Advantage, is available through private insurance companies. Medicare Part C covers everything parts A and B cover, including hospital and medical services. You still have Medicare if you elect Medicare part C coverage. Also, you do not need to sign up for a Medicare Supplement plan. Lastly, Medicare Advantage plans give you access to programs (like wellness, clinical and educational) at no
additional cost to you. Medicare Advantage plans give you the ease of one card and one place to call with questions. With Humana’s plan, members have access to programs such as Go365 which is Humana’s wellness program.
Medicare Part D is prescription drug coverage.
Do I need to continue paying my Medicare Part B premium?
Yes. In order to have this plan, you must have Part A and Part B. Your enrollment on this plan is shared with the Federal government. If you stop paying your Medicare premium(s) to Social Security, Medicare will inform Humana that you are no longer eligible for this plan.
If I enroll in the Humana Medicare Advantage plan, have I lost original Medicare?
No, you have not. Humana enters a contract with Centers for Medicare and Medicaid Services (CMS) to administer the benefits of Original Medicare Part A and Part B along with extra services and benefits above Original Medicare on behalf of CMS. Only people who are Medicare members are eligible for a Medicare Advantage Plan. In order to have this plan, you must have Part A and Part B.
How are the premiums processed if I choose this plan?
Retiree premiums are processed a month in arrears, similar to a utility bill. If you make any plan changes, your January payment will remain the same as in 2025, as it will be applied to your December premium. The new premium payment reflecting your Open Enrollment elections will begin in February, covering your January premium.