Exhibit_E_2026_Humana_Medicare_Advantage_NPPO_Plan.pdf

2026 Humana Group Medicare Your journey to better health, for better retirement

Humana Group Medicare Humana Inc.

P.O. Box 669 Louisville, KY 40201-0669

Important plan information

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BC26

A more human way to healthcare™

MARXTPPOEDIENROLL

HUMANA GROUP MEDICARE ADVANTAGE PPO PLAN

We’re here for you

Humana Group Medicare Customer Care

866-396-8810 (TTY: 711)

Monday – Friday, 8 a.m. – 9 p.m., Eastern time

Humana is a Medicare Advantage PPO plan with a Medicare contract. Enrollment in this Humana plan depends on contract renewal. Call 866-396-8810 (TTY: 711) for more information.

Out-of-network/non-contracted providers are under no obligation to treat plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

All product names, logos, brands and trademarks are property of their respective owners, and any use does not imply endorsement.

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Humana Medicare Employer NPPO Plan

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Inside this packet you’ll find:

Learn more about extra programs and services Humana offers

Scan the QR code with your mobile device.

Let’s get started understanding your benefits and coverage

Welcome to a more human way to healthcare

Your benef ts include

Know before you enroll

Important Enrollment Information

What to expect after you enroll

Manage your Humana account online

Find Care tool

Take this to your Provider

Know your numbers

Medical Summary of Benef ts

Hearing Benef ts

Vision Benef ts

Rx Summary of Benef ts

Important Enrollment Information

Commonly Prescribed Medication List

Welcome to a more human way to healthcare

You will be automatically enrolled

Dear Group Medicare Benef ciary, We’re excited to inform you that City of Tampa has partnered with Humana to offer you a

Medicare Advantage Preferred Provider Organization (PPO) and Prescription Drug Plan (PDP) that provides more benef ts than Original Medicare.

Understanding your Medicare plan and how it works is important. Humana believes everyone should have access to the tools and support needed to have a fair and just opportunity to be as healthy as possible. During our over 30 years of experience with

Medicare, we’ve learned how to be a better partner in health.

Review the enclosed materials

This packet includes information on your Group Medicare healthcare option along with extra services Humana provides.

• If you have questions about your premium, please call City of Tampa Benef ts Department at 813-274-5757 (TTY: 711).

• Review the Important Prescription Drug Information on how to view or request a copy of a

Prescription Drug Guide.

• Please see the Find Care page in this packet for instructions on f nding a list of network providers or network pharmacies.

Enrollment Information

• For enrollment information, please refer to the document titled “Important Enrollment

Information,” located in this packet.

We look forward to serving you now and for many years to come.

Sincerely, Group Medicare Operations

Your benefits include:

ID

All the benefits of

Original Medicare, plus extra benefits

Maximum out-of-pocket protections

Worldwide emergency coverage

Programs to help improve health and well-being

Get the care you deserve

• Your benefit levels are the same for in-network and out-of-network providers

• A network of providers, specialists and hospitals to choose from

• There are more than 61,000 participating pharmacies in our network

• You don’t need a referral to see any healthcare provider

• Coverage for office visits, including routine physical exams

• Almost no claim forms to fill out or mail—we take care of that for you

• Dedicated Customer Care specialists who serve only our Group Medicare members

Coverage that fits the way you live When you become a member of the Humana family, you can expect healthcare designed with you in mind—that meets you where you are today and delivers care that takes you to where you want to be.

Care delivered how and where you need it Humana offers a variety of programs for patients who need care for complex medical situations or support for chronic conditions. Through these programs, care managers collaborate with physicians and other healthcare professionals to help patients manage their healthcare needs at home, in the hospital, by phone or email.

Benefits that put you first Our health and well-being tools and resources make it easy to set health goals, chart your progress, strengthen your mind and body and build connections with others. It’s about giving you the things you expect from an insurance company—and then finding more ways to help make your life better.

Know before you enroll

You must be entitled to Medicare Part A and enrolled in Medicare Part B as the Humana Group

Medicare PPO plan is a Medicare Advantage plan.

When does my coverage begin?

Your former employer or union decides how and when you enroll. Check with your benefits administrator for the proposed effective date of your enrollment. Be sure to keep your current healthcare coverage until your Humana Group Medicare PPO plan enrollment is confirmed.

Is your provider and pharmacy in-network or out-of-network?

You can find a doctor or pharmacy in your network by using Humana’s Find Care tool, visit Humana.com/findcare.

What does insurance cover?

• Every health plan is different. Check coverage details before you see a doctor, use services or have procedures.

• Sometimes, your plan may not cover procedures and treatments, or may require prior authorization.

Knowing what is and is not covered may save you time and money.

• See if your prescription medication is covered and if you have any open transfers that need to occur.

What if I have other health insurance coverage?

You can enroll in only one Medicare Advantage plan and one Medicare prescription drug plan at a time. Enrollment in this plan will cancel your enrollment in a different Medicare Advantage plan and

Medicare prescription drug plan.

If you have other health insurance, show your Humana member ID card and your other insurance cards when you see a healthcare provider. The Humana Group Medicare plans may be eligible in combination with other types of health insurance coverage you may have. This is called coordination of benefits. Please notify Humana if you have any other medical coverage.

Do I need to show my red, white and blue Medicare card when I visit the doctor?

No. You’ll get a Humana member ID card that will take its place. Keep your Medicare ID card in a safe place—or use it only when it’s needed for discounts and other offers from retailers.

What if my provider says they will not accept my plan?

If your provider says they will not accept your PPO plan, you can give your provider the “Member to

Provider” information page in this packet. It explains how your PPO plan works. You can also call

Humana Customer Care to have a Humana representative contact your provider and explain how your

PPO plan works.

What should I do if I need prescriptions filled before I receive my Humana member ID card?

If you need to fill a prescription after your coverage begins but before you receive your Humana member ID card, take a copy of your temporary proof of membership to any in-network pharmacy.

Important Enrollment Information

City of Tampa is enrolling you in the Humana Group Medicare preferred provider organization (PPO) plan. You do not need to do anything to be automatically enrolled in this Medicare health plan. If you do not want to join this plan, you can follow the instructions included below. You must do this before the date set by your benefit administrator. Enrollment in this plan will cancel your enrollment in a different Medicare Advantage or a Medicare Prescription Drug (Part D) plan. However, if you are currently enrolled in a Medicare Supplement plan, you will have to take action to cancel your enrollment.

What do I need to know as a member of the Humana Group Medicare PPO plan?

This enrollment packet includes important information about this plan and what it covers, including a

Summary of Benefits document. Please review this information carefully.

Once enrolled, you will receive information on how to view or request a copy of an Evidence of

Coverage document (also known as a member contract or subscriber agreement) from the Humana

Group Medicare PPO plan. Please read the document to learn about the plan’s coverage and services.

As a member of the Humana Group Medicare PPO plan, you can appeal plan decisions about payment or services if you disagree. Enrollment in this plan is generally for the entire year.

When your Humana Group Medicare PPO plan begins, Humana will cover all medically necessary items and services that are covered by the plan, even if you get the services out of network. However, your member cost share may be lower if you use in-network providers. “In-network” means that your doctor or provider is on our list of participating providers. “Out-of-network” means that you are using someone who isn’t on this list. The exception is for emergency care, out of area dialysis services, or urgently needed services.

You must use network pharmacies to access Humana benefits, except under limited, non-routine circumstances when you can’t reasonably use network pharmacies.

You must keep Medicare Parts A and B as the Humana Group Medicare plan is a Medicare Advantage plan. You must also continue to pay your Part B premium. If you are assessed a Part D-Income

Related Monthly Adjustment Amount (Part D-IRMAA), you will be notified by the Social Security

Administration. You will be responsible for paying this extra amount in addition to your plan premium. You can enroll in only one Medicare Advantage plan at a time. You must let us know if you think you might be enrolled in a different Medicare Advantage plan or a Medicare prescription drug plan and inform us of any prescription drug coverage that you may get in the future.

What happens if I don’t join the Humana Group Medicare PPO plan?

You aren’t required to be enrolled in this plan. If you don’t want to enroll or have enrollment questions, please contact City of Tampa Benefits Department at 813-274-5757 (TTY: 711).

If you choose to join a different Medicare plan, you can contact 800-MEDICARE anytime, 24 hours a day, 7 days a week, for help in learning how. TTY users can call 877-486-2048. Your state may have counseling services through the State Health Insurance Assistance Program (SHIP). They can provide you with personalized counseling and assistance when selecting a plan, including Medicare

Supplement plans, Medicare Advantage plans and prescription drug plans. They can also help you find medical assistance through your state Medicaid program and the Medicare Savings Program.

What if I want to leave the Humana Group Medicare PPO plan?

You can change or cancel your Humana coverage at any time and return to Original Medicare or another Medicare Advantage plan by using a special election. You can send a request to Humana

Group Medicare. You must also contact City of Tampa Benefits Department at 813-274-5757 (TTY:

711). You can also call 800-MEDICARE anytime, 24 hours a day, 7 days a week. TTY users can call

877-486-2048.

What happens if I move?

The Humana Group Medicare PPO plan serves a specific service area. If you move to another area or state, it may affect your plan. It’s important to contact City of Tampa Benefits Department at

813-274-5757 (TTY: 711). Please also call Humana Group Medicare Customer Care at 866-396-8810

(TTY: 711), Monday – Friday, 8 a.m. – 9 p.m., Eastern time, to notify of the new address and phone number.

If you leave this plan and don’t have creditable prescription drug coverage (as good as Medicare’s prescription drug coverage), you may have to pay a late enrollment penalty if you enroll in Medicare prescription drug coverage in the future.

Release of Information

By joining this Medicare Advantage plan, you give us permission to share your information with

Medicare and other plans when needed for treatment, payment and health care operations. We do this to make sure you get the best treatment and to make sure that it is covered by the plan.

Medicare may also use this information for research and other reasons allowed by Federal law.

What to expect after you enroll

• Enrollment confirmation

You’ll receive a letter from Humana once the Centers for Medicare & Medicaid Services (CMS) confirms your enrollment.

• Humana member ID card

Your Humana member ID card will arrive in the mail shortly after you enroll. Once you receive your

ID card, you can create a MyHumana profile. Having access to your important health documents online, all in one place, is a great way to stay organized, and you can get to your information at any time. To activate your account, visit Humana.com/Registration.

• Evidence of Coverage (EOC)

You will receive information on how to view or request a copy of the Evidence of Coverage document (also known as a member contract or subscriber agreement). Please read the document to learn about the plan’s coverage and services. This will also include your privacy notice.

• Your personalized benefits statement

Humana’s SmartSummary® provides a comprehensive overview of your health benefits and healthcare spending. You’ll receive this statement after each month you’ve had a claim processed.

You can also sign in to your MyHumana account and see your past SmartSummary statements anytime.

• Health and Well-being Assessment (HWA)

This is a yearly detailed health review conducted in the comfort of your home, providing an extra set of eyes and ears for your doctor so you can feel more in control of your health and well-being.

You may receive a call from one of our HWA vendors, Signify Health or Matrix Medical Network, to schedule your assessment. If you have questions, you may ask when they call, or contact Humana at the phone number listed on the back of your member ID card.

We’re here for you

If you have questions or need help, call Humana Group Medicare Customer Care, 866-396-8810 (TTY: 711), Monday – Friday, 8 a.m. – 9 p.m., Eastern time

Getting started is easy— just have your Humana member ID card and follow these three steps:

Create your account.

Visit Humana.com/registration and select the “Start activation now” button.

Choose your preferences.

The first time you sign into your MyHumana account, be sure to choose how you want to receive information from us—online or mailed to your home. You can update your communication preferences at any time.

View your plan benefits.

After you set up your account, be sure to view your plan documents so you understand your benefits and costs. You can also update your member profile if your contact information has changed.

Manage your Humana plan online

MyHumana on the go

Get the most out of your plan with a MyHumana account and take your Humana essentials wherever you go with the MyHumana mobile app.

Depending on your plan, you can use the MyHumana mobile app to:

• Explore coverage and benefit details the moment you need them

• Get Humana member ID cards and add them to your phone’s wallet

• Find care close to you and get directions on your phone’s map app

• Review claims status

• Access your exclusive member discounts

Once your Humana plan coverage begins, go to

MyHumana.com to activate your account or download and register on the MyHumana app for iOS and Android.* Learn more at Humana.com/member/manage-your-account.

Scan this QR code Scan this QR code with your mobile device to create your account.

* App Store and Google Play app store are registered trademarks of Apple Inc. and

Google. All rights reserved. Apple and

Google are not participants in or sponsors of this promotion.

Find a doctor using Humana’s Find Care search tool

Choosing a doctor or healthcare facility is an important decision. You can use Humana’s Find Care search tool to find in-network doctors, pharmacies, and more.

Go to Humana.com/FindCare

Search as a Member or Guest

• Sign in to your secure MyHumana account to conduct a search, or

• Search as a guest by entering your location.

Choose the type of care you are looking for Use the tabs to help you search for a doctor or pharmacy.

Choose your medical network Select a lookup method from the drop-down menu.

Find medical care Select a tab to search by Provider Name, Facility or Specialty.

Select the “Search” button for your results Have you found the doctor or facility that you’re looking for? If you need to revise your search, you can search again without leaving the results page.

Already a Humana plan member?

Don’t have an account?

Sign in using your member ID →

Sign in →

Search as a guest Enter your location and network to search near you

Get started →

Address, city, county, or ZIP code Your location

Find Care on the MyHumana mobile app

Once you are enrolled with Humana, you can download and use the

MyHumana mobile app to f nd care near you. On the app dashboard, locate the “Find Care” section.

Call our Customer Care team at 866-396-8810 (TTY: 711), Monday – Friday, 8 a.m. – 9 p.m., Eastern time.

A message for your provider Humana will provide coverage for this member under a Group Medicare PPO plan. The in-network and out-of-network benefits are structured the same for any member of this plan. This means you can provide services to this member or any member of this plan if you are a provider who is eligible to participate in Medicare.

Don’t forget to take your Humana member ID card to your first appointment.

Contracted healthcare providers

If you’re a Humana Medicare Employer PPO-contracted healthcare provider, you’ll receive your contracted rate.

Out-of-network healthcare providers

Humana is dedicated to an easy transition. If you’re a provider who is eligible to participate in

Medicare, you can treat and receive payment for your Humana-covered patients who have this plan. Humana pays providers according to the

Original Medicare fee schedule less any member plan responsibility.

If your healthcare provider says they do not accept Humana insurance, give them this page

Member to provider information

Once you are a member of the Humana Group Medicare Preferred Provider Organization (PPO) plan, sharing this information can help your provider understand how this plan works.

Claims process for providers

If you need more information about our claims processes or about becoming a Humana

Medicare Employer PPO-contracted provider, call Provider Relations at 800-626-2741, Monday – Friday, 9 a.m. – 6 p.m., Eastern time. This number is not for patient use.

Patients, please call the Group Medicare Customer Care number on the back of your

Humana member ID card.

Know your numbers Find important numbers anytime you need them*

*You must be a Humana member to use these services.

Humana Group Medicare Customer Care

866-396-8810 (TTY: 711),

Monday – Friday, 8 a.m. – 9 p.m., Eastern time

MyHumana

Sign in to or register for MyHumana to access your personal and secure plan information at

Humana.com

MyHumana mobile app

Humana.com/mobile-apps

Doctors in your network

Humana.com/findcare

Telehealth

Please contact your local provider to ask about virtual visit opportunities, or access nationwide Humana in-network telehealth options by using the “Find Care” tool on

Humana.com or call the number on the back of your member ID card to get connected with a provider that offers this service.

Humana Clinical Pharmacy Review Team

800-555-2546 (TTY: 711),

Monday – Friday, 8 a.m. – 8 p.m., Eastern time

SilverSneakers®

888-423-4632 (TTY: 711),

Monday – Friday, 8 a.m. – 8 p.m., Eastern time

SilverSneakers.com

Go365 by Humana®

Go365.com

Humana Care Management

866-396-8810 (TTY: 711),

Monday – Friday, 8 a.m. – 9 p.m., Eastern time

Humana.com/home-care

Post-discharge Meal Program

866-396-8810 (TTY: 711),

Monday – Friday, 8 a.m. – 9 p.m., Eastern time

Humana.com/home-care/well-dine

Humana Health Coaching

877-567-6450 (TTY: 711),

Monday – Friday, 8 a.m. – 6 p.m., Eastern time

Caregiver Support

Humana.com/caregiver

CenterWell Pharmacy™

800-379-0092 (TTY: 711),

Monday - Friday, 8 a.m. – 11 p.m., and

Saturday, 8 a.m. – 6:30 p.m., Eastern time

CenterWellPharmacy.com

CenterWell Specialty Pharmacy™

800-486-2668 (TTY: 711),

Monday - Friday, 8 a.m. – 11 p.m., and

Saturday, 8 a.m. – 6:30 p.m., Eastern time

CenterWellSpecialtyPharmacy.com

State health insurance program offices

800-633-4227 (TTY: 711), daily www.cms.gov/apps/contacts/#

PUB Name: GSB032

Y0040_GHHM4NBEN26_M SB079707EN26

Humana Group Medicare Advantage PPO Plan

PPO 079/707

City of Tampa, FL

Summary of Benefits

Our service area includes specific counties within the United States, Puerto Rico and all other major U.S. territories.

3 Summary of Benefits 2026

Let's talk about the Humana Group Medicare Advantage PPO Plan.

Find out more about the Humana Group Medicare Advantage PPO plan – including the services it covers – in this easy-to-use guide.

The benefit information provided is a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. For a complete list of services we cover, refer to the "Evidence of Coverage."

To be eligible To join the Humana Group Medicare Advantage PPO plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area.

Plan name:

Humana Group Medicare Advantage PPO plan

How to reach us:

Members should call toll-free 1-866-396-8810 for questions

(TTY/TDD: 711)

Call Monday – Friday, 8 a.m. - 9 p.m., Eastern time.

Or visit our website: Humana.com

Humana Group Medicare Advantage PPO plan has a network of doctors, hospitals, and other providers. For more information, please call Humana Group Medicare Customer Care.

A healthy partnership Get more from this plan — with extra services and resources provided by Humana!

www.Humana.com

4 Summary of Benefits 2026

Note: This plan requires prior authorization for certain items and services. The following link will take you to a list of items and services that may be subject to prior authorization: Humana.com/PAL.

Note: Some services require prior authorization.

Monthly Premium, Deductible and Limits

PLAN COSTS

Monthly premium You must keep paying your Medicare Part B premium.

For information concerning the actual premiums you will pay, please contact your employer group benefits plan administrator.

Medical deductible $400 per year for some combined in- and out-of-network services

Medical Maximum out-of-pocket responsibility The most you pay for copays, coinsurance and other costs for medical services for the year.

In-Network Maximum Out-of-Pocket $3,500 out-of-pocket limit for Medicare-covered services. The following services do not apply to the maximum out-of-pocket: Part D Pharmacy; Fitness Program; Health Education Services; Hearing Services (Routine); Meal Benefit; Post-Discharge Personal Home Care;

Post-Discharge Transportation Services; Smoking Cessation (Additional); Transportation (Routine); Uniform Flexibility Non-Emergency Medical Transportation; Vision Services (Routine) and the Plan Premium do not apply to the in-network maximum out-of-pocket.

If you reach the limit on out-of-pocket costs, we will pay the full cost for the rest of the year on covered hospital and medical services.

Combined In and Out-of-Network Maximum Out-of-Pocket $3,500 out-of-pocket limit for Medicare-covered services.

In-Network Exclusions: Part D Pharmacy; Fitness Program; Health Education Services; Hearing Services (Routine); Meal Benefit;

Post-Discharge Personal Home Care; Post-Discharge Transportation Services; Smoking Cessation (Additional); Transportation (Routine);

Uniform Flexibility Non-Emergency Medical Transportation; Vision Services (Routine) and the Plan Premium do not apply to the combined maximum out-of-pocket.

Out-of-Network Exclusions: Part D Pharmacy, Vision Services (Routine);

Worldwide Coverage and the Plan Premium do not apply to the combined maximum out-of-pocket.

Your limit for services received from in-network providers will count toward this limit.

If you reach the limit on out-of-pocket costs, we will pay the full cost for the rest of the year on covered hospital and medical services.

http://www.Humana.com/PAL

5 Summary of Benefits 2026

Note: This plan requires prior authorization for certain items and services. The following link will take you to a list of items and services that may be subject to prior authorization: Humana.com/PAL.

Covered Medical Benefits

- IN-NETWORK OUT-OF-NETWORK

ACUTE INPATIENT HOSPITAL CARE

This plan covers an unlimited number of days for an inpatient hospital stay. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.

$250 copay per day for days 1-5 $250 copay per day for days 1-5

OUTPATIENT HOSPITAL COVERAGE

Diagnostic colonoscopy 10% of the cost 10% of the cost

Diagnostic mammography $20 copay $20 copay

Observation services $0 copay $0 copay

Surgery services 10% of the cost 10% of the cost

AMBULATORY SURGICAL CENTER

Diagnostic colonoscopy 10% of the cost 10% of the cost

Surgery services 10% of the cost 10% of the cost

DOCTOR OFFICE VISITS

Primary care provider (PCP) $10 copay $10 copay

Specialists $30 copay $30 copay

6 Summary of Benefits 2026

Note: This plan requires prior authorization for certain items and services. The following link will take you to a list of items and services that may be subject to prior authorization: Humana.com/PAL.

Covered Medical Benefits

- IN-NETWORK OUT-OF-NETWORK

PREVENTIVE CARE

This plan covers all Medicare preventative services including:

• Abdominal aortic aneurysm screening

• Alcohol misuse screening & counseling

• Annual wellness visit

• Bone mass measurement

• Breast cancer screening

• Cardiovascular disease behavioral therapy

• Cardiovascular disease screening

• Cervical and vaginal cancer screening

• Colorectal cancer screening

• Depression screening

• Diabetes self-management training

• Diabetes screening

• Glaucoma screening

• Hepatitis C screening

• HIV screening

• Kidney disease education services

• Lung cancer screening

• Medical nutrition therapy

• Obesity screening and therapy

• Physical exams (routine)

• Prostate cancer screening exam

• Smoking and tobacco use cessation

• STI screening and counseling

• "Welcome to Medicare" preventative visit

Covered at no cost Covered at no cost

• Immunizations

• Medicare diabetes prevention program (MDPP)

Any additional preventative services approved by Medicare during the contract year will be covered.

Covered at no cost Covered at no cost

7 Summary of Benefits 2026

Note: This plan requires prior authorization for certain items and services. The following link will take you to a list of items and services that may be subject to prior authorization: Humana.com/PAL.

Covered Medical Benefits

- IN-NETWORK OUT-OF-NETWORK

EMERGENCY CARE

Emergency room If you are admitted to the hospital within 24 hours for the same condition, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs.

$50 copay for Medicare-covered emergency room visit(s)

$50 copay for Medicare-covered emergency room visit(s)

Urgently needed services

• Primary care provider (PCP) $10 copay $10 copay

• Specialist’s office $30 copay $30 copay

• Urgent care center $35 copay $35 copay Urgently needed services are care provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical attention.

DIAGNOSTIC SERVICES, LABS AND IMAGING

Advanced imaging services (MRI, MRA, PET and CT Scan)

• Primary care provider (PCP) $10 copay $10 copay

• Specialist’s office 10% of the cost 10% of the cost

• Freestanding radiological facility 10% of the cost 10% of the cost

• Outpatient Hospital 10% of the cost 10% of the cost Diagnostic mammography

• Primary care provider (PCP) $10 copay $10 copay

• Specialist’s office $30 copay $30 copay

• Freestanding radiological facility $20 copay $20 copay

• Outpatient Hospital $20 copay $20 copay Diagnostic procedures and tests

• Primary care provider (PCP) $10 copay $10 copay

• Specialist’s office $30 copay $30 copay

• Urgent care center $35 copay $35 copay

• Freestanding radiological facility $20 copay $20 copay

• Outpatient Hospital $20 copay $20 copay EKG screening

• Primary care provider (PCP) $0 copay $0 copay

• Specialist’s office $0 copay $0 copay

8 Summary of Benefits 2026

Note: This plan requires prior authorization for certain items and services. The following link will take you to a list of items and services that may be subject to prior authorization: Humana.com/PAL.

Covered Medical Benefits

- IN-NETWORK OUT-OF-NETWORK

• Freestanding radiological facility $0 copay $0 copay

• Outpatient Hospital $0 copay $0 copay Lab services

• Primary care provider (PCP) $0 copay $0 copay

• Specialist’s office $0 copay $0 copay

• Urgent care center $0 copay $0 copay

• Freestanding laboratory $20 copay $20 copay

• Outpatient Hospital $20 copay $20 copay Nuclear medicine services

• Freestanding radiological facility $20 copay $20 copay

• Outpatient Hospital 20% of the cost 20% of the cost Outpatient x-rays

• Primary care provider (PCP) $10 copay $10 copay

• Specialist’s office $30 copay $30 copay

• Urgent care center $35 copay $35 copay

• Freestanding radiological facility $20 copay $20 copay

• Outpatient Hospital $20 copay $20 copay Radiation therapy

• Specialist’s office $30 copay $30 copay

• Freestanding radiological facility $20 copay $20 copay

• Outpatient Hospital $20 copay $20 copay

HEARING SERVICES

$30 copay $30 copayMedicare-covered hearing:

diagnostic hearing and balance exams Routine hearing

TruHearing Provider must be used. Contact Customer Service to locate a provider.

$0 copay for routine hearing exams up to 1 per year.

$500 maximum benefit coverage amount for hearing aid(s) (all types) up to 2 every 3 years.

Note: Includes 80 batteries per aid and 3 year warranty.

The in-network provider must be used for this service. If you choose to utilize another provider, you are responsible for all charges.

DENTAL SERVICES

Medicare-covered dental $30 copay $30 copay

VISION SERVICES

$30 copay $30 copayMedicare-covered vision services

9 Summary of Benefits 2026

Note: This plan requires prior authorization for certain items and services. The following link will take you to a list of items and services that may be subject to prior authorization: Humana.com/PAL.

Covered Medical Benefits

- IN-NETWORK OUT-OF-NETWORK

$0 copay $0 copayMedicare-covered diabetic eye exam (1 per year)

Medicare-covered glaucoma screening (1 per year)

$0 copay $0 copay

Medicare-covered eyewear (post-cataract)

$30 copay $30 copay

$0 copay for routine exam (includes refraction) up to 1 per year.

$100 combined maximum benefit coverage amount per year for contact lenses, eyeglasses (lenses and frames), including lens options such as ultraviolet protection and scratch resistant coating, fitting for eyeglasses (lenses and frames).

$175 combined maximum benefit coverage amount per year for routine exam (includes refraction).

$0 copay for routine exam (includes refraction) up to 1 per year.

$100 combined maximum benefit coverage amount per year for contact lenses, eyeglasses (lenses and frames), including lens options such as ultraviolet protection and scratch resistant coating, fitting for eyeglasses (lenses and frames).

Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Routine vision

EyeMed is the In-Network provider for the routine vision benefit. Contact Customer Service to locate a provider.

MENTAL HEALTH SERVICES

Inpatient The inpatient hospital care limit applies to inpatient mental services provided in a general hospital or a psychiatric facility.

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.

190 day lifetime limit in a psychiatric facility.

$250 copay per day for days 1-5 $250 copay per day for days 1-5

Partial Hospitalization $30 copay $30 copay

Intensive Outpatient Services $30 copay $30 copay

Outpatient group and individual therapy visits

• Primary care provider (PCP) $10 copay $10 copay

• Specialist’s office $30 copay $30 copay

• Urgent care $35 copay $35 copay

• Outpatient Hospital $30 copay $30 copay

10 Summary of Benefits 2026

Note: This plan requires prior authorization for certain items and services. The following link will take you to a list of items and services that may be subject to prior authorization: Humana.com/PAL.

Covered Medical Benefits

- IN-NETWORK OUT-OF-NETWORK

SKILLED NURSING FACILITY

This plan covers up to 100 days in a SNF.

No 3-day hospital stay is required.

Plan pays $0 after 100 days.

$0 copay per day for days 1-20 $75 copay per day for days 21-100

$0 copay per day for days 1-20 $75 copay per day for days 21-100

AMBULANCE

Per date of service regardless of the number of trips. Limited to Medicare-covered transportation.

$100 copay $100 copay

TRANSPORTATION

Routine Transportation $0 copay for plan approved location up to 24 one-way trip(s) per year.

This benefit is not to exceed 50 miles per trip.

The in-network provider must be used for this service. If you choose to utilize another provider, you are responsible for all charges

Uniform Flexibility Non-Emergency Medical Transportation

$0 copay for plan approved location up to unlimited one-way trip(s) per year by car, rideshare services, van, wheelchair access vehicle for members with a Chronic Kidney Disease (CKD), End Stage Renal Disease (ESRD), or Cancer Diagnosis.

This benefit is not to exceed 50 miles per trip.

The in-network provider must be used for this service. If you choose to utilize another provider, you are responsible for all charges.

MEDICARE PART B PRESCRIPTION DRUGS

Chemotherapy drugs

• Specialist’s office 20% of the cost 20% of the cost

• Outpatient Hospital 20% of the cost 20% of the cost

Medicare Part B covered drugs

• Primary care provider (PCP) $0 copay $0 copay

• Specialist’s office $0 copay $0 copay

• Outpatient Hospital $0 copay $0 copay

• Pharmacy 20% of the cost 20% of the cost

Medicare Part B insulin drugs

• Primary care provider (PCP) $0 copay $0 copay

11 Summary of Benefits 2026

Note: This plan requires prior authorization for certain items and services. The following link will take you to a list of items and services that may be subject to prior authorization: Humana.com/PAL.

Covered Medical Benefits

- IN-NETWORK OUT-OF-NETWORK

• Outpatient Hospital $0 copay $0 copay

• Pharmacy You will pay no more than $35 for a one-month (up to 30-day) supply for all Part B insulin covered by our plan, and if your plan has a deductible it does not apply to Part B insulin.

20% of the cost 20% of the cost

ACUPUNCTURE SERVICES

Medicare-covered acupuncture visit(s) for chronic low back pain

$30 copay for acupuncture for chronic low back pain visits up to 20 combined in and out of network visit(s) per year.

$30 copay for acupuncture for chronic low back pain visits up to 20 combined in and out of network visit(s) per year.

Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

ALLERGY

Allergy shots & serum

• Primary care provider (PCP) $10 copay $10 copay

• Specialist’s office $30 copay $30 copay

CHIROPRACTIC SERVICES

Medicare-covered chiropractic visit(s)

$20 copay $20 copay

DIABETES SERVICES AND SUPPLIES

Continuous glucose monitor

(CGM)

• Durable medical equipment provider 20% of the cost 20% of the cost

• Pharmacy 20% of the cost 20% of the cost

Diabetes management training

• Primary care provider (PCP) $0 copay $0 copay

• Specialist’s office $0 copay $0 copay

• Outpatient hospital $0 copay $0 copay

Diabetes monitoring supplies

• Durable medical equipment provider 20% of the cost 20% of the cost

• Pharmacy 0% of the cost 0% of the cost

• Preferred diabetic supplier $0 copay Not Covered

Diabetes screening

• Primary care provider (PCP) $0 copay $0 copay

12 Summary of Benefits 2026

Note: This plan requires prior authorization for certain items and services. The following link will take you to a list of items and services that may be subject to prior authorization: Humana.com/PAL.

Covered Medical Benefits

- IN-NETWORK OUT-OF-NETWORK

FOOT CARE (PODIATRY)

Medicare-covered foot care $30 copay $30 copay

HOME HEALTH CARE

$0 copay $0 copay

HOSPICE

You must get care from a Medicare-certified hospice. You must consult with this plan before you select hospice.

MEDICAL EQUIPMENT/SUPPLIES

Durable medical equipment

• Durable medical equipment provider 20% of the cost 20% of the cost

• Pharmacy 20% of the cost 20% of the cost

Medical supplies (includes but not limited to:

catheters, IV set-up and supplies)

• Medical supply provider 20% of the cost 20% of the cost

• Pharmacy 20% of the cost 20% of the cost

Prosthetics (artificial limbs or braces)

• Prosthetics provider 20% of the cost 20% of the cost

OUTPATIENT SUBSTANCE ABUSE

Outpatient group and individual substance abuse treatment visits

• Primary care provider (PCP) $10 copay $10 copay

• Specialist’s office $30 copay $30 copay

• Urgent care $35 copay $35 copay

• Outpatient hospital $30 copay $30 copay

REHABILITATION SERVICES

Audiology Therapy

• Specialist’s office $30 copay $30 copay

• Comprehensive outpatient rehab facility $30 copay $30 copay

• Outpatient hospital $30 copay $30 copay

Cardiac rehabilitation

• Specialist’s office $30 copay $30 copay

• Outpatient hospital $20 copay $20 copay

13 Summary of Benefits 2026

Note: This plan requires prior authorization for certain items and services. The following link will take you to a list of items and services that may be subject to prior authorization: Humana.com/PAL.

Covered Medical Benefits

- IN-NETWORK OUT-OF-NETWORK

Occupational therapy

• Specialist’s office $30 copay $30 copay

• Comprehensive outpatient rehab facility $30 copay $30 copay

• Outpatient hospital $30 copay $30 copay

Physical therapy

• Specialist’s office $30 copay $30 copay

• Comprehensive outpatient rehab facility $30 copay $30 copay

• Outpatient hospital $30 copay $30 copay

Pulmonary rehabilitation

• Specialist’s office $20 copay $20 copay

• Comprehensive outpatient rehab facility $20 copay $20 copay

• Outpatient hospital $20 copay $20 copay

Speech therapy

• Specialist’s office $30 copay $30 copay

• Comprehensive outpatient rehab facility $30 copay $30 copay

• Outpatient hospital $30 copay $30 copay

RENAL DIALYSIS

Renal dialysis services

• Dialysis center $30 copay $30 copay

• Outpatient hospital $30 copay $30 copay

Kidney disease education services

• Primary care provider (PCP) $0 copay $0 copay

• Specialist’s office $0 copay $0 copay

• Outpatient hospital $0 copay $0 copay

HUMANA IN-NETWORK TELEHEALTH VENDORS, i.e. MDLive (in addition to Original Medicare) Primary care provider (PCP) $0 copay Not Covered

Specialist $30 copay Not Covered

Urgent care services $0 copay Not Covered

Substance abuse or behavioral health services

$0 copay Not Covered

14 Summary of Benefits 2026

Note: This plan requires prior authorization for certain items and services. The following link will take you to a list of items and services that may be subject to prior authorization: Humana.com/PAL.

Note: Some services require prior authorization.

Additional Benefits

FITNESS AND WELLNESS

Live a healthier, more active life through fitness and social connection at participating SilverSneakers® locations and online.

The in-network provider must be used for this service. If you choose to utilize another provider, you are responsible for all charges.

HEALTH EDUCATION SERVICES

Personal Health Coaching is an interactive inbound and outreach on-line and telephonic wellness coaching for Medicare participants who elect to participate, for wellness improvement, including weight management, nutrition, exercise, back care, blood pressure management, and blood sugar management.

The in-network provider must be used for this service. If you choose to utilize another provider, you are responsible for all charges.

POST-DISCHARGE SERVICES

$0 copay for the following benefits per discharge event following each inpatient or skilled nursing facility stay:

• Assistance from a qualified aid to help perform activities of daily living within the home. Minimum of 4 hours per day, up to a maximum of 8 hours. Types of assistance include bathing, dressing, toileting, walking, eating and preparing meals.

• 2 meals per day for 14 days, up to 28 meals delivered to your door.

• Transportation to plan approved locations by rideshare services, car, van or wheelchair accessible vehicle.

Services must be provided by approved vendors, scheduled within 30 days of discharge event and utilized within 60 days of discharge.

The in-network provider must be used for this service. If you choose to utilize another provider, you are responsible for all charges.

SMOKING CESSATION (ADDITIONAL)

A comprehensive smoking cessation program available online, email and phone. Personal coaches assist via establishing goals and providing articles and resources to aid in the effort to quit smoking.

The in-network provider must be used for this service. If you choose to utilize another provider, you are responsible for all charges.

15 Summary of Benefits 2026

Notes

16 Summary of Benefits 2026

17 Summary of Benefits 2026

SB079707EN26

Humana is a Medicare Advantage PPO plan with a Medicare contract. Enrollment in this Humana plan depends on contract renewal.

If you want to compare this plan with other Medicare health plans, you can call your employer or union sponsoring this plan to find out if you have other options through them.

If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

All product names, logos, brands and trademarks are property of their respective owners, and any use does not imply endorsement.

Humana.com

You can see this plan's provider directory at Humana.com or call us at the number listed at the beginning of this booklet and we will send you one.

Find out more http://www.medicare.gov

Hearing services In-network Out-of-network

N/A

N/A

Humana is a Medicare Advantage organization with a Medicare contract. Enrollment in any Humana plan depends on contract renewal.

Routine Hearing TruHearing (Choice)

Routine hearing services offered through TruHearing® includes a fully-managed network of provider locations across the U.S. There are hearing aid styles to meet all members’ hearing needs with the lowest pricing amongst industry-leading technology.

All plans include a full 3 year manufacturer warranty on every device, 80 free batteries per hearing aid purchase.

$0 exam / $500 allowance

$0 copayment for routine hearing exams up to 1 per year.

$500 maximum benefit coverage amount for hearing aid(s) (all types) up to 2 every 3 years.

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Humana Medicare Insight Network

When members receive necessary routine vision services, they will be covered according to the following schedule.

Vision care services In-network member cost

Out-of-network reimbursement

Exam (One per calendar year)

Routine eye exam (includes refraction)

$0 copay $0 copay

Up to $175

Eyewear benefit (One per calendar year)

Benefit toward the purchase of frame and pair of lenses or contact lenses (conventional or disposable)

Any retail amount over

$100 allowance

Up to $100

The network of providers for your supplemental vision benefits through Humana Medicare Insight Network may be different than the network of providers for the Medicare-covered vision benefits. The provider locator for routine or Medicare-covered vision can be found at Humana.com/FindCare.

The benefit can only be used one time. Any remaining benefit dollars do not "roll over" to a future purchase.

Eyeglass lens options may be available with the maximum benefit coverage amount up to one pair per year.

Maximum benefit coverage amount is limited to one-time use per year.

Benefit allowance is applied toward the retail price. Member is responsible for any costs above the plan-approved amount. Lost or broken materials are not covered. Benefits are offered on a calendar basis. Any amount unused at the end of the year will expire.

2026 VIS200

https://findcare.humana.com/

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Additional discounts:

Member may receive a 20% discount on items not covered by the plan at in-network locations. Discount does not apply to provider's professional services or contact lenses. Plan discounts cannot be combined with any other discounts or promotional offers. In certain states members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see our online provider locator to determine which participating providers have agreed to the discounted rate. Discounts on vision materials may not be applicable to certain manufacturers' products. The Plan reserves the right to make changes to the products on each tier and the member out-of-pocket costs. Fixed pricing is reflective of brands at the listed product level. All providers are not required to carry all brands at all levels. Service and amounts listed above are subject to change at any time.

Members may receive a 40% discount off complete-pair eyeglass purchases and may receive a 15% discount off conventional contact lenses once the funded benefit has been used.

Member may receive a 15% discount off the retail price or may receive 5% off any promotional price of Lasik or photorefractive keratectomy (PRK) laser vision correction procedures. Lasik or PRK correction procedures are provided by the U.S. Laser Network, owned by LCA-Vision. Please note that since Lasik and PRK vision correction are elective procedures, performed by specially trained providers, this discount may not always be available from a provider in your immediate location, so members should first call 844-608-2020 for the nearest facility and to receive authorization for the discount.

All product names, logos, brands and trademarks are property of their respective owners, and any use does not imply endorsement.

Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that may apply to out-of-network services.

Humana is a Medicare Advantage preferred provider organization (PPO) with a Medicare contract. Enrollment in any Humana plan depends on contract renewal.

2026 VIS200

PUB Name: GSB032

Y0040_GHHM4NDEN26_M RX568EN26

Humana Group Medicare Advantage Plan Rx 568

City of Tampa, FL

Prescription Drug

Summary of Benefits

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3 Summary of Benefits 2026

Let's talk about the Humana Group Medicare Advantage Rx Plan.

Find out more about the Humana Group Medicare Advantage Rx plan – including the services it covers – in this easy-to-use guide.

The benefit information provided is a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. For a complete list of services we cover, refer to the "Evidence of Coverage."

4 Summary of Benefits 2026

Deductible Pharmacy (Part D) deductible This plan does not have a deductible.

Prescription Drug Benefits Initial coverage (after you pay your deductible, if applicable) You pay the following until your total out-of-pocket drug costs reach $2,100. Once you reach this amount, you will enter the Catastrophic Stage.

Tier Standard Retail Pharmacy

Standard Mail Order

30-day supply 1 (Generic or Preferred Generic) $15 copay $15 copay

2 (Preferred Brand) $25 copay $25 copay

3 (Non-Preferred Drug) $45 copay $45 copay

4 (Specialty Tier) 25% of the cost 25% of the cost

90-day supply 1 (Generic or Preferred Generic) $30 copay $30 copay

2 (Preferred Brand) $50 copay $50 copay

3 (Non-Preferred Drug) $90 copay $90 copay

4 (Specialty Tier) N/A N/A

There may be generic and brand-name drugs, as well as Medicare-covered drugs, in each of the tiers. To identify commonly prescribed drugs in each tier, see the Prescription Drug Guide/Formulary. To view the most complete and current Drug Guide information online, visit www.humana.com/SearchResources, locate Prescription Drug section, select www.humana.com/MedicareDrugList link; under Printable drug lists, click Printable Drug lists, select future plan year, select Group Medicare under Plan Type and search for GRP67.

Important Message About What You Pay for Vaccines – This plan covers most Part D vaccines at no cost to you (even if you haven't paid your deductible, if applicable). Call Humana Group Medicare Customer Care for more information.

Important Message About What You Pay for Insulin – You won't pay more than $35 for a one-month supply of each insulin product covered by this plan, no matter what cost-sharing tier it's on. Note: Not all tiers may include insulin. Please refer to your Prescription Drug Guide to confirm insulin coverage.

ADDITIONAL DRUG COVERAGE

Original Medicare excluded drugs

Certain drugs excluded by Original Medicare are covered under this plan. You pay the cost share associated with the tier level for certain Cosmetic, Cough/Cold, Dental, Erectile Dysfunction, Fertility, Vitamins/Minerals, Weight Loss drugs. The amount you pay when you fill a prescription for these drugs does not count towards qualifying you for the Catastrophic Coverage stage.

Contact Humana Group Medicare Customer Care at the phone number on the back of your membership card for more details.

http://www.humana.com/SearchResources http://www.humana.com/MedicareDrugList

5 Summary of Benefits 2026

Catastrophic Coverage After your total out-of-pocket costs reach $2,100, you pay $0 for plan-covered Part D and plan-covered excluded drugs.

RX568EN26

Humana is a Medicare Advantage HMO, PPO organization and a stand-alone prescription drug plan with a Medicare contract. Enrollment in any Humana plan depends on contract renewal.

All product names, logos, brands and trademarks are property of their respective owners, and any use does not imply endorsement.

Humana.com

You can see this plan's pharmacy directory at https://www.Humana.com/finder/pharmacy/ or call us at the number listed at the beginning of this booklet and we will…