Brenda Rose Provider Network Consultant October 30, Medicare Advantage Prescription Plans Gwinnett PHO

1. Humana Medicare Advantage Prescription Drug Plans (MAPDs) 2. How Humana MAPDs work 3. What’s new at Humana 4. How Humana makes it easy to navigate 5. Humana’s commitment to well-being and quality care 6. Humana is your partner 2 Insert form number via Header and Footer option or delete, if not needed Agenda Insert date via Header and Footer option

Humana is one of the nation’s largest publicly traded health benefits companies with – 10.1 million medical members – 7 million specialty-product members Offers a wide array of plans for employer groups, government programs and individuals Offers a range of specialty products, including dental and vision plans Operates more than 300 medical centers Operates more than 240 worksite medical facilities 3 About Humana

Open Access HMO Rules  How Does It Work?  How Are Benefits Administered?  Key Features  Benefit Summary  Network Hospitals  HMO Reciprocity Insert date via Header and Footer option 4 Insert form number via Header and Footer option or delete, if not needed

How Does an Open Access Medicare HMO Work? Members select their own Primary Care Physician (PCP) from our list of Humana Gold Plus® Medicare HMO PCPs. Humana Gold Plus® (HMO) ID card has the member’s PCP and contact information PCP referrals are not required for in-network specialists for covered service Members must receive care from Humana Gold Plus® (HMO) providers for in- network benefit No benefit coverage when services are delivered by providers not contracted for Medicare HMO (Humana Gold Plus®), except in an emergency Out-of-network service requires a Humana authorization for benefit coverage Claims submitted by providers not contracted for Medicare HMO (Humana Gold Plus®) are denied for payment

Routine Physical Exam Welcome to Medicare Visit Annual Wellness Exam Pap Smear & Pelvic Exam Prostate Cancer Screening Colorectal Cancer Screening Mammogram Screening Bone Mass Measurement Screening Immunizations/Vaccinations Obesity Screening and Therapy Cardiovascular Screening Cardiovascular Behavioral Therapy STI Screening and Counseling Abdominal Aortic Aneurysm Screening Benefit Summary: Health Benefits at $0 Copayment Depression Screening Alcohol Misuse Screening and Counseling Diabetic Screening EKG Screening Glaucoma Test HIV Screening Nutrition Therapy (Diabetic and ESRD) Smoking Cessation Diabetic Self-Monitoring Training Diabetic Monitoring Supplies (preferred DME provider-RightSource)

This Open Access HMO has reciprocity with other Humana Gold Plus® Medicare HMO plans in Georgia. The Medicare HMO member can seek care from providers in the Humana Gold Plus® Medicare HMO network in (State and Market). The covered service will be paid at in-network level. If the provider is not in the Humana Medicare HMO network, the covered will be denied for payment. The Medicare HMO member will be covered for all emergencies at in-network benefit level. Reciprocity: What is the reciprocity for this Open Access HMO?

8 MAPD - HMO Benefits (In-Network Only)Atlanta-MHMO (H ) PCP/ Specialist/Chiropractor Office Visit$10/$35/$20 copay Rx Drugs (Tiers I, II, III, IV)$3/$6/$45/$92 copay MAPD - DE-SNP HMO BenefitsAtlanta DE-SNP MHMO (H ) PCP/ Specialist/Chiropractor Office Visit20% coinsurance Rx Drugs (Tiers I, II, III, IV)$0/$0 copay/100%/100% coinsurance Transportation (one-way trips)$0 (24 one way trips per year) MAPD - C-SNP HMO BenefitsAtlanta C-SNP MHMO (H ) PCP/ Specialist/Chiropractor Office Visit$5/$35/$20 copay Rx Drugs (Tiers I, II, III, IV)$3/$6/$40/$95 copay Transportation (one-way trips)$0 (24 one way trips per year) ATLANTA HMO, DE-SNP HMO AND C-SNP HMO APPROVED COUNTIES Bartow, Cherokee, Cobb, Coweta, DeKalb, Douglas, Fayette, Floyd, Forsyth, Fulton, Gwinnett, Henry, Paulding and Pickens

DeKalb Medical Center Emory University Hospital Emory University Hospital Midtown Emory University Hospital John Creek Emory Adventist Hospital Eastside Medical Center Gwinnett Medical Center Northside Hospital Northside Hospital Forsyth Northside Hospital Cherokee Piedmont Fayette Hospital Network Hospitals: Atlanta Humana Gold Plus HMO Plan Piedmont Hospital Piedmont Henry Hospital Piedmont Mountainside Hospital Piedmont Newnan Hospital St Joseph’s Hospital of Atlanta Wellstar Cobb Hospital Wellstar Douglas Hospital Wellstar Kennestone Hospital Wellstar Paulding Hospital Wellstar Windy Hill Hospital

10 Sample of Humana Gold Plus (HMO) ID Card Plan Type Primary Physician

Key Features:  Member has at least one of 3 conditions  Pre-qualification form with disease-specific questions  Verification Chronic Condition (VCC) form signed by physician  Signed VCC must be received within first month of coverage  Plan must verify condition(s) within 1 st month  Member will be dis-enrolled if at least one condition is not verified  Year-round enrollment for applicant with one of these 3 conditions  Member cost share is based on plan benefits Humana Gold Plus (HMO) C-SNP (Diabetes/Cardiovascular Disorder/Chronic Heart Failure)

Some Key Features of HMO DE-SNP/Chronic SNP– Cont.  HMO authorization rules apply  No referrals for In-network specialists  No out-of network coverage except for emergent/urgent care  Access to Humana Gold Plus (HMO) network  Member must present their Medicaid ID card at time of service

Verification Chronic Condition (VCC) Form

Humana Medicare PPO Plans LPPO and RPPO  Key Features  Benefit Summary 14

No referral required In-Network and Out-of-Network coverage May have out-of-network deductible Higher member responsibility for out-of-network providers List of participating providers in Humana.com/Physician Finders Plus Member may be requested to select Primary Physician (not required) – Participating primary physicians will see their name displayed on the back of member ID cards – Non-participating providers or specialist swill be noted in Humana systems, NOT on ID cards. – Selection of new primary physician at any time –New ID card generated – Member notified when provider terms and asked to select a new provider Some Key Features of Medicare PPO

Some Key Features of Medicare PPO– Cont. Criteria for listing PCP on member ID card: – Member provide this information during Open Enrollment or from Humana member outreach; – Provider chosen must be participating with Humana and the Member’s LOB; and, – Provider must be a Family Practitioner, General Practitioner, Internal Medicine physician, Pediatrician or OB/GYN Goal Strengthen member-primary physician relationship and engagement  Increased use of preventive services  Improved coordinated care and outcomes  Improved Quality (HEDIS) measures

2013 LPPO BENEFITS MAPD-LPPO Benefits Atlanta (H ) Aiken, SC/Augusta GA (H ) Athens (H ) Columbus (H ) PCP/Specialist Chiropractor Visit IN/OON $15/$40/$20 copay 30% OON$15/$40/$20 copay 30% OON $20/$40/$20 copay 30% OON $15/$35/$20 copay/ 30% OON Rx Drugs (Tiers I, II, III, IV) $6/$12/$45/$90 copay $5/$12/$45/$90 copay $4/$10/$45/$90 copay $4/$12/$45/$90 copay Approved CountiesBarrow; Bartow; Carroll; Cherokee; Clayton; Cobb; Coweta; Dawson; DeKalb; Douglas; Fayette; Floyd; Forsyth; Fulton; Gwinnett; Haralson; Henry; Meriwether; Newton; Paulding; Pickens; Rockdale; Walton GA:Burke; Columbia; Glascock; Hancock; Jefferson; McDuffie; Richmond; Taliaferro; Warren; Washington; Wilkes; SC:Aiken; Barnwell; Edgefield; McCormick; Newberry; Saluda Clarke; Greene; Jackson; Madison; Morgan; Oconee; Oglethorpe AL:Chambers; Lee; Randolph; Russell; GA:Chattahoochee Harris; Marion; Muscogee; Randolph; Stewart; Talbot; Troup; Webster

18 Insert form number via Header and Footer option or delete, if not needed Insert date via Header and Footer option MAPD-RPPO Benefits Region 8 GA & SC (R ) MA Only Region 8 GA & SC (R ) (Same IN/OON Benefits) PCP/Specialist Chiropractor Visit IN/OON $20/$45/$20 copay $45/$45/$40 copay OON $20/$45/$20 copay Rx Drugs (Tiers I, II, III, IV) Not Available$4 /$12 copay/100% /100% coinsurance Approved CountiesGA:Statewide; SC:Statewide 2013 RPPO BENEFITS

Sample of Humana Choice (PPO) ID Card Plan TypePrimary Physician

Sample of Humana Choice GA/SC Regional (PPO) Card (Statewide) R5826 –004 (Traditional RPPO MAPD – IN/OON Benefits) R5826 – 077 (Non-traditional MAPD – Same IN/OON Benefits)

Humana Medicare PFFS Plans  Key Features  Benefit Summary 21

No referral required Members in any PFFS plan (Non-Network / Partial Network/ Full Network) can see any contracted or non-contracted providers throughout the nation. – Non-Network plan – Members can be seen by any provider who agrees to treat and accept Humana Terms and Conditions – Partial Network plan – There is a contracted network for DME/Home Health/Lab; all other services treated as a non-network plan. Some plans may have in-network and out-of-network benefit levels between contract vs. non-contracted DME/HH/Lab – Full Network plan – There is a contracted network for all services; benefit levels are administered based on in-network and out-of-network status List of contracted PFFS providers in Humana.com/Physician Finders Plus Member may be requested to select Primary Physician (not required) Some Key Features of Medicare PFFS

2013 PFFS BENEFITS MAPD-MA PFFS-Benefits South GA (H ) MAPD Partial Network South GA (H ) MA Only Full Network South GA PFFS (H ) MAPD South GA (H ) MA Only PCP/Specialist Chiropractor Visit IN/OON $20/$40/$20 copay20% coinsurance$15/$35/$20 copay20% coinsurance Rx Drugs (Tiers I, II, III, IV) $6/$12/$45/$90 copayNot Available$5/$12/$45/$90 copayNot Available Approved CountiesAtkinson; Bacon; Baker; Ben Hill; Brantley; Brooks; Calhoun; Candler; Clinch; Cook; Crisp; Decatur; Early; Echols; Franklin; Gilmer; Glascock; Grady; Habersham; Hall; Hancock; Heard; Irwin; Jenkins; Johnson; Lanier; Lowndes; Mitchell; Peach; Pulaski; Quitman; Randolph; Seminole; Terrell; Tift; Towns; Treutlen; Turner; Twiggs; Upson; Walton; Washington; Wayne; Wilcox Barrow; Chatham; Chattooga; Clayton; DeKalb; Elbert; Forsyth; Fulton; Gwinnett; Hart; Henry; Jackson; Jefferson; Lincoln; Morgan; Muscogee; Polk; Rockdale; Talbot; Taliaferro; Warren; White; Wilkes Barrow; Chatham; Chattooga; Clayton; DeKalb; Elbert; Forsyth; Fulton; Gwinnett; Hart; Henry; Jackson; Jefferson; Lincoln; Morgan; Muscogee; Polk; Rockdale; Talbot; Taliaferro; Warren; White; Wilkes Atkinson; Bacon; Baker; Ben Hill; Brantley; Brooks; Calhoun; Candler; Clinch; Cook; Crisp; Decatur; Early; Echols; Floyd; Franklin; Gilmer; Glascock; Grady; Habersham Hall; Hancock; Heard; Houston; Irwin; Jenkins; Johnson; Lanier; Lowndes; Lumpkin; Meriwether; Mitchell; Peach; Pulaski; Quitman; Randolph; Seminole; Stephens; Terrell; Thomas; Tift; Towns; Treutlen; Turner; Twiggs; Upson; Walton; Washington; Wayne; Wilcox

24 Sample ID Cards for PFFS Plans Non-Network PFFS Partial Network PFFS Full Network PFFS A Network PFFS, Partial Network PFFS and Non-network PFFS plan would not be marketed in the same county.

Medicare Preauthorization Summary  HMO and PPO 25

Medicare Advantage Preauthorization Summary Humana Gold Plus HMO and Medicare PPO Inpatient Admissions (Acute Hospital; Acute Rehab; LTAC; SNF; MH-partial/residential) Before Admission/Next Business Date Website (Humana.com) or IVR Authorization Plastic Surgery/Cosmetic SurgeryAuthorization Hi-Tech Imaging (MRI, MRA, CT, CTA, SPECT, PET, Nuclear Test & Cardiac Caths) HealthHelpAuthorization Radiation Therapy HealthHelpAuthorization Outpatient Therapy Services (PT; OT; ST) Authorization Durable Medical Equipment (DME over $750 )Authorization Pain Management Procedures OrthoNetAuthorization Cardiac Devices HealthHelpAuthorization Facility-Based Sleep Studies (PSG) Authorization Full list is at Humana Gold Choice PFFS plans are “notification” only

National Vendors Utilization Programs

Diagnostic imaging Radiation therapy Specific cardiac services – Call for Humana radiology services authorizations – Or go online at and use the outpatient radiology authorization and referral link Pain management – Online - Log into the Provider Self-Service Center (Humana.com or Availity.com) – Call OrthoNet at – Fax OrthoNet at National Vendors: Utilization Management Vendors

LifeSynch - Behavioral Health Network Primary care physician (PCP) calls number on back of Humana member ID card PCP tells customer service representative the level of care for authorization PCP coordinates care with appropriate LifeSynch associate. LifeSynch locates in-network provider LifeSynch coordinates referrals and precertifications for covered services Provider lookup at Humana.com in Physician Finder, Lifesynch.com or Lifesynch.com

Apria and Edgepark – Medical Supply Companies Apria - National Home Medical Equipment Includes: – Home oxygen services – CPAP/BiPAP equipment and supplies – Home tube feeding – Outpatient negative pressure wound therapy Providers can contact their local Apria branch for referrals or call Local alternatives to national contract – refer to the Provider Directory Edgepark Medical Supplies Insulin pumps or

RightSource DME / Coram / Rotech / CCS Right Source (Preferred Provider -Diabetic Monitoring Supplies) $0 copay Free shipping to members or TTY: Coram –Home Infusion Therapy Apria-affiliated company or Rotech –DME Mobility needs –wheelchairs and assist-devices CCS Medical Supplies or

Golden Living –Nursing Centers / Hanger Prosthetics Golden Living – Skilled Nursing Facilities Locations throughout Humana markets Hanger Prosthetic and Orthotics or

Laboratory and Prescription Home Delivery Service Laboratory LabCorp Quest Diagnostics Local alternative to national contract (this is where you list special local contracts with hospital systems; check with Contracting to be sure you are sharing current information) RightSourceRx Mail-Order Pharmacy Significant saving to Humana members Discounts for Brands $0 copay for 90-day supply for many generics To submit a new prescription: o Transmit directly to RightSourceRx.com o Call o Fax prescription fax form (online fax form at RightSourceRx.com) Drugs with quantity limits or that require prior authorization must be approved by Humana Clinical Pharmacy Review (HCPR) at Pharmacies and technicians available for member questions Refill reminders via phone or

Medicare Programs Medicare Contacts

Medicare Health Risk Assessment (HRA) Episodic Case Management Renal Disease Management (VillageHealth at (800) or HumanaCares – Complex Care Management ( ) SeniorBridge Health Achieve Field Case Management Disease Management Humana Clinical Programs – Bariatric management program – Medication therapy management (MTM) – Transplant management – HumanaFirst ® Nurse Advice Line Utilization Management (UM)- Post-Acute Care & Onsite Review Nurse (OSRN) Transition of Care Visit: Clinical Management Programs – Promote healthy living – Provide guidance to members with complex conditions

Members complete five eligible health care activities during a calendar year – Eligible to receive five $10 gift cards from restaurants, gas stations, movie theaters and retailers. Gift-card suppliers include Cracker Barrel Old Country Store ®, Applebee’s ®, AMC Theatres ®, Shell ®, BP ®, ExxonMobil ® and Chevron ® Eligible Health Care Activities – For 2012, the following screenings and tests qualify for rewards: – Adult Wellness Visit (new for 2012)- Cardiovascular Disease Screening – Flu Shot- Routine Screening Mammogram – Pneumonia Vaccine- Routine Pap Smear and Pelvic Exam – Hepatitis B Vaccine- Colorectal Cancer Screening – Welcome to Medicare Visit- Prostate Cancer Screening – Glaucoma Eye Exam- Glucose Diabetes Screening – Bone Mass Osteoporosis Test Encourage your Humana Medicare Advantage patients to call if they have questions Humana Medicare Rewards Program

Contacts You Need to Know Medicare customer service:See back of member’s ID card Authorization/IVR: Provider relations: (fee schedule requests, demographic changes, credentialing status) Medicare case management & Concurrent review Disease management program information: RightSourceRx pharmacy: Provider Consulting Team Brenda Rose (North Georgia Market) Karen Andrews (East Georgia Market) Kimberly Bryant (West Georgia Market) Iris Johnson (Georgia Frontline Leader)

Tools for Providers Availity.com and Humana Members Overview of eTools Jilliann Billingsley and Marchelle Sumpter– eBusiness Consultant

Introduction 39 Insert form number via Header and Footer option or delete, if not needed Insert date via Header and Footer option Availity.com Multi-Payer Web Portal HIPAA compliant health plan transactions in real-time on the web and in batch via Electronic Data Interchange (EDI) at no cost to health care professionals – Eligibility and Benefits Inquiry – CareRead – Referral and Authorization Submission – Referral and Authorization Inquiry – Claim Status Inquiry – Claim Reconciliation Tool* – Claim Correction – Claim Attachment – Remittance Information – Fee Schedules* – Medical Records Management* – Service Fund HMO Reports*

ERA/EFT 40 Insert form number via Header and Footer option or delete, if not needed Insert date via Header and Footer option Electronic Remit Advice (ERA) – HIPAA Transaction 835 Electronic Fund Transfer (EFT) – HIPAA Transaction 837 HumanaVendorPMSFile SentWeb Portal

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