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PPOPROGRAM‐HUMANACOMPLETE700‐MC‐Rx3‐19728PR0010‐052014 Rev.05‐2016Page 1 of 37

Humana Insurance of Puerto Rico, Inc. (Hereinafter “the Company”)

PPO Program Humana Complete

RX 3 19728PR0010

Schedule of Benefits Coverage Schedule of Benefits

This schedule of benefits should be attached and made part of PPO Program Policy: Attachment I

Servi ces a nd Benefits Procedures

1. Benefi ts a nd services a re s ubject to the terms a nd conditions i ncluded in the group policy a nd to the

excl usions a nd l imitations described i n thi s a ttachment.

2. Ins ured mus t recei ve s ervices from pa rticipating fa cilities, contracted providers or under the order, direction a nd a pproval of the contracted provider upon pres enta tion of the i dentification card i ssued by the Company. The Ins ured i s responsible for paying a pplicable copayment, coinsurance or deductible.

Annual Maximum Out‐of Pocket

Maximum out‐of pocket limit

Individual Family

Maximum out‐of pocket limit (“MOOP”) Network Provider

[$3,400 ‐ $6,350] [$6,800 – $12,700]

Maximum out‐of pocket limit (“MOOP”) Non‐Network Provider

[$10,200 ‐ $19,050] [$20,400 – $38,100]

Thi s i ncludes copayments a nd coinsurance expenses of the Medi cal a nd Pharmacy coverage, i n a ddition to a ccumulated expenses of the pha rmacy benefits coverage deductibles.

Once the i ndi vidual or fa mily ma ximum out of pocket l imit i s met for the pol icy yea r for network providers, the percenta ge of benefi ts provided by network providers for covered expense wi ll be pa id a t a rate of 100% for the res t of the pol icy yea r, s ubject to a ll terms , limits a nd ex clusions of thi s Schedule of Benefi ts Coverage. Any expens es (medical a nd pharmacy) you mi ght i ncur for covered expenses provided by a network provider wi ll a pply to the ma xi mum out of pocket l imit for network providers. Any expens es (medical a nd pharmacy) you might i ncur (a s contracted fee for s imilar s ervices by a provider i n Puerto Rico) for covered expenses provided by out of network provider will a pply to the ma xi mum out of pocket l imit for out of network providers.

The a ccumulation period wi ll begin on the effecti ve da te of the pol icy a nd wi ll end when the pol icy termi nates. From there on, i t wi l l be from the renova tion date until the pol icy yea r end.

The Ma xi mum Out‐of Pocket i s based on the ma ximum amount a llowed by the Offi ce of the Commi ssioner of I ns urance of Puerto Ri co.


Essential Health Benefits

Ambulatory Services The fol l owing services a re covered, l ess a ny a pplicable co‐insurance or copayment per visit:

1. Unl i mited office vi sits to physicians, l ess a pplicable copayment or coinsurance:

Genera l i s ts : [$5.00 ‐ $10.00] or [40%]

Speci a lists: [$10.00 ‐ $25.00] or [40%]

Sub‐s peci a l i s ts : [$10.00 ‐ $25.00] or [40%] 2. Chi ropractic Services, one (1) initial visit, one (1) follow‐up visit, l ess [$10 ‐ $25] visit [copayment] or [40%]

[coi nsurance] a nd up to twenty (20) ma nipulations per i nsured, per policy yea r.

3. Four (4) Nutri tionist consultations per i nsured per policy yea r, l ess [$10 ‐ $25] visit copayment or [40%] coi nsurance.

4. La bora tories a nd X‐rays, unlimited, l ess [20%‐50%] of coinsurance. Geneti c tes ts require pre‐authorization, l

es s [20%‐50%] of coinsurance.

5. El ectrocardiograms, unlimited, l ess [20%‐50%] of coinsurance.

6. Sonogra ms, unlimited, l ess [20%‐50%] of coinsurance.

7. Computeri zed tomography, unlimited, less [20%‐50%] of coinsurance. Pre‐authorization required.

8. Pos i tron Emission Tomography (PET), unlimited, l ess [20%‐50%] of coinsurance. Pre‐authorization required.

9. El ectroencephalogram, unlimited, l ess [20%‐50%] of coinsurance.

10. El ectromyogram, unlimited, l ess [20%‐50%] of coinsurance.

11. Ma gneti c Resonance, i ncluding MRI a nd MRA, unlimited, l ess [20%‐50%] of coinsurance. Preauthorization requi red.

12. One (1) s l eep s tudy or polysomnography covered per insured, per policy yea r, l ess [20%‐50%] of coinsurance. Pre‐a uthorization required.

13. Nucl ea r medi cine tes ts, unlimited, less [20%‐50%] of coinsurance.

14. Res pi ratory thera py, unlimited, l ess [$ 5 ‐ $10] copayment or [40%] of coinsurance. 15. Phys ical therapy, i ncluding rehabilitation a nd ha bilitation, unlimited, a s prescribed and under the s upervision

of a n orthopedist or a physical medi cine specialist, l ess [$ 5 ‐ $10] copayment or [40%] of coinsurance. 16. Speech thera py, combined at the phys ician office or at home, when ordered by a physician a nd rendered by a

l i censed s peech therapist; up to a ma ximum of forty (40) therapies, per i nsured per policy yea r, l ess [$ 10 ‐ $25] copayment or [40%] of coinsurance. Unlimited therapies for a utism.

17. Occupational therapy for the purpose of tra ining a nd aiding i n the res toration of normal physical function a nd or prevent further deteri oration of the s a me; resulting i llness, from trauma, s troke or a s urgical procedure whi l e i nsured under the pol icy, unlimited less [$ 10 ‐ $25] copayment or [40%] of coinsurance.

18. Ambul a tory s urgery a t a mbulatory s urgery fa cilities, i ncluding Mental Hea lth, less [$25 ‐ $175] of copayment or [40%] of coi nsurance.

19. Endos copies, di agnostic a nd therapeutic, unlimited, l ess [$ 10 ‐ $25] office copayment or l ess [$25 ‐ $175] fa ci lity copayment or [40%] of coinsurance.

20. Li thotri psy, unlimited, less [$25 ‐ $175] a mbulatory fa cility copayment per rendered s ervice or [40%] of coi nsurance. Pre‐authorization required.


21. Va s ectomy a t physician’s office, l ess [$ 10 – $25] office visit copayment or [40%] of coinsurance.

22. Acute a nd chronic s ervices related to End Sta ge Rena l Disease, s uch a s dialysis, hemodialysis a nd compl ications directly rel ated to the di sease a re covered up to a ma ximum of ninety (90) days sta rting on the da te on whi ch the di sease i s diagnosed, I n case of a dmission a pply [$ 50 ‐ $350] copayment or [40%] of coi nsurance.

23. Al l ergy tes ts, i ncluding a llergenic a nd biological extracts, drugs, patches and provocative tes ts , up to a

ma xi mum of fi fty (50) tes ts per i nsured per policy yea r, l ess [20%‐50%] coinsurance. 24. I ntra ‐articular injections, unlimited, l ess [$ 10 ‐ $25] office copayment or l ess [$ 25 ‐ $175] fa cility copayment

or [40%] of coi nsurance. 25. Audi ol ogist visits a ccording to La w No. 127 of September 27, 2007; Audiometry a nd tympanometry tes ts when

ordered by a physician, one (1) of ea ch tes t per i nsured, per policy yea r, l ess [20%‐50%] of coinsurance. 26. Orthognathic s urgery (ma ndibular or ma xillary osteotomy ‐ Le Fort). Expens es for i mplants related to

orthogna thic surgery a re excluded, l ess [$ 50 ‐ $350] fa cility or hospital copayment or [40%] of coinsurance. Pre‐a uthorization required.

27. Trea tment a nd s ervices for morbid obesity a s medically necessary. One (1) bariatric s urgery using one of the fol l owing techniques, gastric bypass, adjusta ble ga stric band or sleeve ga strectomy per lifetime, a ccording to La w 212 da ted on August 9, 2008, l ess [$ 50 ‐ $350] copayment or [20%‐50%] of coinsurance. Surgeries for removi ng excess s kin (commonly known a s folds) s hall not be covered, unless the physician certifies tha t it i s neces s ary to remove the exces s s kin because i t a ffects the functions of a ny part of the body. Ba riatric s urgery requi red pre‐a uthorization.

28. In the event tha t a n i nsured voluntarily enrolls i n a res earch clinical trial, Humana will cover diagnostic tes ts whi ch a re us ually a ssociated wi th his condition as l ong a s they a re covered by hi s/her hea lth insurance policy. Thes e s ervi ces a re s ubject to the ma xi mum l imits specified under the policy, l ess [$ 10 ‐ $25] copayment or [20% ‐ 50%] coi nsurance. Tes ts which are not covered by his/her policy, a nd which a re s trictly l inked to the goa l of the res ea rch, wi ll not be rei mbursed by Humana. The process a nd results of the i nvestigation a re the res ponsibility of the res ea rcher a nd the i nsured.

29. Di a gnosti c tes ts a nd trea tments associated wi th hemophilia, unlimited, l ess [$10 ‐ $25] copayment or [20%‐ 50%] coi nsurance.

30. Unl i mited na turopathic physician visits a ccording to La w 210 dated on December 14, 2007, l ess [$10 ‐ $25] copa yment or [40%] coinsurance.

31. Eye refra ction tes t by a n ophthalmologist or optometrist, one (1) per i nsured per policy year within the Huma na Insurance network, less [$ 10 ‐ $25] copayment or [40%] coinsurance.

32. Ophtha lmic Di agnosti c Tes ts, l ess [$10 ‐ $25] copayment or [20%‐50%] coinsurance.

33. Ma mmography, when they a re not presented a s a preventive tes t required by ACA, but a s a follow up to a di a gnosis or treatment of a condition, less [$25 ‐ $175] facility copayment or [20% ‐ 50%] coinsurance.

34. Podi atry visits; Trea tment of diseases a nd di sorders of the foot a nd a nkle, i ncluding injections a nd s urgical procedures, less [$10 ‐ $25] vi sit copayment or [$25 ‐ $175] facility copayment or [40%] coinsurance.

35. Cervi cal Cryosurgery, l ess [$50 ‐ $350] copayment or [40%] coinsurance.

36. Nerve Conducti ng Vel ocity Tes t, unlimited, per policy yea r, l ess [20% ‐ 50%] coinsurance.


Preventive Services

1. Annua l preventive s ervices a re covered at 100% (wi thout copayment or coinsurance) when provided wi thi n the Huma na Provider Network a nd recommended by the US Preventive Services Ta sk Force (USPTF), the Advi s ory Committee on Immunization Practices (ACIP) of the Centers for Disease Control a nd Preventi on(CDC), The Hea l th Resources a nd Services Admi nistration, a nd the Pu erto Rico Department of Hea l th. For more i nformation a nd updates on preventive s ervices, visit: //www.us preventiveservicestaskforce.org/Page/Name/uspstf‐a‐and‐b‐recommendations.

a) Routi ne physical exa mination, i ncluding hei ght, wei ght, a nd body ma ss i ndex (BMI), for children a nd

a dul ts.

b) Bl ood pressure s creening for children a nd adults

c) Chol es terol s creening, for children and adults

d) Screeni ng for colorectal cancer using fecal occult blood tes ting, s igmoidoscopy, or colonoscopy i n a dul ts 40 years of a ge a nd older a s required by Admi nistrative Order number 334 of Ma rch 3, 2015.

e) Screeni ng for obesity, a nd counseling, for children a nd a dults

f) Screeni ng for Tobacco Use for a ll adult; i nterventi ons for women. Covers smoking cessation drugs for 90 cons ecutive days in a n a ttempt a nd two (2) ces sation a ttempts per policy year. Smoking cessation drugs a re covered under the Pha rmacy Coverage Section wi th prescripti on.

g) Di et couns eling for a dults

h) Screeni ng for Type 2 di abetes for a dults and for ges tatio nal diabetes for pregnant women

i) Screeni ng for a bnormal blood gl ucose a nd Diabetes Mellitus Type 2 i n a dults a ged 40 to 70 yea rs who a re overwei ght or obese.

j) Screeni ng for a lcohol a buse, a nd counseling

k) Eva l uation of a lcohol a nd s ubstance a buse i n children and a dolescents

l) Immuni zations for infants, children, a nd a dults in a ccord with a ccepted medi cal practice a nd as recommended by the Advi sory Committee for I mmunization Practices(ACIP) of the Centers for Di s ea se Control (CDC) a nd the Ameri can Academy of Pediatrics, a s l ong a s the i ndividual is covered by thi s hea lth insurance:

I mmuni zations for Adults (21 yea rs or older), i ncluding catch‐ups – Hepa ti tis A, Hepa titis B, Herpes

Zos ter, Huma n Papilloma Vi rus, I nfluenza (Flu Shot), Meningococcal, Mea sles/Mumps/Rubella, Pneumococcal, Teta nus/Diphtheria/Pertussis, Va ricella

I mmuni zations for Children (l ess than 21 yea rs ol d), i ncluding c atch‐ups – Ha emophilus I nfluenzae Type b, Hepa ti tis A, Hepa ti tis B, Herpes Zoster, Human Pa pilloma Vi rus, I nfluenza (Flu Shot), Meni ngococcal, Measles/Mumps/Rubella, Pneumococcal, Rota virus, Teta nus/Diphtheria/Pertussis, Va ri cella, , i nactivated poliovirus

m) Cervi cal cancer s creening, Human papillomavirus (HPV) tes ting; a nd the HPV va ccine as required by the Food a nd Drug Administration (FDA) to a chieve i mmunization

n) Wel l ‐woman preventive care visit a nnually for a dult women to obta in the recommended preventive s ervi ces tha t a re a ge a nd devel opmentally a ppropriate. Office vi sits a nd consulta tions regarding checkups for healthy women (well‐woman visits). Hea lth and Human Services recognizes tha t several vi s its ma y be necessary to get a l l recommended preventi ve s ervices , depending on the hea lth status of women, thei r hea l th needs a nd other risk factors.

o) Brea s t ca ncer ma mmography s creenings every one (1) to two (2) yea rs for i nsured over 40 yea rs, bi a nnual for insured between fi fty (50) a nd s eventy‐four (74) yea rs. This i ncludes guidance a nd a dvi ce rega rding chemoprevention, a nd the chemoprevention of breast cancer i n women when i ndi cated.

p) Pa p Smea r


q) Pros tati c Specific Anti gen tes t (PSA) for men

r) Ori entati on and guidance rega rding s exually tra nsmitted diseases (STD’s ), for children a nd a dults

s) Screeni ng for the huma n immunodeficiency vi rus (HIV), a nd counseling thereof, for children a nd a dul ts. A fi rst tes t during the fi rst trimester of pregnancy a t the fi rst prenata l visit, a nd a second tes t duri ng the thi rd trimester of pregnancy (between the 28th a nd 34th week of pregna ncy). Both HIV tes ti ng s hould be offered in the order of routine prenatal tes ting, provided notice to tha t tes t pregna nt i s the recommendation by the hea lth authorities.

t) Screeni ng for Interpersonal and domestic violence, a nd counseling thereof

u) Screeni ng for a utism for children up to 36 months

v) Screeni ng for hea ring loss in newborns

w) Screeni ng a nd tes ts for l evels of l ead in children a t high risk of exposure to l ea d a nd a symptomatic pregna nt women

x) One l i feti me screening tes t for a bdominal a ortic a neurism in men 65 ‐75 yea rs ol d who ha ve ever

been s mokers

y) Couns eling regarding the us e of a spirin in prevention of disease, for both men a nd women 45 ‐79 yea rs of a ge who a re ca rdiovascular risks. For aspirin, pres cription is required.

z) Couns eling regarding folic a cid s upplements for women who ma y become pregnant. For folic a cid,

pres cription i s required.

aa ) Iron s upplement counseling for children 6 to 12 months a nd pregnant women a t risk for a nemia. For i ron s upplement, prescription i s required.

bb) Tes ts a nd s pecial examinations for children whi ch i nclude devel opmental screening for children (0 ‐11

months ; 1 to 4 yea rs ; 5 to 10 yea rs), pa st medical history, a nemia s creening, hemoglobin a nd hema tocrit, tes ti ng for hemoglobinopathies a nd dyslipidemia, s creening for obesity, oral health a nd fl uoride chemoprevention, vision screening, beha vioral a ssessment a nd s creening for depression, and exa mi nation to detect cervi cal dysplasia i n young gi rls who a re s exually active; tuber culin tes t. Screeni ng tes ts for newborns, i ncluding newborns recently a dopted a nd neonates placed for a dopti on: congenital hypothyroidism, phenylketonuria (PKU).

cc) Tes ts for a dults: s creening for s igns of depression, os teoporosis

dd) Tes ts for women: BRCA muta ti ons i n women, Rh blood i ncompatibility a nd screening a nd tes ti ng for chl a mydia infection for women who a re 24 yea rs of a ge or younger and who are s exually a ctive – a nd for women a t hi gh ri sk of chlamydial i nfection

ee) For pregna nt women, a nemi a screening, tes ts to detect ba cteriurea, hepatitis B, s creening for urinary

tra ct or other rel ated infections

ff) Screeni ng a nd tes ts for s yphilis a nd gonorrhea, i ncluding preventive medi cati on for the eyes of a l l newborns

gg) Ski n Ca ncer behavioral counseling for children a nd a dults 10‐24 yea rs old

hh) Preecl ampsia prevention: a spirin, recommends the us e of l ow‐dose a spirin (81 mg/d) a s preventive medi ca tion a fter 12 weeks of ges tation i n women who are a t high risk. For a spirin, prescription i s requi red.

ii ) Hea l thy di et a nd physical a ctivity counseling to prevent cardiovascular di sease: a dults wi th ca rdiovascular risk fa ctors: recommends offering or referring a dults who a re overweight or obese and ha ve a dditional cardiovascular di sease (CVD) risk fa ctors to i ntensive behavioral couns eling i nterventi ons to promote a hea lthful diet a nd physical a ctivity for CVD prevention.


jj ) Denta l ca ries prevention: i nfants and children up to a ge 5 yea rs: recommends the a pplication of fl uoride varnish to the pri mary teeth of a l l infants a nd children s tarting a t the a ge of pri mary tooth erupti on i n primary care practices. The USPSTF recommends primary care clinicians prescribe oral fl uoride s upplementation starting a t a ge 6 months for children whose wa ter s upply i s fluoride defi ci ent. The fl uoride va rnish is covered under the Denta l Services Secti on.

kk) Lung ca ncer s creening: recommends a nnual screening for l ung cancer wi th low‐dose computed tomogra phy i n adult a ges 55 to 80 yea rs who have a 30 pa ck‐yea r s moking history a nd currently s moke or ha ve quit wi thin the pa st 15 yea rs. Screening should be di scontinued once a person has not s moked for 15 yea rs or develops a health problem tha t s ubstantially limits l ife expecta ncy or the a bi lity or willingness to ha ve curative l ung surgery.

ll ) Fa l ls prevention i n ol der adults : vitamin DThe USPSTF recommends vi tamin D s upplementation to

prevent fa l ls i n community‐dwelling a dults a ge 65 years and older who a re a t i ncreased risk for fa lls.

mm) Hepa ti ti s C virus i nfection s creening: a dults The USPSTF recommends screening for hep atitis C vi rus (HCV) i nfecti on i n persons a t high risk for i nfection. The USPSTF a lso recommends offering one‐time s creening for HCV i nfection to a dults born between 1945 a nd 1965.

2. Preventi ve s ervices covered at 100% (wi thout copay) when provided within the Huma na Provider Network a nd recommended by the US Preventi ve Services Ta sk Force (USPTF) a nd the Hea lth Res ources a nd Servi ces Admi nistration. For more i nformation and updates on preventive s ervices, visit: //www.us preventiveservicestaskforce.org/Page/Name/uspstf‐a‐and‐b‐recommendations

Women’s contraceptives a nd contraception counseling. Al l women’s contraceptive methods a pproved by the Federa l Drug Admi nistration (FDA) by prescription a re covered, i ncluding counseling, pl a cement a nd removal of devi ces, a dministration of a medication and s terilization.

3. Preventi ve s ervices covered at 100% (wi thout copay) during a nd i mmediatel y following pregnancy when provi ded wi thin the Huma na Provider Network and recommended by the US Preventi ve Services Task Force (USPTF) a nd the Hea lth Res ources a nd Services Admi nistration. For this s ervice, i nsured ha s to call the Humana Beginnings program a t 1‐866‐488‐5992, for s creening process. Humana recommends to pa rti cipate i n the Huma na Beginnings Program s tarting the fi rst trimester of ges tation. For more i nformation a nd updates on preventive s ervices, visit: //www.us preventiveservicestaskforce.org/Page/Name/uspstf‐a‐and‐b‐recommendations

Support for breastfeeding wi th guidance a nd counseling and the necessary s upplies, i ncluding the brea s t pump with prescription.

Hospital Services Hos pi tal a dmissions must be a uthorized by Huma na a nd the s ervices to be offered mus t be provided under the determi na tions of a n attending physician. A member or hi s (her) res ponsible careta ker i s responsible for the predetermi ned co‐payment for a ny a dmission tha t s o s pecifies.

I npa tient Ca re: [$50.00 ‐ $350.00] or [40%] per a dmission

Outpa ti ent Surgery‐Facility: [$25.00 ‐ $175.00] or [40%] per rendered s ervice


1. Hos pi tal services i ncluded i n the contracted per di em:

• Semi ‐private room or similar fa cility, unlimited. In ca ses in which a n i nsured use the s ervi ces of a pri va te room, it i s his/her res ponsibility to pa y the di fference between the cos t of medi cal s ervices bill ed a nd the contra cted fees .

• Speci a lized units for critical care s ervi ces i ncl udi ng: i ntens i ve ca re uni t (ICU), i ntermedi a te ca re uni t,

coronary care unit (CCU), neonatal intensive ca re uni t (NI CU), a nd pedi a tri c i ntens i ve ca re uni t (PI CU).

• Opera ti ng, recovery, a nd ma terni ty rooms .

• Drugs pres cri bed by phys i ci a n duri ng hos pi ta l s ta y tha t a re i ncl uded i n the per di em.

• Oxygen a nd i ts a dmi ni s tra ti on.

• La bora tory a nd ra di ol ogy.

• Di s posable s upplies.

• Speci a l and regular diets.

• Regul a r hospital nursing service

2. Hypera limentation s ervices, unlimited

3. Uni vers al Neona tal Hea ring Screening a ccording to La w No. 311 dated on December 19, 2003, which includes: hea ri ng eva luations for the fol low‐up treatment needed by the pa ti ent.

4. Surgi cal procedures for benefits included under the ba sic coverage.

5. Anes theti c a gents a nd their a dministration i ncluding s edation.

6. Sonogra m, Computerized Tomography a nd Ma gneti c Res onance (MRI a nd MRA), unlimited

7. El ectrocardiogram, unlimited

8. Nucl ea r medi cine studies a nd digital a ngiography, unlimited.

9. Bl ood tra nsfusions i ncluding a utologous process, a ll components a nd compatibility tes ts.

10. Res pi ratory Thera py.

11. Phys ical Therapy, ma ximum of twenty (20) thera py s essions per i nsured, per hospital sta y.

12. Acute a nd chronic s ervices related to End Sta ge Rena l Disease, s uch a s dialysis, hemodialysis a nd compl ications directly rel ated to the di sease a re covered up to a ma ximum of ninety (90) days sta rting on the da te on whi ch the di sease i s diagnosed.

13. Trea tment a nd s ervices for morbid obesity a s medically necessary. One (1) bariatri c s urgery using one of the fol l owing techniques, gastric bypass, and adjusta ble ga stric band or sleeve ga strectomy per lifetime, a ccording to La w No. 212 da ted on Augus t 9, 2008.

14. Surgi cal procedures in a mbulatory s urgery in a hospital, l ess a pplicable copayment or coinsurance.

Transplant or Graft Cornea tra nsplant or bone, s kin graft s ervices received by the i nsured wi ll be covered, l ess [$ 50 ‐ $350] copayment or [40% ‐ 90%] coi nsurance; pre‐authorization is required. The covered tra nsplant or graft i ncludes pre‐transplant, tra ns plant i nclusive of a ny chemotherapy a nd a ssociated s ervices , post‐discharge s ervices, a nd trea tment of compl ications after transplantation.


In‐Home Services

In‐Home Hea l th Services, a uthorized by a ma in doctor a nd Humana. Home hea l th ca re mus t be provided by a n a gency that i s dedicated, l icensed a nd managed according to the regul a tions es tablished by a group of medi cal professionals tha t keeps medi cal records of the pa tients a nd opera tes a ccording to the l a ws of the Commonwealth of Puerto Rico. Thes e services a re covered i f they begin wi thi n fourteen (14) da ys a fter release from a hospital or expert nursing fa cility due to a hos pitalization of a t l ea st three (3) da ys , a nd a re provided because of the s a me condition or i n rel ation to the condition for which the pa tient wa s hos pitalized.

If the pa ti ent i s in the hos pital, Home hea lth s ervices must be reques ted by the a ttending physician in the hos pital. If the pa ti ent i s out of the hos pital, Home hea lth s ervices mus t be requested by the ma in doctor wi th medical j us ti ficati on. The doctor must present a care pl an and es timated ti me of the dura tion of s ervices, a ccording to the i ndi vidual needs of the pa tient. The program will provide education for the pa tient a nd fa mily members res ponsible for his/her hea lth care. Thi s benefit will be covered for forty (40) days initially, a nd a n additi onal twenty (20) da ys, s ubject to medi cal necessity certification.

In‐home hea l th s ervi ces i ncl ude:

1. Ca re by a nurse or under the s upervision of a graduate nurse.

2. Res pi ratory thera py care, l ess [$5 ‐ $10] copayment 3. Col l ecti on of s amples for lab tes ts, l ess [20% ‐ 50%] coinsurance

4. Ca re a nd ma intenance of ca theters.

5. Admi ni stration of i ntravenous a ntibiotics, s ubject to Huma na's case ma nagement program.

6. Ul cer ca re through Humana's case ma nagement program.

7. Phys ical therapies up to a ma ximum of twenty (20) therapy sessions per i nsured per policy year, less [$ 5 ‐ $10] copa yment or [40%] coinsurance.

8. Occupational therapy for the purpose of tra ining a nd aiding i n the res toration of normal physical function a nd or prevent further deteri oration of the s a me; resulting i llness, from trauma, s troke or a s urgical procedure whi l e i nsured under the pol icy, unlimited less [$10 ‐ $25] copayment or [40%] of coinsurance.

9. Speech thera py, when ordered by a physician a nd rendered by a licensed s peech thera pist; combined a t the phys i cian office or a t home, up to a ma ximum of forty (40) therapy s essions per i nsured per policy yea r l ess [$10 ‐ $25] visit copayment. Speech therapies are unlimited for Auti sm.

10. Hypera limentation s ervices, unlimited, l ess [20% ‐ 50%] coinsurance.

Skilled Nursing Facility Ski l led nursing fa cility covered up to a ma ximum of one hundred a nd twenty (120) days per i nsured per policy year, l es s [$50 ‐ $350] a dmission copayment or [40%] coinsurance. Thes e s ervices wi ll be covered i f they begi n within the fourteen (14) da ys following the rel ease from the hos pital due to a hos pitalization of a t l east three (3) da ys, a nd i f they a re rendered because of the s a me condition or in relation to the condition lea ding to the hos pita lization.

If the pa ti ent i s in the hos pital, Home hea lth s ervices must be reques ted by the a ttending physician in the hos pital. I f the pa ti ent i s out of the hos pital, Home hea lth s ervices mus t be requested by the ma in doctor wi th medical j us ti ficati on. Pre‐a uthorization is required.


Durable Medical Equipment, Supplies, Prosthesis, Orthosis and Implants 1. The purchase or rental of medi cally necessary Durable Medical Equipment, i ncluding gl ucometer a nd i nsulin

pump, l es s [20% ‐ 50%] coinsurance. The cos t or rental of durable medi cal equipment wi ll be covered. If the cos t of renti ng the equi pment i s more tha n a n i nsured would pa y to buy i t, Huma na wi ll covered up to the a mount of the purchased equipment. We do not pa y for equipment or devices not s pecifically des igned a nd i ntended for the trea tment of a n i njury or s ickness. Required pre‐authorization.

2. I ni ti al pl acement of a medi cally necessary prosthesis a nd i ts s upportive device, except for those excluded. We

wi l l also cover the replacement of s uch prosthesis i f i t i s determined by the i nsured’s physician to be necessary beca us e of growth or change. Les s [20% ‐ 50%] coinsurance. Required pre‐authorization.

3. Orthoti cs (No cover pre‐fabricated, over‐the‐counter ‐ OTC) a nd s upplemented (No cover over‐the‐counter ‐

OTC), l es s [20% ‐ 50%] coinsurance. Requires pre‐authorization. 4. Impl a nts, l ess [20% ‐ 50%] coinsurance. Requires pre‐authorization.

Ambulance Services Al s o a n emergency ma y arise from a call ma naged thru the 911 System whi ch refer to a dedicated tel ephone s ys tem tha t i s a vailable 24/7 for receiving emergency calls tha t deal wi th public s ecurity. System 9 ‐1‐1 wa s created by vi rtue of La w No. 144 da ted on December 22nd, 1994 a s a mended, known a s the “La w for ra pid response to emergency ca lls wi th Public Security” or “La w for calls 9 ‐1‐1.

1. La nd tra nsportation by a n ambulance, between fa cilities, a uthorized by the Public Service Commission a nd the

Hea l th Depa rtment a s menti on i n La w No. 183 of August 6, 2008, to a hospital or between hea lth fa cilities, e.g. between a hos pital a nd a radiology i nstitute or between a s killed nursing fa cility a nd a hospita l, and when ordered by a physician, i ncluding psychiatric emergencies. Services requested for psychiatric a nd medical emergenci es through the 911 will be pa id in full directly to the provider.

2. La nd tra nsportation by a n ambulance a uthorized by the Public Service Commission a nd the Hea l th Depa rtment a s mention i n La w No. 183 of August 6, 2008, i ncluding psychiatric emergencies, l ess [$ 25 ‐ $100] copa yment or [40%] coinsurance per trip. I t i ncludes land tra nsportation to or from the i nsured home.

3. La nd a mbulance s ervices for psychiatric a nd medi cal emergencies through 911 will be pa id in ful l by Humana di rectly to the provider. The s ervice wi ll only cover i f the i nsured meets the fol lowing requirements:

a. The pa ti ent s uffered a n illness or injury for which other types of tra nsportation a re not recommended;

b. Ps ychiatric emergencies a s mention i n La w No. 183 of August 6, 2008;

c. The hea l th condition of the pa tient does not allow the us e of other types of tra nsportation;

d. It i s not a ca se covered by the Automobile Accident Compensation Administration (ACAA), the Sta te Workmen’s Compensation Fund (CFSE) or a ny other insurance with primary responsibility.

4. Ma ri time a nd a ir tra nsporta tion s ervices by a n ambulance wi thin Puerto Ri co, s ubject to medi cal need for i t, l

es s [$25 ‐ $100] copayment or [40%] coinsurance. Pre‐authorization i s required unless i t is a l ife or death emergency.


Cancer Services and Treatments 1. Ambul a tory s ervices for the trea tment of ra diotherapy a nd/or chemotherapy, i ncluding i ntravenously, via

i nj ection or i ntrathecally, a ccording to the i nstructions of the medi cal doctor or oncolo gist. Oral chemotherapy i s cover under the Pharmacy Coverage Section. Thi s is, a ccording to La w No. 107 dated on June 5, 2012.

2. Medi cally necessary oral and pa renteral medication for pain ma nagement of pa tients s uffering terminal ca ncer.

3. Al l the benefi ts , i ncluding radiotherapy and/or chemotherapy i n the hospital s ervices, l ess [$ 50 ‐ $350] hos pita l copayment or [40%] coinsurance.

4. Stoma ca re a nd ma intenance: colostomy, ga strostomy a nd cystostomy. 5. For the i ns ured who i s receiving benefits in connection with a mastectomy and who el ects breast

recons truction in connection wi th such ma stectomy, the coverage i ncludes:

a) a l l sta ges of reconstruction of the brea st on which the ma s tectomy has been performed

b) s urgery a nd reconstruction of the other brea st to produce a s ymmetrical appearance

c) pros thesis a nd physical complications of ma stectomy, i ncluding l ymphedemas

According to La w No. 275 dated on September 27, 2012, patients wi th a di agnosis of ca ncer have the fol lowing ri ghts :

To know a nd understand thei r treatment a nd rehabilita tion plans, a nd the pa in ma nagement protocol s peci fically a ppropriate for thei r case. The pa tient wi th cancer ha s the right to priority trea tment for hi s /her pa in; a nd i s enti tled to a ggressive pain management techniques based on s cienti fic evidence a nd a pproved by the Food a nd Drug Administration (FDA).

To recei ve a copy of thei r fi le i n a n expeditious ma nner when they wi sh a s econd medi cal opinion or a

cons ultation wi th another provider.

The ri ght to i nformation, counseling and guidance rega rding the possible s hort a nd l ong term effects on ferti l ity of the ca ncer itself, a nd of the di a gnostic tes ts a nd trea tments to be recei ved.

Conti nuity in medical care a nd other health s ervices, s uch as di agnostic tes ts for ea rly detection, a nd a cces s to oncologists, radiation therapists and surgical s pecialists involved i n the i nitial di agnosis, a nd i n hi s /her ma nagement once regarded a cancer survivor; continuity is necessary for close monitoring a gainst recurrence a nd a dverse effects of trea tment, a nd to ma i ntain physical a nd emoti onal health a s a surviving pa ti ent wi th cancer.

To be i ncl uded in thei r employer’s group hea lthcare i nsurance pl an wi th no i ncrease i n thei r premium compa red to a ll other members of the Group, a nd wi thout exclusion of coverage because of a previous di a gnosis of cancer.

No pri va te i nsurer can reduce benefi ts or terminate the pol icy of a patient wi th cancer, or that of a child who ha s s urvived cancer, a s l ong a s the hea lth emergency l asts.

El derl y patients who have a diagnosis of cancer or who a re ca ncer s urvivors will be offered clea r a nd up ‐ to‐da te i nformation a bout the preventi on, detection and trea tment of ca ncer ta king i nto a ccount condi tions which mi ght a ffect communication and their sensory, mobility or cognitive i mpairmen ts. El derl y patients wi th a diagnosis of cancer will receive the s upport a ppropriate for thei r a ge, i ncluding but not l i mi ted to community s upport s ervices and psychosocial a nd pa lliative s ervices .

Incl uded as covered s ervices wi ll be pel vic examinations, a nd all type of va ginal cytology preparations whi ch ma y be s pecifically required by medical order to detect, di a gnose a nd trea t ea rly a nomalies which mi ght l ea d to ca ncer of the cervix.


To provi de extended coverage for the pa yment of s tudies a nd tes ts to monitor ca ncer of the brea st, s uch a s offi ce vi sits to s pecialists, clinical breast exa minations, ma mmography and di gita l mammography, ma gneti c resonance ma mmography a nd s ono‐mammography, a nd such treatments a s, but not l imited to, ma s tectomies, reconstructive s urgery a fter mastectomy for the reconstruction of the removed brea st, the recons truction of the other breast to a chieve a s ymmetrical appea rance, breast prosthesis, trea tment of compl icati ons at a ll s tages of the ma s tectomy, i ncluding l ymphedema (a n i nflammation which sometimes occurs a fter trea tment for brea st cancer), a nd a ny other reconstructive s urgery a fter ma stectomy which ma y be neces s ary for the physical a nd emoti onal recovery of the pa tient.

Maternity Services The fema l e empl oyee, the wi fe or cohabitant, a nd the dependent da ughter of a ny employee covered by the i ns urance pl an for families or couples, will ha ve ma ternity benefit coverage. The mi nimum hospital s tay for both pa ti ent a nd newborn has been es ta blished by La w No. 248 of the Commonwealth of Puerto Ri co dated on August 15, 1999, a t 48 hours for a normal delivery, wi thout complications, a nd 96 hours for a Ces arean ‐section del ivery. Hos pi tal discharges prior to l ength of s ta ys s tipulated by the l aw mus t have the consent of the pa tien t. The ma terni ty benefit covers a follow‐up vi sit during the 48‐hour period following discharge, a t which ti me the newborn i nfant ca n a lso be checked. Services will i nclude, but not be l i mited to s upport a nd physical care for the benefi ts of the mi nor, education to both pa rents on caring for the mi nor, support a nd training on breast feedi ng, ori enta tion on s upport a t home a nd the performance of a ny treatments a nd medi cine tes t both for the i nfant a nd the mother.

Covered ma ternity benefits i nclude the fol lowing services:

1. Hos pi talization, l ess [$50 ‐ $350] copayment [40%] coinsurance.

a. Del i very, including Cesarea n Section.

b. Del i very and recovery rooms.

c. Nurs ery a nd i ncubator.

d. Neona ta l i ntensive care unit (NI CU)

e. Feta l moni toring during delivery.

f. Pos tpa rtum sterilization before di scharge

2. Ambul a tory (unl i mi ted s ervi ces )

a. Pre‐na tal a nd post‐natal care, l ess [$10 ‐ $25] copayment per visit

b. Geneti c a mniocentesis, l ess [20%‐50%] coinsurance

c. Sponta neous a bortion

d. Ambul a tory feta l monitoring, l ess [20%‐50%] coinsurance

3. Bi ophysical profile

4. Va cci nes

a. RhoGa m Va ccine, l ess [20%‐50%] of coinsurance b. Va cci ne for the trea tment of the Res pi ratory Syncyti al Vi rus a ccording to La w No. 165 da ted on August 30,

2006 a nd protocol a pproved by Puerto Rico’s Department of Hea lth. 5. Ambul a tory s terilization, covered a t 100%


Pediatric Services 1. Unl i mited visits, l ess [$10 ‐ $25] copayment or [40%] coinsurance per visit.

2. Wel l Child Ca re, l ess [$10 ‐ $25] copayment or [40%] coinsurance per visit.

3. Uni vers al Neona tal Hea ring Screening, a ccording to La w No. 311 da ted on December 19, 2003, which i ncludes: hea ri ng eva luations for the fol low‐up treatment needed by the pa ti ent.

4. Annua l exam a ccording to La w No. 296 da ted on September 1st, 2000, whi ch i ncludes: physical a nd menta l eva l uation, oral hea lth, hea ring a nd vision s creening, a nd s creenings recommended by the Ameri can Academy of Pedi a trics.

5. Ci rcumcision a nd dilatation for newborns before discharge from the hos pital, a t a mbulatory facility, or

phys i cian office, l ess [$10 ‐ $75] copayment or [40%] coinsurance. 6. I mmuni zations a ccording to es ta blished medical practices a nd as recommended by the Advi sory Committee

on I mmuni zation Practices (CDC) a nd the Ameri can Academy of Pediatrics, while i ncluded a s i nsured under the pol i cy, Human Papilloma Vir us va ccine a ccording to La w No. 255 da ted on September 15, 2012. For children who ha ve been s exua lly a bused, the HPV va ccine (HPV) i s covered begi nning a t a ge nine (9).

7. Covera ge for technical equipment of venti lators for children which are vital for the ma intenance of l ife, i ncl uding children who depend on medical equipment s uch a s respirators or supplemental oxygen, a n 8 ‐hour da i ly s hift of a s killed nurse wi th experience i n respiratory thera py or respiratory thera pists wi th nursing experi ence, the neces sary supplies to work wi th the techni cal equipment, physical a nd occupational therapy, l a boratories, ra diology, a nd prescribed medications whi ch mus t be di spensed by a participating pharmacy of our network whi ch i s freely s elected by our i nsured, a ll as a uthorized by the l a ws of Puerto Rico a s outlined i n La w No. 62 da ted Ma y 4, 2015, l ess copayment. For those who ha ve sta rted trea tment a s mi nors a nd become a ge 21, a l l the a forementioned services will conti nue to be covered. This benefit a pplies a lso to children who ha ve ha d a tra cheotomy to ena ble breathing and require home ca re because of the ri sk of airway obstruction; thi s requires a prescription by a physician.

8. Ca re a nd trea tment of congenital defects a nd a nomalies diagnosed by a doctor, wi thout excl usion due to a

preexi s ting condition. This covers newborns, recently a dopted newborns or newborns recently placed for a dopti on. Thes e s ervices a re s ubject to a ny applicable copayment or coinsurance.

9. Va cci ne for the trea tment of the Res pi ratory Syncyti al Vi rus a ccording to La w No. 165 da ted August 30, 2006 a nd protocol a pproved by Puerto Rico’s Department of Hea lth. Pre‐authorization required.

Urgent / Emergency Room Services Servi ces provided i n Urgent / Emergency Rooms wi ll be provided wi thout prior ‐authorization or waiting period; will be provi ded regardless i f the provider i s a participating provider, a ccording to the La w number 194 of Augus t 25, 2000. For s ervices provided i n Urgent / Emer gency Rooms of non‐participant providers, the i nsured will pa y to the provi der the s a me a mount a s i f a participating provider, as l ong a s there i s a n i mporta nt a nd j ustifiable medical rea s on for not tra nsferring the pa tient to a contracted fa cility.

If Urgent / Emergency s ervices a re provided to a patient by a non ‐participant provider, the pa tient i s not res ponsible for pa yment of s ervices that exceed the a pplicable a mount i f it ha d received the s ervices of a pa rti cipant provider. Huma na wi ll compensate the provider that offers the s ervice a nd i t wi ll be obl igated to a ccept s uch compensation wi th a n a mount of not l ess tha n the contracted by Humana to offer the s a me s ervices. I n a ddi tion, under thes e circumsta nces , such Urgent / Emergency services will be provided regardless of the condi tions by the hea lth i nsurance.


If the pa ti ent receives health s ervices posterior to the urgent / emergency s ervices, or after being s tabilized, a nd thes e woul d normally be covered s ervices except for the fa ct that they a re rendered by a non ‐participating provi der, Humana wi ll rei mburse the pa tient for tha t part of the costs i ncurred tha t would be normally pa id by the pl a n, a s l ong as there i s a n important a nd justifiable rea son for not tra nsferring the pa ti ent to a contracted fa cility.

Emergenci es handled by the 911 s ystem – thi s refers to the publ ic s afety system of urgent / emergency calls through the number 9‐1‐1.

After the i ns ured i ndividual receives complete urgent / emergency ca re a nd s tabilization, the fa cility will transfer the pa ti ent to a Huma na or Choice Ca re fa cility as s oon a s it i s medi cally possible. Such tra nsfer must not i n any wa y a ffect the trea tment bei ng gi ven or harm the i nsured pa tient’s health. Humana will a ssist i n the coordination of thi s tra nsfer, a s sti pulated in La w No. 194 da ted on August 25, 2000.

1. Urgent / Emergency room s ervices due to a ccidents a re covered i n full.

2. Urgent room s ervices resulting from illness are covered, l ess [$25 ‐ $100] copayment or [40%] coinsurance

3. Emergency room s ervices resulting from illness are covered, l ess [$25 ‐ $100] copayment or [40%] coi nsurance

4. Urgent / Emergency room s ervices ’ copayment or coinsurance wi ll be wa ived i f patient i s a dmitted; i n that ca s e the hos pita l admission copayment or coinsurance wi ll apply.

For exa mpl es of emergency condi ti ons , refer to the def i ni ti on “Condi ti on of emergency”. Protocol to be followed in the process of transferring patients with psychiatric conditions from one health facility to another.

Rega rdi ng a n in‐patient who presents emotional disturbances i n a general hospital or i n a n u rgent / emergency room:

1. Screeni ng a nd evaluation of the pa tient wi ll be performed a s stipulated i n La w No. 35 of 1994 a nd EMTALA, i

ncl uding a ll the necessary tes ts to es ta blish a diagnosis. 2. Orga nic disease mus t be ruled‐out before reaching a ps ychiatric diagnosis. 3. Duri ng i nitial eva luation, the genera l hospital mus t consider a nd rule‐out the pos sibility that the eti ol ogy of

the s ymptoms of a nxiety a nd a gitation presented by the pa tient a t the moment of the emergency a re of orga nic origin.

4. The pers onnel of the genera l hospital must consult a menta l‐health professional to es ta blish continuity of care

a nd obta in permission for transfer from the fa mily or a person properly a uthorized. 5. The pa ti ent i s to be s ta bilized i n regard to hi s/her physical condition or i l lness. The ti me s pent a t the genera l

hos pita l will depend on the eva l uations of organic conditions necessary to es tablish the s ta te of hea lth of the i ndi vidual. I n cases of poisoning, the genera l hospital will be res ponsible for contacting the Poison Cont rol Center i n order to determi ne how l ong it wi ll ta ke to el iminate the potenti ally toxic s ubstance ta ken by the pa ti ent. Tha t ti me‐frame wi ll become the mi nimal period of ti me for the pa ti ent to rema in i n the urgent / emergency room before tra nsfer to a psychiatric fa cility.

6. Once the pa ti ent’s physical condition i s stabilized he/s he ca n be tra nsferred to a ps ychiatric hospital.

Si mul taneously, the emergency room must s end a clea r a nd concise s ummary to the ps ychiatric fa cility of a ll tes ts a nd trea tment done, follow‐up recommended a nd information on the physician who a ttended the pa ti ent i n the emergency room.


7. The a ttendi ng physician a t the genera l hospital is res ponsible for communicati ng by tel ephone with the ps ychiatric facility i n order to di scuss the ca se i n detail a nd explain the s ymptoms a nd signs presented by the pa ti ent to be tra ns ferred. At the s a me ti me the pa ti ent’s tra nsfer can be coordinated.

8. The ps ychiatric hospital must commit to a ccept the pa tient to be tra nsferred for further care.

I f the pa ti ent i nvolved has the economic capacity to pa y for the tra nsportati on by a mbulance or other mea ns neces s ary for transfer, or has i nsurance which covers this s ervice, the tra nsportation necessary for transfer wi ll be pa i d by the pa tient or his i nsurance. In s uch cases the hos pital wi ll be paid directly, i f i t ha s actually paid for thes e s ervi ces; the hea l th insurance plan is res ponsible for thi s payment to the hos pital. Ca ses i n which the pa ti ent i s covered for menta l hea lth s ervices by the government hea lth insurance. If necessary, a nd in the a bsence of other a l ternatives, transporta tion will be provided by the a mbulances which service the public s afety s ystem of emergency ca lls through 9‐1‐1. Tra nsportation will be covered from wherever the pa tient who needs the s ervice i s l oca ted to wha tever hospital facility tha t can provide the ca re necessary. Ambul ance tra nsportation mus t comply wi th the requi rements of La w No. 35 of 1994 a nd EMTALA.

The genera l hospital a nd the ps ychiatric hospital must both comply with a ll EMTALA regul ations regarding the draft a nd prepa ration of a “Protocol for the Process of Tra nsferring Patients” whi ch is here requested a nd required.

NOTE: Urgenci es / Emergencies whi ch a re s econdary to a ccidents a re covered 100%. The urgent / emergency room copa yment or coinsurance does not a pply if the pa tient i nsured i s a dmitted to the hos pital; i n that case the co ‐ pa yment of a dmi ssion to hos pital a pplies.

Ps ychiatric urgencies / emergencies will be covered wi th the a pplicable copayment or coinsurance.

Cardiovascular Procedures

1. Di a gnosti c Tes ts a nd treatment, i ncluding the i nvasive a nd non‐invasive cardiovascular procedures, l ess [20%‐

50%] of coi nsurance.

2. Phys ician s ervices, l ess [$10 – $25] office copayment or [40%] coinsurance

3. Surgi cal procedures, l ess [$50 – $350] facility copayment or [20% ‐ 50%] coinsurance

4. Repa i r or replacement of hea rt va lves, pa cemaker and any other a pplicable device, wi th $0.00 copayment. Defi brillator pa cemaker required pre‐authorization.

Neurological Procedures 1. Di a gnosti c tes ts a nd trea tment, l ess [20%‐50%] of coinsurance.

2. Phys ician s ervices, l ess [$10 – $25] office copayment or [40%] coinsurance

3. Surgi cal procedures, i ncluding neuroendovascular, less [$ 50 ‐ $350] facility copayment or [20% ‐ 50%] coi nsurance

4. Repa i r or replacement of valves, a nd a ny other medically necessary device, wi th $0.00 copayment.


Mental Health Services

1. Unl i mited visits to professionals, psychology doctors and other providers who because of thei r educati on,

tra i ning or experience, a nd the proper competency, a re a ble to offer ps ychological health services, l ess [$10 ‐ $25] copayment or [40%] coinsurance

2. Unl i mited office vi sits to ps ychiatrist a nd/or psychologist of children a nd teens /adults l ess [$10 ‐ $25] copa yment or [40%] coinsurance

3. Group thera pies, less [$10 ‐ $25] copayment or [40%] coinsurance

4. Col l ateral visits, l ess [$10 ‐ $25] copayment or [40%] coinsurance

5. Unl i mited hospita l services, l ess [$ 50 ‐ $350] a dmission copayment or [40%] coinsurance. Two (2) da ys of pa rti al hospitalization a re equi valent to one (1) da y of regular hospitalization.

Thi s s ervice includes emergency psychiatric transportati on by a n a mbulance a uthorized by the Service Public Commi s sion (Comisión de Servicio Público) a nd the Hea lth Department (Departamento de Salud), a s s tated i n Arti cl e 4.20 (b) of La w No. 183 of 6 August 2008. Services requested for psychiatric emergencies through the 911 wi l l be paid i n full directly to the provider.

Alcoholism & Substance Abuse Services 1. Unl i mited visits to professionals, psychology doctors and other providers who because of thei r educati on,

tra i ning or experience, a nd the proper competency, a re a ble to offer hea lth s ervices i n s ubstance a buse, l ess [$10 ‐ $25] copayment or [40%] coinsurance

2. Unl i mited office vi sits to ps ychiatrist a nd/or psychologist of children a nd teens /adults, l ess [$10 ‐ $25] copa yment or [40%] coinsurance

3. Unl i mited therapies, trea tment a nd follow‐up a t one or more s ervice l evels, which ma y combine mul tiple

types of thera py, l ess[$10 ‐ $25] copayment or [40%] coinsurance 4. Unl i mited residential treatment for a lcoholism a nd s ubstance a buse i ncluding detox, l ess [$50 ‐ $350]

copa yment or [40%] coinsurance. 5. Unl i mited hospita l services, l ess [$50 ‐ $350] a dmission copayment or [40%] coinsurance. Two (2) da ys of

pa rti al hospitalization a re equi valent to one (1) da y of regular hospitalization. Pre‐authorization required.

Autism Auti s m is recognized as physicomental hea lth condition. I n compliance wi th La w of Puerto Ri co No. 220 dated on September 4, 2012 wi th the Puerto Rico Depa rtment of Hea lth a nd utilizing a s reference the gui delines of the Ameri ca n Association of Pediatrics coverage for these conditions wi ll include di agnostic a nd therapeuti c s ervices i n pers ons diagnosed wi th di sorders within the conti nuum of Auti sm.

Covered benefi ts i nclude visits to physicians a nd other health providers a nd the ordered tes ts a nd procedures determi ned to be medi ca lly necessary. The s pecialized s ervices most commonly utilized a re rel ated to neurology, ps ychotherapy, i mmunology, geneti cs, gastroenterology, nutrition, s peech a nd l anguage therapy, occupational and phys i cal therapy. Coverage/benefits are not l imited only to the previ ously mentioned s ervices. Thes e s ervices are s ubj ect to a ny a pplicable copayment or coinsurance, except for the s creening for a utism for children up to 36 months .


Dental Services The denta l care benefits described bel ow a re a vailable us ing Humana's provider network i n Puerto Ri co.

Preventive and Diagnostic Services

The fol l owing services will be covered at 100% In‐network:

1. I ni ti al oral exa mination, one (1) every three (3) yea rs

2. Peri odic exa mination, one (1) every s ix (6) months

3. Speci fic oral eva luation, one (1) every six (6) months

4. Compl ete s eries of radiographs (FMX), one (1) every thr ee (3) years

5. Pa noramic radiographs, up to one (1) every three (3) yea rs

6. Peri a pical ra diographs, one (1) a nd five (5) a dditional per policy year

7. Bi tewi ng ra diographs, one (1) s et every twel ve (12) months

8. Prophylaxis a dult a nd child, one (1) every s ix (6) months

9. Appl i cation of fluoride to chi ldren up to ni neteen (19) yea rs, one (1) every s ix (6) months 10. Sea l a nts a pplication, limited to children up to fourteen (14) yea rs, one (1) treatment per tooth per l ifetime i n

perma nent mol ars a nd premolars not previously restored.

11. Appl i cation of fluoride va rnish for i nfants and children up to a ge 5 yea rs , one (1) every s ix (6) months.

12. Spa ce ma intainers, to repl ace deciduous teeth tha t a re l ost permanently, one (1) per a rea per l ifetime.

13. Pul p vi tality tes t, one (1) per visit

14. Re‐cementa ti on of space ma intainer

15. Genera l a nes thesia, a dministered by an a nesthesiologist, a nd hospital s ervices a ccording to La w No. 352 of December 22, 1999.

Non‐Contracted Dentists

If the i ns ured uses the s ervices of a non‐participant dentist or fa cility, Huma na wi ll reimburse the i nsured the fee of the contra cted dentist or fa cility (with the receipt of the pa yment ma de to the denti st tha t provided the s ervi ce).

Pediatric Vision Care Services

The vi s ion care benefits desc ribed bel ow a re a vailable until the 21 st bi rthday.

Lenses: One (1) set of l enses per i nsured, per policy yea r, wi th $0.00 copayment. Service is a vailable i n the l ocation of the [Ivi sion] pa rticipating providers. Lens es for eyegl asses: the l ens es included the fol lowing sel ection:

o CR‐39 Pl astic for single vision l enses, bi‐focal lenses, or tri‐focal lenses o Pol ycarbonate for s ingle vision l enses

Frames: The i ns ured can s elect a ny frame a vailable i n the l ocation of the [Ivision] participating providers throughout Puerto Ri co with $0.00 copayment. The benefi t i ncludes frame from the collection. Coverage i ncludes one (1) fra me per pol icy yea r.


Contact lenses: Instea d of eyegl ass benefit (frame a nd l enses), the member ma y choose sta ndard disposable conta ct l enses . The di sposable contact l ens benefit consists of two (2) boxes per policy yea r, with $0.00 copa yment. Services a re a vailable i n the l ocation of the [I vision] pa rticipating providers. One (1) pa i r of l ow vision eyegl asses or ma gnifiers as medi cally n ecessary for i nsured wi th s ignificant l oss of vision (l ow vi sion), but not tota l blindness using a n exclusive network of Huma na Insurance, l ess [$10 ‐ $25] copayment or [40%] coi nsurance.

Pharmacy Coverage What is the formulary?

A Formul ary i s a prescription drug list devel oped a nd a pproved by Humana a nd which is regularly eva luated to i ncl ude or exclude pres cription drugs, which i s used to determi ne benefits covered under the pha rmacy covera ge. The formulary i ncludes generic, preferred brand, non ‐preferred brand, a nd s pecialty drugs.

The formul ary is a vailable i n our webpage, Humana.com. There, you can a lso find information a bout your pres cription medi cations tha t ma y ha ve Uti lization Ma nagement requirements a nd the a uthorization forms with the i nformation required to eva luate them, i f a pplicable. Humana will provide the i ns ured a copy of the formul ary, a long wi th i nformation about whi ch prescription drugs are s ubject to Uti l ization Management requi rements.

Huma na will require tha t the Pha rmacy a nd Therapeutics Committee ha s a n es tablished process, i n writing, to cons ider a nd update changes i n formulary or thos e that ma y require Uti lization Management, on a ti mely ma nner a nd ba sed on:

New s ci entific medical evidence or a ny other prescription drug related i nformation for covered, non‐ covered or thos e tha t may require Uti lization Management, to determi ne if a change i s needed i n the formul ary or the uti lization ma nagement criteria;

i f a pplicable, a ny clinical information that Huma na receives, related to a n exception request that would a l l ow the Pha rmacy a nd Therapeutics Committee to determi ne i f the drugs covered i n the formulary or thos e tha t ma y require Uti lization Ma nagement, meet the member’s needs , a nd

s a fety a nd effectiveness i nformation for covered drugs or those tha t ma y require Uti lization Ma na gement, i nformation about prescription drugs that ma y be clinically s imilar or bioequivalent, but tha t a re not covered i n the formulary nor require Uti lization Ma nagement, i nformation that ma y a rise from qua lity a ssurance a ctivities in the i nsurance company or i nformation from prescription drug claims recei ved a fter the l ates t Pharmacy a nd Therapeutic meeti ng.

Huma na will require tha t the Pha rmacy a nd Therapeutics Committee performs the eva luation of new pres cription drugs a pproved by the Food a nd Drug Admi nistration (FDA) i n no more tha n a ninety (90) da ys period, from the FDA a pproval da te. The Pha rmacy a nd Therapeutics Committee s hould ma ke a determi na tion to i nclude or not i nclude a new prescription drug i n the formulary, i n a term no more tha n ni nety (90) da ys from the da te the drug i s a vailable on the ma rket.


Huma na guarantees that the Pha rmacy a nd Therapeutics Committee wi ll es tablish a nd comply with a written procedure to eva luate medi cal a nd s cientific evi dence rel ated to the s a fety a nd efficacy of pres cription medi ca tions, i ncluding i nformation to compare s imilar prescription medi cations a nd bi oequivalent, on deciding whi ch prescription medi cations a re to be i ncluded i n the formulary a nd on devel oping other pharmacy benefit ma na gement processes. Humana a lso guarantees that the Pha rmacy and Thera peutics Committee wi ll es tablish protocols for the a nalysis, a nd possible i nclusion i n formulary, of medi cati ons for “off ‐label use” for those hea lth condi tions i n which, through medical or s cientific evi dence, the effi cacy of the medi cation has been es ta blished.

Pha rmacy a nd Therapeutics Committees mus t document all thei r protocols a nd processes a nd pres ent regi sters a nd documents to Huma na upon request.

Huma na ma y contract wi th other persons to perform the functions of the Pha rmacy a nd Therapeuti cs Committee. Huma na will be a ccountable to the Commi ssioner of I nsurance for non‐compliance a nd vi olations i ncurred by i ts’ Pha rmacy a nd Therapeutics Committee.

Huma na will only be a ble to ma ke changes i n the formulary or the Uti l ization Management while the pol icy is a cti ve; i f the cha nge i s because of s afety, the drug i s no l onger a vailable i n the ma rket, i f a new prescription drug wi l l be a dded i n the formulary. If this ha ppened, Huma na wi ll notify this no l ater than when the cha nge i s ma de, to:

Al l covered members a nd pa rti cipating pharmacies, only i f the change i s because a new prescripti on drug will be a dded to the

formul ary. I n this case, Huma na wi ll notify thirty (30) days before the cha nge i s ma de. Huma na will meet the fol l owing requirements: Huma na will ma inta in a nd fa cilitate the i nformation bel ow to the members , pres cribers a nd pharmaciess, by el ectronic mea ns a nd i f requested by the member or the Pha rmacy, written:

The formul ary (pres cription drug l ist) organized by therapeutic categories a nd the l i st known a s “Ma xi mum Al lowable Cos t”;

i nformation a bout prescription drugs a nd those tha t ma y require Uti lization Management, i f a pplicable, whi ch wa s developed a nd ma nta ined a ccording to the “Códi go de Seguros de Sa lud de Puerto Ri co”.

i nformation a bout the documenta tion that ma y need to be pres ented by the i nsured or the personal repres enta tive to reques t a medical exception a nd the wa y i n which to present this documentation. For deta i l s, see Secti on Application and Process Excepti on in this Certificate.

How do I use the formulary?

Drugs a re listed in the formulary alphabetically.

Are there any restrictions on my coverage?

Some covered drugs may have a dditional requirements or limits on coverage ba sed on FDA i ndi ca tions a nd dosing, l ike gender, a ge, a nd dos e l imitations. Requi rements and limits may i ncl ude:

Prior Authorization (PA): Humana requires you or your doctor to get pri or

a uthorization for certain drugs. Thi s mea ns tha t your doctor mus t contact Huma na to get a pproval before you fill or refill a prescription for a ny drug that needs prior a uthorization. Your plan benefits won’t cover this drug without prior a uthorization. You’l l pay the enti re cost of the drug i f you decide to buy i t.


Quantity limits (QL): For certain drugs Humana limits the amount of the drug that we’ll cover. Huma na might limit how many refills you can get, or how much of a drug you can get ea ch ti me you fill your prescription. For example, if it is normally considered safe to ta ke only one pill per day for a certain drug, we may limit coverage for your pres cription to no more tha n one pill per day. Specialty drugs are limited to a 30‐day supply regardless of drug‐ti er placement.

Specialty drugs (SP): Hi gh‐cost drugs, i ncl udi ng hi gh technol ogy a nd s el f‐a dmi ni s tered i nj ecta bl e

medi ca ti ons , requi ri ng s peci a l moni tori ng.

This coverage focuses on the use of bioequivalent drugs as a first alternative; however, the insu red has the option to choose between a brand drug or a bioequivalent . I f a n i ns ured choos es to purchase a brand drug, a nd a n equivalent generic is a vailable, the i nsured must pa y the di fference i n cos t between the bra nd a nd the generi c, pl us a ny a pplicable brand copay or coinsurance di spensed. If the i ns ured chooses the bi oequivalent drug, he or s he wi ll only pa y the copayment or coinsurance for the bi oequivalent drug dispensed. If there i s no bioequivalent a lternative on the ma rket, the i ns ured wi l l pay the a pplicable copayment or coinsurance for the bra nd ‐na me drug di s pens ed. However, i f the phys icia n orders a bra nd‐na me drug a nd wri tes a pres cri pti on a s di s pens ed a s wri tten, the i ns ured i s res pons i bl e onl y for the copa yment or coi ns ura nce of the bra nd na me drug.

What if my drug is not on the formulary?

If your drug isn’t included in this printed list of covered drugs , you s hould vi s i t Humana.com to s ee i f your drug is covered. You can a lso contact Customer Care a nd a s k if your drug is covered.

If Huma na doesn’t cover your drug, you ha ve two opti ons:

You ca n a sk Customer Care for a list of similar drugs that a re covered by Humana. When you receive the list, s how it to your doctor and ask him or her to prescribe a s i milar drug that i s covered by Humana.

You ca n a sk Humana to ma ke an excepti on and cover your drug. See bel ow for i nformation a bout how to request an exception.

You a re res pons i bl e, when a ppl i ca bl e, for a l l or s ome of the pa yments for the fol l owi ng:

The copa yment or coi ns ura nce*; a nd

* I f the cha rge from the pharmacy dispensing the medi cation i s lower tha n the copayment or coinsurance, you will be res ponsible for the l esser a mount. The a mount we pa y the pha rmacy for the medi cation might not reflect the fi na l cos t to us . Your copa yments or co i ns ura nces a re ma de a ccordi ng to the pres cri pti on or refi l l of the pres cription a nd wi ll not be a djusted i f Humana gets a discount for volume or a sale on prescription medi cations.

Pharmacy Annual Deductibles

Deductible Individual Family Deducti ble Network Provider [$0 ‐ $200] [$0 ‐ $400] Deducti ble Non‐network Provider [$0 ‐ $600] [$0 ‐ $1,200]

Pha rmacy Annual Deductible is the a mount that a n I ndividual / Fa mily must pa y for calendar yea r before Huma na provi des payment for pharmacy covered benefits. The deductible will not a pply to Ti er 1 Drugs. Once the Indi vidual member i n a n Individual policy meets the a pplicable Individual a nnual deductible, Humana shall provide pa yment for covered benefi ts.


For Indi vidual coverage or Fa mily coverage, there i s a deductible pha rmacy s ervices i n‐network and a deductible for pha rmacy s ervices out‐of‐network. Pharmacy expenses of benefits you mi ght i ncur for covered expenses provi ded by a network provider will a pply to the network providers’ deductible. Pharmacy exp enses you might i ncur (as provider fee for i n‐network) for covered expenses provided by out of network wi ll a pply to the out of network providers’ deductible.

The a ccumulation period wi ll begin on the effecti ve da te of the pol icy a nd wi ll end when the pol icy termi nates. From there on, i t wi l l be from the renova tion date until the pol icy yea r end. Coverage Description Covered Pres cri pti on Drugs Li s t

The fol l owi ng drugs wi l l be covered when pres cri bed by a n a uthori zed doctor: 1. Drugs, medicines or medications that under Federal or state law, may be dispensed onl y by pres cri pti on from a

hea l th ca re pra cti ti oner; thi s i ncl udes bra nd, generi c, a cute a nd ma i ntena nce medi ca ti ons ; 2. Drugs, medicines or medications that a re included on the drug list, includi ng the drugs covered by the “Pa ti ent

protection and Affordable Care Act”, like contraceptives, breast ca ncer risk‐reducing medications, a mong others. 3. I ns ul i n a nd di a betes s uppl i es ; 4. Hypodermic needles or syringes when pres cri bed by a hea l th ca re pra cti ti oner for us e wi th i ns ul i n or s el f‐

a dmi nistered injectable drugs (Hypodermic needles and syringes used i n conjunction with covered drugs ma y be a va i l a bl e a t no cos t to you);

5. Speci a l ty drugs a nd Sel f‐Admi ni s tered I nj ecta bl e Drugs a pproved by Huma na ; 6. Formula and nutritional s upplements necessary for the treatment of phenylketonuria or other inherited metabolic

di s ea s es ; 7. Spa cers a nd/or pea k fl ow meters for the trea tment of a s thma ; 8. Drugs, medicines or medications on the Women’s Healthcare Drug Lis t wi th a pres cri p ti on from a hea l th ca re

pra cti ti oner; 9. Buprenorphi ne. Huma na provides for the di spensed of covered drug, rega rdless of the condition, i llness, i njury, condition or

di s ease for which they a re prescribed, i f:

• The drug ha s FDA a pprova l for a t l ea s t one i ndi ca ti on a nd

• the drug i s recognized for treatment of the di s ease, i llness, i njury, condition or disease i n ques ti on i n one of the

s ta nda rd reference compendi a or through peer ‐revi ewed medi ca l l i tera ture genera l l y a ccepted. Thi s drug coverage a lso i ncludes medi cally necessary services that a re a ssociated wi th drug a dministration.

I f you reques t a brand‐name medication when a generic medication i s a vailable, your payment i s greater. You a re res ponsible for the a pplicable generic medication copayment or coinsurance a nd 100% of the di fference between the a mount we woul d have paid the di spensing pharmacy for the brand‐name medication a nd the a mount we woul d ha ve paid the di spensing pharmacy for the generic medication. If the pres cribing physician determines tha t the brand‐name medication is medically necessary, you a re only responsible for the a pplicable copayment or coinsurance of a brand‐name medication.


Drugs, Medicines or Medications on the Women's Healthcare Drug List from a N etwork Pharmacy are Covered in Full (without cost‐sharing)

Prescription Drugs Covered without cost sharing from a Pharmacy Network Pharmacy

1. Generi c aspirin, for both men a nd women from 45 to 79 with cardiovascular risk a nd as prevention of pre‐ ecl a mpsia: a fter 12 weeks of ges tation i n women who a re a t high risk of pre‐clampsia, both wi th a medical pres cription.

2. Generi c fol i c a ci d for women pl a nni ng a pregna ncy, wi th medi ca l pres cri pti on 3. I ron supplement for infant 6 – 12 months with anemia risk and for pregnant women, with medical

pres cription 4. Ca ncer trea tment i ncluded wi thin the pha rmacy benefit a nd processed (including oral a nd a uto ‐

a dmi nistered i njectable) in a Network Pharmacy is covered i n full, with medical prescription. Intravenously a nd i ntrathecally are covered under the Ca ncer Services and Trea tment Section.

5. Brea st cancer risk‐reducing medications, with medical prescription s uch a s ta moxifen or raloxifene for women who a re a t i ncreased risk for breast ca ncer a nd a t l ow risk of a dverse effects to the drug.

6. Smoki ng cessation drugs, i ncluding over‐the‐counter (OTC), wi th medical prescription. Covers s moking ces s ation drugs for 90 consecutive days in a n a ttempt a nd two (2) ces sation a ttempts per yea r.

I mmuni zations for infants, children, a nd a dults are covered through the Medi cal Coverage i n a ccord wi th a ccepted medi cal practice a nd a s recommended by the Advisory Committee for I mmunization Practices (ACIP) of the Centers for Di sease Control (CDC), the Ameri can Academy of Pedi atrics, a nd a re a lso covered under the va ccination s chedule of the Puerto Ri co Depa rtment of Hea lth.

Benefit Program

The hea l thcare provider will be a ble to prescribe maintenance medications to the member with enough refills not to exceed 180 days, according to the plan limitations, when the medical history of the member permits i t and no risk are i dentified.

Contracted/participant pharmacy Contra cted or pa rticipant pha rmacies a re pha rmacies tha t a re l egally a uthorized by the rel evant a uthorities, which ha s s igned a contract wi t

humana insurance of puerto rico, inc.ocs.pr.gov/ocspr/files/descripcion de beneficios... ·...

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