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{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | $1.45 copay; or
$4.15 copay ;or
15% of the cost
For all other drugs,
either: $0 copay; or
$4 .30 copay; or
$10.35 copay ;or
15% of the cost $0 copay; or
$4 .30 copay; or
$10.35 copay ;or
15% of the cost
Other pharmacies are available in our network.
*Some drugs are limited to a30-day supply
ADDITIONAL DRUG COVERAGE
Erectile dysfunction (ED) drugs Covered at Tier 1cost-share amount.
Anti-Obesity drugs Covered at Tier 2cost-share amount. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | *Some drugs are limited to a30-day supply
ADDITIONAL DRUG COVERAGE
Erectile dysfunction (ED) drugs Covered at Tier 1cost-share amount.
Anti-Obesity drugs Covered at Tier 2cost-share amount.
Prescription Vitamins Covered at Tier 1cost-share amount.
Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the
Part Dbenefit and if you qualify for "Extra Help." To find out if you qualify for "Extra Help," please contact |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Part Dbenefit and if you qualify for "Extra Help." To find out if you qualify for "Extra Help," please contact
the Social Security Office at 1-800-772-1213 Monday —Friday, 7a.m. —7p.m. TTY users should call
1-800-325-0778. For more information on your prescription drug benefit, please call us or access your
"Evidence of Coverage" online.
If you reside in along-term care facility, you pay the same as at aretail pharmacy. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | "Evidence of Coverage" online.
If you reside in along-term care facility, you pay the same as at aretail pharmacy.
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network
pharmacy. 16 Summary of Benefits H5216324000SB23 H5216324000
Coverage Gap
After you enter the coverage gap, you pay 25 percent of the plan's cost for covered brand name drugs
and 25 percent of the plan's cost for covered generic drugs until your out-of-pocket costs total $7,400 — |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | and 25 percent of the plan's cost for covered generic drugs until your out-of-pocket costs total $7,400 —
which is the end of the coverage gap. Not everyone will enter the coverage gap.
Under this plan, you may pay even less for the following:
Tier 1(Preferred Generic) - All Drugs
Tier 2(Generic) - All Drugs
Tier 3(Preferred Brand) - Select Insulin Drugs
For more information on cost sharing in the coverage gap, please call us or access your Evidence of
Coverage online.
Catastrophic Coverage |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Tier 3(Preferred Brand) - Select Insulin Drugs
For more information on cost sharing in the coverage gap, please call us or access your Evidence of
Coverage online.
Catastrophic Coverage
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and
through mail order) reach $7,400 ,you pay the greater of:
•5% of the cost, or
•$4.15 copay for generic (including brand drugs treated as generic) and a $10.35 copay for all other
drugs
Additional Benefits |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | •5% of the cost, or
•$4.15 copay for generic (including brand drugs treated as generic) and a $10.35 copay for all other
drugs
Additional Benefits
IN-NETWORK OUT-OF-NETWORK
Medicare-covered foot care
(podiatry) $30 copay $30 copay
Medicare-covered chiropractic
services $20 copay $20 copay
MEDICAL EQUIPMENT/SUPPLIES
Durable medical equipment (like
wheelchairs or oxygen) 20% of the cost 20% of the cost
Medical Supplies 20% of the cost 20% of the cost
Prosthetics (artificial limbs or |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | MEDICAL EQUIPMENT/SUPPLIES
Durable medical equipment (like
wheelchairs or oxygen) 20% of the cost 20% of the cost
Medical Supplies 20% of the cost 20% of the cost
Prosthetics (artificial limbs or
braces) 20% of the cost 20% of the cost
Diabetic monitoring supplies
Cost share may vary depending
on where service is provided. $0 copay or 10% to 20% of the
cost 10% to 20% of the cost
REHABILITATION SERVICES
Occupational and speech
therapy
Cost share may vary depending |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | on where service is provided. $0 copay or 10% to 20% of the
cost 10% to 20% of the cost
REHABILITATION SERVICES
Occupational and speech
therapy
Cost share may vary depending
on the service and where service
is provided. $20 to $30 copay $20 to $30 copay
Cardiac rehabilitation $10 copay $10 copay H5216324000SB23 Summary of Benefits 17 H5216324000
Pulmonary rehabilitation $10 copay $10 copay
TELEHEALTH SERVICES (in addition to Original Medicare) |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Cardiac rehabilitation $10 copay $10 copay H5216324000SB23 Summary of Benefits 17 H5216324000
Pulmonary rehabilitation $10 copay $10 copay
TELEHEALTH SERVICES (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 18 Summary of Benefits H5216324000SB23 H5216324000
More benefits with your plan |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Urgent care services $0 copay Not Covered
Substance abuse or behavioral
health services $0 copay Not Covered 18 Summary of Benefits H5216324000SB23 H5216324000
More benefits with your plan
Enjoy some of these extra benefits included in your plan .
This is asummary of what we cover. It doesn't list every service that we cover or list
every limitation or exclusion. The Evidence of Coverage (EOC) provides acomplete list of |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | This is asummary of what we cover. It doesn't list every service that we cover or list
every limitation or exclusion. The Evidence of Coverage (EOC) provides acomplete list of
coverage and services. Visit Humana.com/medicare to view acopy of the EOC or call
1-800-833-2364 .
Travel Coverage
The PPO national network gives you
in-network coverage across the country,
so you can see any doctor who accepts
the plan terms and conditions. You'll be
able to travel with ease or split your |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | The PPO national network gives you
in-network coverage across the country,
so you can see any doctor who accepts
the plan terms and conditions. You'll be
able to travel with ease or split your
time between locations. Visit
Humana.com or contact Customer Care
on the back of your ID card if you need
help finding an in-network provider.
Humana Well Dine ®Meal Program
Humana's home delivered meal
program for members following an
inpatient stay in the hospital or nursing
facility. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | help finding an in-network provider.
Humana Well Dine ®Meal Program
Humana's home delivered meal
program for members following an
inpatient stay in the hospital or nursing
facility.
Over-the-Counter (OTC) mail order
$50 maximum benefit coverage
amount per quarter (3 months) for
select over-the-counter health and
wellness products.
Unused quarterly funds carry over to the
next quarter and expire at the end of
the plan year.
Rewards and Incentives
Go365 by Humana ®aRewards and |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | wellness products.
Unused quarterly funds carry over to the
next quarter and expire at the end of
the plan year.
Rewards and Incentives
Go365 by Humana ®aRewards and
Incentive program for completing
certain preventive health screenings and
health and wellness activities.
SilverSneakers ®fitness program
Basic fitness center membership
including fitness classes. H5216324000SB23 Summary of Benefits 19 H5216324000 |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | health and wellness activities.
SilverSneakers ®fitness program
Basic fitness center membership
including fitness classes. H5216324000SB23 Summary of Benefits 19 H5216324000
Humana MyOption optional supplemental benefits (OSB) are only available to members of certain Humana Medicare
Advantage (MA) plans. Members of Humana plans that offer OSBs may enroll in OSBs throughout the year. Benefits |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Advantage (MA) plans. Members of Humana plans that offer OSBs may enroll in OSBs throughout the year. Benefits
may change on January 1each year. Enrollees must use network providers for specific OSBs when stated in the
Evidence of Coverage (EOC); otherwise, covered services may be received from non-network providers at ahigher
cost. Enrollees must continue to pay the Medicare Part Bpremium, their Humana plan premium and the OSB
premium. Optional Supplemental Benefits |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | cost. Enrollees must continue to pay the Medicare Part Bpremium, their Humana plan premium and the OSB
premium. Optional Supplemental Benefits
Customize your coverage for an extra monthly premium when you enroll. You can
choose from the following to help create your Medicare plan.
$37.10 MyOption DEN478
Offers coverage for certain preventive, basic, and major services at both
in-network (HumanaDental Medicare network) and out-of-network |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | $37.10 MyOption DEN478
Offers coverage for certain preventive, basic, and major services at both
in-network (HumanaDental Medicare network) and out-of-network
dentists. These extra benefits –in addition to your basic benefits –have
an additional monthly premium. 20
H5216_SB_MAPD_PPO_324000_2023_M Summary of Benefits H5216324000SB23 To find out more about the coverage and costs of Original Medicare, look in the current “Medicare &You” |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | H5216_SB_MAPD_PPO_324000_2023_M Summary of Benefits H5216324000SB23 To find out more about the coverage and costs of Original Medicare, look in the current “Medicare &You”
handbook. View it online at http://www.medicare.gov or get acopy by calling 1-800-MEDICARE (1-800-633-4227),
24 hours aday, seven days aweek. TTY users should call 1-877-486-2048.
Telehealth services shown are in addition to the Original Medicare covered telehealth. Your cost may be different |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 24 hours aday, seven days aweek. TTY users should call 1-877-486-2048.
Telehealth services shown are in addition to the Original Medicare covered telehealth. Your cost may be different
for Original Medicare telehealth.
Limitations on telehealth services, also referred to as virtual visits or telemedicine, vary by state. These services
are not asubstitute for emergency care and are not intended to replace your primary care provider or other |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | are not asubstitute for emergency care and are not intended to replace your primary care provider or other
providers in your network. Any descriptions of when to use telehealth services are for informational purposes only
and should not be construed as medical advice. Please refer to your evidence of coverage for additional details
on what your plan may cover or other rules that may apply.
Plans may offer supplemental benefits in addition to Part Cbenefits and Part Dbenefits. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | on what your plan may cover or other rules that may apply.
Plans may offer supplemental benefits in addition to Part Cbenefits and Part Dbenefits.
Out-of-network/non-contracted providers are under no obligation to treat Humana members, except in
emergency situations. Please call our customer service number or see your Evidence of Coverage for more |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 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. You can see our plan's provider and pharmacy directory at our website at
humana.com/finder/search or call us at the number listed at the beginning of
this booklet and we will send you one.
You can see our plan's drug guide at our website at |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | humana.com/finder/search or call us at the number listed at the beginning of
this booklet and we will send you one.
You can see our plan's drug guide at our website at
humana.com/medicaredruglist or call us at the number listed at the beginning
of this booklet and we will send you one. Find out more H5216_OSB_23_454_M H5216324000OSB23 Optional
Supplemental Benefits
HumanaChoice H5216-324 (PPO)
Kentucky |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | of this booklet and we will send you one. Find out more H5216_OSB_23_454_M H5216324000OSB23 Optional
Supplemental Benefits
HumanaChoice H5216-324 (PPO)
Kentucky
Kentucky and Southern Indiana 2023 22 – 2023 OPTIONAL SUPPLEMENTAL BENEFITS My Options, My Choice
Adding Benefits to Your Plan
You’re unique and have unique needs. That's why Humana offers optional supplemental benefits (OSB). For
an extra monthly premium you can customize your Humana Medicare Advantage plan. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | You’re unique and have unique needs. That's why Humana offers optional supplemental benefits (OSB). For
an extra monthly premium you can customize your Humana Medicare Advantage plan.
The information in this booklet will tell you about the benefits you can add to your plan. You can add
these extra benefits when you sign up for your Medicare Advantage plan. You can also add these
benefits after Medicare open enrollment ends on December 7by contacting your agent or calling OSB |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | these extra benefits when you sign up for your Medicare Advantage plan. You can also add these
benefits after Medicare open enrollment ends on December 7by contacting your agent or calling OSB
sales at 1-888-413-7026. OSB sales is available from 8a.m. –8p.m. local time, seven days aweek
October 1–March 31, and Monday through Friday April 1–September 30.
MyOption (DEN478)
This dental plan covers certain preventive, basic and major dental services. It is an extra benefit you may |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | October 1–March 31, and Monday through Friday April 1–September 30.
MyOption (DEN478)
This dental plan covers certain preventive, basic and major dental services. It is an extra benefit you may
choose to add to your Medicare Advantage plan. However, you will have to pay an extra monthly premium
for it.
In this plan, you may receive your care from either an in-network or out-of-network dentist. If you use an
out-of-network dentist, your share of the cost may be higher.
Monthly Cost |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | for it.
In this plan, you may receive your care from either an in-network or out-of-network dentist. If you use an
out-of-network dentist, your share of the cost may be higher.
Monthly Cost
Monthly Premium $37.10
Coverage Information
Maximum plan benefit
(combined in and out-of-network) $2,000 per calendar year
Deductible $0 per calendar year
You may receive the following dental services:
Plan covers up to $2,000 allowance every year for non-Medicare covered preventive and comprehensive |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Deductible $0 per calendar year
You may receive the following dental services:
Plan covers up to $2,000 allowance every year for non-Medicare covered preventive and comprehensive
dental services. You are responsible for any amount above the dental coverage limit. Any amount unused
at the end of the year will expire.
Your benefit can be used for most dental treatments such as:
•Preventive dental services, such as exams, routine cleanings, etc. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | at the end of the year will expire.
Your benefit can be used for most dental treatments such as:
•Preventive dental services, such as exams, routine cleanings, etc.
•Basic dental services, such as fillings, extractions, etc.
•Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges, etc.
Note: The allowance cannot be used on cosmetic services and implants. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | •Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges, etc.
Note: The allowance cannot be used on cosmetic services and implants.
*Network dentists have agreed to provide services at anegotiated rate. If you see anetwork dentist, you
cannot be billed more than that rate.
Out-of-network dentists have not agreed to provide services at contracted fees. Benefits received |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | cannot be billed more than that rate.
Out-of-network dentists have not agreed to provide services at contracted fees. Benefits received
out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. You may
be billed by the out-of-network provider for any amount greater than the payment made by Humana to
the provider. Please see below for provider locator instructions. 2023 OPTIONAL SUPPLEMENTAL BENEFITS – 23 OPTIONAL SUPPLEMENTAL BENEFITS S(continued) |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | the provider. Please see below for provider locator instructions. 2023 OPTIONAL SUPPLEMENTAL BENEFITS – 23 OPTIONAL SUPPLEMENTAL BENEFITS S(continued)
Dental services are subject to our standard claims review procedures which could include dental history to
approve coverage. Dental benefits may not cover all American Dental Association procedure codes.
Information regarding each plan is available at Humana.com/sb . |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | approve coverage. Dental benefits may not cover all American Dental Association procedure codes.
Information regarding each plan is available at Humana.com/sb .
The Humana Optional Supplemental Dental benefits are provided through the Humana Dental Medicare
Network. The provider locator can be found at Humana.com >Find aDoctor >Select the Dentist icon
from the menu >From the Distance drop down select preferred distance >Enter zip code >From the |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Network. The provider locator can be found at Humana.com >Find aDoctor >Select the Dentist icon
from the menu >From the Distance drop down select preferred distance >Enter zip code >From the
look up method select All Dental Networks >Then select HumanaDental Medicare. Humana is aMedicare Advantage PPO plan with aMedicare contract. Enrollment in this Humana plan depends on
contract renewal. Humana MyOption Optional Supplemental Benefits (OSB) are only available to members of |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | contract renewal. Humana MyOption Optional Supplemental Benefits (OSB) are only available to members of
certain Humana Medicare Advantage (MA) plans. Members of Humana plans that offer OSBs may enroll in OSBs
throughout the year. Benefits may change on January 1st each year. Enrollees must use network providers for
specific OSBs when stated in the Evidence of Coverage (EOC); otherwise, covered services may be received from |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | specific OSBs when stated in the Evidence of Coverage (EOC); otherwise, covered services may be received from
non-network providers at ahigher cost. Enrollees must continue to pay the Medicare Part Bpremium, their
Humana premium, and the OSB premium.
Humana.com Notes Notes H5216324000SB23 Summary of Benefits 27 H5216324000
GHHLNNXEN 0522 Important________________________________________________
At Humana, it is important you are treated fairly. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | Humana.com Notes Notes H5216324000SB23 Summary of Benefits 27 H5216324000
GHHLNNXEN 0522 Important________________________________________________
At Humana, it is important you are treated fairly.
Humana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color, national
origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity, marital status, |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity, marital status,
religion, or language. Discrimination is against the law. Humana and its subsidiaries comply with applicable
federal civil rights laws. If you believe that you have been discriminated against by Humana or its
subsidiaries, there are ways to get help.
•You may file acomplaint, also known as agrievance:
Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618. |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | subsidiaries, there are ways to get help.
•You may file acomplaint, also known as agrievance:
Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.
If you need help filing agrievance, call 1-877-320-1235 or if you use a TTY ,call 711 .
•You can also file acivil rights complaint with the U.S. Department of Health and Human Services ,Office
for Civil Rights electronically through their Complaint Portal, available at |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | •You can also file acivil rights complaint with the U.S. Department of Health and Human Services ,Office
for Civil Rights electronically through their Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf ,or at U.S. Department of Health and Human Services ,
200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019,
800-537-7697 (TDD) .Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html . |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019,
800-537-7697 (TDD) .Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html .
•California residents: You may also call California Department of Insurance toll-free hotline number:
1-800-927-HELP (4357) ,to file agrievance.
Auxiliary aids and services, free of charge, are available to you.
1-877-320-1235 (TTY: 711) |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | 1-800-927-HELP (4357) ,to file agrievance.
Auxiliary aids and services, free of charge, are available to you.
1-877-320-1235 (TTY: 711)
Humana provides free auxiliary aids and services, such as qualified sign language interpreters, video remote
interpretation, and written information in other formats to people with disabilities when such auxiliary aids |
{'source': PosixPath('pdf_library/H5216_324_H5216324000SB23.pdf')} | interpretation, and written information in other formats to people with disabilities when such auxiliary aids
and services are necessary to ensure an equal opportunity to participate. 28 Summary of Benefits H5216324000SB23 H5216324000 H5216324000SB23 Summary of Benefits 29 H5216324000 HumanaChoice H5216-324 (PPO)
H5216324000 ENG
Kentucky and Southern Indiana
Humana.com
GNHH4HGEN_23_C Summary of Benefits H5216324000SB23 |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Summary of Benefits SBOSB033
Humana Gold Plus SNP-DE H5619-075 (HMO D-SNP)
Central Kentucky
Central Kentucky Area
Our service area includes the following county/counties in Kentucky: Allen, Anderson,
Barren, Bath, Bourbon, Boyd, Boyle, Bullitt, Butler, Carter, Casey, Clark, Edmonson,
Fayette, Franklin, Greenup, Hardin, Hart, Henry, Jefferson, Jessamine, Lincoln, Logan,
Madison, Menifee, Metcalfe, Monroe, Montgomery, Nelson, Oldham, Powell, Scott, |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Fayette, Franklin, Greenup, Hardin, Hart, Henry, Jefferson, Jessamine, Lincoln, Logan,
Madison, Menifee, Metcalfe, Monroe, Montgomery, Nelson, Oldham, Powell, Scott,
Shelby, Simpson, Spencer, Warren, Woodford. 2023
GNHH4HIEN_23_C Summary of Benefits H5619075000SB23 Pre-Enrollment Checklist
Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | GNHH4HIEN_23_C Summary of Benefits H5619075000SB23 Pre-Enrollment Checklist
Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you
have any questions, you can call and speak to acustomer service representative at 1-800-833-2364 (TTY:
711) .
Understanding the Benefits
The Evidence of Coverage (EOC) provides acomplete list of all coverage and services. It is important |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | 711) .
Understanding the Benefits
The Evidence of Coverage (EOC) provides acomplete list of all coverage and services. It is important
to review plan coverage, costs and benefits before you enroll. Visit Humana.com/medicare or call
1-800-833-2364 (TTY: 711) to view acopy of the EOC.
Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the
network. If they are not listed, it means you will likely have to select anew doctor. |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the
network. If they are not listed, it means you will likely have to select anew doctor.
Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is
in the network. If the pharmacy is not listed, you will likely have to select anew pharmacy for your
prescriptions.
Review the formulary to make sure your drugs are covered.
Understanding Important Rules |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | prescriptions.
Review the formulary to make sure your drugs are covered.
Understanding Important Rules
Benefits, premiums and/or copayments/co-insurance may change on January 1, 2024.
Except in emergency or urgent situations, we do not cover services by out-of-network providers
(doctors who are not listed in the provider directory).
This plan is adual eligible special needs plan (D-SNP). Your ability to enroll will be based on |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | (doctors who are not listed in the provider directory).
This plan is adual eligible special needs plan (D-SNP). Your ability to enroll will be based on
verification that you are entitled to both Medicare and medical assistance from astate plan under
Medicaid. This plan may enroll FBDE, QMB, QMB+, SLMB+. Summary of Benefits
Humana Gold Plus SNP-DE H5619-075 (HMO D-SNP)
Central Kentucky
Central Kentucky Area 2023 |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Medicaid. This plan may enroll FBDE, QMB, QMB+, SLMB+. Summary of Benefits
Humana Gold Plus SNP-DE H5619-075 (HMO D-SNP)
Central Kentucky
Central Kentucky Area 2023
Our service area includes the following county/counties in Kentucky: Allen, Anderson,
Barren, Bath, Bourbon, Boyd, Boyle, Bullitt, Butler, Carter, Casey, Clark, Edmonson,
Fayette, Franklin, Greenup, Hardin, Hart, Henry, Jefferson, Jessamine, Lincoln, Logan, |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Barren, Bath, Bourbon, Boyd, Boyle, Bullitt, Butler, Carter, Casey, Clark, Edmonson,
Fayette, Franklin, Greenup, Hardin, Hart, Henry, Jefferson, Jessamine, Lincoln, Logan,
Madison, Menifee, Metcalfe, Monroe, Montgomery, Nelson, Oldham, Powell, Scott,
Shelby, Simpson, Spencer, Warren, Woodford.
H5619_SB_MAPD_HMO_075000_2023_M Summary of Benefits H5619075000SB23 H5619075000SB23 Summary of Benefits 5H5619075000
Let's talk about Humana Gold Plus SNP-DE
H5619-075 (HMO D-SNP) |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | H5619_SB_MAPD_HMO_075000_2023_M Summary of Benefits H5619075000SB23 H5619075000SB23 Summary of Benefits 5H5619075000
Let's talk about Humana Gold Plus SNP-DE
H5619-075 (HMO D-SNP)
Find out more about the Humana Gold Plus SNP-DE H5619-075 (HMO D-SNP) plan -including
the health and drug services it covers -in this easy-to-use guide.
Humana Gold Plus SNP-DE H5619-075 (HMO D-SNP) is aCoordinated Care plan HMO with a |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | the health and drug services it covers -in this easy-to-use guide.
Humana Gold Plus SNP-DE H5619-075 (HMO D-SNP) is aCoordinated Care plan HMO with a
Medicare contract and acontract with the Kentucky Department of Medicaid Services (DMS)
program. Enrollment in this Humana plan depends on contract renewal.
The benefit information provided is asummary of what we cover and what you pay. It doesn't |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | program. Enrollment in this Humana plan depends on contract renewal.
The benefit information provided is asummary of what we cover and what you pay. It doesn't
list every service that we cover or list every limitation or exclusion. For acomplete list of services
we cover, ask us for the "Evidence of Coverage".
As amember you must select an in-network doctor to act as your Primary Care Provider (PCP). Humana Gold |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | we cover, ask us for the "Evidence of Coverage".
As amember you must select an in-network doctor to act as your Primary Care Provider (PCP). Humana Gold
Plus SNP-DE H5619-075 (HMO D-SNP) has anetwork of doctors, hospitals, pharmacies and other providers. If
you use providers who aren’t in our network, the plan may not pay for these services. You have access to
Care Managers. Care Managers are nurses or care coordinators who support your health and well-being by |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Care Managers. Care Managers are nurses or care coordinators who support your health and well-being by
providing additional services including: acute and chronic-care management, telephonic and in-person
health support, assistance in coordinating Medicare and Medicaid benefits, educational resources and
workshops, and support for families and caregivers.
To be eligible
To enroll in Humana Gold Plus SNP-DE H5619-075
(HMO D-SNP), aDual Eligible Special Needs Plan, you |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | workshops, and support for families and caregivers.
To be eligible
To enroll in Humana Gold Plus SNP-DE H5619-075
(HMO D-SNP), aDual Eligible Special Needs Plan, you
must be entitled to Medicare Part Aand enrolled in
Medicare Part B, live in our service area and also
receive certain levels of assistance from the Kentucky
Department of Medicaid Services (DMS). If you
receive both Medicare and Medicaid benefits, this
means you are dual eligible.
Humana Gold Plus SNP-DE H5619-075 (HMO D-SNP) |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Department of Medicaid Services (DMS). If you
receive both Medicare and Medicaid benefits, this
means you are dual eligible.
Humana Gold Plus SNP-DE H5619-075 (HMO D-SNP)
may enroll FBDE, QMB, QMB+, SLMB+.
Qualified Medicare Beneficiary (QMB): Helps pay
Medicare Part Aand Part Bpremiums, and other cost
sharing (like deductibles, coinsurance, and
copayments).
Qualified Medicare Beneficiary Plus (QMB+): Helps pay
Medicare Part Aand Part Bpremiums, and other |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | sharing (like deductibles, coinsurance, and
copayments).
Qualified Medicare Beneficiary Plus (QMB+): Helps pay
Medicare Part Aand Part Bpremiums, and other
cost-sharing (like deductibles, coinsurance, and
copayments) and provides full Medicaid benefits for
Medicaid services provided by Medicaid providers.
Specified Low-Income Medicare Beneficiary Plus
(SLMB+): Helps pay Part Bpremiums and provides full
Medicaid benefits for Medicaid services provided by
Medicaid providers. |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Specified Low-Income Medicare Beneficiary Plus
(SLMB+): Helps pay Part Bpremiums and provides full
Medicaid benefits for Medicaid services provided by
Medicaid providers.
Full Benefit Dual Eligible (FBDE): Financial assistance
may be available to pay Medicare Part APremiums,
and/or Medicare Part BPremiums, and other
cost-sharing (like deductibles, coinsurance, and
copayments) and provides full Medicaid benefits.
Plan name: |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | may be available to pay Medicare Part APremiums,
and/or Medicare Part BPremiums, and other
cost-sharing (like deductibles, coinsurance, and
copayments) and provides full Medicaid benefits.
Plan name:
Humana Gold Plus SNP-DE H5619-075 (HMO D-SNP) More about Humana Gold Plus SNP-DE
H5619-075 (HMO D-SNP)
As amember of this plan, you will not be responsible
for cost sharing for plan benefits. The Medicaid
Comparison Chart shows specific benefits that |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | H5619-075 (HMO D-SNP)
As amember of this plan, you will not be responsible
for cost sharing for plan benefits. The Medicaid
Comparison Chart shows specific benefits that
Medicaid may cover for some dual eligible members.
You will work with your Humana care coordinator to
understand and access these benefits from the
Kentucky Department of Medicaid Services (DMS)
after any Humana Gold Plus SNP-DE H5619-075 (HMO
D-SNP) benefits are used. The Covered Medical and |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | understand and access these benefits from the
Kentucky Department of Medicaid Services (DMS)
after any Humana Gold Plus SNP-DE H5619-075 (HMO
D-SNP) benefits are used. The Covered Medical and
Hospital Benefits chart shows the benefits you will
receive from Humana.
Be sure to show the Kentucky Department of
Medicaid Services (DMS) ID card in addition to your
Humana membership card to make your provider
aware that you also have Medicaid coverage. You |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Be sure to show the Kentucky Department of
Medicaid Services (DMS) ID card in addition to your
Humana membership card to make your provider
aware that you also have Medicaid coverage. You
may be required to pay asmall Medicaid specific
co-payment. Your services are paid first by Humana
and then by Medicaid.
How to reach us:
If you have questions about your benefits or your level
of eligibility for assistance from Medicaid, you should
contact Humana's Customer Care department or the |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | How to reach us:
If you have questions about your benefits or your level
of eligibility for assistance from Medicaid, you should
contact Humana's Customer Care department or the
Kentucky Department of Medicaid Services (DMS)for
further details.
If you’re amember of this plan, call toll-free:
1-800-457-4708 (TTY: 711) .6 Summary of Benefits H5619075000SB23 H5619075000
If you’re not amember of this plan, call toll free:
1-800-833-2364 (TTY: 711) .
October 1-March 31: |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | 1-800-457-4708 (TTY: 711) .6 Summary of Benefits H5619075000SB23 H5619075000
If you’re not amember of this plan, call toll free:
1-800-833-2364 (TTY: 711) .
October 1-March 31:
Call 7days aweek from 8a.m. -8p.m.
April 1-September 30:
Call Monday -Friday, 8a.m. -8p.m.
Or visit our website: Humana.com/medicare .
Medicaid benefits last validated on 07/01/2022 and
are subject to change.
For the most current Kentucky Medicaid coverage
information, please visit the Kentucky Department of |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Medicaid benefits last validated on 07/01/2022 and
are subject to change.
For the most current Kentucky Medicaid coverage
information, please visit the Kentucky Department of
Medicaid Services (DMS) website at
https://chfs.ky.gov/agencies/dms/Pages/default.as
px or call the Medicaid Hotline at 1-800-635-2570
(TTY: 711). Ahealthy partnership
Get more from your plan —with
extra services and resources |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | https://chfs.ky.gov/agencies/dms/Pages/default.as
px or call the Medicaid Hotline at 1-800-635-2570
(TTY: 711). Ahealthy partnership
Get more from your plan —with
extra services and resources
provided by Humana !You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please
contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
H5619075000SB23 Summary of Benefits 7H5619075000
Monthly Premium, Deductible and Limits
Monthly plan premium $0
You must keep paying your Medicare Part Bpremium. Your Part A
and/or Part Bpremium may be paid on your behalf by the Kentucky |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Monthly Premium, Deductible and Limits
Monthly plan premium $0
You must keep paying your Medicare Part Bpremium. Your Part A
and/or Part Bpremium may be paid on your behalf by the Kentucky
Department of Medicaid Services (DMS) Program.
Medical deductible This plan does not have adeductible.
Pharmacy (Part D) deductible $0 if you qualify for "Extra Help"
Maximum out-of-pocket
responsibility This plan does not have amaximum out-of-pocket responsibility.
Covered Medical and Hospital Benefits |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Maximum out-of-pocket
responsibility This plan does not have amaximum out-of-pocket responsibility.
Covered Medical and Hospital Benefits
N/A WHAT YOU PAY ON THIS HUMANA PLAN
ACUTE INPATIENT HOSPITAL CARE
N/A $0 copay
OUTPATIENT HOSPITAL COVERAGE
Outpatient surgery at
outpatient hospital $0 copay
Outpatient surgery at
ambulatory surgical center $0 copay
DOCTOR OFFICE VISITS
Primary care provider (PCP) $0 copay
Specialists $0 copay
PREVENTIVE CARE |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | outpatient hospital $0 copay
Outpatient surgery at
ambulatory surgical center $0 copay
DOCTOR OFFICE VISITS
Primary care provider (PCP) $0 copay
Specialists $0 copay
PREVENTIVE CARE
N/A Our plan covers many preventive services at no cost when you see
an in-network provider including:
•Abdominal aortic aneurysm Screening
•Alcohol misuse counseling
•Bone mass measurement
•Breast cancer screening (mammogram)
•Cardiovascular disease (behavioral therapy)
•Cardiovascular screenings |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | •Abdominal aortic aneurysm Screening
•Alcohol misuse counseling
•Bone mass measurement
•Breast cancer screening (mammogram)
•Cardiovascular disease (behavioral therapy)
•Cardiovascular screenings
•Cervical and vaginal cancer screening
•Colorectal cancer screenings (colonoscopy, fecal occult blood test,
flexible sigmoidoscopy)
•Depression screening
•Diabetes screenings |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | •Cervical and vaginal cancer screening
•Colorectal cancer screenings (colonoscopy, fecal occult blood test,
flexible sigmoidoscopy)
•Depression screening
•Diabetes screenings
•HIV screening You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please
contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
8 Summary of Benefits H5619075000SB23 H5619075000
Covered Medical and Hospital Benefits (cont.)
N/A WHAT YOU PAY ON THIS HUMANA PLAN
•Medical nutrition therapy services
•Obesity screening and counseling
•Prostate cancer screenings (PSA) |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Covered Medical and Hospital Benefits (cont.)
N/A WHAT YOU PAY ON THIS HUMANA PLAN
•Medical nutrition therapy services
•Obesity screening and counseling
•Prostate cancer screenings (PSA)
•Sexually transmitted infections screening and counseling
•Tobacco use cessation counseling (counseling for people with no
sign of tobacco-related disease)
•Vaccines, including flu shots, hepatitis Bshots, pneumococcal shots
•"Welcome to Medicare" preventive visit (one-time)
•Annual Wellness Visit |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | sign of tobacco-related disease)
•Vaccines, including flu shots, hepatitis Bshots, pneumococcal shots
•"Welcome to Medicare" preventive visit (one-time)
•Annual Wellness Visit
•Lung cancer screening
•Routine physical exam
•Medicare diabetes prevention program
Any additional preventive services approved by Medicare during the
contract year will be covered.
EMERGENCY CARE
Emergency room
If you are admitted to the
hospital within 24 hours, you do
not have to pay your share of the |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | contract year will be covered.
EMERGENCY CARE
Emergency room
If you are admitted to the
hospital within 24 hours, you do
not have to pay your share of the
cost for the emergency care. $0 copay
Urgently needed services
Urgently needed services are
provided to treat a non-emergency,
unforeseen medical illness, injury or
condition that requires immediate
medical attention.$0 copay
DIAGNOSTIC SERVICES, LABS AND IMAGING
Diagnostic mammography $0 copay
Diagnostic radiology $0 copay |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | condition that requires immediate
medical attention.$0 copay
DIAGNOSTIC SERVICES, LABS AND IMAGING
Diagnostic mammography $0 copay
Diagnostic radiology $0 copay
Lab services $0 copay
Diagnostic tests and procedures $0 copay
Outpatient X-rays $0 copay
Radiation therapy $0 copay
HEARING SERVICES
Medicare-covered hearing $0 copay
Routine hearing HER945 |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Lab services $0 copay
Diagnostic tests and procedures $0 copay
Outpatient X-rays $0 copay
Radiation therapy $0 copay
HEARING SERVICES
Medicare-covered hearing $0 copay
Routine hearing HER945
•$0 copay for routine hearing exams up to 1every year. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please
contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
H5619075000SB23 Summary of Benefits 9H5619075000
Covered Medical and Hospital Benefits (cont.)
N/A WHAT YOU PAY ON THIS HUMANA PLAN
•$0 copay for each Advanced level hearing aid up to 1per ear every
3years.
Hearing aid purchase includes: |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Covered Medical and Hospital Benefits (cont.)
N/A WHAT YOU PAY ON THIS HUMANA PLAN
•$0 copay for each Advanced level hearing aid up to 1per ear every
3years.
Hearing aid purchase includes:
•Unlimited follow-up provider visits during first year following
TruHearing hearing aid purchase
•60-day trial period
•3-year extended warranty
•80 batteries per aid for non-rechargeable models
You must see aTruHearing provider to use this benefit. Call |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | TruHearing hearing aid purchase
•60-day trial period
•3-year extended warranty
•80 batteries per aid for non-rechargeable models
You must see aTruHearing provider to use this benefit. Call
1-844-255-7144 to schedule an appointment (for TTY, dial 711).
DENTAL SERVICES
Medicare-covered dental $0 copay
Routine dental
Dental services are subject to our
standard claims review
procedures which could include
dental history to approve
coverage. Dental benefits under |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Routine dental
Dental services are subject to our
standard claims review
procedures which could include
dental history to approve
coverage. Dental benefits under
this plan may not cover all
American Dental Association
procedure codes. Information
regarding each plan is available
at Humana.com/sb .
Network dentists have agreed to
provide services at contracted
fees (the in-network fee
schedules, or INFS). If amember
visits aparticipating network
dentist, the member will not |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Network dentists have agreed to
provide services at contracted
fees (the in-network fee
schedules, or INFS). If amember
visits aparticipating network
dentist, the member will not
receive abill for charges more
than the negotiated fee schedule
on covered services (coinsurance
payment still applies).
Use the HumanaDental Medicare
network for the Mandatory
Supplemental Dental. The
provider locator can be found at DEN142 |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | on covered services (coinsurance
payment still applies).
Use the HumanaDental Medicare
network for the Mandatory
Supplemental Dental. The
provider locator can be found at DEN142
•$0 copay for scaling and root planing (deep cleaning) up to 1per
quadrant every 3years.
•$0 copay for comprehensive oral evaluation or periodontal exam,
occlusal adjustment, scaling for moderate inflammation up to 1
every 3years.
•$0 copay for bridges, complete dentures, crown recementation, |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | occlusal adjustment, scaling for moderate inflammation up to 1
every 3years.
•$0 copay for bridges, complete dentures, crown recementation,
denture recementation, panoramic film or diagnostic x-rays, partial
dentures up to 1every 5years.
•$0 copay for crown, root canal, root canal retreatment up to 1per
tooth per lifetime.
•$0 copay for bitewing x-rays, intraoral x-rays up to 1set(s) per year.
•$0 copay for adjustments to dentures, denture rebase, denture |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | tooth per lifetime.
•$0 copay for bitewing x-rays, intraoral x-rays up to 1set(s) per year.
•$0 copay for adjustments to dentures, denture rebase, denture
reline, denture repair, emergency diagnostic exam, tissue
conditioning up to 1per year.
•$0 copay for emergency treatment for pain, fluoride treatment, oral
surgery, periodic oral exam, prophylaxis (cleaning) up to 2per year.
•$0 copay for periodontal maintenance up to 4per year.
•$0 copay for amalgam and/or composite filling, necessary |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | surgery, periodic oral exam, prophylaxis (cleaning) up to 2per year.
•$0 copay for periodontal maintenance up to 4per year.
•$0 copay for amalgam and/or composite filling, necessary
anesthesia with covered service, simple or surgical extraction up to
unlimited per year.
•$5000 maximum benefit coverage amount per year for preventive
and comprehensive benefits. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | and comprehensive benefits. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please
contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
10 Summary of Benefits H5619075000SB23 H5619075000
Covered Medical and Hospital Benefits (cont.) |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | plan .
c
10 Summary of Benefits H5619075000SB23 H5619075000
Covered Medical and Hospital Benefits (cont.)
N/A WHAT YOU PAY ON THIS HUMANA PLAN
Humana.com >Find aDoctor >
from the Search Type drop down
select Dental >under Coverage
type select All Dental Networks >
enter zip code >from the
network drop down select
HumanaDental Medicare.
VISION SERVICES
Medicare-covered vision
services $0 copay
Medicare-covered diabetic eye
exam $0 copay
Medicare-covered glaucoma
screening $0 copay |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | network drop down select
HumanaDental Medicare.
VISION SERVICES
Medicare-covered vision
services $0 copay
Medicare-covered diabetic eye
exam $0 copay
Medicare-covered glaucoma
screening $0 copay
Medicare-covered eyewear
(post-cataract) $0 copay
Routine vision
The provider locator for routine
vision can be found at
Humana.com >Find aDoctor >
select Vision care icon >Vision
coverage through Medicare
Advantage plans. VIS733
•$0 copay for routine exam up to 1per year. |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | vision can be found at
Humana.com >Find aDoctor >
select Vision care icon >Vision
coverage through Medicare
Advantage plans. VIS733
•$0 copay for routine exam up to 1per year.
•$300 maximum benefit coverage amount per year for contact
lenses or eyeglasses-lenses and frames, fitting for
eyeglasses-lenses and frames.
•Eyeglass lens options may be available with the maximum benefit
coverage amount up to 1pair per year.
•Maximum benefit coverage amount is limited to one time use per
year. |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | •Eyeglass lens options may be available with the maximum benefit
coverage amount up to 1pair per year.
•Maximum benefit coverage amount is limited to one time use per
year.
MENTAL HEALTH SERVICES
Inpatient
Your plan covers up to 190 days
in alifetime for inpatient mental
health care in apsychiatric
hospital $0 copay
Outpatient group and individual
therapy visits $0 copay
SKILLED NURSING FACILITY (SNF)
Your plan covers up to 100 days
in aSNF $0 copay
PHYSICAL THERAPY |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | health care in apsychiatric
hospital $0 copay
Outpatient group and individual
therapy visits $0 copay
SKILLED NURSING FACILITY (SNF)
Your plan covers up to 100 days
in aSNF $0 copay
PHYSICAL THERAPY
N/A $0 copay You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please
contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
H5619075000SB23 Summary of Benefits 11 H5619075000
Covered Medical and Hospital Benefits (cont.)
N/A WHAT YOU PAY ON THIS HUMANA PLAN
AMBULANCE
Ambulance $0 copay
TRANSPORTATION
N/A $0 copay for plan approved location up to 24 one-way trip(s) per year. |