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|---|---|
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | 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.
This benefit is not to exceed 150 miles per trip.
The member must contact transportation vendor to arrange
transportation and should contact Customer Care ... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | their plan's specific transportation provider.
MEDICARE PART BDRUGS
Chemotherapy drugs $0 copay
Other Part Bdrugs $0 copay
Prescription Drug Benefits
PRESCRIPTION DRUGS
Medicare Part DDrugs See chart below for plan coverage information for
prescription drugs
$0 Rx Copay Benefit If you qualify for "Extra Help", ... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | prescription drugs on your formulary, for all tiers, and through all stages.
Pharmacy options
Mail Order Mail Order cost-sharing
$0 CenterWell Pharmacy ™,
Walmart Mail ,PillPack
Other pharmacies are available in
our network. To find pharmacy
mail order options go to
Humana.com/pharmacyfinder
Retail Retail co... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Retail Retail cost-sharing All network retail pharmacies
For generic drugs (including 30-day supply 90-day supply*
brand drugs treated as generic),
either: $0 $0
For all other drugs ,either: $0 $0
Other pharmacies are available in our network.
*Some drugs are limited to a30-day supply 12 Summary of Benefits H561... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | *Some drugs are limited to a30-day supply 12 Summary of Benefits H5619075000SB23 H5619075000 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
pharmacy-specific cost-shar... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | pharmacy-specific cost-sharing, please call us or refer to Chapter 6of the Evidence of Coverage for more
details.
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.
Catastr... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | 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 nothing for all drugs.
Additional Benefits
N/A WHAT YOU PAY ON THIS HUMANA PLAN
Medicare-covered foot care
(podiatry) $0 copay
Medicare-covered c... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Medicare-covered chiropractic
services $0 copay
MEDICAL EQUIPMENT/SUPPLIES
Durable medical equipment
(like wheelchairs or oxygen) $0 copay
Medical Supplies $0 copay
Prosthetics (artificial limbs or
braces) $0 copay
Diabetic monitoring supplies $0 copay
REHABILITATION SERVICES
Occupational and speech
therapy... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | therapy $0 copay
Cardiac rehabilitation $0 copay
Pulmonary rehabilitation $0 copay
TELEHEALTH SERVICES (in addition to Original Medicare)
Primary care provider (PCP) $0 copay
Specialist $0 copay
Urgent care services $0 copay
Substance abuse or behavioral
health services $0 copay H5619075000SB23 Summary of Ben... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Medicaid Benefit Comparison
The benefits described in the Covered Medical and Hospital Benefits sections above are covered by
Humana Gold Plus SNP-DE H5619-075 (HMO D-SNP). Below is acomparison of benefits that some Medicaid
eligible individuals could receive directly from the Kentucky Department of Medicaid Service... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | each benefit listed below, you can see what the Kentucky Department of Medicaid Services (DMS) covers
and what our plan covers. All Medicaid benefits are subject to Medicaid eligibility guidelines and
requirements, and are available only to full dual eligible individuals. If you have questions about your
Medicaid el... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Medicaid eligibility and what benefits you are entitled to, review your member handbook or contact the
Kentucky Department of Medicaid Services (DMS) at 1-800-635-2570.
BENEFIT MEDICAID BENEFIT OUR PLAN BENEFIT
Acute inpatient hospital care Covered Covered
Ambulance Covered Covered
Ambulatory surgical center Cover... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Ambulatory surgical center Covered Covered
Dentures Not Covered Covered
Diagnostic
services/labs/imaging Covered Covered
Doctor office visits (Primary
care provider (PCP)/specialists Covered Covered
Emergency care Covered Covered
Eyeglasses Not Covered Covered
Hearing aids Not Covered Covered
Home and communit... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Home and community based
waiver service programs Covered Not Covered
Inpatient hospital, nursing
facility and intermediate care
facility services in institutions
for mental diseases (MD), age
65 and older Covered Covered with limitations
Inpatient psychiatric services,
under age 21 Covered Covered with limitati... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | under age 21 Covered Covered with limitations
Intermediate care facility for
intellectual disabilities
(ICF-IDD) Covered Not Covered
Intermediate care facility
services for individuals with
intellectual disabilities Covered Covered with limitations 14 Summary of Benefits H5619075000SB23 H5619075000
BENEFIT MEDI... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | BENEFIT MEDICAID BENEFIT OUR PLAN BENEFIT
Mental health services
(outpatient group therapy and
individual therapy visit) Covered Covered
Nursing facility services, other
than in an institution for mental
diseases Covered Covered with limitations
Outpatient hospital coverage Covered Covered
Physical therapy C... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Physical therapy Covered Covered
Prescription drugs –Medicare
Part Bdrugs Covered Covered
Prescription drugs –outpatient
prescription drugs; Medicare
covered &non-Medicare
covered Covered Covered
Preventive care (e.g., flu
vaccine, diabetic screenings) Covered Covered
Routine non-emergency medical
transporta... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | transportation Covered Covered
Skilled nursing facility Covered Covered
Urgently needed services Covered Covered H5619075000SB23 Summary of Benefits 15 H5619075000
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 se... |
{'source': PosixPath('pdf_library/H5619075000SB23.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 .
Humana Flex Allowance
$1000 annual allo... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Humana Flex Allowance
$1000 annual allowance on aprepaid
card to use toward out of pocket costs
for the plan's preventive and
comprehensive dental, vision, or hearing
services including copays.
Members can use this benefit at
participating providers where the
primary business is Dental Care, Vision
Services, o... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Services, or Hearing Services and Visa®
is accepted.
Cannot be used for procedures such as
cosmetic dentistry and teeth whitening.
Unused amount expires at the end of
the plan year.
Allowance amounts cannot be
combined with other benefit allowances.
Limitations and restrictions may apply.
Humana Healthy Opti... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Humana Healthy Options Allowance
$100 automatically loaded on aprepaid
card every month to use toward the
purchase of food, over-the-counter
(OTC) products, and home supplies from
anational network of retailers. The card
may also be used to pay for
non-medical transportation, general
supports for living (such a... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | supports for living (such as rent
assistance, internet, and utilities), social
needs, aging support and assistive
devices, pest control, and pet care and
supplies. Unused funds will roll over to
the next month and expire at the end of
the plan year. Allowance amounts
cannot be combined with other benefit
allowa... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | allowances. Limitations and restrictions
may apply. Humana Spending Account Card
The allowances listed below will be
loaded onto this prepaid card. Each
allowance is separate from any other
allowance listed. Allowances shown are
accessed by using this card. Allowance
amounts cannot be combined with
other bene... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | amounts cannot be combined with
other benefit allowances. Limitations
and restrictions may apply.
*Healthy Options Allowance
*Humana Flex Allowance
HMO Travel Benefit
Members can receive in-network
benefits when services are received
from aparticipating HMO National
Network provider during their travels to ... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Network provider during their travels to
other states and Puerto Rico.
Special Supplemental Benefits for
the Chronically Ill (SSBCI) Humana
Flexible Care Assistance
Humana Flexible Care Assistance is
available to members with chronic
health conditions, who are participating
in care management services, and meet... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | in care management services, and meet
program criteria. Eligible members may
receive medical expense assistance and
other additional benefits, either
primarily health related or non-primarily
health related, to address the member's
unique individual needs. Benefits are
limited up to $1,000 per year and must
be... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | be coordinated and authorized by acare
manager. There is no cost to participate. 16 Summary of Benefits H5619075000SB23 H5619075000
Chiropractic services
Routine chiropractic:
$0 copay per visit for up to 12 visits.
Smoking cessation program
To further assist in your effort to quit
smoking or tobacco product u... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | smoking or tobacco product use, we
cover one additional counseling quit
attempt within a12-month period as a
service with no cost to you. This is in
addition to the two counseling attempts
provided by Medicare and includes up to
four face-to-face visits. This service can
be used for either preventive measures
o... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | or for diagnosis with atobacco related
disease.
Routine foot care
$0 copay per visit for up to 6visits
Humana Well Dine ®Meal Program
Humana's home delivered meal
program for members following an
inpatient stay in the hospital or nursing
facility.
Rewards and Incentives
Go365 by Humana ®aRewards and
Incent... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | Incentive program for completing
certain preventive health screenings and
health and wellness activities.
Wigs (related to chemotherapy
treatment)
Up to an unlimited maximum benefit
per year.
SilverSneakers ®fitness program
Basic fitness center membership
including fitness classes. 17
H5619_SB_MAPD_HMO_0750... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | H5619_SB_MAPD_HMO_075000_2023_M Summary of Benefits H5619075000SB23 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... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | 24 hours aday, seven days aweek. TTY users should call 1-877-486-2048.
Humana has been approved by the National Committee for Quality Assurance (NCQA) to operate as aSpecial
Needs Plan (SNP) until 12/31/2023 based on areview of Humana's Model of Care.
Your provider may choose to submit to the Kentucky Department of ... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | additional secondary payment for an amount applied to deductibles, coinsurance, or copayments. If you are Cost
Share Protected, providers are required by federal regulation to accept Humana Gold Plus SNP-DE H5619-075
(HMO D-SNP) primary payment and the Kentucky Department of Medicaid Services (DMS) secondary payment ... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | payment in full for covered Medicare Part Aand Part Bservices –even when the Medicaid payment is zero or a
provider chooses to not submit to Medicaid.
If you are cost-share protected by the Kentucky Department of Medicaid Services (DMS), Humana Gold Plus
SNP-DE H5619-075 (HMO D-SNP) providers aren't allowed to colle... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | under Medicare Part Aand Part B, including deductibles, coinsurance, and copayments –even when Medicaid
payment is zero or aprovider chooses to not submit to Medicaid. If aprovider asks you to pay, that's against the
law. You may however be responsible for asmall Medicaid copayment.
If you are cost-share protected ... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | law. You may however be responsible for asmall Medicaid copayment.
If you are cost-share protected and you are billed or asked to pay the provider for deductibles, coinsurance, or
copayments on covered Medicare Part Aand Part Bservices tell your provider you are cost-share protected and
can't be charged. If you hav... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | can't be charged. If you have already made payment you have the right to arefund. If your provider will not stop
billing, you can call us at 1-800-457-4708 or you can call Medicare at 1-800-Medicare (1-800-633-4227), (TTY
1-877-486-2048). Humana or Medicare can ask your provider to stop billing you and refund any pay... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | have made.
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... |
{'source': PosixPath('pdf_library/H5619075000SB23.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 add... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | 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. You can see our plan's provider and pharmacy directory at... |
{'source': PosixPath('pdf_library/H5619075000SB23.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 Notes Notes... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | 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... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | 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:
Discriminati... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | 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 Compla... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | 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 avai... |
{'source': PosixPath('pdf_library/H5619075000SB23.pdf')} | •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)
Humana provides free auxiliary aids and services, such as qualified sign lang... |
{'source': PosixPath('pdf_library/H5619075000SB23.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. H5619075000SB23 Summary of Benefits 21 H5619075000 22 Summary of Benefits H5619075000SB23 H5619075000 Humana Gold Plus SNP-DE H5619-075... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Summary of Benefits
Optional Supplemental BenefitsSBOSB046
Humana Community HMO Diabetes and Heart (HMO C-SNP)
H1036-234
Louisville
Jefferson County
Our service area includes the following county/counties in Kentucky: Jefferson. 2023
GNHH4HGEN_23_C Summary of Benefits H1036234000SB23 Pre-Enrollment Checklist
Be... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | GNHH4HGEN_23_C Summary of Benefits H1036234000SB23 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 B... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.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... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.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... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | prescriptions.
Review the formulary to make sure your drugs are covered.
Understanding Important Rules
You must continue to pay your Medicare Part Bpremium. This premium is normally taken out of your
Social Security check each month.
Benefits, premiums and/or copayments/co-insurance may change on January 1, 2024.... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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 achronic condition special needs plan (C-SNP). Your ability to enroll will be based on
verification that you have aqualifying specific severe or disabli... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Humana Community HMO Diabetes and Heart (HMO C-SNP)
H1036-234
Louisville
Jefferson County 2023
Our service area includes the following county/counties in Kentucky: Jefferson.
H1036_SB_MAPD_HMO_234000_2023_M Summary of Benefits H1036234000SB23 H1036234000SB23 Summary of Benefits 5H1036234000
Let's talk about Human... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Let's talk about Humana Community HMO
Diabetes and Heart (HMO C-SNP)
Find out more about the Humana Community HMO Diabetes and Heart (HMO C-SNP)
plan -including the health and drug services it covers -in this easy-to-use guide.
Humana Community HMO Diabetes and Heart (HMO C-SNP) is aCoordinated Care HMO
plan with ... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | plan with aMedicare contract. 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 a
complete list of services we cover, ask us for the "Evide... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | To be eligible
To join Humana Community HMO
Diabetes and Heart (HMO C-SNP), you
must be entitled to Medicare Part A, be
enrolled in Medicare Part B,be
diagnosed with Cardiovascular
Disorders, Chronic Heart Failure, and/or
Diabetes Mellitus and live in our service
area.
Plan name:
Humana Community HMO Diabetes... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | area.
Plan name:
Humana Community HMO Diabetes and
Heart (HMO C-SNP)
How to reach us:
If you're amember of this plan, call
toll-free: 1-800-457-4708 (TTY: 711) .
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-Se... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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 More about Humana Community
HMO Diabetes and Heart (HMO
C-SNP)
Doyou have Medicare and Medicaid? If you are a
dual-eligible beneficiary enrolled in both
Medicare and the state's ... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Medicare and the state's program, you may not
have to pay the medical costs displayed in this
booklet and your prescription drug costs will be
lower, too.
If you have Medicaid, be sure to show your
Medicaid ID card in addition to your Humana
membership card to make your provider aware
that you may have additiona... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | that you may have additional coverage. Your
services are paid first by Humana and then by
Medicaid.
As amember you must select an in-network
doctor to act as your Primary Care Provider (PCP).
Humana Community HMO Diabetes and Heart
(HMO C-SNP) has anetwork of doctors, hospitals,
pharmacies and other providers. I... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | pharmacies and other providers. If you use
providers who aren't in our network, the plan
may not pay for these services. You also have
access to Care Managers. Care Managers are
nurses or care coordinators who are skilled at
helping to improve your quality of life by
providing proactive support and coordinating k... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | services to help you better manage your health.
If you're managing aserious illness or chronic
condition, we'll be there to support you and your
doctor's plan for care.
Ahealthy partnership
Get more from your plan —with extra
services and resources provided by
Humana! You do not need areferral to receive covered... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.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
6 Summary of Benefits H1036234000SB23 H1036234000
Monthly Premium, Deductible and ... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Monthly Premium, Deductible and Limits
Monthly Plan Premium $0
You must keep paying your Medicare Part Bpremium.
Medical deductible This plan does not have adeductible.
Pharmacy (Part D) deductible This plan does not have adeductible.
Maximum out-of-pocket
responsibility $3,900 in-network
The most you pay for c... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | medical services for the year.
Covered Medical and Hospital Benefits
Acute inpatient hospital care $250 copay per day for days 1-7
$0 copay per day for days 8-90
Your plan covers an unlimited number of days for an inpatient stay.
Outpatient hospital coverage •Outpatient surgery at Outpatient Hospital: $250 copay... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Outpatient hospital coverage •Outpatient surgery at Outpatient Hospital: $250 copay
•Outpatient surgery at Ambulatory Surgical Center: $200 copay
Doctor visits •Primary care provider: $0 copay
•Specialist: $15 copay You do not need areferral to receive covered services from plan providers. Certain procedures, s... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.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
H1036234000SB23 Summary of Benefits 7H1036234000
Covered Medical and Hospital Bene... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Covered Medical and Hospital Benefits (cont.)
Preventive care 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 (be... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | •Cardiovascular screenings
•Cervical and vaginal cancer screening
•Colorectal cancer screenings (colonoscopy, fecal occult blood test,
flexible sigmoidoscopy)
•Depression screening
•Diabetes screenings
•HIV screening
•Medical nutrition therapy services
•Obesity screening and counseling
•Prostate cancer screeni... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | •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)
•Ann... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | •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 $90 copay
If you are admitted to the hospital within 24 hours, you do not ha... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | pay your share of the cost for the emergency care.
Urgently needed services $20 copay at an urgent care center
Urgently needed services are provided to treat anon-emergency,
unforeseen medical illness, injury or condition that requires immediate
medical attention. You do not need areferral to receive covered servic... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.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 H1036234000SB23 H1036234000
Covered Medical and Hospital Ben... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Covered Medical and Hospital Benefits (cont.)
OUTPATIENT CARE AND SERVICES
Diagnostic services, labs and
imaging
Cost share may vary depending
on the service and where service
is provided •Diagnostic mammography: $0 to $15 copay
•Diagnostic colonoscopy $0 copay
•Diagnostic radiology: $180 to $300 copay
•... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | •Lab services: $0 to $20 copay
•Diagnostic tests and procedures: $0 to $105 copay
•Outpatient X-rays: $0 to $75 copay
•Radiation therapy: $15 copay or 20% of the cost
Hearing Medicare-covered hearing exam: $15 copay
Routine hearing:
In-Network:
HER939
•$0 copay for routine hearing exams up to 1per y... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | •$499 copay for each Advanced level hearing aid up to 1per ear per
year.
•$799 copay for each Premium level hearing aid up to 1per ear per
year.
Hearing aid purchase includes:
•Unlimited follow-up provider visits during first year following
TruHearing hearing aid purchase
•60-day trial period
•3-year extende... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | •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 Medicare-covered dental services: $15 copay
Routine dental:
The cost-share indicated below is what you p... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Routine dental:
The cost-share indicated below is what you pay for the covered service.
In-Network:
DEN319
•$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 inflamm... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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 u... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | •$0 copay for bitewing x-rays, intraoral x-rays up to 1set(s) per 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
contact your PCP or re... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
H1036234000SB23 Summary of Benefits 9H1036234000
Covered Medical and Hospital Benefits (cont.)
•$0 copay for adjustments to dentures, denture rebase, denture
reline, denture repair, emergen... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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 com... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | anesthesia with covered service, simple or surgical extraction up to
unlimited per year.
•$1000 maximum benefit coverage amount per year for preventive
and comprehensive benefits.
Dental services are subject to our standard claims review procedures
which could include dental history to approve coverage. Dental ... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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, of INFS). If amember visits a
participating network dentist, the mem... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | participating 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
Humana.com >Find aDoctor... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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 •Medicare-covered vision services: $15 copay
•Medicare-covered diabetic eye exam: $0 copay
•Medicare-covered ... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | •Medicare-covered glaucoma screening: $0 copay
•Medicare-covered eyewear (post-cataract): $0 copay
Routine vision:
In-Network:
VIS735
•$0 copay for routine exam up to 1per year.
•$200 maximum benefit coverage amount per year for contact
lenses or eyeglasses-lenses and frames, fitting for eyeglasses-lenses ... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | 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. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advan... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.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
10 Summary of Benefits H1036234000SB23 H1036234000
Covered Medical and Hospital Be... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | The provider locator for routine vision can be found at Humana.com >
Find aDoctor >select Vision care icon >Vision coverage through
Medicare Advantage plans.
Mental health services Inpatient:
•$250 copay per day for days 1-5
•$0 copay per day for days 6-90
•Your plan covers up to 190 days in alifetime for inpa... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | health care in apsychiatric hospital.
Outpatient (group and individual therapy visits): $15 to $65 copay
Cost share may vary depending on where service is provided.
Skilled nursing facility (SNF) •$0 copay per day for days 1-20
•$188 copay per day for days 21-100
•Your plan covers up to 100 days in aSNF
Physica... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Physical Therapy •$15 copay
ADDITIONAL BENEFITS
Ambulance $290 copay per date of service
Transportation $0 copay for plan approved location up to 48 one-way trip(s) per year.
This benefit is not to exceed 50 miles per trip.
The member must contact transportation vendor to arrange
transportation and should con... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | transportation and should contact Customer Care to be directed to
their plan's specific transportation provider.
Medicare Part Bdrugs •Chemotherapy drugs: 19% of the cost
•Other Part Bdrugs: 19% of the cost H1036234000SB23 Summary of Benefits 11 H1036234000
Prescription Drug Benefits
PRESCRIPTION DRUGS
Importan... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Prescription Drug Benefits
PRESCRIPTION DRUGS
Important Message About What You Pay for Vaccines
Our plan covers most Part Dvaccines at no cost to you, no matter what cost-sharing tier it’s on .
Important Message About What You Pay for Insulin
You won’t pay more than $35 for aone-month (up to 30-day) supply of each ... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | covered by our plan, no matter what cost-sharing tier it’s on .This applies to all Part Dcovered insulins,
including the Select Insulins covered under the Insulin Savings Program as described below. If you receive
"Extra Help", you will still pay no more than $35 for aone-month supply for each Part Dcovered insulin. ... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | Please see your Prescription Drug Guide to find all Part Dinsulins covered by your plan.
If you don't receive Extra Help for your drugs, you'll pay the following:
Deductible This plan does not have adeductible.
Initial coverage
You pay the following until your total yearly drug costs reach $4,660 .Total yearly ... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | drug costs paid by both you and our plan. Once you reach this amount, you will enter the Coverage Gap.
Mail Order Cost-Sharing
Pharmacy options Standard
Walmart Mail ,PillPack
Other pharmacies are
available in our network. To find
pharmacy mail order options go to
Humana.com/pharmacyfinder Preferred
CenterWel... |
{'source': PosixPath('pdf_library/HMO_Diabetes_and_Heart_H1036234000SB23.pdf')} | CenterWell Pharmacy ™
N/A 30-day supply 90-day supply* 30-day supply 90-day supply*
Tier 1: Preferred Generic $10 $30 $0 $0
Tier 2: Generic $20 $60 $0 $0
Tier 3: Preferred Brand $47 $141 $42 $116
Tier 4: Non-Preferred
Drug $100 $300 $100 $290
Tier 5: Specialty Tier 33% N/A 33% N/A
Tier 6: Select Care Drugs $0 $0... |
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