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{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
You may be billed by the
out-of-network provider for any
amount greater than the
payment made by Humana to
the provider.
Use the HumanaDental Medicare
network for the Mandatory
Supplemental Dental. The
provider locator can be found at
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 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.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. •50% of the cost for amalgam
and/or composite filling, simple
or surgical extraction up to 2
per year.
•$1000 combined maximum
benefit coverage amount per
year for preventive and
comprehensive benefits. •55% of the cost for amalgam
and/or composite filling, simple |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | per year.
•$1000 combined maximum
benefit coverage amount per
year for preventive and
comprehensive benefits. •55% of the cost for amalgam
and/or composite filling, simple
or surgical extraction up to 2
per year.
•$1000 combined maximum
benefit coverage amount per
year for preventive and
comprehensive benefits.
•Benefits received
out-of-network are subject to
any in-network benefit
maximums, limitations, and/or
exclusions.
VISION SERVICES
Medicare-covered vision |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | comprehensive benefits.
•Benefits received
out-of-network are subject to
any in-network benefit
maximums, limitations, and/or
exclusions.
VISION SERVICES
Medicare-covered vision
services $40 copay 30% of the cost
Medicare-covered diabetic eye
exam $0 copay 30% of the cost
Medicare-covered glaucoma
screening $0 copay 30% of the cost
Medicare-covered eyewear |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | services $40 copay 30% of the cost
Medicare-covered diabetic eye
exam $0 copay 30% of the cost
Medicare-covered glaucoma
screening $0 copay 30% of the cost
Medicare-covered eyewear
(post-cataract) $0 copay 30% of the cost 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/H5216_107_PPO_H5216107000SB23.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
H5216107000SB23 Summary of Benefits 11 H5216107000
Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
Routine vision
The provider locator for routine
vision can be found at
Humana.com >Find aDoctor >
select Vision care icon >Vision |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | IN-NETWORK OUT-OF-NETWORK
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. VIS751
•$0 copay for routine exam up
to 1per year.
•$75 combined maximum
benefit coverage amount per
year for routine exam.
•$100 combined maximum
benefit coverage amount per
year for contact lenses or
eyeglasses-lenses and frames,
fitting for eyeglasses-lenses
and frames. |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | year for routine exam.
•$100 combined 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. VIS751
•$0 copay for routine exam up
to 1per year.
•$75 combined maximum
benefit coverage amount per
year for routine exam.
•$100 combined maximum |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | amount is limited to one time
use per year. VIS751
•$0 copay for routine exam up
to 1per year.
•$75 combined maximum
benefit coverage amount per
year for routine exam.
•$100 combined 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/H5216_107_PPO_H5216107000SB23.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.
•Benefits received
out-of-network are subject to
any in-network benefit
maximums, limitations, and/or
exclusions.
MENTAL HEALTH SERVICES
Inpatient
Your plan covers up to 190 days
in alifetime for inpatient mental
health care in apsychiatric
hospital $750 copay per admit 30% of the cost |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | exclusions.
MENTAL HEALTH SERVICES
Inpatient
Your plan covers up to 190 days
in alifetime for inpatient mental
health care in apsychiatric
hospital $750 copay per admit 30% of the cost
Outpatient group and individual
therapy visits
Cost share may vary depending
on where service is provided. $40 to $90 copay 30% of the cost
SKILLED NURSING FACILITY (SNF)
Your plan covers up to 100 days
in aSNF $0 copay per day for days 1-20
$188 copay per day for days |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | on where service is provided. $40 to $90 copay 30% of the cost
SKILLED NURSING FACILITY (SNF)
Your plan covers up to 100 days
in aSNF $0 copay per day for days 1-20
$188 copay per day for days
21-100 30% of the cost for days 1-100 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/H5216_107_PPO_H5216107000SB23.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
12 Summary of Benefits H5216107000SB23 H5216107000
Covered Medical and Hospital Benefits (cont.)
IN-NETWORK OUT-OF-NETWORK
PHYSICAL THERAPY
Cost share may vary depending
on the service and where service
is provided. $20 to $40 copay 30% of the cost
AMBULANCE |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | IN-NETWORK OUT-OF-NETWORK
PHYSICAL THERAPY
Cost share may vary depending
on the service and where service
is provided. $20 to $40 copay 30% of the cost
AMBULANCE
Ambulance $290 copay per date of service $290 copay per date of service
TRANSPORTATION
N/A Not covered Not covered
MEDICARE PART BDRUGS
Chemotherapy drugs 20% of the cost 20% of the cost
Other Part Bdrugs 20% of the cost 20% of the cost
Prescription Drug Benefits
PRESCRIPTION DRUGS
Important Message About What You Pay for Vaccines |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Chemotherapy drugs 20% of the cost 20% of the cost
Other Part Bdrugs 20% of the cost 20% of the cost
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 ,even if
you haven’t paid your deductible .
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 Part Dinsulin product |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | you haven’t paid your deductible .
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 Part Dinsulin product
covered by our plan, no matter what cost-sharing tier it’s on ,even if you haven’t paid your deductible .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 a |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Program as described below. If you receive "Extra Help", you will still pay no more than $35 for a
one-month supply for each Part Dcovered insulin. Please see your Prescription Drug Guide to find all Part D
insulins covered by your plan.
If you don't receive Extra Help for your drugs, you'll pay the following:
Deductible No deductible for Tier 1and Tier 2. This plan has a $200 deductible for Tier 3, Tier 4, Tier 5 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | If you don't receive Extra Help for your drugs, you'll pay the following:
Deductible No deductible for Tier 1and Tier 2. This plan has a $200 deductible for Tier 3, Tier 4, Tier 5
drugs .You pay the full cost of these drugs until you reach $200 .Then, you only pay your cost-share.
Initial coverage (after you pay your deductible)
You pay the following until your total yearly drug costs reach $4,660 .Total yearly drug costs are the total |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Initial coverage (after you pay your deductible)
You pay the following until your total yearly drug costs reach $4,660 .Total yearly drug costs are the total
drug costs paid by both you and our plan. Once you reach this amount, you will enter the Coverage Gap. H5216107000SB23 Summary of Benefits 13 H5216107000
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 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | 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
CenterWell Pharmacy ™
N/A 30-day supply 90-day supply* 30-day supply 90-day supply*
Tier 1: Preferred Generic $10 $30 $5 $0
Tier 2: Generic $20 $60 $15 $0
Tier 3: Preferred Brand $47 $141 $47 $131
Tier 4: Non-Preferred
Drug $100 $300 $97 $281
Tier 5: Specialty Tier 29% N/A 29% N/A |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Tier 1: Preferred Generic $10 $30 $5 $0
Tier 2: Generic $20 $60 $15 $0
Tier 3: Preferred Brand $47 $141 $47 $131
Tier 4: Non-Preferred
Drug $100 $300 $97 $281
Tier 5: Specialty Tier 29% N/A 29% N/A
Retail Cost-Sharing
Pharmacy options Retail All network retail pharmacies. To find the retail pharmacies near
you, go to Humana.com/pharmacyfinder
N/A 30-day supply 90-day supply*
Tier 1: Preferred Generic $5 $15
Tier 2: Generic $15 $45
Tier 3: Preferred Brand $47 $141
Tier 4: Non-Preferred |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | you, go to Humana.com/pharmacyfinder
N/A 30-day supply 90-day supply*
Tier 1: Preferred Generic $5 $15
Tier 2: Generic $15 $45
Tier 3: Preferred Brand $47 $141
Tier 4: Non-Preferred
Drug $97 $291
Tier 5: Specialty Tier 29% N/A
Your plan participates in the Insulin Savings Program. You will pay no more than $35 for aone-month (up
to a30-day) supply for Select Insulins, no matter what cost-sharing tier it’s on ,even if you haven’t paid |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | to a30-day) supply for Select Insulins, no matter what cost-sharing tier it’s on ,even if you haven’t paid
your deductible .To identify which Select Insulins are included within the Insulin Savings Program, look for
the ISP indicator in your Prescription Drug Guide. You are not eligible for this program if you receive "Extra
Help".
Your plan also provides enhanced insulin coverage which means you will pay no more than $35 for a |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Help".
Your plan also provides enhanced insulin coverage which means you will pay no more than $35 for a
one-month (up to 30-day) supply for all Part Dinsulins covered by our plan, including Select Insulins, no
matter what cost-sharing tier it’s on ,even if you haven’t paid your deductible .The enhanced insulin
coverage is available, even if you receive "Extra Help".
Your share of the cost for Select Insulins: 14 Summary of Benefits H5216107000SB23 H5216107000 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | coverage is available, even if you receive "Extra Help".
Your share of the cost for Select Insulins: 14 Summary of Benefits H5216107000SB23 H5216107000
Mail Order Cost-Sharing for Select Insulins
Pharmacy
options Standard
Walmart Mail ,PillPack
Other pharmacies are available in
our network. To find pharmacy mail
order options, go to
Humana.com/pharmacyfinder
Walmart Mail ,PillPack Preferred
CenterWell Pharmacy ™
- 30-day supply 90-day supply* 30-day supply 90-day supply* |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | our network. To find pharmacy mail
order options, go to
Humana.com/pharmacyfinder
Walmart Mail ,PillPack Preferred
CenterWell Pharmacy ™
- 30-day supply 90-day supply* 30-day supply 90-day supply*
Tier 3: Preferred Brand $35 $105 $35 $95
Retail Cost-Sharing for Select Insulins
Pharmacy
options Retail
All network retail pharmacies. To find the retail pharmacies near you, go
to Humana.com/pharmacyfinder
- 30-day supply 90-day supply*
Tier 3: Preferred Brand $35 $105 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Pharmacy
options Retail
All network retail pharmacies. To find the retail pharmacies near you, go
to Humana.com/pharmacyfinder
- 30-day supply 90-day supply*
Tier 3: Preferred Brand $35 $105
If you receive Extra Help for your drugs, you'll pay the following:
Deductible You may pay $0 or $104 depending on your level of "Extra Help" (for Tier 3, Tier 4, Tier 5) .If
your deductible is $104 ,you pay the full cost of these drugs until you reach $104 .Then, you only pay your
cost-share. |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | your deductible is $104 ,you pay the full cost of these drugs until you reach $104 .Then, you only pay your
cost-share.
Pharmacy cost-sharing
For generic drugs
(including 30-day supply 90-day supply*
brand drugs treated as
generic), either: $0 copay; or
$1.45 copay; or
$4.15 copay ;or
15% of the cost $0 copay; or
$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 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.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
Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | *Some drugs are limited to a30-day supply
ADDITIONAL DRUG COVERAGE
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_107_PPO_H5216107000SB23.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 H5216107000SB23 Summary of Benefits 15 H5216107000 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_107_PPO_H5216107000SB23.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.
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_107_PPO_H5216107000SB23.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 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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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) $40 copay 30% of the cost
Medicare-covered chiropractic
services $20 copay 30% of the cost
MEDICAL EQUIPMENT/SUPPLIES
Durable medical equipment (like
wheelchairs or oxygen) 20% of the cost 30% of the cost
Medical Supplies 20% of the cost 20% of the cost
Prosthetics (artificial limbs or |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | MEDICAL EQUIPMENT/SUPPLIES
Durable medical equipment (like
wheelchairs or oxygen) 20% of the cost 30% of the cost
Medical Supplies 20% of the cost 20% of the cost
Prosthetics (artificial limbs or
braces) 20% of the cost 30% 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 30% of the cost 16 Summary of Benefits H5216107000SB23 H5216107000
REHABILITATION SERVICES
Occupational and speech
therapy |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | on where service is provided. $0 copay or 10% to 20% of the
cost 30% of the cost 16 Summary of Benefits H5216107000SB23 H5216107000
REHABILITATION SERVICES
Occupational and speech
therapy
Cost share may vary depending
on the service and where service
is provided. $20 to $40 copay 30% of the cost
Cardiac rehabilitation $10 copay 30% of the cost
Pulmonary rehabilitation $10 copay 30% of the cost
TELEHEALTH SERVICES (in addition to Original Medicare) |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Cardiac rehabilitation $10 copay 30% of the cost
Pulmonary rehabilitation $10 copay 30% of the cost
TELEHEALTH SERVICES (in addition to Original Medicare)
Primary care provider (PCP) $0 copay Not Covered
Specialist $40 copay Not Covered
Urgent care services $0 copay Not Covered
Substance abuse or behavioral
health services $0 copay Not Covered H5216107000SB23 Summary of Benefits 17 H5216107000
More benefits with your plan
Enjoy some of these extra benefits included in your plan . |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | health services $0 copay Not Covered H5216107000SB23 Summary of Benefits 17 H5216107000
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
coverage and services. Visit Humana.com/medicare to view acopy of the EOC or call
1-800-833-2364 .
Travel Coverage |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | 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
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 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | 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.
Over-the-Counter (OTC) mail order
$75 maximum benefit coverage
amount per quarter (3 months) for
select over-the-counter health and
wellness products.
Rewards and Incentives
Go365 by Humana ®aRewards and |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | $75 maximum benefit coverage
amount per quarter (3 months) for
select over-the-counter health and
wellness products.
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. 18 Summary of Benefits H5216107000SB23 H5216107000 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | health and wellness activities.
SilverSneakers ®fitness program
Basic fitness center membership
including fitness classes. 18 Summary of Benefits H5216107000SB23 H5216107000
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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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.
$26.20 MyOption Enhanced Dental DEN840
Enhances the dental coverage already included in your Medicare
Advantage plan with additional benefits for preventive, basic, and major |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | $26.20 MyOption Enhanced Dental DEN840
Enhances the dental coverage already included in your Medicare
Advantage plan with additional benefits for 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.
$33.70 MyOption Total Dental DEN984
Enhances the dental coverage already included in your Medicare |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | benefits –have an additional monthly premium.
$33.70 MyOption Total Dental DEN984
Enhances the dental coverage already included in your Medicare
Advantage plan with additional benefits 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. 19 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | 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. 19
H5216_SB_MAPD_PPO_107000_2023_M Summary of Benefits H5216107000SB23 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), |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | 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
for Original Medicare telehealth.
Limitations on telehealth services, also referred to as virtual visits or telemedicine, vary by state. These services |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | 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
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 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.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.
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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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_280_M H5216107000OSB23 Optional
Supplemental Benefits
HumanaChoice H5216-107 (PPO)
Kentucky and Southern Indiana |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | of this booklet and we will send you one. Find out more H5216_OSB_23_280_M H5216107000OSB23 Optional
Supplemental Benefits
HumanaChoice H5216-107 (PPO)
Kentucky and Southern Indiana
Select counties in Kentucky 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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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 Enhanced Dental (DEN840)
The MyOption Enhanced Dental benefit helps make it easy for you to plan for your dental care. |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | October 1–March 31, and Monday through Friday April 1–September 30.
MyOption Enhanced Dental (DEN840)
The MyOption Enhanced Dental benefit helps make it easy for you to plan for your dental care.
Here's how the benefit works:
Monthly Premium $26.20
Maximum Benefit Humana pays up to $2,000 per calendar year
Covered Dental Services In-Network*
You Pay Out-Of-
Network**
You Pay Benefit Limitations Per
Calendar Year
Preventive and Diagnostic Dental Services
Periodic oral exam |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Covered Dental Services In-Network*
You Pay Out-Of-
Network**
You Pay Benefit Limitations Per
Calendar Year
Preventive and Diagnostic Dental Services
Periodic oral exam
Emergency diagnostic exam 0%
0% 50%
50% Two per year
Periodontal exam
Comprehensive oral evaluation 0%
0% 50%
50% One procedure every
three years
Dental prophylaxis (cleanings) 0% 50% Two per year
Fluoride treatment 0% 50% Two per year
Bitewing X-ray 0% 50% One set per year
Intraoral X-ray 0% 50% One per year |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | three years
Dental prophylaxis (cleanings) 0% 50% Two per year
Fluoride treatment 0% 50% Two per year
Bitewing X-ray 0% 50% One set per year
Intraoral X-ray 0% 50% One per year
Panoramic or diagnostic X-ray 0% 50% One every three years
Periodontal maintenance 0% 50% Four per year
Basic Dental Services (Minor Restorative)
Amalgam restorations (silver
fillings)
Composite resin restorations
(white fillings) 50%
50% 55% |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Periodontal maintenance 0% 50% Four per year
Basic Dental Services (Minor Restorative)
Amalgam restorations (silver
fillings)
Composite resin restorations
(white fillings) 50%
50% 55%
55% Two per year 2023 OPTIONAL SUPPLEMENTAL BENEFITS – 23 OPTIONAL SUPPLEMENTAL BENEFITS S(continued)
Covered Dental Services In-Network*
You Pay Out-Of-
Network**
You Pay Benefit Limitations Per
Calendar Year
Basic Dental Services (Minor Restorative)
Extractions (pulling teeth), simple |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Covered Dental Services In-Network*
You Pay Out-Of-
Network**
You Pay Benefit Limitations Per
Calendar Year
Basic Dental Services (Minor Restorative)
Extractions (pulling teeth), simple
or surgical 50% 55% Two per year
Recementation –Crown 50% 55% One procedure every five years
Emergency treatment for pain 50% 55% Two per year
Anesthesia 0% 50% Unlimited procedures per year
Major Dental Services (Endodontics, Periodontics, and Oral Surgery)
Crowns 70% 75% Two per year |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Emergency treatment for pain 50% 55% Two per year
Anesthesia 0% 50% Unlimited procedures per year
Major Dental Services (Endodontics, Periodontics, and Oral Surgery)
Crowns 70% 75% Two per year
Periodontal scaling and root
planing (deep cleaning) 70% 75% One procedure for each quadrant
every three years
Scaling –generalized
inflammation 70% 75% One procedure every three years
Covered dental services are subject to conditions, limitations, exclusions, and maximums. Please see your |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | every three years
Scaling –generalized
inflammation 70% 75% One procedure every three years
Covered dental services are subject to conditions, limitations, exclusions, and maximums. Please see your
Evidence of Coverage for details.
*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_107_PPO_H5216107000SB23.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. |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | 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.
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 . |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | 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 .
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_107_PPO_H5216107000SB23.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.
MyOption Total Dental (DEN984)
The MyOption Total Dental benefit helps make it easy for you to plan for your dental care.
Here's how the benefit works: |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | MyOption Total Dental (DEN984)
The MyOption Total Dental benefit helps make it easy for you to plan for your dental care.
Here's how the benefit works:
Monthly Premium $33.70 24 – 2023 OPTIONAL SUPPLEMENTAL BENEFITS OPTIONAL SUPPLEMENTAL BENEFITS S(continued)
Maximum Benefit Humana pays up to $2,000 per calendar year
Covered Dental Services In-Network*
You Pay Out-Of-
Network**
You Pay Benefit Limitations Per
Calendar Year
Preventive and Diagnostic Dental Services
Periodic oral exam |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Covered Dental Services In-Network*
You Pay Out-Of-
Network**
You Pay Benefit Limitations Per
Calendar Year
Preventive and Diagnostic Dental Services
Periodic oral exam
Emergency diagnostic exam 0%
0% 50%
50% Two per year
Periodontal exam
Comprehensive oral evaluation 0%
0% 50%
50% One procedure every
three years
Dental prophylaxis (cleanings) 0% 50% Two per year
Fluoride treatment 0% 50% Two per year
Bitewing X-ray 0% 50% One set per year
Intraoral X-ray 0% 50% One set per year |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | three years
Dental prophylaxis (cleanings) 0% 50% Two per year
Fluoride treatment 0% 50% Two per year
Bitewing X-ray 0% 50% One set per year
Intraoral X-ray 0% 50% One set per year
Panoramic or Diagnostic X-ray 0% 50% One per year
Periodontal maintenance 0% 50 % Four per year
Basic Dental Services (Minor Restorative)
Amalgam restorations (silver
fillings)
Composite resin restorations
(white fillings) 50%
50% 55%
55% Two per year
Extractions (pulling teeth), simple |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Basic Dental Services (Minor Restorative)
Amalgam restorations (silver
fillings)
Composite resin restorations
(white fillings) 50%
50% 55%
55% Two per year
Extractions (pulling teeth), simple
or surgical 50% 55% Unlimited per year
Recementation –Crown 50% 55% One procedure every five years
Recementation –Bridge 50% 55% One procedure every five years
Emergency treatment for pain 50% 55% Two per year
Anesthesia 0% 50% Unlimited per calendar year |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Recementation –Bridge 50% 55% One procedure every five years
Emergency treatment for pain 50% 55% Two per year
Anesthesia 0% 50% Unlimited per calendar year
Major Dental Services (Endodontics, Periodontics, and Oral Surgery)
Root canal treatment 70% 75% One per year
Crowns 70% 75% Two per year
Periodontal scaling and root
planing (deep cleaning) 70 % 75 %One procedure for each quadrant
per year
Scaling –generalized
inflammation 70 % 75 % One procedure per year
Complete dentures (including |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | planing (deep cleaning) 70 % 75 %One procedure for each quadrant
per year
Scaling –generalized
inflammation 70 % 75 % One procedure per year
Complete dentures (including
routine post-delivery care) 70% 75% One upper and/or one lower
complete denture every five years 2023 OPTIONAL SUPPLEMENTAL BENEFITS – 25 OPTIONAL SUPPLEMENTAL BENEFITS S(continued)
Covered Dental Services In-Network*
You Pay Out-Of-
Network**
You Pay Benefit Limitations Per
Calendar Year |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Covered Dental Services In-Network*
You Pay Out-Of-
Network**
You Pay Benefit Limitations Per
Calendar Year
Major Dental Services (Endodontics, Periodontics, and Oral Surgery)
Partial dentures (including routine
post-delivery care) 70% 75% One upper and/or one lower
partial denture every five years
Denture adjustments (not covered
within six months of initial
placement) 70% 75% One per year
Denture reline (not allowed on
spare dentures) 70% 75% One per year
Denture rebase (not covered |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Denture adjustments (not covered
within six months of initial
placement) 70% 75% One per year
Denture reline (not allowed on
spare dentures) 70% 75% One per year
Denture rebase (not covered
within six months of initial
placement) 70% 75% One procedure per year
Denture repair 70% 75% One procedure per year
Tissue conditioning 70% 75% One procedure per year
Occlusal adjustments 70% 75% One procedure every three years
Oral surgery 70% 75% Two per year |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Denture repair 70% 75% One procedure per year
Tissue conditioning 70% 75% One procedure per year
Occlusal adjustments 70% 75% One procedure every three years
Oral surgery 70% 75% Two per year
Covered dental services are subject to conditions, limitations, exclusions, and maximums. Please see your
Evidence of Coverage for details.
*Network dentists have agreed to provide services at anegotiated rate. If you see anetwork dentist, you
cannot be billed more than that rate. |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Evidence of Coverage for details.
*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
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 |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | 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.
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 . |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | 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 .
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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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 H5216107000SB23 Summary of Benefits 27 H5216107000
GHHLNNXEN 0522 Important________________________________________________
At Humana, it is important you are treated fairly. |
{'source': PosixPath('pdf_library/H5216_107_PPO_H5216107000SB23.pdf')} | Humana.com H5216107000SB23 Summary of Benefits 27 H5216107000
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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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_107_PPO_H5216107000SB23.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 H5216107000SB23 H5216107000 H5216107000SB23 Summary of Benefits 29 H5216107000 HumanaChoice H5216-107 (PPO)
H5216107000 ENG
Select counties in Kentucky
Humana.com
GNHH4HGEN_23_C Summary of Benefits H5216107000SB23 |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | 2022
Summary of Benefits
H1036265001SB22 GNHH4HIEN_22_C SBOSB035
Humana Gold Plus H1036-265 (HMO)
Greater Tampa Bay
Tampa Metro Area
Our service area includes the following county/counties in Florida: Hernando,
Hillsborough, Pasco, Pinellas. 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) . |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | have any questions, you can call and speak to acustomer service representative at 1-800-833-2364 (TTY:
711) .
Understanding the Benefits
Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services
that you routinely see adoctor. 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 |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | 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.
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.
Understanding Important Rules |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | in the network. If the pharmacy is not listed, you will likely have to select anew pharmacy for your
prescriptions.
Understanding Important Rules
You do not pay aseparate monthly plan premium for this Humana plan but ,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, 2023. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | 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, 2023.
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). 2022
H1036_SB_MAPD_HMO_265001_2022_M H1036265001SB22 Summary of Benefits
Humana Gold Plus H1036-265 (HMO)
Greater Tampa Bay
Tampa Metro Area |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | (doctors who are not listed in the provider directory). 2022
H1036_SB_MAPD_HMO_265001_2022_M H1036265001SB22 Summary of Benefits
Humana Gold Plus H1036-265 (HMO)
Greater Tampa Bay
Tampa Metro Area
Our service area includes the following county/counties in Florida: Hernando,
Hillsborough, Pasco, Pinellas. 2022 - 5 - Summary of Benefits H1036265001
Let's talk about Humana Gold Plus
H1036-265 (HMO)
Find out more about the Humana Gold Plus H1036-265 (HMO) plan -including the |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Let's talk about Humana Gold Plus
H1036-265 (HMO)
Find out more about the Humana Gold Plus H1036-265 (HMO) plan -including the
health and drug services it covers -in this easy-to-use guide.
Humana Gold Plus H1036-265 (HMO) is aMedicare Advantage HMO plan with a
Medicare 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 |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Medicare 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 "Evidence of Coverage".
To be eligible
To join Humana Gold Plus H1036-265
(HMO), you must be entitled to
Medicare Part A, be enrolled in Medicare
Part Band live in our service area.
Plan name: |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | To be eligible
To join Humana Gold Plus H1036-265
(HMO), you must be entitled to
Medicare Part A, be enrolled in Medicare
Part Band live in our service area.
Plan name:
Humana Gold Plus H1036-265 (HMO)
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-September 30:
Call Monday -Friday, 8a.m. -8p.m. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | 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 More about Humana Gold Plus
H1036-265 (HMO)
Doyou have Medicare and Medicaid? If you are a
dual-eligible beneficiary enrolled in both Medicare
and the state's program, you may not have to pay
the medical costs displayed in this booklet and your |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | dual-eligible beneficiary enrolled in both 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 additional coverage. Your services are paid first
by Humana and then by Medicaid.
As amember you must select an in-network |
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