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{'source': PosixPath('pdf_library/H1036-265.pdf')} | 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
doctor to act as your Primary Care Provider (PCP).
Humana Gold Plus H1036-265 (HMO) has a
network of doctors, hospitals, pharmacies and
other providers. If you use providers who aren't in
our network, the plan may not pay for these
services.
Ahealthy partnership
Get more from your plan —with extra |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | other providers. If you use providers who aren't in
our network, the plan may not pay for these
services.
Ahealthy partnership
Get more from your plan —with extra
services and resources provided by
Humana! Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other
providers in the network. This is called a"referral." Certain procedures, services and drugs may need advance |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | providers in the network. This is called a"referral." Certain procedures, services and drugs may need advance
approval from your plan. This is called a"prior authorization" or "preauthorization." Please contact your PCP or refer
to the Evidence of Coverage (EOC) for services that require areferral and/or prior authorization from the plan .
2022 - 6 - Summary of Benefits H1036265001
Monthly Premium, Deductible and Limits
Monthly Plan Premium $0
You must keep paying your Medicare Part Bpremium. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | 2022 - 6 - Summary of Benefits H1036265001
Monthly Premium, Deductible and Limits
Monthly Plan Premium $0
You must keep paying your Medicare Part Bpremium.
Part Bpremium reduction Your plan will reduce your Monthly Part Bpremium by up to $145
Medical deductible This plan does not have adeductible.
Pharmacy (Part D) deductible This plan does not have adeductible.
Maximum out-of-pocket
responsibility $2,750 in-network
The most you pay for copays, coinsurance and other costs for medical |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Pharmacy (Part D) deductible This plan does not have adeductible.
Maximum out-of-pocket
responsibility $2,750 in-network
The most you pay for copays, coinsurance and other costs for medical
services for the year.
Covered Medical and Hospital Benefits
Acute inpatient hospital care $150 copay per day for days 1-8
$0 copay per day for days 9-90
Your plan covers an unlimited number of days for an inpatient stay.
Outpatient hospital coverage •Outpatient surgery at Outpatient Hospital: $150 copay |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | $0 copay per day for days 9-90
Your plan covers an unlimited number of days for an inpatient stay.
Outpatient hospital coverage •Outpatient surgery at Outpatient Hospital: $150 copay
•Outpatient surgery at Ambulatory Surgical Center: $100 copay
Doctor visits •Primary care provider: $0 copay
•Specialist: $25 copay Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Doctor visits •Primary care provider: $0 copay
•Specialist: $25 copay Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other
providers in the network. This is called a"referral." Certain procedures, services and drugs may need advance
approval from your plan. This is called a"prior authorization" or "preauthorization." Please contact your PCP or refer |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | 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 areferral and/or prior authorization from the plan .
2022 - 7 - Summary of Benefits H1036265001
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 |
{'source': PosixPath('pdf_library/H1036-265.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 (behavioral therapy)
•Cardiovascular screenings
•Cervical and vaginal cancer screening
•Colorectal cancer screenings (colonoscopy, fecal occult blood test,
flexible sigmoidoscopy) |
{'source': PosixPath('pdf_library/H1036-265.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 screenings (PSA)
•Sexually transmitted infections screening and counseling
•Tobacco use cessation counseling (counseling for people with no
sign of tobacco-related disease) |
{'source': PosixPath('pdf_library/H1036-265.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)
•Annual Wellness Visit
•Lung cancer screening
•Routine physical exam
•Medicare diabetes prevention program
Any additional preventive services approved by Medicare during the |
{'source': PosixPath('pdf_library/H1036-265.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 $120 copay
If you are admitted to the hospital within 24 hours, you do not have to
pay your share of the cost for the emergency care.
Urgently needed services $15 copay at an urgent care center
Urgently needed services are provided to treat anon-emergency, |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | pay your share of the cost for the emergency care.
Urgently needed services $15 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.
OUTPATIENT CARE AND SERVICES
Diagnostic services, labs and
imaging
Cost share may vary depending
on the service and where service
is provided •Diagnostic mammography: $25 to $80 copay
•Diagnostic radiology: $100 to $150 copay |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | imaging
Cost share may vary depending
on the service and where service
is provided •Diagnostic mammography: $25 to $80 copay
•Diagnostic radiology: $100 to $150 copay
•Lab services: $0 to $50 copay
•Diagnostic tests and procedures: $0 to $150 copay
•Outpatient X-rays: $0 to $110 copay
•Radiation therapy: $25 copay or 20% of the cost Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | •Radiation therapy: $25 copay or 20% of the cost Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other
providers in the network. This is called a"referral." Certain procedures, services and drugs may need advance
approval from your plan. This is called a"prior authorization" or "preauthorization." Please contact your PCP or refer |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | 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 areferral and/or prior authorization from the plan .
2022 - 8 - Summary of Benefits H1036265001
Covered Medical and Hospital Benefits (cont.)
Hearing Medicare-covered hearing exam: $25 copay
Routine hearing:
In-Network:
HER691
•$0 copayment for fitting/evaluation, routine hearing exams up to 1
per year. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Hearing Medicare-covered hearing exam: $25 copay
Routine hearing:
In-Network:
HER691
•$0 copayment for fitting/evaluation, routine hearing exams up to 1
per year.
•$399 copayment for each Value Technology hearing aid up to 1per
ear per year.
•$899 copayment for each Advanced Technology hearing aid up to 1
per ear per year.
•$1299 copayment for each Premium Technology hearing aid up to 1
per ear per year.
•Note: Includes 1year warranty and 1month battery supply. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | per ear per year.
•$1299 copayment for each Premium Technology hearing aid up to 1
per ear per year.
•Note: Includes 1year warranty and 1month battery supply.
Dental Medicare-covered dental services: $25 copay
Routine dental:
The cost-share indicated below is what you pay for the covered service.
In-Network:
DEN613
•0% coinsurance for scaling and root planing (deep cleaning) up to 1
per quadrant every 3years.
•0% coinsurance for comprehensive oral evaluation or periodontal |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | In-Network:
DEN613
•0% coinsurance for scaling and root planing (deep cleaning) up to 1
per quadrant every 3years.
•0% coinsurance for comprehensive oral evaluation or periodontal
exam, scaling for moderate inflammation up to 1every 3years.
•0% coinsurance for panoramic film or diagnostic x-rays up to 1
every 5years.
•0% coinsurance for bitewing x-rays, intraoral x-rays up to 1set(s)
per year.
•0% coinsurance for emergency diagnostic exam up to 1per year. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | every 5years.
•0% coinsurance for bitewing x-rays, intraoral x-rays up to 1set(s)
per year.
•0% coinsurance for emergency diagnostic exam up to 1per year.
•0% coinsurance for fluoride treatment, periodic oral exam,
prophylaxis (cleaning) up to 2per year.
•0% coinsurance for periodontal maintenance up to 4per year.
•0% coinsurance for amalgam and/or composite filling, necessary
anesthesia with covered service up to unlimited per year. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | •0% coinsurance for periodontal maintenance up to 4per year.
•0% coinsurance for amalgam and/or composite filling, necessary
anesthesia with covered service up to unlimited per year.
•$1000 maximum benefit coverage amount per year for preventive
and comprehensive benefits.
Dental benefits may not cover all American Dental Association
procedure codes. Information regarding each plan is available at
Humana.com/sb .
Use the CAREington Medicare network for the Mandatory Supplemental |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | procedure codes. Information regarding each plan is available at
Humana.com/sb .
Use the CAREington Medicare network for the Mandatory Supplemental
Dental. The provider locator can be found at Humana.com >Find a
Doctor >from the Search Type drop down select Dental >under
Coverage Type select All Dental Networks >enter zip code >from the
network drop down select CAREington Medicare. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Doctor >from the Search Type drop down select Dental >under
Coverage Type select All Dental Networks >enter zip code >from the
network drop down select CAREington Medicare.
Vision •Medicare-covered vision services: $25 copay Your primary care provider (PCP) will work with you to coordinate the care you need with specialists or certain other
providers in the network. This is called a"referral." Certain procedures, services and drugs may need advance |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | providers in the network. This is called a"referral." Certain procedures, services and drugs may need advance
approval from your plan. This is called a"prior authorization" or "preauthorization." Please contact your PCP or refer
to the Evidence of Coverage (EOC) for services that require areferral and/or prior authorization from the plan .
2022 - 9 - Summary of Benefits H1036265001
Covered Medical and Hospital Benefits (cont.)
•Medicare-covered diabetic eye exam: $0 copay |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | 2022 - 9 - Summary of Benefits H1036265001
Covered Medical and Hospital Benefits (cont.)
•Medicare-covered diabetic eye exam: $0 copay
•Medicare-covered glaucoma screening: $0 copay
•Medicare-covered eyewear (post-cataract): $0 copay
Routine vision:
In-Network:
VIS178
•$0 copayment for routine exam up to 1per year.
•$115 maximum benefit coverage amount per year for contact
lenses, eyeglasses-lenses and frames, fitting for eyeglasses-lenses |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | In-Network:
VIS178
•$0 copayment for routine exam up to 1per year.
•$115 maximum benefit coverage amount per year for contact
lenses, eyeglasses-lenses and frames, fitting for eyeglasses-lenses
and frames or 1pair of select eyeglasses at no cost.
•Eyeglasses include ultraviolet protection and scratch resistant
coating.
Refraction is only covered when billed as part of the routine vision
exam.
Search for Vision providers in the Medical network of this Medicare
Advantage plan. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | coating.
Refraction is only covered when billed as part of the routine vision
exam.
Search for Vision providers in the Medical network of this Medicare
Advantage plan.
Mental health services Inpatient:
•$150 copay per day for days 1-8
•$0 copay per day for days 9-90
•Your plan covers up to 190 days in alifetime for inpatient mental
health care in apsychiatric hospital.
Outpatient (group and individual therapy visits): $25 to $100 copay |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | •Your plan covers up to 190 days in alifetime for inpatient mental
health care in apsychiatric hospital.
Outpatient (group and individual therapy visits): $25 to $100 copay
Cost share may vary depending on where service is provided.
Skilled nursing facility (SNF) •$0 copay per day for days 1-20
•$150 copay per day for days 21-100
•Your plan covers up to 100 days in aSNF
Physical Therapy
Cost share may vary depending
on the service and where service
is provided. •$15 to $30 copay |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | •$150 copay per day for days 21-100
•Your plan covers up to 100 days in aSNF
Physical Therapy
Cost share may vary depending
on the service and where service
is provided. •$15 to $30 copay
ADDITIONAL BENEFITS
Ambulance (ground) $250 copay per date of service
Ambulance (air) 20% of the cost
Transportation $0 copay for plan approved location up to 24 one-way trip(s) per year.
The member must contact transportation vendor to arrange
transportation. 2022 - 10 - Summary of Benefits H1036265001 |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | The member must contact transportation vendor to arrange
transportation. 2022 - 10 - Summary of Benefits H1036265001
Prescription Drug Benefits
Medicare Part Bdrugs •Chemotherapy drugs: 20% of the cost
•Other Part Bdrugs: 20% of the cost
PRESCRIPTION DRUGS
If you don't receive Extra Help for your drugs, you'll pay the following:
Deductible This plan does not have adeductible.
Initial coverage |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | •Other Part Bdrugs: 20% of the cost
PRESCRIPTION DRUGS
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 $4,430 .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. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | drug costs paid by both you and our plan. Once you reach this amount, you will enter the Coverage Gap.
As part of the Insulin Savings Program, you will pay no more than $35 for aone-month (up to a30-day)
supply for Select Insulins in the initial coverage stage. See the Additional Drug Coverage section of this
document for specific details.
Preferred cost-sharing
Pharmacy options Retail
To find the preferred cost-share retail
pharmacies near you, go to
Humana.com/pharmacyfinder Mail order |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | document for specific details.
Preferred cost-sharing
Pharmacy options Retail
To find the preferred cost-share retail
pharmacies near you, go to
Humana.com/pharmacyfinder Mail order
Humana Pharmacy ®
N/A 30-day supply 90-day supply 30-day supply 90-day supply
Tier 1: Preferred Generic $0 $0 $0 $0
Tier 2: Generic $0 $0 $0 $0
Tier 3: Preferred Brand $45 $135 $45 $125
Tier 4: Non-Preferred
Drug $95 $285 $95 $275
Tier 5: Specialty Tier 33% N/A 33% N/A 2022 - 11 - Summary of Benefits H1036265001 |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Tier 2: Generic $0 $0 $0 $0
Tier 3: Preferred Brand $45 $135 $45 $125
Tier 4: Non-Preferred
Drug $95 $285 $95 $275
Tier 5: Specialty Tier 33% N/A 33% N/A 2022 - 11 - Summary of Benefits H1036265001
Standard cost-sharing
Pharmacy options Retail
All other network retail pharmacies. Mail order
Walmart Mail ,PillPack
N/A 30-day supply 90-day supply 30-day supply 90-day supply
Tier 1: Preferred Generic $10 $30 $10 $30
Tier 2: Generic $20 $60 $20 $60
Tier 3: Preferred Brand $47 $141 $47 $141 |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Walmart Mail ,PillPack
N/A 30-day supply 90-day supply 30-day supply 90-day supply
Tier 1: Preferred Generic $10 $30 $10 $30
Tier 2: Generic $20 $60 $20 $60
Tier 3: Preferred Brand $47 $141 $47 $141
Tier 4: Non-Preferred
Drug $100 $300 $100 $300
Tier 5: Specialty Tier 33% N/A 33% N/A
Generic drugs may be covered on tiers other than Tier 1and Tier 2so please check this plan's Humana
Drug Guide to validate the specific tier on which your drugs are covered. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Generic drugs may be covered on tiers other than Tier 1and Tier 2so please check this plan's Humana
Drug Guide to validate the specific tier on which your drugs are covered.
Other pharmacies are available in our network.
Specialty drugs are limited to a30-day supply.
If you receive Extra Help for your drugs, you'll pay the following:
Deductible This plan does not have adeductible.
Pharmacy cost-sharing
For generic drugs (including 30-day supply 90-day supply
brand drugs treated as generic), |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Deductible This plan does not have adeductible.
Pharmacy cost-sharing
For generic drugs (including 30-day supply 90-day supply
brand drugs treated as generic),
either: $0 copay; or
$1.35 copay; or
$3.95 copay ;or
15% of the cost $0 copay; or
$1.35 copay; or
$3.95 copay ;or
15% of the cost
For all other drugs, either: $0 copay; or
$4 copay; or
$9.85 copay ;or
15% of the cost $0 copay; or
$4 copay; or
$9.85 copay ;or
15% of the cost
ADDITIONAL DRUG COVERAGE
Erectile dysfunction (ED) |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | $4 copay; or
$9.85 copay ;or
15% of the cost $0 copay; or
$4 copay; or
$9.85 copay ;or
15% of the cost
ADDITIONAL DRUG COVERAGE
Erectile dysfunction (ED)
drugs Covered at Tier 1cost-share amount.
Prescription Vitamins Covered at Tier 1cost-share amount.
This plan participates in the Insulin Savings Program which provides affordable, predictable copayments
on Select Insulins through the first three drug payment stages (Deductible (if applicable), Initial Coverage |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | on Select Insulins through the first three drug payment stages (Deductible (if applicable), Initial Coverage
and Coverage Gap) of the Part Dbenefit. The Insulin Savings Program does not apply to the Catastrophic
Coverage stage. To find out which drugs are Select Insulins, please check this plan's Humana Drug Guide.
You can identify Select Insulins by the "ISP "indicator in the Drug Guide. You are not eligible for this
program if you receive Extra Help. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | You can identify Select Insulins by the "ISP "indicator in the Drug Guide. You are not eligible for this
program if you receive Extra Help.
Your share of the cost for Select Insulins through the Deductible Stage (if applicable), Initial
Coverage Stage and Coverage Gap Stage as part of the Insulin Savings Program: 2022 - 12 - Summary of Benefits H1036265001
Preferred cost-sharing for Select Insulins
Pharmacy
options Retail To find the preferred cost-share
retail pharmacies near you, go to |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Preferred cost-sharing for Select Insulins
Pharmacy
options Retail To find the preferred cost-share
retail pharmacies near you, go to
Humana.com/pharmacyfinder Mail Order Humana Pharmacy ®
- 30-day supply 90-day supply 30-day supply 90-day supply
Tier 2: Generic $0 $0 $0 $0
Tier 3: Preferred
Brand $35 $105 $35 $95
Standard cost-sharing for Select Insulins
Pharmacy
options Retail All other network retail
pharmacies. Mail Order Walmart Mail ,PillPack |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Tier 3: Preferred
Brand $35 $105 $35 $95
Standard cost-sharing for Select Insulins
Pharmacy
options Retail All other network retail
pharmacies. Mail Order Walmart Mail ,PillPack
- 30-day supply 90-day supply 30-day supply 90-day supply
Tier 2: Generic $20 $60 $20 $60
Tier 3: Preferred
Brand $35 $105 $35 $105
Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Tier 2: Generic $20 $60 $20 $60
Tier 3: Preferred
Brand $35 $105 $35 $105
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
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 the additional pharmacy-specific cost-sharing and the phases |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | 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 the additional pharmacy-specific cost-sharing and the phases
of the 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 astandard retail pharmacy.
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network
pharmacy. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network
pharmacy.
Days’ Supply Available
Unless otherwise specified, you can get your Part Ddrug in the following days’ supply amounts:
•One-month supply (up to 30 days)*
•Two-month supply (31-60 days)
•Three-month supply (61-90 days)
*Long term care pharmacy (one-month supply =31 days) 2022 - 13 - Summary of Benefits H1036265001
Coverage Gap |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | •Two-month supply (31-60 days)
•Three-month supply (61-90 days)
*Long term care pharmacy (one-month supply =31 days) 2022 - 13 - Summary of Benefits H1036265001
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 costs total $7,050 —which is the
end of the coverage gap. As part of the Insulin Savings Program, you will pay no more than $35 for a |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | end of the coverage gap. As part of the Insulin Savings Program, you will pay no more than $35 for a
one-month (up to a30-day) supply for Select Insulins in the coverage gap. See the Additional Drug
Coverage section of this document for specific details. Not everyone will enter the coverage gap.
Under this plan, you may pay even less for the following:
Tier 1(Preferred Generic) - All Drugs
Tier 2(Generic) - All Other Drugs, Select Insulin Drugs
Tier 3(Preferred Brand) - Select Insulin Drugs |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Under this plan, you may pay even less for the following:
Tier 1(Preferred Generic) - All Drugs
Tier 2(Generic) - All Other Drugs, Select Insulin Drugs
Tier 3(Preferred Brand) - Select Insulin Drugs
For more information on cost sharing in the coverage gap, please call us or access your Evidence of
Coverage online.
Catastrophic Coverage
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | Coverage online.
Catastrophic Coverage
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and
through mail order) reach $7,050 ,you pay the greater of:
•5% of the cost, or
•$3.95 copay for generic (including brand drugs treated as generic) and a $9.85 copayment for all other
drugs
Additional Benefits
Medicare-covered foot care
(podiatry) $25 copay
Medicare-covered chiropractic
services $20 copay
Medical equipment/ supplies |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | drugs
Additional Benefits
Medicare-covered foot care
(podiatry) $25 copay
Medicare-covered chiropractic
services $20 copay
Medical equipment/ supplies
Cost share may vary depending
on the service and where service
is provided •Durable medical equipment (like wheelchairs or oxygen): $0 copay
or 20% of the cost
•Medical supplies: $0 copay
•Prosthetics (artificial limbs or braces): 20% of the cost
•Diabetic monitoring supplies: $0 copay or 20% of the cost
Rehabilitation services |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | or 20% of the cost
•Medical supplies: $0 copay
•Prosthetics (artificial limbs or braces): 20% of the cost
•Diabetic monitoring supplies: $0 copay or 20% of the cost
Rehabilitation services
Cost share may vary depending
on the service and where service
is provided. •Occupational and speech therapy: $15 to $30 copay
•Cardiac rehabilitation: $25 copay
•Pulmonary rehabilitation: $25 copay
Telehealth services
(in addition to Original
Medicare) •Primary care provider (PCP): $0 copay |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | •Cardiac rehabilitation: $25 copay
•Pulmonary rehabilitation: $25 copay
Telehealth services
(in addition to Original
Medicare) •Primary care provider (PCP): $0 copay
•Specialist: $25 copay
•Urgent care services: $0 copay
•Substance abuse and behavioral health services: $0 copay 2022 - 14 - Summary of Benefits H1036265001
More benefits with your plan
Enjoy some of these extra benefits included in your plan .
COVID-19 Testing and Treatment
$0 copay for testing and treatment |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | More benefits with your plan
Enjoy some of these extra benefits included in your plan .
COVID-19 Testing and Treatment
$0 copay for testing and treatment
services for COVID-19.
Routine foot care
$25 copay per visit for unlimited visits.
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
Incentive program for completing |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | 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. 15
To find out more about the coverage and costs of Original Medicare, look in the current “Medicare &You” |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | SilverSneakers ®fitness program
Basic fitness center membership
including fitness classes. 15
To find out more about the coverage and costs of Original Medicare, look in the current “Medicare &You”
handbook. View it online at http://www.medicare.gov or get acopy by calling 1-800-MEDICARE (1-800-633-4227),
24 hours aday, seven days aweek. TTY users should call 1-877-486-2048.
Medicare-covered eye refractions during aspecialist medical visit are not covered. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | 24 hours aday, seven days aweek. TTY users should call 1-877-486-2048.
Medicare-covered eye refractions during aspecialist medical visit are not covered.
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/H1036-265.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/H1036-265.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.
Humana.com 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. |
{'source': PosixPath('pdf_library/H1036-265.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 GCHJV5REN 0220 Important!________________________________________________
At Humana ,it is important you are treated fairly. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | of this booklet and we will send you one. Find out more Notes Notes GCHJV5REN 0220 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, marital status or religion. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, marital status or religion.
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/H1036-265.pdf')} | 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/H1036-265.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/H1036-265.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/H1036-265.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
and services are necessary to ensure an equal opportunity to participate.
Language assistance services, free of charge, are available to you. |
{'source': PosixPath('pdf_library/H1036-265.pdf')} | and services are necessary to ensure an equal opportunity to participate.
Language assistance services, free of charge, are available to you.
1-877-320-1235 (TTY: 711) Humana Gold Plus H1036-265 (HMO)
H1036265001 ENG
Tampa Metro Area
Humana.com
H1036265001SB22 |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Summary of Benefits SBOSB030
Humana Community HMO SNP-DE (HMO D-SNP) H1036-235
Louisville
Jefferson County
Our service area includes the following county/counties in Kentucky: Jefferson. 2023
GNHH4HIEN_23_C Summary of Benefits H1036235000SB23 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/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | have any questions, you can call and speak to acustomer service representative at 1-800-833-2364 (TTY:
711) .
Understanding the Benefits
The Evidence of Coverage (EOC) provides acomplete list of all coverage and services. It is important
to review plan coverage, costs and benefits before you enroll. Visit Humana.com/medicare or call
1-800-833-2364 (TTY: 711) to view acopy of the EOC.
Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | 1-800-833-2364 (TTY: 711) to view acopy of the EOC.
Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the
network. If they are not listed, it means you will likely have to select anew doctor.
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. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | in the network. If the pharmacy is not listed, you will likely have to select anew pharmacy for your
prescriptions.
Review the formulary to make sure your drugs are covered.
Understanding Important Rules
Benefits, premiums and/or copayments/co-insurance may change on January 1, 2024.
Except in emergency or urgent situations, we do not cover services by out-of-network providers
(doctors who are not listed in the provider directory). |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.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 adual eligible special needs plan (D-SNP). Your ability to enroll will be based on
verification that you are entitled to both Medicare and medical assistance from astate plan under
Medicaid. This plan may enroll FBDE, QMB, QMB+, SLMB+. Summary of Benefits
Humana Community HMO SNP-DE (HMO D-SNP) H1036-235
Louisville |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Medicaid. This plan may enroll FBDE, QMB, QMB+, SLMB+. Summary of Benefits
Humana Community HMO SNP-DE (HMO D-SNP) H1036-235
Louisville
Jefferson County 2023
Our service area includes the following county/counties in Kentucky: Jefferson.
H1036_SB_MAPD_HMO_235000_2023_M Summary of Benefits H1036235000SB23 H1036235000SB23 Summary of Benefits 5H1036235000
Let's talk about Humana Community HMO
SNP-DE (HMO D-SNP)
Find out more about the Humana Community HMO SNP-DE (HMO D-SNP) plan -including the |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Let's talk about Humana Community HMO
SNP-DE (HMO D-SNP)
Find out more about the Humana Community HMO SNP-DE (HMO D-SNP) plan -including the
health and drug services it covers -in this easy-to-use guide.
Humana Community HMO SNP-DE (HMO D-SNP) is aCoordinated Care plan HMO with a
Medicare contract and acontract with the Kentucky Department of Medicaid Services (DMS)
program. Enrollment in this Humana plan depends on contract renewal. |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Medicare contract and acontract with the Kentucky Department of Medicaid Services (DMS)
program. Enrollment in this Humana plan depends on contract renewal.
The benefit information provided is asummary of what we cover and what you pay. It doesn't
list every service that we cover or list every limitation or exclusion. For acomplete list of services
we cover, ask us for the "Evidence of Coverage". |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | list every service that we cover or list every limitation or exclusion. For acomplete list of services
we cover, ask us for the "Evidence of Coverage".
As amember you must select an in-network doctor to act as your Primary Care Provider (PCP). Humana
Community HMO SNP-DE (HMO D-SNP) has anetwork of doctors, hospitals, pharmacies and other providers.
If you use providers who aren’t in our network, the plan may not pay for these services. You have access to |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | If you use providers who aren’t in our network, the plan may not pay for these services. You have access to
Care Managers. Care Managers are nurses or care coordinators who support your health and well-being by
providing additional services including: acute and chronic-care management, telephonic and in-person
health support, assistance in coordinating Medicare and Medicaid benefits, educational resources and
workshops, and support for families and caregivers.
To be eligible |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | health support, assistance in coordinating Medicare and Medicaid benefits, educational resources and
workshops, and support for families and caregivers.
To be eligible
To enroll in Humana Community HMO SNP-DE (HMO
D-SNP), aDual Eligible Special Needs Plan, you must
be entitled to Medicare Part Aand enrolled in
Medicare Part B, live in our service area and also
receive certain levels of assistance from the Kentucky
Department of Medicaid Services (DMS). If you |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | be entitled to Medicare Part Aand enrolled in
Medicare Part B, live in our service area and also
receive certain levels of assistance from the Kentucky
Department of Medicaid Services (DMS). If you
receive both Medicare and Medicaid benefits, this
means you are dual eligible.
Humana Community HMO SNP-DE (HMO D-SNP) may
enroll FBDE, QMB, QMB+, SLMB+.
Qualified Medicare Beneficiary (QMB): Helps pay
Medicare Part Aand Part Bpremiums, and other cost
sharing (like deductibles, coinsurance, and |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | enroll FBDE, QMB, QMB+, SLMB+.
Qualified Medicare Beneficiary (QMB): Helps pay
Medicare Part Aand Part Bpremiums, and other cost
sharing (like deductibles, coinsurance, and
copayments).
Qualified Medicare Beneficiary Plus (QMB+): Helps pay
Medicare Part Aand Part Bpremiums, and other
cost-sharing (like deductibles, coinsurance, and
copayments) and provides full Medicaid benefits for
Medicaid services provided by Medicaid providers.
Specified Low-Income Medicare Beneficiary Plus |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | cost-sharing (like deductibles, coinsurance, and
copayments) and provides full Medicaid benefits for
Medicaid services provided by Medicaid providers.
Specified Low-Income Medicare Beneficiary Plus
(SLMB+): Helps pay Part Bpremiums and provides full
Medicaid benefits for Medicaid services provided by
Medicaid providers.
Full Benefit Dual Eligible (FBDE): Financial assistance
may be available to pay Medicare Part APremiums,
and/or Medicare Part BPremiums, and other |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Medicaid providers.
Full Benefit Dual Eligible (FBDE): Financial assistance
may be available to pay Medicare Part APremiums,
and/or Medicare Part BPremiums, and other
cost-sharing (like deductibles, coinsurance, and
copayments) and provides full Medicaid benefits.
Plan name:
Humana Community HMO SNP-DE (HMO D-SNP) More about Humana Community HMO
SNP-DE (HMO D-SNP)
As amember of this plan, you will not be responsible
for cost sharing for plan benefits. The Medicaid |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Humana Community HMO SNP-DE (HMO D-SNP) More about Humana Community HMO
SNP-DE (HMO D-SNP)
As amember of this plan, you will not be responsible
for cost sharing for plan benefits. The Medicaid
Comparison Chart shows specific benefits that
Medicaid may cover for some dual eligible members.
You will work with your Humana care coordinator to
understand and access these benefits from the
Kentucky Department of Medicaid Services (DMS)
after any Humana Community HMO SNP-DE (HMO |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | You will work with your Humana care coordinator to
understand and access these benefits from the
Kentucky Department of Medicaid Services (DMS)
after any Humana Community HMO SNP-DE (HMO
D-SNP) benefits are used. The Covered Medical and
Hospital Benefits chart shows the benefits you will
receive from Humana.
Be sure to show the Kentucky Department of
Medicaid Services (DMS) ID card in addition to your
Humana membership card to make your provider |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | receive from Humana.
Be sure to show the Kentucky Department of
Medicaid Services (DMS) ID card in addition to your
Humana membership card to make your provider
aware that you also have Medicaid coverage. You
may be required to pay asmall Medicaid specific
co-payment. Your services are paid first by Humana
and then by Medicaid.
How to reach us:
If you have questions about your benefits or your level
of eligibility for assistance from Medicaid, you should |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | and then by Medicaid.
How to reach us:
If you have questions about your benefits or your level
of eligibility for assistance from Medicaid, you should
contact Humana's Customer Care department or the
Kentucky Department of Medicaid Services (DMS)for
further details.
If you’re amember of this plan, call toll-free:
1-800-457-4708 (TTY: 711) .6 Summary of Benefits H1036235000SB23 H1036235000
If you’re not amember of this plan, call toll free:
1-800-833-2364 (TTY: 711) .
October 1-March 31: |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | 1-800-457-4708 (TTY: 711) .6 Summary of Benefits H1036235000SB23 H1036235000
If you’re not amember of this plan, call toll free:
1-800-833-2364 (TTY: 711) .
October 1-March 31:
Call 7days aweek from 8a.m. -8p.m.
April 1-September 30:
Call Monday -Friday, 8a.m. -8p.m.
Or visit our website: Humana.com/medicare .
Medicaid benefits last validated on 07/01/2022 and
are subject to change.
For the most current Kentucky Medicaid coverage
information, please visit the Kentucky Department of |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Medicaid benefits last validated on 07/01/2022 and
are subject to change.
For the most current Kentucky Medicaid coverage
information, please visit the Kentucky Department of
Medicaid Services (DMS) website at
https://chfs.ky.gov/agencies/dms/Pages/default.as
px or call the Medicaid Hotline at 1-800-635-2570
(TTY: 711). Ahealthy partnership
Get more from your plan —with
extra services and resources |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | https://chfs.ky.gov/agencies/dms/Pages/default.as
px or call the Medicaid Hotline at 1-800-635-2570
(TTY: 711). Ahealthy partnership
Get more from your plan —with
extra services and resources
provided by Humana !You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.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
H1036235000SB23 Summary of Benefits 7H1036235000
Monthly Premium, Deductible and Limits
Monthly plan premium $0
You must keep paying your Medicare Part Bpremium. Your Part A
and/or Part Bpremium may be paid on your behalf by the Kentucky |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Monthly Premium, Deductible and Limits
Monthly plan premium $0
You must keep paying your Medicare Part Bpremium. Your Part A
and/or Part Bpremium may be paid on your behalf by the Kentucky
Department of Medicaid Services (DMS) Program.
Medical deductible This plan does not have adeductible.
Pharmacy (Part D) deductible $0 if you qualify for "Extra Help"
Maximum out-of-pocket
responsibility This plan does not have amaximum out-of-pocket responsibility.
Covered Medical and Hospital Benefits |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Maximum out-of-pocket
responsibility This plan does not have amaximum out-of-pocket responsibility.
Covered Medical and Hospital Benefits
N/A WHAT YOU PAY ON THIS HUMANA PLAN
ACUTE INPATIENT HOSPITAL CARE
N/A $0 copay
OUTPATIENT HOSPITAL COVERAGE
Outpatient surgery at
outpatient hospital $0 copay
Outpatient surgery at
ambulatory surgical center $0 copay
DOCTOR OFFICE VISITS
Primary care provider (PCP) $0 copay
Specialists $0 copay
PREVENTIVE CARE |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | outpatient hospital $0 copay
Outpatient surgery at
ambulatory surgical center $0 copay
DOCTOR OFFICE VISITS
Primary care provider (PCP) $0 copay
Specialists $0 copay
PREVENTIVE CARE
N/A Our plan covers many preventive services at no cost when you see
an in-network provider including:
•Abdominal aortic aneurysm Screening
•Alcohol misuse counseling
•Bone mass measurement
•Breast cancer screening (mammogram)
•Cardiovascular disease (behavioral therapy)
•Cardiovascular screenings |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | •Abdominal aortic aneurysm Screening
•Alcohol misuse counseling
•Bone mass measurement
•Breast cancer screening (mammogram)
•Cardiovascular disease (behavioral therapy)
•Cardiovascular screenings
•Cervical and vaginal cancer screening
•Colorectal cancer screenings (colonoscopy, fecal occult blood test,
flexible sigmoidoscopy)
•Depression screening
•Diabetes screenings |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | •Cervical and vaginal cancer screening
•Colorectal cancer screenings (colonoscopy, fecal occult blood test,
flexible sigmoidoscopy)
•Depression screening
•Diabetes screenings
•HIV screening You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.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 H1036235000SB23 H1036235000
Covered Medical and Hospital Benefits (cont.)
N/A WHAT YOU PAY ON THIS HUMANA PLAN
•Medical nutrition therapy services
•Obesity screening and counseling
•Prostate cancer screenings (PSA) |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Covered Medical and Hospital Benefits (cont.)
N/A WHAT YOU PAY ON THIS HUMANA PLAN
•Medical nutrition therapy services
•Obesity screening and counseling
•Prostate cancer screenings (PSA)
•Sexually transmitted infections screening and counseling
•Tobacco use cessation counseling (counseling for people with no
sign of tobacco-related disease)
•Vaccines, including flu shots, hepatitis Bshots, pneumococcal shots
•"Welcome to Medicare" preventive visit (one-time)
•Annual Wellness Visit |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | sign of tobacco-related disease)
•Vaccines, including flu shots, hepatitis Bshots, pneumococcal shots
•"Welcome to Medicare" preventive visit (one-time)
•Annual Wellness Visit
•Lung cancer screening
•Routine physical exam
•Medicare diabetes prevention program
Any additional preventive services approved by Medicare during the
contract year will be covered.
EMERGENCY CARE
Emergency room
If you are admitted to the
hospital within 24 hours, you do
not have to pay your share of the |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | contract year will be covered.
EMERGENCY CARE
Emergency room
If you are admitted to the
hospital within 24 hours, you do
not have to pay your share of the
cost for the emergency care. $0 copay
Urgently needed services
Urgently needed services are
provided to treat a non-emergency,
unforeseen medical illness, injury or
condition that requires immediate
medical attention.$0 copay
DIAGNOSTIC SERVICES, LABS AND IMAGING
Diagnostic mammography $0 copay
Diagnostic radiology $0 copay |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | condition that requires immediate
medical attention.$0 copay
DIAGNOSTIC SERVICES, LABS AND IMAGING
Diagnostic mammography $0 copay
Diagnostic radiology $0 copay
Lab services $0 copay
Diagnostic tests and procedures $0 copay
Outpatient X-rays $0 copay
Radiation therapy $0 copay
HEARING SERVICES
Medicare-covered hearing $0 copay
Routine hearing HER945 |
{'source': PosixPath('pdf_library/HMO_SNP_DE_H1036_235_H1036235000SB23.pdf')} | Lab services $0 copay
Diagnostic tests and procedures $0 copay
Outpatient X-rays $0 copay
Radiation therapy $0 copay
HEARING SERVICES
Medicare-covered hearing $0 copay
Routine hearing HER945
•$0 copay for routine hearing exams up to 1every year. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please |