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{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Summary of Benefits SBOSB045
Humana Community (HMO) H1036-236
Louisville
Jefferson County
Our service area includes the following county/counties in Kentucky: Jefferson. 2023
GNHH4HIEN_23_C Summary of Benefits H1036236000SB23 Pre-Enrollment Checklist
Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you
have any questions, you can call and speak to acustomer service representative at 1-800-833-2364 (TTY:
711) .
Understanding the Benefits |
{'source': PosixPath('pdf_library/H1036236000SB23.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/H1036236000SB23.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/H1036236000SB23.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
You must continue to pay your Medicare Part Bpremium. This premium is normally taken out of your
Social Security check each month.
Benefits, premiums and/or copayments/co-insurance may change on January 1, 2024. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Social Security check each month.
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). Summary of Benefits
Humana Community (HMO) H1036-236
Louisville
Jefferson County 2023
Our service area includes the following county/counties in Kentucky: Jefferson. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Humana Community (HMO) H1036-236
Louisville
Jefferson County 2023
Our service area includes the following county/counties in Kentucky: Jefferson.
H1036_SB_MAPD_HMO_236000_2023_M Summary of Benefits H1036236000SB23 H1036236000SB23 Summary of Benefits 5H1036236000
Let's talk about Humana Community
(HMO)
Find out more about the Humana Community (HMO) plan -including the health and
drug services it covers -in this easy-to-use guide. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Let's talk about Humana Community
(HMO)
Find out more about the Humana Community (HMO) plan -including the health and
drug services it covers -in this easy-to-use guide.
Humana Community (HMO) is aMedicare Advantage HMO plan with aMedicare
contract. Enrollment in this Humana plan depends on contract renewal.
The benefit information provided is asummary of what we cover and what you pay. It
doesn't list every service that we cover or list every limitation or exclusion. For a |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | 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 Community (HMO), you
must be entitled to Medicare Part A, be
enrolled in Medicare Part Band live in
our service area.
Plan name:
Humana Community (HMO)
How to reach us:
If you're amember of this plan, call |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | must be entitled to Medicare Part A, be
enrolled in Medicare Part Band live in
our service area.
Plan name:
Humana Community (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.
Or visit our website:
Humana.com/medicare More about Humana Community
(HMO) |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | 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 Community
(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 prescription drug costs will be
lower, too.
If you have Medicaid, be sure to show your |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Medicare and the state's program, you may not
have to pay the medical costs displayed in this
booklet and your prescription drug costs will be
lower, too.
If you have Medicaid, be sure to show your
Medicaid ID card in addition to your Humana
membership card to make your provider aware
that you may have 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). |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | that you may have additional coverage. Your
services are paid first by Humana and then by
Medicaid.
As amember you must select an in-network
doctor to act as your Primary Care Provider (PCP).
Humana Community (HMO) 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.
Ahealthy partnership
Get more from your plan —with extra
services and resources provided by |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | 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! 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/H1036236000SB23.pdf')} | may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please
contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
6 Summary of Benefits H1036236000SB23 H1036236000
Monthly Premium, Deductible and Limits
Monthly Plan Premium $0
You must keep paying your Medicare Part Bpremium.
Medical deductible This plan does not have adeductible. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Monthly Premium, Deductible and Limits
Monthly Plan Premium $0
You must keep paying your Medicare Part Bpremium.
Medical deductible This plan does not have adeductible.
Pharmacy (Part D) deductible This plan does not have adeductible.
Maximum out-of-pocket
responsibility $3,900 in-network
The most you pay for copays, coinsurance and other costs for covered
medical services for the year.
Covered Medical and Hospital Benefits
Acute inpatient hospital care $250 copay per day for days 1-7 |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | medical services for the year.
Covered Medical and Hospital Benefits
Acute inpatient hospital care $250 copay per day for days 1-7
$0 copay per day for days 8-90
Your plan covers an unlimited number of days for an inpatient stay.
Outpatient hospital coverage •Outpatient surgery at Outpatient Hospital: $250 copay
•Outpatient surgery at Ambulatory Surgical Center: $200 copay
Doctor visits •Primary care provider: $0 copay |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Outpatient hospital coverage •Outpatient surgery at Outpatient Hospital: $250 copay
•Outpatient surgery at Ambulatory Surgical Center: $200 copay
Doctor visits •Primary care provider: $0 copay
•Specialist: $15 copay You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please |
{'source': PosixPath('pdf_library/H1036236000SB23.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
H1036236000SB23 Summary of Benefits 7H1036236000
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/H1036236000SB23.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/H1036236000SB23.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/H1036236000SB23.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/H1036236000SB23.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 $110 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 $20 copay at an urgent care center
Urgently needed services are provided to treat anon-emergency, |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | pay your share of the cost for the emergency care.
Urgently needed services $20 copay at an urgent care center
Urgently needed services are provided to treat anon-emergency,
unforeseen medical illness, injury or condition that requires immediate
medical attention. You do not need areferral to receive covered 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/H1036236000SB23.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 H1036236000SB23 H1036236000
Covered Medical and Hospital Benefits (cont.)
OUTPATIENT CARE AND SERVICES
Diagnostic services, labs and
imaging
Cost share may vary depending
on the service and where service |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Covered Medical and Hospital Benefits (cont.)
OUTPATIENT CARE AND SERVICES
Diagnostic services, labs and
imaging
Cost share may vary depending
on the service and where service
is provided •Diagnostic mammography: $0 to $15 copay
•Diagnostic colonoscopy $0 copay
•Diagnostic radiology: $180 to $300 copay
•Lab services: $0 to $20 copay
•Diagnostic tests and procedures: $0 to $100 copay
•Outpatient X-rays: $0 to $75 copay
•Radiation therapy: $15 copay or 20% of the cost |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | •Lab services: $0 to $20 copay
•Diagnostic tests and procedures: $0 to $100 copay
•Outpatient X-rays: $0 to $75 copay
•Radiation therapy: $15 copay or 20% of the cost
Hearing Medicare-covered hearing exam: $15 copay
Routine hearing:
In-Network:
HER963
•$0 copay for routine hearing exams up to 1per year.
•$0 copay for each Advanced level hearing aid up to 1per ear every 3
years.
•$299 copay for each Premium level hearing aid up to 1per ear every
3years. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | •$0 copay for each Advanced level hearing aid up to 1per ear every 3
years.
•$299 copay for each Premium level hearing aid up to 1per ear every
3years.
Hearing aid purchase includes:
•Unlimited follow-up provider visits during first year following
TruHearing hearing aid purchase
•60-day trial period
•3-year extended warranty
•80 batteries per aid for non-rechargeable models
You must see aTruHearing provider to use this benefit. Call |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | TruHearing hearing aid purchase
•60-day trial period
•3-year extended warranty
•80 batteries per aid for non-rechargeable models
You must see aTruHearing provider to use this benefit. Call
1-844-255-7144 to schedule an appointment (for TTY, dial 711).
Dental Medicare-covered dental services: $15 copay
Routine dental:
The cost-share indicated below is what you pay for the covered service.
In-Network:
DEN046
•$0 copay for scaling and root planing (deep cleaning) up to 1per |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Routine dental:
The cost-share indicated below is what you pay for the covered service.
In-Network:
DEN046
•$0 copay for scaling and root planing (deep cleaning) up to 1per
quadrant every 3years.
•$0 copay for comprehensive oral evaluation or periodontal exam,
occlusal adjustment, scaling for moderate inflammation up to 1
every 3years.
•$0 copay for bridges, complete dentures, crown recementation,
denture recementation, panoramic film or diagnostic x-rays, partial |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | every 3years.
•$0 copay for bridges, complete dentures, crown recementation,
denture recementation, panoramic film or diagnostic x-rays, partial
dentures up to 1every 5years.
•$0 copay for crown, root canal, root canal retreatment up to 1per
tooth per lifetime.
•$0 copay for bitewing x-rays, intraoral x-rays up to 1set(s) per year. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | •$0 copay for bitewing x-rays, intraoral x-rays up to 1set(s) per year. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please
contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
H1036236000SB23 Summary of Benefits 9H1036236000 |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
H1036236000SB23 Summary of Benefits 9H1036236000
Covered Medical and Hospital Benefits (cont.)
•$0 copay for adjustments to dentures, denture rebase, denture
reline, denture repair, emergency diagnostic exam, tissue
conditioning up to 1per year.
•$0 copay for emergency treatment for pain, fluoride treatment, oral |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | reline, denture repair, emergency diagnostic exam, tissue
conditioning up to 1per year.
•$0 copay for emergency treatment for pain, fluoride treatment, oral
surgery, periodic oral exam, prophylaxis (cleaning) up to 2per year.
•$0 copay for periodontal maintenance up to 4per year.
•$0 copay for amalgam and/or composite filling, necessary
anesthesia with covered service, simple or surgical extraction up to
unlimited per year.
•$3000 maximum benefit coverage amount per year for preventive |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | anesthesia with covered service, simple or surgical extraction up to
unlimited per year.
•$3000 maximum benefit coverage amount per year for preventive
and comprehensive benefits.
Dental services are subject to our standard claims review procedures
which could include dental history to approve coverage. Dental 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/H1036236000SB23.pdf')} | under this plan may not cover all American Dental Association
procedure codes. Information regarding each plan is available at
Humana.com/sb .
Network dentists have agreed to provide services at contracted fees
(the in-network fee schedules, of INFS). If amember visits a
participating network dentist, the member will not receive abill for
charges more than the negotiated fee schedule on covered services
(coinsurance payment still applies). |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | participating network dentist, the member will not receive abill for
charges more than the negotiated fee schedule on covered services
(coinsurance payment still applies).
Use the HumanaDental Medicare network for the Mandatory
Supplemental Dental. The provider locator can be found at
Humana.com >Find aDoctor >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. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Humana.com >Find aDoctor >from the Search Type drop down select
Dental >under Coverage Type select All Dental Networks >enter zip
code >from the network drop down select HumanaDental Medicare.
Vision •Medicare-covered vision services: $15 copay
•Medicare-covered diabetic eye exam: $0 copay
•Medicare-covered glaucoma screening: $0 copay
•Medicare-covered eyewear (post-cataract): $0 copay
Routine vision:
In-Network:
VIS733
•$0 copay for routine exam up to 1per year. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | •Medicare-covered glaucoma screening: $0 copay
•Medicare-covered eyewear (post-cataract): $0 copay
Routine vision:
In-Network:
VIS733
•$0 copay for routine exam up to 1per year.
•$300 maximum benefit coverage amount per year for contact
lenses or eyeglasses-lenses and frames, fitting for eyeglasses-lenses
and frames.
•Eyeglass lens options may be available with the maximum benefit
coverage amount up to 1pair per year.
•Maximum benefit coverage amount is limited to one time use per |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | and frames.
•Eyeglass lens options may be available with the maximum benefit
coverage amount up to 1pair per year.
•Maximum benefit coverage amount is limited to one time use per
year. You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs
may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | may need advance approval from your plan. This is called a"prior authorization" or "preauthorization." Please
contact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the
plan .
c
10 Summary of Benefits H1036236000SB23 H1036236000
Covered Medical and Hospital Benefits (cont.)
The provider locator for routine vision can be found at Humana.com >
Find aDoctor >select Vision care icon >Vision coverage through
Medicare Advantage plans. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | The provider locator for routine vision can be found at Humana.com >
Find aDoctor >select Vision care icon >Vision coverage through
Medicare Advantage plans.
Mental health services Inpatient:
•$250 copay per day for days 1-6
•$0 copay per day for days 7-90
•Your plan covers up to 190 days in alifetime for inpatient mental
health care in apsychiatric hospital.
Outpatient (group and individual therapy visits): $15 to $65 copay
Cost share may vary depending on where service is provided. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | health care in apsychiatric hospital.
Outpatient (group and individual therapy visits): $15 to $65 copay
Cost share may vary depending on where service is provided.
Skilled nursing facility (SNF) •$0 copay per day for days 1-20
•$196 copay per day for days 21-100
•Your plan covers up to 100 days in aSNF
Physical Therapy •$15 copay
ADDITIONAL BENEFITS
Ambulance $270 copay per date of service
Transportation $0 copay for plan approved location up to 48 one-way trip(s) per year. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Physical Therapy •$15 copay
ADDITIONAL BENEFITS
Ambulance $270 copay per date of service
Transportation $0 copay for plan approved location up to 48 one-way trip(s) per year.
This benefit is not to exceed 25 miles per trip.
The member must contact transportation vendor to arrange
transportation and should contact Customer Care to be directed to
their plan's specific transportation provider.
Medicare Part Bdrugs •Chemotherapy drugs: 19% of the cost |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | transportation and should contact Customer Care to be directed to
their plan's specific transportation provider.
Medicare Part Bdrugs •Chemotherapy drugs: 19% of the cost
•Other Part Bdrugs: 19% of the cost H1036236000SB23 Summary of Benefits 11 H1036236000
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 . |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Prescription Drug Benefits
PRESCRIPTION DRUGS
Important Message About What You Pay for Vaccines
Our plan covers most Part Dvaccines at no cost to you, no matter what cost-sharing tier it’s on .
Important Message About What You Pay for Insulin
You won’t pay more than $35 for aone-month (up to 30-day) supply of each Part Dinsulin product
covered by our plan, no matter what cost-sharing tier it’s on .This applies to all Part Dcovered insulins, |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | covered by our plan, no matter what cost-sharing tier it’s on .This applies to all Part Dcovered insulins,
including the Select Insulins covered under the Insulin Savings Program as described below. If you receive
"Extra Help", you will still pay no more than $35 for aone-month supply for each Part Dcovered insulin.
Please see your Prescription Drug Guide to find all Part Dinsulins covered by your plan.
If you don't receive Extra Help for your drugs, you'll pay the following: |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Please see your Prescription Drug Guide to find all Part Dinsulins covered by your plan.
If you don't receive Extra Help for your drugs, you'll pay the following:
Deductible This plan does not have adeductible.
Initial coverage
You pay the following until your total yearly drug costs reach $4,660 .Total yearly 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.
Mail Order Cost-Sharing
Pharmacy options Standard |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | drug costs paid by both you and our plan. Once you reach this amount, you will enter the Coverage Gap.
Mail Order Cost-Sharing
Pharmacy options Standard
Walmart Mail ,PillPack
Other pharmacies are
available in our network. To find
pharmacy mail order options go to
Humana.com/pharmacyfinder Preferred
CenterWell Pharmacy ™
N/A 30-day supply 90-day supply* 30-day supply 90-day supply*
Tier 1: Preferred Generic $10 $30 $0 $0
Tier 2: Generic $20 $60 $0 $0
Tier 3: Preferred Brand $47 $141 $42 $116 |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | CenterWell Pharmacy ™
N/A 30-day supply 90-day supply* 30-day supply 90-day supply*
Tier 1: Preferred Generic $10 $30 $0 $0
Tier 2: Generic $20 $60 $0 $0
Tier 3: Preferred Brand $47 $141 $42 $116
Tier 4: Non-Preferred
Drug $100 $300 $100 $290
Tier 5: Specialty Tier 33% N/A 33% N/A 12 Summary of Benefits H1036236000SB23 H1036236000
Retail Cost-Sharing
Pharmacy options Retail All network retail pharmacies. To find the retail pharmacies near
you, go to Humana.com/pharmacyfinder |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | 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 $0 $0
Tier 2: Generic $0 $0
Tier 3: Preferred Brand $42 $126
Tier 4: Non-Preferred
Drug $100 $300
Tier 5: Specialty Tier 33% N/A
Your plan participates in the Insulin Savings Program. You will pay no more than $35 for aone-month (up |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Tier 4: Non-Preferred
Drug $100 $300
Tier 5: Specialty Tier 33% 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 .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". |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | 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
one-month (up to 30-day) supply for all Part Dinsulins covered by our plan, including Select Insulins, no |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | 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 .The enhanced insulin coverage is available, even if you receive "Extra
Help".
Your share of the cost for Select Insulins:
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 Preferred |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | 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 ™
- 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 |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | 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 H1036236000SB23 Summary of Benefits 13 H1036236000
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* |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | 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), 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/H1036236000SB23.pdf')} | $1.45 copay; or
$4.15 copay ;or
15% of the cost
For all other drugs,
either: $0 copay; or
$4 .30 copay; or
$10.35 copay ;or
15% of the cost $0 copay; or
$4 .30 copay; or
$10.35 copay ;or
15% of the cost
Other pharmacies are available in our network.
*Some drugs are limited to a30-day supply
ADDITIONAL DRUG COVERAGE
Erectile dysfunction (ED)
drugs Covered at Tier 1cost-share amount.
Anti-Obesity drugs Covered at Tier 2cost-share amount. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | *Some drugs are limited to a30-day supply
ADDITIONAL DRUG COVERAGE
Erectile dysfunction (ED)
drugs Covered at Tier 1cost-share amount.
Anti-Obesity drugs Covered at Tier 2cost-share amount.
Prescription Vitamins Covered at Tier 1cost-share amount.
Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the
Part Dbenefit and if you qualify for "Extra Help." To find out if you qualify for "Extra Help," please contact |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Part Dbenefit and if you qualify for "Extra Help." To find out if you qualify for "Extra Help," please contact
the Social Security Office at 1-800-772-1213 Monday —Friday, 7a.m. —7p.m. TTY users should call
1-800-325-0778. For more information on your prescription drug benefit, please call us or access your
"Evidence of Coverage" online.
If you reside in along-term care facility, you pay the same as at aretail pharmacy. |
{'source': PosixPath('pdf_library/H1036236000SB23.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/H1036236000SB23.pdf')} | and 25 percent of the plan's cost for covered generic drugs until your out-of-pocket costs total $7,400 —
which is the end of the coverage gap. Not everyone will enter the coverage gap.
Under this plan, you may pay even less for the following:
Tier 1(Preferred Generic) - All Drugs
Tier 2(Generic) - All Drugs
Tier 3(Preferred Brand) - Select Insulin Drugs
For more information on cost sharing in the coverage gap, please call us or access your Evidence of |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Tier 2(Generic) - All Drugs
Tier 3(Preferred Brand) - Select Insulin Drugs
For more information on cost sharing in the coverage gap, please call us or access your Evidence of
Coverage online. 14 Summary of Benefits H1036236000SB23 H1036236000
Catastrophic Coverage
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and
through mail order) reach $7,4 00 you pay the greater of:
•5% of the cost, or |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and
through mail order) reach $7,4 00 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
Medicare-covered foot care
(podiatry) $15 copay
Medicare-covered chiropractic
services $20 copay
Medical equipment/ supplies
Cost share may vary depending
on the service and where service |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Medicare-covered foot care
(podiatry) $15 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): 16% of
the cost
•Medical supplies: 20% of the cost
•Prosthetics (artificial limbs or braces): 20% of the cost
•Diabetic monitoring supplies: $0 copay or 10% to 20% of the cost |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | the cost
•Medical supplies: 20% of the cost
•Prosthetics (artificial limbs or braces): 20% of the cost
•Diabetic monitoring supplies: $0 copay or 10% to 20% of the cost
Rehabilitation services •Occupational and speech therapy: $15 copay
•Cardiac rehabilitation: $10 copay
•Pulmonary rehabilitation: $10 copay
Telehealth services
(in addition to Original
Medicare) •Primary care provider (PCP): $0 copay
•Specialist: $15 copay
•Urgent care services: $0 copay |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | •Pulmonary rehabilitation: $10 copay
Telehealth services
(in addition to Original
Medicare) •Primary care provider (PCP): $0 copay
•Specialist: $15 copay
•Urgent care services: $0 copay
•Substance abuse and behavioral health services: $0 copay H1036236000SB23 Summary of Benefits 15 H1036236000
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 |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | 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 .
Humana Flex Allowance
$1000 annual allowance on aprepaid
card to use toward out of pocket costs
for the plan's preventive and |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | 1-800-833-2364 .
Humana Flex Allowance
$1000 annual allowance on aprepaid
card to use toward out of pocket costs
for the plan's preventive and
comprehensive dental, vision, or hearing
services including copays.
Members can use this benefit at
participating providers where the
primary business is Dental Care, Vision
Services, or Hearing Services and Visa®
is accepted.
Cannot be used for procedures such as
cosmetic dentistry and teeth whitening.
Unused amount expires at the end of
the plan year. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Services, or Hearing Services and Visa®
is accepted.
Cannot be used for procedures such as
cosmetic dentistry and teeth whitening.
Unused amount expires at the end of
the plan year.
Allowance amounts cannot be
combined with other benefit allowances.
Limitations and restrictions may apply.
Over-the-Counter (OTC) Allowance
$50 maximum benefit coverage
amount per month for over-the-counter
(OTC) prepaid card to purchase eligible
OTC health and wellness products at
participating retailers. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | $50 maximum benefit coverage
amount per month for over-the-counter
(OTC) prepaid card to purchase eligible
OTC health and wellness products at
participating retailers.
Unused funds carry over to the next
month and expire at the end of the plan
year.
Allowance amounts cannot be
combined with other benefit allowances.
Limitations and restrictions may apply. Humana Spending Account Card
The allowances listed below will be
loaded onto this prepaid card. Each
allowance is separate from any other |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Limitations and restrictions may apply. Humana Spending Account Card
The allowances listed below will be
loaded onto this prepaid card. Each
allowance is separate from any other
allowance listed. Allowances shown are
accessed by using this card. Allowance
amounts cannot be combined with
other benefit allowances. Limitations
and restrictions may apply.
*Humana Flex Allowance
*OTC Allowance
Special Supplemental Benefits for
the Chronically Ill (SSBCI) Humana
Flexible Care Assistance |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | other benefit allowances. Limitations
and restrictions may apply.
*Humana Flex Allowance
*OTC Allowance
Special Supplemental Benefits for
the Chronically Ill (SSBCI) Humana
Flexible Care Assistance
Humana Flexible Care Assistance is
available to members with chronic
health conditions, who are participating
in care management services, and meet
program criteria. Eligible members may
receive medical expense assistance and
other additional benefits, either |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | health conditions, who are participating
in care management services, and meet
program criteria. Eligible members may
receive medical expense assistance and
other additional benefits, either
primarily health related or non-primarily
health related, to address the member's
unique individual needs. Benefits are
limited up to $1,000 per year and must
be coordinated and authorized by acare
manager. There is no cost to participate.
Chiropractic services
Routine chiropractic: |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | limited up to $1,000 per year and must
be coordinated and authorized by acare
manager. There is no cost to participate.
Chiropractic services
Routine chiropractic:
$0 copay per visit for unlimited visits.
Routine foot care
$0 copay per visit for up to 12 visits 16 Summary of Benefits H1036236000SB23 H1036236000
Humana Well Dine ®Meal Program
Humana's home delivered meal
program for members following an
inpatient stay in the hospital or nursing
facility.
Rewards and Incentives |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Humana Well Dine ®Meal Program
Humana's home delivered meal
program for members following an
inpatient stay in the hospital or nursing
facility.
Rewards and Incentives
Go365 by Humana ®aRewards and
Incentive program for completing
certain preventive health screenings and
health and wellness activities.
SilverSneakers ®fitness program
Basic fitness center membership
including fitness classes. 17 |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | certain preventive health screenings and
health and wellness activities.
SilverSneakers ®fitness program
Basic fitness center membership
including fitness classes. 17
H1036_SB_MAPD_HMO_236000_2023_M Summary of Benefits H1036236000SB23 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/H1036236000SB23.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/H1036236000SB23.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/H1036236000SB23.pdf')} | and should not be construed as medical advice. Please refer to your evidence of coverage for additional details
on what your plan may cover or other rules that may apply.
Plans may offer supplemental benefits in addition to Part Cbenefits and Part Dbenefits. You can see our plan's provider and pharmacy directory at 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/H1036236000SB23.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 20 Summary of Benefits H1036236000SB23 H1036236000
GHHLNNXEN 0522 Important________________________________________________
At Humana, it is important you are treated fairly. |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | GHHLNNXEN 0522 Important________________________________________________
At Humana, it is important you are treated fairly.
Humana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color, national
origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity, marital status,
religion, or language. Discrimination is against the law. Humana and its subsidiaries comply with applicable |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | religion, or language. Discrimination is against the law. Humana and its subsidiaries comply with applicable
federal civil rights laws. If you believe that you have been discriminated against by Humana or its
subsidiaries, there are ways to get help.
•You may file acomplaint, also known as agrievance:
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 . |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.
If you need help filing agrievance, call 1-877-320-1235 or if you use a TTY ,call 711 .
•You can also file acivil rights complaint with the U.S. Department of Health and Human Services ,Office
for Civil Rights electronically through their Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf ,or at U.S. Department of Health and Human Services , |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | for Civil Rights electronically through their Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf ,or at U.S. Department of Health and Human Services ,
200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019,
800-537-7697 (TDD) .Complaint forms are 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: |
{'source': PosixPath('pdf_library/H1036236000SB23.pdf')} | •California residents: You may also call California Department of Insurance toll-free hotline number:
1-800-927-HELP (4357) ,to file agrievance.
Auxiliary aids and services, free of charge, are available to you.
1-877-320-1235 (TTY: 711)
Humana provides free auxiliary aids and services, such as qualified sign language interpreters, video remote
interpretation, and written information in other formats to people with disabilities when such auxiliary aids |
{'source': PosixPath('pdf_library/H1036236000SB23.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. H1036236000SB23 Summary of Benefits 21 H1036236000 22 Summary of Benefits H1036236000SB23 H1036236000 Humana Community (HMO)
H1036236000 ENG
Jefferson County
Humana.com
GNHH4HIEN_23_C Summary of Benefits H1036236000SB23 |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | Summary of Benefits SBOSB045
Humana Basic Rx Plan (PDP) S5884-138
States of Indiana and Kentucky
Our service area includes the following state(s): Indiana, Kentucky. 2023
GNHH4HIEN_23_C Summary of Benefits S5884138000SB23 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 1-800-706-0872 (TTY:
711) .
Understanding the Benefits |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | have any questions, you can call and speak to acustomer service representative at 1-800-706-0872 (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
1-800-706-0872 (TTY: 711) to view acopy of the EOC.
Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | 1-800-706-0872 (TTY: 711) to view acopy of the EOC.
Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is
in the network. If the pharmacy is not listed, you will likely have to select anew pharmacy for your
prescriptions.
Review the formulary to make sure your drugs are covered.
Understanding Important Rules
In addition to your monthly plan premium, you must continue to pay your Medicare Part Bpremium. |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | prescriptions.
Review the formulary to make sure your drugs are covered.
Understanding Important Rules
In addition to your monthly plan premium, you must continue to pay your Medicare Part Bpremium.
This premium is normally taken out of your Social Security check each month.
Benefits, premiums and/or copayments/co-insurance may change on January 1, 2024. Summary of Benefits
Humana Basic Rx Plan (PDP) S5884-138
States of Indiana and Kentucky 2023 |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | Benefits, premiums and/or copayments/co-insurance may change on January 1, 2024. Summary of Benefits
Humana Basic Rx Plan (PDP) S5884-138
States of Indiana and Kentucky 2023
Our service area includes the following state(s): Indiana, Kentucky.
S5884_SB_PD_PDP_138000_2023_M Summary of Benefits S5884138000SB23 S5884138000SB23 Summary of Benefits 5S5884138000
Let's talk about Humana Basic Rx Plan
(PDP)
Find out more about the Humana Basic Rx Plan (PDP) -including the drug services it |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | Let's talk about Humana Basic Rx Plan
(PDP)
Find out more about the Humana Basic Rx Plan (PDP) -including the drug services it
covers -in this easy-to-use guide.
Humana Basic Rx Plan (PDP) is a stand-alone prescription drug plan with aMedicare
contract. Enrollment in this Humana plan depends on contract renewal.
The benefit information provided is asummary of what we cover and what you pay. It
doesn't list every service that we cover or list every limitation or exclusion. For a |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | 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 Basic Rx Plan (PDP), you
must be entitled to Medicare Part A,
and/or be enrolled in Medicare Part B
and live in our service area.
Plan name:
Humana Basic Rx Plan (PDP)
How to reach us:
If you're amember of this plan, call |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | must be entitled to Medicare Part A,
and/or be enrolled in Medicare Part B
and live in our service area.
Plan name:
Humana Basic Rx Plan (PDP)
How to reach us:
If you're amember of this plan, call
toll-free: 1-800-281-6918 (TTY: 711) .
If you're not amember of this plan,
call toll free: 1-800-706-0872 (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 Basic Rx |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | 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 Basic Rx
Plan (PDP)
Do you have Medicare and Medicaid? If you are a
dual-eligible beneficiary enrolled in both
Medicare and the state's program, your
prescription drug costs may be lower.
If you have Medicaid, be sure to show your
Medicaid ID card in addition to your Humana
membership card to make your provider aware |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | prescription drug costs may be lower.
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.
Humana Basic Rx Plan (PDP) offers apharmacy
network with preferred cost sharing at select
pharmacies. You may pay more at other
pharmacies.
Ahealthy partnership
Get more from your plan —with extra |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | Humana Basic Rx Plan (PDP) offers apharmacy
network with preferred cost sharing at select
pharmacies. You may pay more at other
pharmacies.
Ahealthy partnership
Get more from your plan —with extra
services and resources provided by
Humana! 6 Summary of Benefits S5884138000SB23 S5884138000
Monthly Premium, Deductible and Limits
Monthly Plan Premium $30.70
If you receive premium assistance, your plan premium may be
reduced.
If you have Part B, you must keep paying your Medicare Part B
premium. |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | Monthly Plan Premium $30.70
If you receive premium assistance, your plan premium may be
reduced.
If you have Part B, you must keep paying your Medicare Part B
premium.
Pharmacy (Part D) deductible $505
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 |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | 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
covered by our plan, no matter what cost-sharing tier it’s on ,even if you haven’t paid your deductible .
Please see your Prescription Drug Guide to find all Part Dinsulins covered by your plan. |
{'source': PosixPath('pdf_library/Rx_Plan_PDP_S5884_138_S5884138000SB23.pdf')} | covered by our plan, no matter what cost-sharing tier it’s on ,even if you haven’t paid your deductible .
Please see your Prescription Drug Guide to find all Part Dinsulins covered by your plan.
If you don't receive Extra Help for your drugs, you'll pay the following:
Deductible This plan has a $505 deductible .You pay the full cost of your drugs until you reach $505 .
Then, you only pay your cost-share.
Initial coverage (after you pay your deductible) |