{"docstore/metadata": {"4536c7a5-f8a1-49c6-a684-2bc5c5c8b362": {"doc_hash": "fab5f5dcde0394deeb7797887bce5e1e9c0efb2be054a6389104ee9a6f11251b"}, "b8e0fd88-9c5c-4bee-8d5f-34c7cfddf61b": {"doc_hash": "de4c7fd47df9a7151c93ba1c4f157ff77ac3e444ce449dee97413d708caf238a"}, "dcb8d134-6b29-4205-9f66-2571af10521a": {"doc_hash": "0d7146c4ec75c1d31b8bd3c55675705aedd85c434febe8aeeb958f9b15768f8e"}, "44e6b813-b597-4855-8c73-abd185bdc9ab": {"doc_hash": "3e5a3136b76227151a439aa0d3074edcfbc14d904542602f38d94391c1fe6232"}, "090f6cbd-7594-4c59-ab80-cdfa9103caf3": {"doc_hash": "f5c41f14108cb3f3968235476b9e80b401250eb7394c618bc51280f94c73d943"}, "4828d225-5d1f-4e35-b4fd-717e3351c219": {"doc_hash": "ec18919b143c2d95b466e45e61b4d8b9afbc624e2fd20babb89c59d3419cc7a7"}, "7078060a-ea3a-4282-9c23-db78c9d21dff": {"doc_hash": "f180f1e8922c2641423ac268a3a59fd38981a6487ba6894409c2a063da0597f7"}, "1484d1dd-5f29-4f11-927c-a575f7810445": {"doc_hash": "0be49e3dfc8397ae20b444c53f849c294b1ab2c54b054a0440ac6d0effb3aeab"}, "1c2ffb2b-2ff1-4786-8c1e-6a2206ee767b": {"doc_hash": "930bca57faca3cf2628c570024734022bd9136724b6d2b950c61774dcf4af960"}, "37543027-c634-4a4f-91cc-dfdaff6de13a": {"doc_hash": "e81217dd37c5d9e743190c3eb4f9d5447886850aca7c0f6ca5f79eb069657b16"}, "f7ba0b1a-e60e-4015-b8de-4b4ff07d3b44": {"doc_hash": "49d7a88a2652517f6ddc29bbb75bab2bdbc33ff171a725c0e0c9703c6675c26c"}, "16f976f9-6952-4ce8-b03b-fcb350f08f01": {"doc_hash": "618b8a90c26868a5d13701e4a43600775d135ff5d7d81ec16e0d9a379171d492"}, "5dd7398c-23f1-4e80-92e9-da81baaa2f7f": {"doc_hash": "9ab750afdf4297843fc9ffa65017845fa06b868b080a5f8ac74932326628128d"}, "2fad2dca-54a6-4c85-b947-124bf62f5a6d": {"doc_hash": "b68803a320a49ed5e6ad6dd9fbec0a305f570af15f6293ade15e6689aa4be490"}, "24880012-18f6-456d-af2b-076a33f5067c": {"doc_hash": "c23260cfb460a168adc9bb4f6c268b43086d46a19ca3135ccb3183612aeaf3a3"}, "63719f8c-6ce3-4d45-b06a-14e0f1334343": {"doc_hash": "a4448682bed82c05fde02d9121a100e28f3fb8145bf522e669854e38714d68e0"}, "d68c272e-e910-4430-bd9d-5a33c35064fe": {"doc_hash": "115b3cb7957719d77aa2c62f63d67aae220251943c0c8951b3e4f711d0232bbf"}, "1a41dd19-ac4c-4f83-bd47-daf1a2d21ef6": {"doc_hash": "5e1660402d89589e0d4bcc62a2ad33469c2c933bd820fcf439f256882812eefb"}, "e6f86a9a-b581-495f-8243-5ea667154734": {"doc_hash": "11c97f1681b34519bf215a6b6f78c4f54bbde9bf22b573b0c815a183ce64b462"}, "2ae52e95-7e2b-44bf-97fd-e28f183ecf1d": {"doc_hash": "1bf770896ba11a6f0486766430f6b11a63238f9fdaf4c480b6dcde651911b3a3"}, "b1065af6-39c3-4a18-9bdb-7c6c134d20d9": {"doc_hash": "f2ef8618bf66db944bcc1395a6afb3298444bd371f439c4983b9bb15733aa393"}, "eb66606e-d697-4ccc-ad77-d8228b4bb745": {"doc_hash": "21eef70a776b00022a417c4aa2e0087a94454b340d5d96f6536c80c997bfd06d"}, "ddde86fc-815b-4682-8fad-1f5189243770": {"doc_hash": "886c219efb630abb78a783a005af3363761ef649c5743e1e3e3f55dffff61dad"}, "477640e2-4f9b-4613-962b-409368857896": {"doc_hash": "b7da13266762448b8da32de4bbd8b6619fde4977712fe3022ea3c162dd466553"}, "59d84232-09ab-4b2e-8973-665b464d8278": {"doc_hash": "84777ec9c1751827021fcc3556c7772911e2cc2c616c8e835f4f3f3ff3e7e03e"}, "4a42ac7a-14b5-4066-849f-68b1bd25395d": {"doc_hash": "7c290a8cd0470d157d70a5486ffb294d716341a70b028f612b8de0e9f4635fd1"}, "1b061e34-9fa7-4aa7-8fce-b16fb7f0617e": {"doc_hash": "0357bbd151e33d1af7f2ab68471c2526f61dfdbbd4fb5aa1eaa18ea5e85a66c9"}, "b327e644-bfa6-4c8d-8917-1952346384a5": {"doc_hash": "eabc4808f26295aa6bcc3943acbdb79105bbb56de9ee574a178c4db09f9e1887"}, "3b80bc31-f6d5-45ee-8d44-54714a155751": {"doc_hash": "e3add2426395f6b0531b0b2465a5ea1ad9f55cc17427f15778887083bcba9c20"}, "c863b8d5-e3fd-4a57-9c4e-0ed9cc10fae5": {"doc_hash": "fe8f29a60a91a37e33b888d1b8db4746caec3695e6f2e6956e464f33e9ddc96e"}, "01db5cee-01e4-435b-ba79-11ad2dcc85a1": {"doc_hash": "5b64196d8001f62f7e48383ac7e2a85c29db5f2f9e65373a9e2e5f467e5950f7"}, "bc5bdfd5-1f27-4c78-8c43-05609d3dd81c": {"doc_hash": "26a83c85efa443756be73aea96c289e330cc5eefdb6304566cb75ac1b787bf68"}, "875963a2-286c-459b-8e98-cf38085768de": {"doc_hash": "90b52454c537dfacc0e4170c61f91baa10980e356eee7ec665540342d2bf74de"}, "b9b1cb18-875a-4b21-b97a-48ae12cfa6dd": {"doc_hash": "5d15cc336d4416507bfd89c65b4567da562e3ca0984588ecc701c4c85f0f9e27"}, "e3c1a094-d8a2-47cf-b4bf-cfa98da8ef0e": {"doc_hash": "dde897dc5ef74d33c986e5d559cea62c52121920061186b02686a3bb0d629282"}, "e4ae379f-9d63-413b-8afa-afc20b5d0840": {"doc_hash": "5891e79129a300d5773a3dc3cc65028f81ded462a4b99cf7f02233696aad6148"}, "0902737a-cecc-43dc-a42c-f1170e797f3e": {"doc_hash": "d3b12621a74676641591280dc80537bf3e467e139f3cb9fb667cb1c96f7b6f91"}, "1dd89492-3c6b-45cf-bf4c-0f0846bd5e6a": {"doc_hash": "9d900b42b177e2b4a05e0aaa237ebd55da0a7a85a1ef5c1bf22060c9c9c5da85"}, "453afa2a-95c5-464a-ab4c-71d860b2f67e": {"doc_hash": "36d2228d3a1dbe90d6b9ef67989b6edd6aa962f1119d608e68889f297e5c1140"}, "5dbde026-bebb-42ed-b237-366ab5b3815d": {"doc_hash": "5d47ffc4474dd8e46e260b57a39958f7d18afa61f8b7d1323fab0eb094781ae8"}, "4bc1f1b7-8730-4a4f-8e64-705677c17aad": {"doc_hash": "a9a82548ebfd8c8a12654f0da36ce2e3498f33d64cc701817749fd3b12010c5a"}, "86c64624-4863-40cf-a897-99aada3d293e": {"doc_hash": "488e2473bf2b20e2db90665fd5ee04cd0a5b10609c50354c365591288d124edc"}, "ead21676-478c-4016-8130-55d7a1b30667": {"doc_hash": "434a7b52cb35bac8daa08cf7708cf2fbf257992924697947338acef2e8617a5a"}, "07bf2223-6f67-4480-9464-061c9446a7ba": {"doc_hash": "c3c8b0e8a7f421f1aa51703966725aa3e8b4706e5630d67f68be96a2cf631708"}, "3e310d24-ca9b-406d-afa6-ca08e60a881f": {"doc_hash": "a758e4b060a423375fc6cd8912cb29dcbb2a3d181adbd8c9c9571d32200f3cf9"}, "503af8fc-f4f8-4a53-9d59-1bf920fefe11": {"doc_hash": "1dc72777c34474e413660cd4a5401e77aa083c407d8301ce17d58d5a682fe677"}, "a7edf12c-ddf8-4bd2-9d1e-74fe6714b246": {"doc_hash": "b471e3b8094946ba29c0e1f5be471b5e24200e875ffc555b5c2157b74871d3dd"}, "1cd7ed3d-28fc-486b-a305-fe41714edd67": {"doc_hash": "8cc68ba328895de6b2ac51f191381347b1f5f755daeafd657c429316d201ede3"}, "9a45a111-0d63-4a6d-a051-ef74ab85bd94": {"doc_hash": "efc21db147df4182cf3ff6d57e1bc5f3d63e8da8fc531cfc05a17c6b7cc8fee6"}, "5727633c-2a70-4b63-850e-f9a827e549c2": {"doc_hash": "789b81edfcfe2bc7da238f62499152350165c6c6d582bd79190815c8acad8a46"}, "3301a21a-1eac-4e82-a4f8-d1a7799151ac": {"doc_hash": "16121edf64f19ef3667148581c0e1eeb1cefb56054de5cb2650f2f7fba09672f"}, "8577f61f-7da5-4b39-aa64-93207290cb2f": {"doc_hash": "0e5e9085bf9d24122e8cd541ead21adce63ce28bf2f36cc93d31e8f3e1f39d6c"}, "7d021290-03b8-4928-ae52-30e37ea681e1": {"doc_hash": "86bd7cfa7f3e64974c37e19d846199b6f3d9a8cf8b8943ed7268fc72fa4296d7"}, "04296aab-2a9d-4182-80b0-9d6fd5485bfa": {"doc_hash": "5ee458dbe40450ec316a6a10997fa46ef9d02076aa0dbb6db8717c4f7a805c26"}, "13f8f39f-0fd5-4540-9645-4f5c7e4dca54": {"doc_hash": "30611f2dab6c26d3ba5e6d99e7796c168173030e8d0614ae7635dde424033b2c"}, "752f075f-b7f3-446d-83b1-9aa5b36e58a3": {"doc_hash": "337ee5f0d3d7b40b2511861ae7c24dba9978fb5eb935fd8f20579ae370133a54"}, "1b057de8-418b-45c3-945b-de77c1d90051": {"doc_hash": "3565a28cea842bccab56074582ff676c375bde3ce56cc3a7c61814cb291318ea"}, "5e3b5a88-532c-4bf3-a6de-2e3ba09049a4": {"doc_hash": "d815da0113137b0529890a06ae06e6e9a03421e0cff14e036d480ba587b424fd"}, "d4f7dce2-6393-4313-bc0c-2cdfebe762cc": {"doc_hash": "1200997680bb4ee086bf36980fd62469cfd4b141208b6b229b773c051f7de23d"}, "cccd72e1-8f73-41d2-b15e-b5ec34e88f6e": {"doc_hash": "a2c138d79b6a274fa97e2c2574e6c3ffb6fe764330fa92309cd7dd2f02b091a6"}, "e187c352-dbdc-4526-8a11-acb8819f1e88": {"doc_hash": "0d93731ef1455b79d850a1b44d987b8551f81c9da345a7d262f1b26657ec8039"}, "f2316407-e14b-4c19-be75-42bc7b59b074": {"doc_hash": "e66d5561573a6f0585fe2b053ff29f1b3e32ee6eea7dcd2baa18e656ed28fc53"}, "2777322f-b9ce-46e2-b8d4-c17b971e1b72": {"doc_hash": "6efba0bb12b748cf087531d5119c596c0a5051a03f1ef65751cf275e8f04853e"}, "85466ec0-cd68-485a-ac5a-e4faa41257bd": {"doc_hash": "17225b402bb733f0dbf9ae55151a8cf7789f675f65a2c74f727f36a1be15969e"}, "6a785e8e-6fcb-4f83-93e9-663da5167de6": {"doc_hash": "5d581896dbaaaa0ad95c0a53ded3be44dd5e6a1fe174af3aad3ef11c15b64fd8"}, "5f614161-3f67-43c0-84fd-d1814299e861": {"doc_hash": "38605c6a58ce835d35a6cc472fb720b693cfc4c06646d4af3036ea9a8601f648"}, "cb003932-8052-4708-a030-7392202b9adf": {"doc_hash": "fd9ce39f8fa1c03d23c07a453ba606162dc4bbdf6d9d1583b00c60dcd8290342"}, "04edc4bb-4ad9-4bd4-a7dd-93add88a3521": {"doc_hash": "88f3c0e579b3b764398c276801e1e22df9b79350596e51c007e9315eccff9927"}, "b564ceac-4cef-4a26-9c80-a23be11dc10b": {"doc_hash": "ea5cd98335b6b7a4229dc8429cc6c409d68f54b76ae3f963a4268852decbee81"}, "32cc05f1-2a71-4f76-a2dd-21b48a0f732f": {"doc_hash": "2c5f5a430eaa9592473329c7b0e698a8e1e9c1fd3df8af0c4446930db98e57b1"}, "f2589de3-8eaf-4cb4-aa97-0364ffa07d21": {"doc_hash": "b0107c77faa0885d95f048cc3d11cb36eaa3d31d1f3522fce988f15d2e817df6"}, "cce6f646-7384-487c-b324-309fc6affb77": {"doc_hash": "e4ae3a1b7fbf10702da421d50fbc23398f5000f6b37cf77e1dbf1625407b26f8"}, "b6bad8bd-bdbb-4ad6-a3b0-4b2f6c32cc30": {"doc_hash": "31d47c6439d5780406b551dc02f64a8d3ad8deb44b33c0bc04db653f7b5aabe0"}, "3554f076-0cf7-4007-872e-53ad1157c837": {"doc_hash": "bdca984fe8949826514bbdd4e41c420058ae7439b35efa56e6acf7ba77085e3b"}, "1ab8f553-673b-4e15-a1b3-9ce906842891": {"doc_hash": "f70f318e896696cc1fcdd9138b270763db293eef378f81560fc08a0260f76d74"}, "d987d3a4-06d7-4953-9805-66d59b44e91c": {"doc_hash": "cf26626764b9b8226650736298292e090252e360b516bd0c31e26c0cd6cc3217"}, "7bf72344-40b0-469b-b6ee-81ad3c35aa5a": {"doc_hash": "ec459fc2f3aa97db8c7d35e24d74aafaf72233f6049a96b93e61fdd69f86d740"}, "c14d73e6-7c07-489d-a20c-b75f6cdb00c3": {"doc_hash": "3a78eed90f68da9e9cb5c9216bef574dd7580c2ef5631cf6d14a13cccbfd51b9"}, "f336b233-6662-4dd3-9adb-17a39907b54f": {"doc_hash": "5d823a597f391c2e17f3ca3da3a8beb681b432e68d6c8769e0d36429b28ecbe1"}, "82429d40-80fd-4194-bfee-b641afe43cdf": {"doc_hash": "06a385cad239267f8f2fde7bb58543185f026be383c0411ce2a13faa60d2ad4c"}, "ef6a1017-7adc-4f8f-82fa-3b8a87431952": {"doc_hash": "c7e2a4ebe79133e934325bde718289d6f22622e431fa52f2d4bda1671ec0a06c"}, "13d1e588-85e5-4d85-a5fb-c9e94b74d89c": {"doc_hash": "d58fc92584fd45455af9d4d03c8e93386b20eab76679eef0491835e5d31fdb92"}, "9ef26203-762a-4b72-8726-f5367480317d": {"doc_hash": "1d9d19f6370c092273fc1a723720dffe511799ef894ab888a9bfa7645af0d870"}, "10c41412-5362-413a-ac6d-784a2258db5b": {"doc_hash": "eae79ac0bb54e6aa6c51f3ee0dade41d8c7dcca19651e1f2ae49892719e4c199"}, "8acec875-a1d0-4812-87c9-12141bdcde8c": {"doc_hash": "6667ae549b19f636f4669e788a8e5a9566c8ac589b74f17c3c24f0b34d2d5f7a"}, "a306a787-2b16-4671-b764-4821848409fe": {"doc_hash": "218886456a5d583d5e20ef410a22795ad37736981ab188904db4dd0e3e7cfc2c"}, "95582803-7714-4dfc-a935-817b5ddb574f": {"doc_hash": "17ca4fb17edb7a6befdec8f6bd4cba6dfdaec1955be63c50bf6b538b34c4920e"}, "83d42ba2-d396-45ff-97a2-1a713a34b7a2": {"doc_hash": "56d46265eb543fc606c42331a69a6effbe4ede1ea5ed7faacbdeb9c59ce8095b"}, "8ffd8653-1c20-45b5-a9d6-2444054ff836": {"doc_hash": "5e398082628ad2928f03079fb5266106a8fc8621d6d6051d5d79171497864ce4"}, "f0533645-d4d0-4a93-a302-190251cd23a2": {"doc_hash": "5112ac9502787cf6b99ad872bc68055df280e48dc46d36bd1524075b8c6eb9c0"}, "ef8895c9-e158-4328-8bb0-2808888628e9": {"doc_hash": "52ebfe5250eb7bd8e9f08090668e298191d07936656a68f81acee82e29f69262"}, "a738b865-19f4-40ae-8ecd-17704b1880a0": {"doc_hash": "3f5b9963ec0bb57ec75c0b3c727c54bf8a8bf5b69e365a0d533d5394c93337eb"}, "74b9126a-4fcc-4a57-88ca-2afc34d8526d": {"doc_hash": "d72a095e0787d461c9d2f224862b346cd5bd5cdf66d25b44fb6ae16e1628a7eb"}, "cbdccf59-e8d9-424b-8ca6-f7a16e015737": {"doc_hash": "79b9ee090c647c70ae358dd701fc2ebb52c7aad4b16c8e0a320c45ef8c6fa9ec"}, "d1cdb3d5-03f1-41f6-ad61-3bb8d2200581": {"doc_hash": "d8d3b2c6ce38782b5118871e9861507c01af41a3cea3f87d44d1118e484a4670"}, "885b3087-a36d-442c-9748-d0dc6c9d6dfa": {"doc_hash": "0e3e366d6a1e3b5298416dcb986b0a7f3517e3c14d5b96fdb36cd2fc6ad4d660"}, "61671732-245a-4392-b420-0ba6ad322ff3": {"doc_hash": "0eccc70245efbb57ade2b55748e92dda40d6341e54511deed1dcded16bd4327c"}, "9775e379-01ee-4811-afca-34f66c2ce5cf": {"doc_hash": "2fac6a04c8d1143a00b87dcd89477049777bba9610a5de0e9e7db7692ecbd31b"}, "dacf3b98-0f27-48b1-8f36-c5876bc493aa": {"doc_hash": "a2e55d01b32a60b89f5b54b2c228c5a52ab22ac6b6a5c8e394a401fd8f6d62c4"}, "c4bbe220-e335-42fd-8d45-3babaf36e6d7": {"doc_hash": "e9292be3c0e1912f98a3eb3efed03da276d2991961b8e8f407e6381d153e5a75"}, "fe2c398a-a70a-480e-a9ba-5c310d24d1d3": {"doc_hash": "3669ef4629cf6a45123a7fa31899fafa0c81e3c50d3108e230825bb9be2d2e77"}, "0c348d79-8048-43a4-afe6-1923171d4c80": {"doc_hash": "cbc30336b1178002dd9ac6f0428c81f70270e9d38c18ad0e45d2eaecddd232cc"}, "bf1e24a4-fa67-4d33-b1f8-86f8cf06c7db": {"doc_hash": "9069cf48d34449924a9a1170e6da99f5ed419f83ef53e9c017402f9bf9218b24"}, "30ec26a6-82c1-4566-bcdf-1452c417d567": {"doc_hash": "6892a508f6cdcb8d1fda331814ef998225cd8fd88e256002aaeb65fcc7c00aeb"}, "9fcb5435-78c7-46ac-bdcb-690fec057055": {"doc_hash": "89d96546f1f1cd1e81e70ab6625ef427f9525c6385c707d2eb61205783cc0ac9"}, "f017f507-17d9-4e64-ac1e-3056163f7b08": {"doc_hash": "4d3e98bc87bdb366ae15f2007c005703e182b8541f33643b245b659e197c95d4"}, "eefc82cc-e904-4d89-a023-bca35633a97d": {"doc_hash": "97411b8108986c82872d1c7a7941d16ec7cf5af914f4efa0f2e3c8949413c05b"}, "09e818fc-385c-40cb-93f7-712fdc1b278c": {"doc_hash": "a07189e94d89a2a171f59f739d885e2893a86c5ba9700b33677f56624f0c9422"}, "30edcdcf-0697-41f2-9946-196bc9ba443d": {"doc_hash": "e54d41e085aec7ffe0781270c7a21a01b3b1786fac13f59c916bbe5cf802be6b"}, "1a6cdde4-18c3-4946-a53f-dae2a6d0f588": {"doc_hash": "9c20bca27eb21ff9912367707b5be031d7c53dfe6fb061ee1653181c76c3039c"}, "ad2cfc73-37bb-4b7b-8287-97522bc256f6": {"doc_hash": "b0d85c4593619cf46d77bf8066c399c6862ea6cf9d7bec87715e0bb71bd1f697"}, "e60b55ef-bf2a-4951-b66e-a215a4162631": {"doc_hash": "41892d718cb404bd9dfc0574c700ebb8ff32af6c53fa81ff432b500c525ceb86"}, "9e7d1fd9-0ab5-423c-b6fb-10464d6473dc": {"doc_hash": "7fc1ab9167f0ee4a3cbebda12cdd1d3afa6f4c51bc573c8816d186d568ace5c8"}, "a4dcecf6-1b5e-4629-823c-f817d01251cc": {"doc_hash": "522aecd1f385bb82082f54d98385538b37f08f1333e5819e368ea40da8ee7da4"}, "02911eb1-2714-4d45-bf2a-4fe19fc55871": {"doc_hash": "e408e29dc2642d555c39c15ae203521b12b1eaaa33444421535558348df1f16e"}, "6f6de8f1-566a-4a1a-bc12-b7a11691b387": {"doc_hash": "10ab72e5e69364f72f773ff4bf7d93537340b5d4d325a96d6401b509c86d542c"}, "49a431a9-503f-4da5-8753-d2ddf82c09c0": {"doc_hash": "c9d68634c0f57d2d4f09d8fdbfd4aa2ab26a57bb7a03ddac7cb218d416d007ef"}, "309537af-1378-4104-8f65-94d2640eb42c": {"doc_hash": "7fe869fec9316d8774d88805f1a06083a3d5670617c820299484bb797c8e6667"}, "b7bb677d-5c59-4983-b2b6-c2b90239a7d2": {"doc_hash": "881a236b0f2ca9e2cb57cffe36ef9d848652357942645d228408cd06eb50042e"}, "2de9dc72-a627-458f-9305-fe7108028a51": {"doc_hash": "8ef82ddc48f9a707cc4bea3e748d46c8ad818fc5da4f0c5f2147b6d6e6bec684"}, "c6dc1253-7056-4dd8-a98d-da1ea0cabc43": {"doc_hash": "77996b3176b80ac4ef93a92872609a2f004712c135c62b0763c6312be97e3d1d"}, "833bb4ed-8f5b-4f6e-98a2-8981f3fcd4f3": {"doc_hash": "f2daa8262de83b1014f9a8293921669c20ddf558e245650c75ee6a6813031750"}, "facdb65f-d37a-40ad-8360-87994a1e99f2": {"doc_hash": "20bb405bd0cda48290751c31117dd0ffa3247815a228d0fdb6bfbb74570233f7"}, "d2f989bf-23df-4a52-aca4-fdaf3c61e40c": {"doc_hash": "a28304b6110f9da0ffe876bed628de4a4e33279641bd05cd9a14915d72c347a4"}, "859dcc04-6c25-4e38-a92e-ab31569fb10e": {"doc_hash": "03bacadbb0db74f770e06bec6cbf905e7c4286a4bb907d77d94bcf2464010a07"}, "a0758f96-3e2a-484b-96db-7cde00181ef7": {"doc_hash": "ee7dcab555c60f46d086b5fb5a67cef8aff4dcf32d1c219f28f872979eeb6c45"}, "19f9203a-c83f-454f-98c4-7fda199da842": {"doc_hash": "68b43a85a7c0f8bce3ed65ca1596f8626cea11a631e5d1c16a5ecb9fa6a7b207"}, "57837dcc-6cb4-4636-bd65-75849f1527b8": {"doc_hash": "fcd616d775318050549eac53caa0d0bd52675d07c35106265fe919db575a4a72"}, "01fc81ba-2b6f-494d-a19e-5ff325ee76d2": {"doc_hash": "e69d5aa9acaf4566d03a056f8ee433047c10d2f48ddd18049c82073caf3cd134"}, "9ed539ad-4de5-49be-b369-8be2de44fb0a": {"doc_hash": "1020cd1936396582ee63ff3db3644b13b1a29dcf835308e6b7da4538117dcc5a"}, "bc786873-541c-4b3f-85c7-0955ad2f451d": {"doc_hash": "9a06affd609e592218e177d7b62895f1ae0a47c68e5379701ecc6f1b2465fe5d"}, "e87cca45-641c-4d94-86e0-edc884c57306": {"doc_hash": "48571d81208932d18c255ed574a94a7466f20cfbafa74f2985a0486fc17bee7e"}, "26f23882-bf36-452b-af54-54b53ed5960a": {"doc_hash": "2a55eaccb634e2f29e9ab2d526c37733aef343fd97e0fbc3687f7a23021a3822"}, "4ae098b9-96ea-4d5f-8223-bcfb092929cd": {"doc_hash": "4365b48859dec229bfcc7c385f6c90b91c6104af1372ca76fdd4f017c43a6843"}, "3903c9a9-23fc-4532-ab00-8b72b2b6c86d": {"doc_hash": "43a479966479e5cd4788d693259a9c8277e38b03775df159f3a1141ff789b442"}, "4bdaae58-2b10-452b-aafb-2f17de3f6bbf": {"doc_hash": "ee6a043f0ca4e44f77e4a75bde13426b15cf7898745dbf90d0b2beac3fe14dc9"}, "49c4b941-19bc-478d-909e-9a948b55b01f": {"doc_hash": "4c4f273f297d581093a8a9f11b75503311d57d12eafa9d2452bc14cbe1dafd40"}, "654bd8d8-b21f-4ffb-bfd6-72213b3647d7": {"doc_hash": "e0167c6532c719b6cb98ee4fd4dff2d94cdcd9af919d59340a7ec9db07d2aa23"}, "080d7dbc-6178-4cd6-af31-e968bc1c3968": {"doc_hash": "306adc27b22fbd6e381f5ab1393974d8b9a517c38c2e40fa9920b7c775c5c246"}, "10bb9270-5549-4eb1-a5f9-a531e9b25c0c": {"doc_hash": "4198fab5e67999fe6ae50e650cc828dddbf50b83da661b7335be4b0f261296ce"}, "ef4ecd3b-89e2-4a16-a5ef-20558ce1fc7d": {"doc_hash": "87ddde35e319e4414a8991a71b4485099f51ece331f34ff90dfc18c9575e3904"}, "61773825-8cb5-4f7d-b774-aa1b4f79353f": {"doc_hash": "24497870e281a8ad226b4223780418ec2f9708665fae9ca9426a7ee63721a9d5"}, "384c3c45-4c1e-4d8f-8008-4a5a3d99a820": {"doc_hash": "40e826083aa556d6ba8465931f36795541641ea682d1b7958cc91e710aaf2131"}, "b4a2fcfb-fa1c-429b-ad31-67e32e895782": {"doc_hash": "a726f0d209e47e856848a95378664e0ea0f7f6caa006f78ce0d74b7607139dc6"}, "19245fe9-5920-4588-b097-3e3037210b38": {"doc_hash": "639df1e09ebbfe8835883592a1b41d2802bb5c8886640eadbdcce45e3b513b48"}, "0222444a-79c4-409b-ab08-8cc11b5350d1": {"doc_hash": "f57b3ab7f286a24cf72c51b773728340da447ec8f599d91252057e4fef2d9d7c"}, "381adc2c-39d4-496a-b659-c8f9e006baf9": {"doc_hash": "ade30a815be6a83be9b03e83bf89732136b0252990d1d4b39d6db848f5f9a4ea"}, "e669b8a5-8b94-401c-87ca-c455bec2cccf": {"doc_hash": "b70ad2ac4680119b73bb9e4e3276da81853048463c5ee02031d6ca1955565a50"}, "04e0ee8e-1549-4fd0-81b5-8362d5063f1c": {"doc_hash": "9eee2528f0b65b48b5ff70844b3a0218b0813d6f263b0cf7561268633fe4c98a"}, "fa3dd9c2-37d8-4212-98bc-ff33a78d13ef": {"doc_hash": "f24f74d783f4fee1b7819a221bc8a4b06527fe465443431fb6c550717527eca1"}, "e6f6cb78-0499-45b4-b641-dcf9ec1313c9": {"doc_hash": "7768cdbd289e8f1dc7c88cd0c2b743217388d1e78b961a206e65947247fcdf4e"}, "1051bc8e-760f-458d-a7c3-8607998f6544": {"doc_hash": "062aea63641a0dfe43b25163acdd3d2463bd3463998dd6b70b70d50552cd28c5"}, "3716dcb5-ef79-418e-9cef-fc42d6698941": {"doc_hash": "2d4599c3e72bd23b494e35ee55dad47b190c013bf3574c3b9079184654636c86"}, "a9ad9932-f173-42bf-a2a0-274329934761": {"doc_hash": "4d94f46a35ce4d397c968cdb17e91cb0e5339d01d618c52d6996099119937235"}, "23b4b4d3-c20a-4125-aaa3-3001c1391991": {"doc_hash": "643e3c79702f3c4bf59b0161cb17cc64186537bd6128766943c71f85e3aae77c"}, "36983539-293c-4fb5-ba1c-498c660d378c": {"doc_hash": "85845f6c66ed14db18ef5ba49213448aa4a8ecdb6ae62c9671192198774bf643"}, "4e41c544-0e85-4158-9a71-03caf334c5d1": {"doc_hash": "312a6909684f9883519f4e67fdee37e3b804982af520339ade9a1c7c1722dd1a"}, "0fbb0971-ca86-4553-99fd-24290ea96b73": {"doc_hash": "948722028d03ba49860b5c2f75b28d85ca85f1cdfc3396bd0b1ee707899f9022"}, "5ac865b7-d61c-40e1-a8bd-193b81176674": {"doc_hash": "f54e510ad36ae550e4dc164991b9588f629f6064f64aed1f86f7a0553b15f4dc"}, "bc5e2b1f-acd1-4d64-8129-5adf07008f1a": {"doc_hash": "aece1f405ccae134d4493a1c4e3d9aa3feb9d416485416c990a881395cae3f52"}, "e5acc09e-b152-4060-9ac6-7b1db967cca3": {"doc_hash": "26b367ca32f2bcaa0823e15b37252bf1671de800e85bf8ed96694e51a5f3a4aa"}, "050dc063-032a-4c64-a2af-45edc8873841": {"doc_hash": "3431c30e39503690985cf8d0586b697308d5182b0abcb95922f0445b05532d0c"}, "6f4e2028-596c-4f3a-9e3e-2554cd28a671": {"doc_hash": "39a6c3855e1e137bfa3cbac8dbafc6ee864a09c1739063d9f7cccc1b94e0a182"}, "225e94cf-350e-405a-b3e2-61df0ec86773": {"doc_hash": "55a95c1a8d5290d4149f6f6e134f494e550eff6db3039ac3eaf19f379ca23a89"}, "6d6c2bfa-f8d2-45aa-bf85-01619cc04fc9": {"doc_hash": "a9d67eb09a5ed9bb072fbcb4c02813f15fd04fca39e6b89c22c3c5d7b0f47c56"}, "467a2faa-e226-478e-a1af-a51c2b915c56": {"doc_hash": "2f9d1c3f251a3fd7dd1f0378861d5bb2559959721b4a4c78716b1e317cd65c00"}, "9295b091-d5ea-4707-90d4-5ee7c350b671": {"doc_hash": "e8752fd7bf14f428903a93fb8939cda7dc61954829387df007c3de62e8a7cfd3"}, "ffaf2043-50a9-4108-892e-686ccc034040": {"doc_hash": "d5e54c511b6496ac0e6627965b720da59850cefea8a36e1dd261918273520cf7"}, "311b2664-abdf-4d5a-8a5c-bcd3d84dad1b": {"doc_hash": "8fbe21defeccdd47a358b59e729b723f569183b474782cd6933d932120189975"}, "1aaf53aa-d230-4f36-98df-5dcbf12a7122": {"doc_hash": "95c9e5b418127198619fc313386505c30e7e02fa5c4b6d33cdc362c88038fc21"}, "186aae32-e1a3-40db-b9a8-1a5546a1c5d6": {"doc_hash": "d59be6ea103910ebe948331f307cb42510b8e20e112954e5624da817d31f8d17"}, "bbf2c993-92ac-4d0a-a0e3-9abca7772803": {"doc_hash": "a02bfe9df4b1ee0947a643590e05a78825fc7b776a230d472172bbd7fd1a1e46"}, "3f359dd5-73f9-41b9-a83f-52233b605e52": {"doc_hash": "89b0cb141b7de363b1dec24e0bff7a472cd74b4426a756a7d1a13dfa441c110e"}, "6967c86c-1a7a-4622-b37d-c149cb25b9a4": {"doc_hash": "40ce151c3c35c16c2d1e5e14148b6ec1703906ad534bbd368b861a8f328321b1"}, "ca796061-17d2-4a54-8690-7a689866464c": {"doc_hash": "b08354662e5cd257f1c2f532922388f2b8423358a8edf6fa908a6065a28f1ed9"}, "c36bf82a-afcf-435b-a3d0-a2da3b23dfec": {"doc_hash": "3f8d6aaab26aa8e479ee2938f274222b4f2555f882c376c9bc3021bd591bd125"}, "784e52ed-599c-4027-af5e-595073e8c393": {"doc_hash": "6c76dc00620c52981fc37a77fea16bf224061edb597d80b27625bbaa501166c2"}, "07a5fd13-ba12-4aea-b14e-520f3bbd5ad7": {"doc_hash": "8ee7f059fbcd80d15fa23a42bec1f35573cc4a07a759a65f5964e2985b464548"}, "9f269857-45fc-46a1-bf17-446c6772f562": {"doc_hash": "4c9819c046aabcba11757dcd6d4d744e945a476be19c1e02f0059dc0e5a3d962"}, "0330562b-976d-4a14-8514-faadd4b93e9c": {"doc_hash": "5fd9ba105e31d667cf27867af90003a77182c9b4ee6631a5f39e35ad844e8fe4"}, "223d09d7-7f17-4a4c-9b8f-38a5a78bf3fd": {"doc_hash": "b1b727916c179af2ab470c8dee462c018a604dcb809a54a7200bc5cb4dfd2744"}, "bab5d1ee-f912-489c-802e-f05a01e9e615": {"doc_hash": "79683ffea35c4a79a3e53872c96f9818273c06cc2c12b7688e06c966f4c1b6bd"}, "add48fdb-f87c-4242-afbf-d6c5855f31a1": {"doc_hash": "fc0205905c80fd8a0bb99ad0354b3d71e58876cef3211f532ddbc306ddbc7ecb"}, "22a839b0-dd01-46cb-b359-e664363c7b65": {"doc_hash": "cc19145828543c4df6b9eebf675fccdf1f2ebfa35a821cbdde28f4fac12a9b42"}, "8205764f-8b54-4ccc-bc44-d96bec6e74e6": {"doc_hash": "51f994c313f740e37153a71c7260c042fc5f4126bf466cb05c6a67c01884e6ab"}, "e17503da-2fe7-4b9e-ab95-ec5cd4adef92": {"doc_hash": "f626b69bbf8c916c8eea7cc528895c841c0f264456a80170b12054f4c304389f"}, "16ac06f2-a3b4-43e8-b3d1-5f3690d392d8": {"doc_hash": "f81cc621882e541a3b174cb595838000ec49609b763d604be0d14aadd15522d9"}, "4098719c-bc0b-43dc-a9a9-8dec11ca74ea": {"doc_hash": "dda35918a7bd8c1ef34dd3354505fc1d3ce289c06ff2705e2fd3c5dbdb4daeb3"}, "db0f6059-bc1e-4c5e-9470-6d80717499c4": {"doc_hash": "415e01f1b09a5418368ba06f0229e0f4291a6bdc7e9f42ea7672149c69c049f6"}, "395d74e0-4a3d-4909-af58-21190d5aac47": {"doc_hash": "a151ba4201e9d7f0db9bb0f6b2a0201cb710803918e6b4f3af921dd9ac46a32c"}, "6eec134f-e7e0-4127-9590-0435c418ab26": {"doc_hash": "0d0431ea64fdf82caffaf4c067449121f7c7b301144656e65bc145f6fbda6dfc"}, "8e68cf70-da3d-430c-8652-0dfc6b229d81": {"doc_hash": "6dbdef6d37fb47fa486d637a17bf356c9fee576a62447b88bc177d0311d3b831"}, "5c91be46-4c92-468a-a62e-5a58aa1ed438": {"doc_hash": "565fb74c5ccfc51519bea7da803e771963a53ac2f0cf1de9eeb7d534ee846b17"}, "aff23f75-465e-4de4-9621-545c33fd25db": {"doc_hash": "c0517aecd7b5bd68bdac1d18b329e770f18a104a1e6cbedd4f75927d65aa0790"}, "31f40556-d89e-4618-a099-21378c60ab41": {"doc_hash": "c1ab0be56fbb9892fd6bf168293c3da5100edfb79ac256ec60e6fa57653124f2"}, "515ce81b-4cb9-4c33-8692-d963dc07dd1a": {"doc_hash": "75230314ccf2287dde4a7519f45c7bb8c54458a718e45fb5f72db40e9823fb5c"}, "cf7dffa8-b7ae-4665-b417-e3c40fbe1eae": {"doc_hash": "9364c4c6d6b921517dcb8795a319af749970ae2fd9068bf8883be1dbd78112af"}, "2ce169af-9c75-4954-bd8c-61e9e547d4d8": {"doc_hash": "fdcb58701b4662ded95ac7edffd991e82b4a81e979cf0ba3e21f50026c7b9828"}, "88efc990-3a38-4ce1-bcbc-e0dcc9dbf796": {"doc_hash": "f075af929f3bbbbee1274a4b3126a20bc48cceb4c9ec0352af92048739204972"}, "9e7f1bb1-68c7-46e9-a1cf-6bbacc756325": {"doc_hash": "e1fb0352c16ef54084d409c0a7c6b0b8e86604c1d6a11aec42fcc2a0874fd510"}, "f2e4249d-e15d-405f-97f6-d8018e31a218": {"doc_hash": "8f9794c59a413a310fa761ac3cf3e56acc9d876c220afa4f1b94c97492c0fcf3"}, "df0bc6fe-91d7-4636-8ca4-3cb82145452c": {"doc_hash": "827964a421a3eaa463b9821caa09150a6dc30b3ddfd46c37f782c0ab4dd86d54"}, "1b6692f0-8a9d-41a3-a424-2ab79a89e903": {"doc_hash": "b8b8961a0e199dcbfc4a4ae811424615d192ba1edda2e132083c488be3f08f79"}, "4532fb0b-cf8b-4269-b405-503f8fb21bfb": {"doc_hash": "4d552aa934fce7e7e597a7814fb38653f18a208fd734a2226efdcb64e1d28807"}, "ca0defeb-721d-472e-ba3e-e8c97b63728d": {"doc_hash": "e15036e86785139319010d4f67582802ad7004f0136b6b6c2cf9d0c923182413"}, "a7a37174-b2de-4619-83cb-e3b5b2880308": {"doc_hash": "ceb53152e0073cac778c699ea2667e4b8bf81bb120071cbc780c9693a885c9a0"}, "a650ba24-99fa-4529-a655-6a9758b749b4": {"doc_hash": "c03814a1a101150706d2a7e1c4fd18c0bc6d0c9bd87339546022b3f6931bc9ec"}, "9aaafd07-0dbe-46de-a807-db2bddb5a1ef": {"doc_hash": "1b294c88fe0331856c5e18960246c17eee44100d7a81c898001add2bf350597d"}, "a7bd2634-f8bb-4d1b-ac1b-35dfa5812c95": {"doc_hash": "e2f5c3afc8a789fef020ebd8462d7f39d78bbde4170d9c727c31e753280ddcdc"}, "d34d95b8-067b-42f3-b33c-37f03d4c5084": {"doc_hash": "eb90671ecd8e2fd8a553bc0cfef20028eb2d618f12580aae82e60dfffaeaf4fc"}, "c5600311-5653-473d-9907-f058f7dc1ef7": {"doc_hash": "c35f3ff4bc3b9590b412fcfca110ff15a6f677ae7b6d95c08ce5ba8b1ca21c93"}, "f82acea8-6960-4f77-a05c-8f0c29235005": {"doc_hash": "266cf08d4885581d2129f6d7e2b7325636f29790355a05574139b993176fb92e"}, "80a4a387-9259-4822-833d-f441f61427c0": {"doc_hash": "89ee5d4bcd0610ee5b457f48dfa86a2b75c734218b1d16d493da8f9be7f687c6"}, "5042599c-c5b2-41c4-865f-294fd1925747": {"doc_hash": "3778b2177e09326885a3a8e887b19eb4f42764c7ef300e1f98ddb1997040e6da"}, "2e6e0ddb-3fb5-43f6-8ff2-6ff2db2bc415": {"doc_hash": "e06a0012501f84f79d3deea9c761d982dcb29c178bfdfb5e982b8b80c3adda6e"}, "97fe2a42-c7f5-4791-ad62-fed15a8a09af": {"doc_hash": "5131b4735036f72b438006ab59c03659550c32323f355c0a9618cc5b346f5dfc"}, "c47da29f-03e2-4faf-8ef2-3ac153b0b948": {"doc_hash": "ff66f4f481d9345d245ef91800e6f6ba20370adbb2d8b6c7b4823a8db6b7eee2"}, "921179c8-13e4-4498-a53e-7da71168f8c1": {"doc_hash": "adfacf2b1bad8265b2355cdfae18ec9b4db1449fd159bf6ed292d2d279e59ae2"}, "820b7bb8-8cc0-4e8c-8361-b073814eccf6": {"doc_hash": "62630af1d3bc204747715191d78ed36a8d909a4f47a82c64f69814e9511e5970"}, "1a5bd254-3c5f-49e4-9bfa-0ea7c3d3b5d6": {"doc_hash": "40f69c2d88bd7796d89a37c38630397da74d08f5166d5cde9677b72662ff060a"}, "9e634128-7380-4a31-a476-e59b006ae219": {"doc_hash": "c523f996152b654596641229fcc179733d0cc27c33f53e9decc8f493eaf886ee"}, "c95dadce-0036-46f6-b922-f1f7b144ab7b": {"doc_hash": "9303bb9bec1ca9692336aa22d58f04df5bc52f9791b9816084b7d083f320df8f"}, "b282b006-a3a4-4a9a-9568-1d3813d96331": {"doc_hash": "1f0ea1e5f21593bd2d88e8a1a15bf67d6c55e143ae72ee2e54fa9115a5f4cacd"}, "5083885a-9e33-4ae2-be1f-52c17e1fa7f8": {"doc_hash": "b30fcd93708f124315c1f37790e08d84fc2ceb59e02badacdfec521f41686a56"}, "09a94798-b5dd-4e28-9466-2b11935e44c6": {"doc_hash": "96d408b47f58b79774a41d7754588ffc1c9fd2f86128c638a0cd581907594be1"}, "a85ae421-1251-43ab-8257-3fab2e49558d": {"doc_hash": "0e1fa2c470a8627b0d480a186f370c359979947ae3e6278a101444d310baf052"}, "4f75d18a-c65d-463d-9461-119a7a3b82fe": {"doc_hash": "5e435aee6b975be2a888b6baecc939e11b54008386f6340c46c720657bd67cac"}, "f716064f-54d7-4f7c-870d-db6731765726": {"doc_hash": "22d00a0647ee8aa8ab8f90fe787ffc3972f5d3873eb4ee1d1dc3a5fe5a1e2290"}, "74b779e1-c56e-49a1-8d6f-f85520d7b423": {"doc_hash": "fc2c5d130f51027b6486264dc24c1b663165a8b68caf716c8f8b6e9b2f3fae71"}, "da89ba99-0217-4f36-bd95-dec10a8a8807": {"doc_hash": "cfaa619ece89cb4a0fd69191c593f45cf813d7061137836c3d3b5dfb1bee35b8"}, "fe17b061-dbd2-4cf9-a76d-aed523ba3e70": {"doc_hash": "74096bee67e24bd37a117d8d3d8e18c6098b55b45697010a57c641c7d60b2eb8"}, "d2de1fa2-3ff9-47cf-a2e0-0ebc5f0b3ab6": {"doc_hash": "14f72b349e10a186b9402e25d4248a98daef6353271147b562849c33695759a0"}, "884cb8a4-2841-4183-b584-7ff5cda2f74e": {"doc_hash": "87431c88c3200786c5e49dafe5272c9a15fb04d606167d2f4c39ec8a99941323"}, "3c8f4483-6048-46d5-934b-4b032c978045": {"doc_hash": "b53e571012709ba127d7b0b63e8bebfff21b81d7c11efd3290fbc1a03d5de11a"}, "4b4ab300-c2c6-4867-a345-ebee1456000d": {"doc_hash": "276cb9c9ee38ccfa8fe28e0cfc22bfcdf6fc2fb28607d3f2de018dfc1e6f783e"}, "43eaba79-dcfc-43a2-86d9-e67d4fe5b27a": {"doc_hash": "300c3e727dcf0a8140c0521a128a8d3a04dc261602124ce5a65e540ecb0ebc79"}, "af36c7fe-2446-4921-9a75-d542a14d1818": {"doc_hash": "02b7ccba0b79986e5134f0d8f7668c81b886918664044fda03bc089c0c1d0764"}, "807f6830-5174-48b0-85e2-1e4e94baf25e": {"doc_hash": "69b58068294d0ba13820656f4c64830cb7bd4b303d03f91511fc794a9106ff09"}, "4deca681-0f42-45ca-864c-a891f789d3a0": {"doc_hash": "8e8a0045513dda26d94de89010ce20400931ef9f63dd25d2f708991800d1606c"}, "a3c57a4f-3b7f-4752-854e-1402f2d8e1fe": {"doc_hash": "10668657bf09a0d19ddc1d97588fa058d7580faea632d41d20c4bd44c5987a7f"}, "cecc755e-4e1f-4326-b872-70d8416a8089": {"doc_hash": "89c4a0d6ad2175f0482f832f97a6fbb24a6ba49a9d12e111a1dedf912c8d2d39"}, "704b0097-9abc-4d35-ac27-9ee24fb50b75": {"doc_hash": "71d282095297b7e6e22cbc2e699223cd631cf6058f0dd456982f6acf107bcdde"}, "6a3a78f5-4589-41a6-938e-31863e2025df": {"doc_hash": "faa2df22899dc42e1b3f82c233b37fc0fe9aab4c7dd990d1734c64aa8b341853"}, "33bc5d97-0a61-4c2f-9a89-15fadecf2bdd": {"doc_hash": "9c4592fe674cb01010c811d165b34b5586e1ceebfd40cebb4d9698a728ff02ca"}, "d6cd24f2-26db-4ed8-a41c-977b84d21f43": {"doc_hash": "db2634daf3470bae3276423787fa4960fc5e7410f11685b6ea5b7c4eae3874c9"}, "3cab2bf7-6485-4244-a1f2-66a920a972d5": {"doc_hash": "ad3d91ff2d78ecc46f8efeafddb32895e64b5fc5c05080689725552ff74beb39"}, "b545e59c-7d2e-4083-942b-1bb5a07252d9": {"doc_hash": "e68c5b583087440b3964b135aa50dc5a37a20c6c6d3412625bcd502b2bf44458"}, "174a73e0-48ee-464f-b096-d42386dce72b": {"doc_hash": "8dadc201e4d53dcde875c02feb9b7a0b1ff62ea73964d14af710429c61a1e56a"}, "b4256e63-cadc-4267-9e50-0d9a3ac6e583": {"doc_hash": "b650e2e1871418b2d57bee7fc21180f568990a07b865113919bbfe5f2748f477"}, "0a04ba7a-aa78-4966-be89-410e482072d0": {"doc_hash": "69324d4c2ddb9fe48156f85ed37136e0921e50853aa5ec3708e37443a42674b0"}, "58a98e6c-6583-4c89-9d2a-4f6e3470136c": {"doc_hash": "dc7a42485eb7b5d8910c78ead41ef4425b405053e69b09fa6f5365f23956af81"}, "66eb556b-1e46-4bb6-be06-d22c182d2f37": {"doc_hash": "ff46484c5fe13064c8143ec477bc9bf5095d5d806a6393e8f9b97d91209de917"}, "dedd53a2-9955-43a4-b487-b2079a3558eb": {"doc_hash": "ea9c144f17f6ee2df6f9841a80f9997c81daac2322ceab84478bd9f493929b1c"}, "5f68319b-4c0d-4d78-8e72-fdaffcc68721": {"doc_hash": "2ad860a4a1fe3d3dfad3aad1f28ebc1265c2cd8e3331ff2d0a530bb7fd00a1c6"}, "10c3b9d1-171d-47f2-8fa3-91ed85d01645": {"doc_hash": "4fd401c3be8f82d7177741f087197d26d9b3a9c7cbddc73931461cb01c19f477"}, "544f69fa-b053-4b1c-9703-fa89c2a02c28": {"doc_hash": "8ce892e425222f50a1b4142887c9d9b6abd167131540ab70e7465a63aaf17daa"}, "fd7499f4-2259-44b6-9b27-42746c425901": {"doc_hash": "41a7f48257e0a44880592ffb1279c8ab988658d9d1e976c4756ef28dd93d8b1a"}, "966bacbe-d9e7-4dda-b7ff-7e730254403e": {"doc_hash": "f001f0122be965d1321f6124615ce81449f0a562f40f87bb741a3bc9acbeabfa"}, "ef812af2-ba1c-4900-82b0-4ff292578afe": {"doc_hash": "9b6a5727a30781210ae21d76f9cfa2a20f47e9179a121a5959f8fb8b5f07d695"}, "510c1dcf-5ff9-407d-a25b-6f6fce06cb11": {"doc_hash": "4dbf5601625e6dc239a227fb027e481ded7dbf0209cc2739c2dc8868cff51097"}, "8a81d30a-fb05-46f2-b486-3923c7966585": {"doc_hash": "5b84f3ef8d61366cc33aa692693e1391296167e9ac1fd385de09b3f5fee2fc4a"}, "45bbce71-1d4f-4777-9b76-469978086d5f": {"doc_hash": "fd7e2956e7ed9d2ecc1c3e590912b0a6f714edf5a54a02d6d42e8d6561cd825d"}, "31f37692-0992-49b9-8919-c24d914a667f": {"doc_hash": "ead4f499a33a734c247991d7c77ba5702d16ba97033de2c478c2c61294ebe143"}, "c6f9c487-c132-4e8f-9115-a0247c8a6bb0": {"doc_hash": "b6192ed136b6ef82758c122a13acbb9af27592882e0cb09b637e327b3c231e2e"}, "6c73d408-bf30-454d-876c-020652c30d26": {"doc_hash": "097026420b23ba02d98e084658a08d96a967691ecc35d22d5068cd65a523e533"}, "e5fdc819-83a7-4408-b9b3-d9603860111a": {"doc_hash": "ea287858b9278418efc8af2182154aa5e3104eea01925d173957e581206ba19e"}, "7c0e5279-d099-49a9-a1a5-c6bbc4de70dd": {"doc_hash": "c8662a92810a1cb6d93e31873d3f11ae59eb4d0509afe5423da5d1b24a710e18"}, "9b745e95-5f45-484e-a2cb-f1f51ec7d7c9": {"doc_hash": "ef9a51f94bba0965ee6626e5577c83ea36f9dfadb34c6ae0d93f3a34eaa3cd4d"}, "dacde70f-6303-498f-88c4-228258ad41d6": {"doc_hash": "2c32e2437f56aa557bc1aa06cd5058aacb02870dea26d99c7a92d3baa84db397"}, "c643571a-869b-41aa-b4b7-642c04a97188": {"doc_hash": "44757af8dcb0e447b17292a3911dcb9934c6921325101ad5cde007e92e86c0ca"}, "296f502f-5dc3-448c-8263-6e57b455e853": {"doc_hash": "6f470636a1b4ba7d51b58bafb127fcb547f54aca85bc9325a98370912e0517fd"}, "58847e30-56da-43ad-b663-948ae03f25d8": {"doc_hash": "318226f1f23502121df6f13fdb82f0c112d47e41ac7694ed6adbb154de1e520f"}, "c7bf0aaa-f0b9-413c-a2d6-e5af9ca69e56": {"doc_hash": "67311743c23bc4d98484410c40a903a5bb156368dadecfa1047a9825e0d5af41"}, "544b24e7-9c5b-4ad5-b763-a94d9c2f994c": {"doc_hash": "66aa0a89631c771972c0039c418c1bea3bb65a635a61d09b03358c993452783e"}, "4ac916dc-319f-4d53-98fc-291a6745fcd1": {"doc_hash": "d5334e583caf2d9304f3e4f090a60c4b03de1687601356429f2e073d9b6bd4d1"}, "4b3cc256-c207-4841-aaf4-6aeb02f3594e": {"doc_hash": "831e24743029b5c072af4e7ab98f8203e868f002b8a090f7c0191bab128e2373"}, "6510f538-9d4d-445f-8c3e-8beac6916d13": {"doc_hash": "436552daa66507179fece44d99d7889feb4aafde12b1c556b1f253e81dd8246d"}, "482d3eae-6f93-424b-a9bd-f48f4f155571": {"doc_hash": "3f926d30db131061293ee9b12fcc1d3041a96aaff9e78daff357c80d34e7baf9"}, "3b3bae26-2679-4d69-b4ac-241fad854b4a": {"doc_hash": "c75187386f85bed0ddb9938eec3ad4bf2d9ae8d9a0eb06861881774950ac4705"}, "b96b03ce-619e-4b51-a791-a81aeedb0b2e": {"doc_hash": "17a6ac6bfbf4b70f46f4fd35e132136349680e01dc6fcc2f352eb89b6a35dad2"}, "0f560b38-6656-42ea-9cac-25ac01665a69": {"doc_hash": "3afb3b4ea7c1757f5a9cdb3addd27e77d2ee08104dd55ea9489f8920c2cf8899"}, "3932114f-473f-4efe-baf9-43ad0bad696f": {"doc_hash": "a68328d89cbfa015db58ea4bd9d3f259970c2bfd2f35f6bcc50b36112fa52218"}, "9219484d-514f-46a0-99fa-8a83302f3717": {"doc_hash": "59e91432df746d6480b30cfee04f92add9ace6666f1c856c425b28074e6dc130"}, "03bbb391-4b4b-4d5d-a7fb-4563444c9d3c": {"doc_hash": "467d287782ff818c4dd0810b609c0f241db543f19abd1f8d7ff65202e4678056"}, "59d89076-9535-4e90-b0bd-1f17a9a40fd5": {"doc_hash": "29a6ff3e6f1b9aca8145af0a72487bc405f3578626deef43f26b5c2be88a92ce"}, "5ced7010-2d4c-47d3-a51f-4f9d3c421a23": {"doc_hash": "69d1f0ffa00980fe6300bd4c4e710a8e54394294579ad5a7cd6e4a654b25ade7"}, "a706f6f5-e5ee-4ff7-830a-4ee3707013f4": {"doc_hash": "2780fc54112f7b53791bba54acaa77faad986b2347ee6aab2d801398166baea8"}, "4805c533-3b25-4edc-bf61-49a4bccb5ecb": {"doc_hash": "189988d8e26eff0e6be0d9ed55ff7421080bc95bf516bbfba9de228aa5f51fdf"}, "e52e8c07-f7f5-48a8-ac35-02b9add8bd47": {"doc_hash": "86e1b2064438dce02a5015b5c3d4f878d193f73add2105ae26402df33bcf887e"}, "9c59b63c-fe5e-4b6f-9fd5-b1049d2baa06": {"doc_hash": "747b6129ec2fa788766be9c28e7a2561fec9aa9c4939ea8b7b608d3a447163f2"}, "a7efc45e-2821-4e4e-993b-36224131874a": {"doc_hash": "67921f0672bd12ac34abaad5d0a6882a9b037232014af24c9f44a7cefd690874"}, "8aef6527-0a81-4f37-bee1-eec9b48a2eb6": {"doc_hash": "41b43cef4c70175a28cc5ae215e39e9322ca29812926f7a6bbaa197eccfa532c"}, "81eecd6b-b598-47bb-b934-87e50e9ec70d": {"doc_hash": "773dfc028838f8f61940dd3aa37106d1734b3570870da3b4c3d2f9bd302ce3b1"}, "84cb59ad-8699-4c1f-a8d3-5c769454edd0": {"doc_hash": "b5c160cbd9c43af982f61d942fec453006c975d3fa846ad0f6f2d4841276fad9"}, "fa4c7ccf-727f-401a-93e5-7211d33e0564": {"doc_hash": "ed214848e7f4a4c78ad9b3412c56e2c792678a258d4ac25cc8abc8e3ba915292"}, "4b842583-60ab-45f8-9251-7bcc388758a7": {"doc_hash": "8f6c63a0931b200fa4abffc09c45f70110c48f4c2875e2ce620a897d7e609d3a"}, "b9346e9d-e13f-4afd-bdca-adeedfd3fc61": {"doc_hash": "4897a87f48db6abf9551d70e6fac32ff7c80e68323c2683a39807a14b607b76d"}, "436fda78-8e7b-4ded-a029-eb6d6a121339": {"doc_hash": "cabaa45e4c1ae4c8c40803a1bab13e5109dba82c60c794a5dbd4b93a7c18c82f"}, "a775a1dd-094f-4d00-8f39-f1cc79afe210": {"doc_hash": "5dfa3ef804f7207d9ff6801c2651bae0c91a35d8809794d8359e7d4db15e5da5"}, "a383b9ee-818d-443b-aedc-6a61db937df1": {"doc_hash": "8420c1324a10ebc8e063029107b9ac4343a7cf65db494bb18ccf47a1a967d077"}, "6373c8a1-70fa-4cf0-8028-a46de1e70f13": {"doc_hash": "1c8e406a417314cdf686bba2a806ada64d45295ce8fcfea41a297d62e6fe527e"}, "11eaf81e-caac-43ec-817b-ff6cfc101f98": {"doc_hash": "fac2cda3ff7a28d888a9dbb5e2fc54d43de4521ce200489ba13f219e88a51eba"}, "56282b31-05c6-4fad-b366-5c27e8e7705d": {"doc_hash": "f954d810a7904ac11ede2dca42d3b67841cd6e74dfcc0a50591b5fcb2a9d2dcd"}, "40ffceba-1735-4058-881d-47ed34d9435d": {"doc_hash": "3a8b74caaadc81c650bb45159e240eeb53d7e70b1d617761b9f52cfa60bbcc83"}, "f7d2b211-732f-4d96-af71-8f3d76bcec6f": {"doc_hash": "05d99acf7dcf1203aee4476b5632da9c04dbdde3fb863e572ff0a844799b300e"}, "ccd87f54-0401-44d3-a6d9-4e7d0f15e92e": {"doc_hash": "6b930269ec89bcb1601d82a17a7c788df144a1a6dbb3055738e0205f363cc0e5"}, "bcfcbb84-3773-418d-b919-584da9309e02": {"doc_hash": "64b279e562c0b796ae88857b5b2e768d08d62cfc129565a6d79ac9c9fb11c28a"}, "e961ed54-2513-4b47-8af9-3d930b6c4c2a": {"doc_hash": "c4c1058da54f592c144ca228fcf56c6d8026451b4be20bff9f30e8d17c983630"}, "c88d1f96-f076-400d-b3f8-d2aa917ed864": {"doc_hash": "90e9a1dff240ed611c15e06340324a2349929743a1c2a79e6bf325c23999004d"}, "23bd0390-9873-4f79-b39d-7986091b95c9": {"doc_hash": "517238f0138b2710c7882fb6e864e56800df34a70283a8b85803f42792c1c9a0"}, "e4cb947a-e679-4dc4-8731-da11ef37cf79": {"doc_hash": "78f926e5f3d456624f31a91f598a29c511d9411b6a066308456fc33996207959"}, "ffd50294-da1f-49db-a69d-b11603a71f48": {"doc_hash": "6cadd9f345ab8472411f96b0e6c9c82c92610de99510fca13a4163cf62ae585f"}, "61965537-de19-451e-a2b8-9a50a00ea209": {"doc_hash": "3e235e1595abf124f2a7a63025a279f2e4e2436333b5f3bb66b3ff7e5aa4aedf"}, "3cfd0ae8-d695-43f3-b76d-e9aad7687d5f": {"doc_hash": "881217efa3eb547a4d28dbdc0e2e7b3e33e8ea260b0d45263ca4a04977818297"}, "66b580d7-8fc7-4173-a9b0-017b9f33f715": {"doc_hash": "76e15a8af864512f6afcc77d8fec77c6f246ab9b7144ac3d919ac6bbc9e54c67"}, "0d870915-aac8-4d37-b3a2-5d0d8e5684fa": {"doc_hash": "3b3039f127f219eb94ed89a369cebc38fc53fcad768a69b036e8ecedc78826ce"}, "250c7ab8-5d0d-4b6e-8f13-ddf200acb4de": {"doc_hash": "5f30bdf8a10777b606f882721c29c62b20637689c00c58363766a4cce38d286d"}, "0b4c10e3-330e-4e9d-abb6-2270e73d033c": {"doc_hash": "30e3753ffabec366638a5cdf14ec37d174a9a57d632a21ae0fb204cfec3e0464"}, "218850bc-f4bb-4d34-9605-5e32f0eed11b": {"doc_hash": "0a0f4f8b1c417ea6e1486cd0b2547731a5d626826eb37d7a7f3709b2332002ac"}, "3d966de5-0ad6-4fc5-afa8-d5fb5bea8dea": {"doc_hash": "e10f213ca26eaf38a1a7df8c86eb68b53fece797b48acddb092f862ce7c7753c"}, "d46063ca-d326-4e2e-8d41-3d1e45e3e916": {"doc_hash": "29921aa7110658fb6edf1275971d2481883e26cafa793a89971de20f41670d24"}, "618f0b0e-0280-4ebd-b425-573356244342": {"doc_hash": "9d31a37839a91a8dde85830adb90164456793e42996a945dfa0f5002a155231c"}, "6b93020e-4ea3-4496-99e1-afbfeaa282c2": {"doc_hash": "eb0b3ebeed7359a55b6cb86afffcb1c06b599bea1faba2c00807a0a13b3d0b10"}, "04411f5b-c85d-4e3a-afbb-8f8ca753af40": {"doc_hash": "d78a948fe25f197cca191968f0995717044438be12ce9bdcc4f1cb391b1c5b32"}, "89279d59-07b1-459f-bed9-7601d10cf5ff": {"doc_hash": "d98e087e661e84e2baf618fef8d92c24ebbb7063d402b30fd64031c54c443927"}, "ef37630a-9d87-4041-8339-9d48ef7f8923": {"doc_hash": "edd914c1f376d63acdc697dc6ef3665bcf3a6b191df7b211d6e5f96173751336"}, "7fe7fa3e-23a2-4076-bdf8-e92d32af9bfe": {"doc_hash": "14e6638ab4582fab7afdc4e761342b8f05ceb2ab40072f73cbcc3f286bd03cbd"}, "26aad095-9fe3-487b-b7cd-233458e193e1": {"doc_hash": "86c2dc426b3321c3ea0534076976f40311272a0ea3ca47cb966ec4135104ae52"}, "94cc97c7-300c-4ecd-a8a8-afd424e6fe58": {"doc_hash": "47f201014ce8bc867fb699ebca1cfaa4db2c2e7301ad2772cc4ee7febf6994bc"}, "32e6b1a4-8f47-4d5e-ac52-0b5af7f73a06": {"doc_hash": "078f4cb35a460303abd218412dfb619efeba5ee45369387c7eb70127000e70cd"}, "cf9febae-13d4-4a70-bcbd-b5b361261269": {"doc_hash": "16ae14e423138b24cc9fb247f09326cc4fb281fee1e39d45b6aac8a4e60e1cc6"}, "f843f40c-ec1f-4f08-aae5-447eb2f53fd0": {"doc_hash": "26bd75d0501021e33e4cf13a3fbb1450acde76729ddd66372acf3a87c98ff1bb"}, "afb7f9b4-0557-4b6c-abde-0615f548a017": {"doc_hash": "f6b285e3122baf16584a7fa59de47b8ce84324fe7a51b5e432a0222acacedfbd"}, "44cf9109-923b-4e43-a620-986b8a529727": {"doc_hash": "c160c1118137058ebc65eb62b2142d7f0ba4888a5847d67b99f37c62574c2759"}, "2017b307-5093-44d6-bcdd-85767ec7023e": {"doc_hash": "2831c6be1f74d4ee5385420549df3feb1400067b89316b70fa7ac38b0d65027f"}, "a13f7229-c6d5-421c-b873-6f6ba0ea357f": {"doc_hash": "3ec918b75c28b81615d33ffa9c2fac9a1e600c20ff2dff11f9e648cf92f269e1"}, "258369db-6c9c-40de-9132-6b93d5c87879": {"doc_hash": "7d7a9e45772108fcda597a6090a4998e939dd5201e6d8cb06f28ba6f7c1676d5"}, "d60374bd-9b21-4e85-8ae9-70ec300ee0d4": {"doc_hash": "a57d6bf1f5fb500e8aaba2b5e05a6a1ccee2b5ce25f89e877da598fbc1f897b5"}, "16e4c4dc-0fd1-41a0-a1de-8edcfbe03f0d": {"doc_hash": "cb83526305190906bb74b35c8ae0f0ce06d26ca102aad9a6e3c6da81c2c80ccc"}, "0576b29b-5e00-4809-90de-a5d8d4ed643e": {"doc_hash": "660c80922a5b82aea47abdc9c05cf4719310572cc5a0f315409fb86136c34afe"}, "62f5c672-f3bf-4871-9ba5-1fab45527137": {"doc_hash": "b047639c863fd93a59d41e00f2e941ba35a6d606f7f66ee70e7a97c8a863a244"}, "59e085da-64aa-48e3-8376-04ff018abdcf": {"doc_hash": "d8cca9289a427da243899699731d4fe09b90a42ff448fa58faadb9fb980ad6e6"}, "6c1b0711-7477-47a6-b17d-b611cc0e5ee7": {"doc_hash": "87d2b16b1abedb61cfcbfd66f17594abb7bc3a100983259edbe3adaed126e33e"}, "0ceaf771-8c0c-4a33-a6f5-f5456143c647": {"doc_hash": "14aca307d2ff2df28c9d8bbed44beb3be73dfe8009c2b7d7d3e4d724543fdca0"}, "e0b19272-5427-47cb-9bb9-95139ad8c3fc": {"doc_hash": "d18151be03226e7822e9c73ce785d065289e77c301afb15ec4439179a8a8c7f6"}, "360f886a-27c3-40fe-83bf-2306d46050a1": {"doc_hash": "4af63c3c8478cc1a6b8087c690e0aef01e6e8c2297fa745f3cf02cc9a3c7afb1"}, "5c49e22a-64eb-48d5-8876-811a6a5d8da6": {"doc_hash": "9c600eab7d281a7778c38a26aebcb370ad434ab346babd14b656dfca72f7b1cd"}, "59813012-8b2e-4709-863d-a9216907ec7b": {"doc_hash": "27f02cf3820032f458d4bcb9ba829df1dd56de9ebdf8172be8b41d0911ccd726"}, "934b3f04-0fd5-415c-b746-ad733055737a": {"doc_hash": "3d1cac10e6e7aa4bb29b4723293a8d1774f2833fcd4f618c7a1cff454d20ce47"}, "749d9153-134e-40c8-8fe7-cd55fc8e56d9": {"doc_hash": "fb2c39b4234dd7b02cabbae402c8aa26583e32252f085d7598f7d50dfa7b7275"}, "84e62828-a4af-46e5-b397-637ebe5c1f77": {"doc_hash": "eb5fa0167e104a8b47b857d664fffe6ef5c4d999107c1619beee79a709ef28a4"}, "d2b7d5a7-f229-44ec-bb73-a1f5acd69a3d": {"doc_hash": "589b25398e1f1873df211b4f16be63441b957511457ae1c938f0531a718c04a5"}, "97ea8c55-3378-42a5-8d9c-d8a90eb5bf38": {"doc_hash": "884c277d1b6973e41ad9fc5c30fd021a9ddfe287bf2e951379b45db467329187"}, "6bbb5786-d069-4820-8cfb-ef41df5ebaf5": {"doc_hash": "d267ee623af3f2a0160c3615f7b302a5917dc6386f39a5b2ee9e302e5f77d55d"}, "bff0204d-9979-4181-9a8b-13f87a5515dc": {"doc_hash": "790bd546ef9b4e016db0874d08eb186b9f692a964a52baaf0e30d108017dbbde"}, "1849de7d-16ee-43e9-a046-b93ae74bd7c9": {"doc_hash": "77b3f86221e616d234157ed9974e97255cedad9abd389b04f23b4f48ca8c4747"}, "8f90fb16-e21e-420d-a1f1-2a1a328443e1": {"doc_hash": "b785e16f889d5f3a9d6d01b1b0a2205c0a55bee47ec43c02ee6db98d279564e0"}, "45e3b0aa-015a-49fe-a240-fea8a328564b": {"doc_hash": "5bf15cd8080a698ec5ed33b6ac97aee90fe7fb3acbe4aa893b10785a9d03a580"}, "b9b2128b-d471-41b7-8004-9fb4f8c646b4": {"doc_hash": "74da2da02223ecd6628feb7f12eb2b65aa2c7fa97f0f445a4309a51176a3ab62"}, "f9e923bd-c5c7-45b9-827c-077cebe35dac": {"doc_hash": "0d50a062b57eaffb56800acc42fe16ede0eb289b30038bc3c7024fac19dd4aa8"}, "44d3251a-2d18-44bd-855d-d8cd31ac32c9": {"doc_hash": "33c751f22c215be4613a039802344667120ee68218a5da1022298a5b4ecd4401"}, "c4bb568f-006a-4adc-a56f-5ec5b54f3438": {"doc_hash": "2fc574012fb2be50d1d267c88a3250241ca579b37942650d6138b1895d76ac98"}, "e31c649e-73b0-453e-8092-0f94482cd098": {"doc_hash": "ca66566bf43500b501e64a30dd8a61066c79e7a2cac06c441eb33925f285607f"}, "b99d4fc7-9452-4a88-a056-e71f2e9c8bfd": {"doc_hash": "9310dee8c89fd829adc2129a518fd786316b719a73aabc11ea957a382c7a187f"}, "29a23499-5b04-4646-b1ec-73d6ea9241ca": {"doc_hash": "64a1bc37e6801ded3419aee3bdf310e36d16e3b875b6682b46c4087d73116cd0"}, "416e82dd-6bc0-4ce3-97ef-ea6400ede39a": {"doc_hash": "2539e927999852f33d95c32c8fc8f44a4f694ff3c1aacb571717169030337a44"}, "5b8f4140-266d-400b-8e44-0a1add4f54ce": {"doc_hash": "14154bc6c9bd76663484d712134fb274cb91ba18e3cb86ec1cfafec6d13a5ed3"}, "42bfff9b-9c25-4385-acf4-244125f691e8": {"doc_hash": "8f379dffc3a9b8395a5f3e9372c819f900a3d07d8262b0762241d97472236d7b"}, "2ccd8a58-b19c-4aa3-bcc2-c8b922fc1694": {"doc_hash": "3a713467805b4adb3cc652a00f9e5d5f10c72a3775c9833ff2afc4cc38ded6e5"}, "9d57e201-fe3c-46ba-85d6-f7559fbb1d0c": {"doc_hash": "69cc2aa6479becf37cd5cf6d3d15370be7b1f6ea4e6bab7423234eef00537ff4"}, "ebff97c3-a7e0-4422-a33d-ec441c202fc3": {"doc_hash": "44f985a68452cb4c1508e84a296c44933a59d822c3c0dd64bbccc03a15814519"}, "f7b53843-b7ad-494a-b357-28eda3ae9bc7": {"doc_hash": "9f24e9b8ce5d10c1152f29a6445725762a9810e640e4676bc9f0a329357b0aec"}, "cf8444cc-83bf-4fb5-824a-9311ba0090ab": {"doc_hash": "4a910ec3c8965cec6bdc94317532a9609d35f15d92cdd08d4df16128ca5fbc4b"}, "6cc43358-0eec-49fd-b048-dbc55893946f": {"doc_hash": "5ff29e0eac0a878b28a5e509a11958a3412b32450f4f5e47b5310f7068dddeaa"}, "1918193b-cc28-4ce8-bf80-30cc3f5c6c6f": {"doc_hash": "fa20ce910b45496a72470223f78b187f80741b97bb1fba47a97939ed30cebb02"}, "837f3afc-a706-47d5-9f1d-10d0b84b427a": {"doc_hash": "0e5513fc0961c5536fbe491af36e92cc39a759cf583fa33164c9f4c8d6bd1056"}, "8461dade-a8c0-4999-8679-7110164daafc": {"doc_hash": "c10c09162acf9d6a2e0adb4e2271d931a26147bc606502a18c60571083c66d55"}, "6f5e62fb-5ea4-4e2e-9826-12f28138f0ab": {"doc_hash": "d917042dc9e8f193af92aac0d78601c965972a8ede1f23b35d1f7784a2f3539b"}, "56776356-42dc-468d-8fa1-bf8805380591": {"doc_hash": "d7b289c71513bfc15a312666f9817024217bcef814d4657d4504c570ba26c200"}, "47792a3d-13a2-4ab1-8dd2-137025fe3bfe": {"doc_hash": "f2bdc5da2fcbe3733afbf964d030b7ce4e98b7ddb39e969f0321bce7cf5faaa9"}, "e093c856-b912-422e-813e-50e2b05f092b": {"doc_hash": "df71db93871e1108faad7ed663f9fee1717c3fed061896ff192253692cc4c82a"}, "1411bed5-47b7-4ef0-8938-f750b1ce02cc": {"doc_hash": "c1e37aacfbb01e039ec5bcf6a5e909cf3258669c26e1a9a131dc25b0fb99e544"}, "abf5a3d4-e5ee-40c4-8c58-acb5e30c45c0": {"doc_hash": "a657696a04d29fe680a1e958bd61f23eb6cf80c9d248bc0947062cc3115921e4"}, "2effd3c2-524f-445e-9ba4-82c6a58828b2": {"doc_hash": "24c1fa4b9b392f00a23482b2da291891523e363af52f3fc84820e5968c5cb9ad"}, "7104ddbd-03f5-4a85-9515-a888ea1d0515": {"doc_hash": "6ff58a5a0f7b5b63cec697fce0666d7b9f689b03794f1de00fae2dd0fc4cadb1"}, "5ba809d3-89d1-41c0-9909-d1133f1bcfae": {"doc_hash": "7c235946b54020e23a1de862209e7b250dbe965bb18ea11fc64a8b6c17883132"}, "2fe869cf-e6cc-4ddb-b046-c581b98dc151": {"doc_hash": "0da2ebad263ff5e9f8c2f022660572ffd8217d3c53cde8e4050462a7e2e4504a"}, "c5fbd5a8-c1f1-4f2c-a045-cfcb044df77c": {"doc_hash": "f5bfae21901bb04ba783ebfc710130da4ad3ba0b6014ccc992650a8d2ba91de3"}, "e6007b0b-793f-433e-a0fa-f93addf09297": {"doc_hash": "c92a285dd9e91fe005d2f3f3f7755d35b3024c517d5dc829cbf99508f5766058"}, "641ee814-2572-41d2-b321-e25ad41c3bc6": {"doc_hash": "ed79265abc5e8e20cd2a7eff11b84d814f1237bdf293d469ee6b48e9c40c53dd"}, "d004f951-b0b3-4224-91c4-bf85499b7d94": {"doc_hash": "18441cdbdceb83869437072fdcf60e9a6b91a25a3d3ae305151e7b28273bb28d"}, "4f833ec8-0fae-4892-ba47-eeca1f1902d4": {"doc_hash": "370907b48abb353e4694da6eda2a56c432defb6539548424fb76cb8bbc3558b8"}, "9f5de443-543b-4b9d-b700-59fad19d7868": {"doc_hash": "e4c7e27e693bf9a619a3bb3c00cbb2cbcf2deff88d981a14506cac02febc35e6"}, "d9f8bddd-72e3-46b7-b52a-77642dffc75d": {"doc_hash": "0ab224f192c425b5c2eae2d68289ed3485090e2a443094433d375b67635a2bb6"}, "080cfcdc-cdca-4926-82e5-f8cd1f79dc37": {"doc_hash": "0efbb4eb0ab8abf9ec7817f6548b30176e594c884c8af146fd8d438d16405053"}, "32288a3b-aae2-4dc0-a4a3-b98e9bce57a0": {"doc_hash": "bc9277bebfadf21c60faf1b9efb78e1ef7e2ff1794a5b2f5abdd79c4f05568e2"}, "8ef8f965-8653-401f-9fa8-637eb4fe33e9": {"doc_hash": "9848a1543f13a2c5f9c833de0a058827f0347cb2de1c641a33c520afe2809cf1"}, "71407cce-75d1-4a79-8154-a6b18d91f9da": {"doc_hash": "ca0abf3ccc41fa1193bb5cf2e1c9d1296f92d3a972dd652a60001d42fc641304"}, "955870ca-cea4-4b08-80cd-025aca2b84f4": {"doc_hash": "ca22856cda255429d0d1342242ed11260ef818fd76ce341261724fa597e1aaf1"}, "0d3f70c7-c292-423d-8064-a7053216c696": {"doc_hash": "58e91091e32bcbf1f62e8c66d739915458d45eb87be6c7addf594cb9a4fb3f31"}, "35cb2e3e-6a10-47a9-8ab8-ab061f10a990": {"doc_hash": "80c70bb5fe2389bab95a31093cb0fde7120e9f766155db5cf63e322d0445c915"}, "ca1a4570-f7ed-46e7-8254-4c674ec8a5cf": {"doc_hash": "d53471a8d572baca0b01e49a636d1afeaa01c93f33fc3d3416653e8ac518cd01"}, "4afc3a2d-9cf7-49d8-a199-49157562715c": {"doc_hash": "98c3ff635f0d4f9fc867efe037924cbab0ff7689b91a197d775d2e5ba553b135"}, "b0e5d0dd-0cb4-4ad4-a216-7b6fc7dd9993": {"doc_hash": "a77166cba1441476b82508fefa3fbb32872a7edae6a458b490b127a6c06205ba"}, "f0854f3a-1b23-410e-bbee-8bbcb3a95b43": {"doc_hash": "15d19aedc7ee9e18543ef34715bb566164a9d54775869863bc0891fad575a66e"}, "56a34ccb-1230-4398-a1be-4047b59759f4": {"doc_hash": "600af43e8fb941efadd542160833ca41801caa3d2ad9952250e41e6a86f21a27"}, "118f0783-de88-4784-88d5-e6569a952627": {"doc_hash": "fc9cf1806f7fd8dc8941d90093f86cc450c798fee2a0693421507b7e55b369b4"}, "588789f3-a7a3-4a83-a060-9cbd07ea0570": {"doc_hash": "b06951c0cb20a5d0a439c7a8cf1cc6da9aa3f541ebb6e855ae1d974763e9e72a"}, "84a4b8c7-feb1-405b-ae25-381c480e5879": {"doc_hash": "41726b4f3fc4c137112f4677a5b24611ab4ba92c3a3965522f8fae36a3aa74f8"}, "e3b0d3e7-f660-4b82-9078-d74ebcd64c49": {"doc_hash": "1cd642e3482d9bc9299831e981aa64879f198f80318ae9fd91c32273205ca945"}, "a961b99b-1ffc-4136-9c88-d0210f832534": {"doc_hash": "4abe7d922822836571f522d3eeb295d4595a1324cde06a39763d5722a5a3e1af"}, "d15252dd-f92c-4529-9570-fb05f318160a": {"doc_hash": "ec6e4619b4ab14f3756b5e433ab58f52aeb69716ac10b90595296b770398975e"}, "cb3ceb9a-38a3-4639-8970-f43b4b0531b1": {"doc_hash": "ab1ff147b348670025e683cd35a5358cd412c96292ea1948de94677dd01109f0"}, "19e41f82-7ad5-46e5-8be5-0bca1d7dc047": {"doc_hash": "820410c714a5399b329c91d1e20c8507c535b9fc6ee1b68491131ab26f638688"}, "b41f90d9-db7a-4d0e-b68f-9ba91b67d8a9": {"doc_hash": "740bd019ff29adfc6a837bc408ce9fdc1a5fb2a3f8458093f1152e313e8c2efb"}, "af45d2f4-a6cd-4e50-87b3-6dde7094047e": {"doc_hash": "28d6a41d8a9376e690fe77d8512c585bc70430a348c82b778f4dd4a3d77159ad"}, "5eca12dc-cab1-4271-bbe9-d6e0d19058f1": {"doc_hash": "8467033889fbe5c69011d9857664d6e9f6a34e53a470d7740eb38de8ed2c8a5e"}, "31453792-fe49-4abe-a39e-fabc3df8f5de": {"doc_hash": "7b62ed9040e1291f2dd509f3f45b0acc19f4b5b76c29dc225fbfcb4d9411bf09"}, "cd6e6069-8236-4141-b1d9-e425e4df6260": {"doc_hash": "9fb138bda2399413a6e7c2eaec04edbd5697a7dea5fe57143024cc8c09cfdcdb"}, "0cd937f5-7c18-459f-8ecb-2f7a0e6d68a7": {"doc_hash": "47a395fb61ea0c5fc8f8098ddacb7a847c485e6255687f39c686bdd462f2f493"}, "36e6279b-6442-4137-ae8a-3811045f78d7": {"doc_hash": "cef8fc9ac4866e8ccbf4064a1c826e4ad075a164f02b0667e6556e3cf3ef47cd"}, "d886fb8f-e41c-4d5e-932c-b34d342149d4": {"doc_hash": "1718b452449d9979b045e31fa6589799fa3608fd8f16ce263585ee418a3e9dd0"}, "cf6c7754-2bf2-4c11-b784-bb3cb24be9ca": {"doc_hash": "3c36cd89bf581a4cbdf15a1af3cc27ad185d8dd55b180a5096388881e2e049e1"}, "2f4b08a4-94c9-4b13-85c1-af90c0027bb6": {"doc_hash": "9d2d05aed5111e65a50c894a20cb1fa817a44fc742c1934dc12fa13736f1bc96"}, "f77a0e64-a9f2-44f0-b89f-cedfbef10fe2": {"doc_hash": "e21aee9f313559089826b382d2a38925873fdd01f56db3b43cdab043873a33df"}, "0bba286e-cb34-4520-98f9-10da3bfd851e": {"doc_hash": "0f75ad95946f376386e23fe7919b8e92e0e4c0d9ee177a07f5a5966e782967c2"}, "a99c9c94-831e-43ca-99ad-2215ae11f7ad": {"doc_hash": "c101680db3d1370ce510e4ee3a2e2f25b4ad766eb68f07e076670b958d8de770"}, "bcff4d9f-5fe1-4fee-be8b-dc7f31c150df": {"doc_hash": "71e76d368eb707a1559bef189c7395821dd5d2f41d13a84cc164a800a9fc8e22"}, "15010ef0-c017-44da-9b50-b2a34972e3b0": {"doc_hash": "7abd168466553766b6b3b91a573f475778e935c4936c415d2b3507a9fef2f1de"}, "d79e78f9-6978-4ab8-8a86-d729d345e751": {"doc_hash": "a15f0d680522c761ccd922749629829178f699c176132195c7f0037a2c6e55f5"}, "4bfc82ca-f567-42d4-95e5-b3c63ecfed6c": {"doc_hash": "1783e38a53ed64d0d7ca8a8b311364dee4647d0345b1bd2cae50d7b2e2e49648"}, "17358d04-2a13-450d-8d23-17f1e0fcc891": {"doc_hash": "1e35c6dc16e8a6b8d3957c2cf3db1a2bfc664f784ea3b72c3b033b395bdec0cf"}, "590250cd-1555-4994-8c35-cb304b1c97d6": {"doc_hash": "1a94fb2877342f889fc66a098ab0170ae7d00f72985ad89acdc65249d98e1691"}, "a7eb9891-3e6f-45f6-8ffd-6a7eba663823": {"doc_hash": "2a3b1bcd331f1c18675424c86b0771f373adc4b2504c4c263bd901b11f46e8e1"}, "290bf3d4-2eac-43c0-8719-0913776aeb58": {"doc_hash": "6808d95e97c2c496d573f44abe8f40fe6d869e79f952e4a081a54c6d586eb8db"}, "f2979cca-f3f1-4c85-9dc7-6b71909e5c11": {"doc_hash": "558c5ab6ec61dddd49d08223bbafd1b81730cb644f2c30f5c7c7a888bd8577af"}, "2f7566b9-b47d-4f73-b863-f0675de59f27": {"doc_hash": "ee381026017f012cf0ec2d7552bc7d2e1d08e96cb945e7fb4ac602782f71e368"}, "93fda818-e244-4274-8a21-6eac4fc8af1a": {"doc_hash": "fdca7a491ba81e272596dda71b0c54d24b3f2f0cc9f04ab3e252a81ee3af1187"}, "d08e6245-3ca4-43c1-9ea1-1d826c39ab76": {"doc_hash": "5887ac2dbfaac2fb4e779196844bc5d798a972ec2f40a1b4286dbc1361b65128"}, "c287ac8e-5547-4afc-85a2-55c18929302e": {"doc_hash": "5016c8d70276df60ec45d1d3ad7209dc4d6d9e92604adb67f91f7f5d503b6801"}, "0295e345-ddfa-4a1b-8eff-425927b618e9": {"doc_hash": "4447657a44b6c3b39320d75a4cf753dcf1390388ee3218863bc52f8eae008adf"}, "5ae8a322-d326-4a55-8302-b1faff5a537a": {"doc_hash": "16f5675fd602b38e3deb3244406b4730bd2dbf72c7ba2d2b4932beb6a378c52e"}, "8582b286-0da6-4138-ad08-3107ffd7f79a": {"doc_hash": "6463f9978544664c41c7785d2378e5502f8be66081a3501558a055d4f63fe8ad"}, "95099e15-a51c-4805-b7b5-a42074066edf": {"doc_hash": "a4a5e135dc4988853fefacebf6d42d51489eb5666c8823ce79db905791621a6b"}, "6b777d8d-aef8-4d8e-bebe-a087999fbd2f": {"doc_hash": "af591d0e62f5c86969f2957df3ef8d1e6800c4077fc7142051e897006cd57063"}, "fe58eac7-671d-41e3-a5a1-fc342d177fe8": {"doc_hash": "435d919f5461eaf160d13d02a82b2f8ed142484083d183ed90b48bc6cf5e4cfa"}, "9ece048d-fe7a-4e23-89c9-3aa0e609a4d9": {"doc_hash": "6bcc609e612d7af771ecb402f8fb339d1f818462a65b94d753ace6d3c67cdd4e"}, "d6a934ec-1504-4a8e-b92d-a15167b22b64": {"doc_hash": "b9300da1de6d4ef6fc36e451ce10dab9b8829a1869c37936d658781978949186"}, "5ff7e443-9744-483a-b578-aa5a0d27ac6e": {"doc_hash": "46992ee0c2d94c18554a420997cc27da3f3d92bf1b53b66d46e0eb77c592f48d"}, "631f9317-f065-47d7-8911-eb035681c3c4": {"doc_hash": "8356df9b6a38eee7720aa4afb719f174609e2abda286e60b9258d546aeed7fef"}, "e5ec2d86-962c-4ade-a6c0-31b4412b800b": {"doc_hash": "7200064717924b786cc44b080efab64160099dbc907379c4cf6daf54983b7270"}, "ef9fb24d-3767-4090-be5b-8220237b7c08": {"doc_hash": "a1adf851eaa1350f40bb07739549e178ca2cd05bb2a54ec8a7e5d7a9858d8032"}, "13f9dcfb-473a-4a25-88cc-a3645d3b6bef": {"doc_hash": "aa4e318a7acbfffc83e3ae6db1d71a61b07eb60fa71bd4ba17f77e8be12ad63a"}, "e754db18-3a4e-42f0-a851-9eb873b16211": {"doc_hash": "b204800c01b6de812dc3a648b24e39b6fec7f56ed29dd1e510b5a9c75f641d3e"}, "64b810b6-fb40-4562-86f3-39406f51d672": {"doc_hash": "da27793b5267d95a0900ce7fe2bec6030a38b5ed302973d942b16f6211a7184a"}, "12c0f22c-492d-45bb-adb3-2195637e15f5": {"doc_hash": "847f77bcca9f35da14d167ba7f449900ba409994d5db1d10da7bf1d05f008d45"}, "8da80870-f31e-46d9-99d6-dce3b78796f4": {"doc_hash": "dbfd7fe69a8718c55ecb8236c653e13adf912c69fca4b7e7003071e4816f98f5"}, "37d4574e-cad4-48bb-8b69-db9c5a148303": {"doc_hash": "db2d38804d6a55385d7d07767dce15b57f83b7d7c9837d05070a032b190e2ff0"}, "f69c2141-d86e-4bdc-925c-6d8f9931b193": {"doc_hash": "e2ca4bb28733b96c8bc898b59a1d24f79872919110c9be4ae91f4214b7441293"}, "b7f1b4b8-4e57-4dd7-8c25-03bca6ecdb2c": {"doc_hash": "333a210e2d92a56db27a4ad141878363ba374893d036604e7e4d8f7fe1235366"}, "51da49e5-6763-4acb-87cf-876d154928d9": {"doc_hash": "def4c3084df4581445bd433f58c044bb6d5f0af368a09d3541abfdab50a1cf68"}, "9cee441f-2b4e-445e-8fae-3115bc05d523": {"doc_hash": "e64f5f71b05186f48df90077d87736b5c2819312e0c2099eebe7533c7b610a4e"}, "28c40e9c-1430-48ac-88ea-6ab22cad52d2": {"doc_hash": "e0e754e61f324df53f9e47553cab893f25f1bdd5bc01f71732b23fc9979abaa5"}, "ac3462f8-06a2-4f85-ac0e-e0653d1b4538": {"doc_hash": "7ce28b2218b1b724da56f43b8b23c2183a61025a9d986a4e587d58d0e56ba3bd"}, "14d54e81-6d48-4813-81d2-158dc456e8de": {"doc_hash": "bfb659ac7dd505c552b6ade9a83c5a08d4da2a13a077cead958b108d0deb6251"}, "7f82ba6f-0fd0-4977-87eb-b14ed646812d": {"doc_hash": "c2d34a337d41dc66abc92b2de402acfb728f9e3c8dd17d6feb68a2ef83f00ea1"}, "8790262d-3f30-468b-9bff-de566cb7c570": {"doc_hash": "2fd1b8b7be30387a3f8ed90fc0e64e9ee0282f8676551283c582a551e500f65b"}, "8ac6cb8e-d80a-4c22-8d7b-35f2cd0b7500": {"doc_hash": "cf0b28002d69d802569521e92a0d5dfb0fd4667c7ab3270d5e09bfcecd61b25e"}, "f9b74f6c-594f-43b3-be3c-2636b36f7b74": {"doc_hash": "5e618758b218418ddf91b4a8aec4cd7453dbafe9f1e8f0ca2057edb5121244fe"}, "e860fbb1-9133-4256-8a33-592f8e569053": {"doc_hash": "eb7cd043a9e47cbf2661e70df689d0e98150a73a10ee44e3088ab3facce3d124"}, "fd951588-6bb7-40b9-b69c-66e04fd7b003": {"doc_hash": "4aac22331f72b3edcc7c3f49948a22492bb0aa4540f52dc17cd92af015c4f639"}, "81feace2-5c3c-4789-a06c-67c498746960": {"doc_hash": "2f1aa375ae1fab4746df2ff6f12784df2dbd71178552774763d96dd593e54dd9"}, "19104fd7-7f05-4ade-bbb9-15e569baefe6": {"doc_hash": "8dc7e914b09bfdb0cc4bb9f660ad088d308e385966b9eb4e7ece9e34b8cb4449"}, "71f392a5-e16e-4f81-8ae2-c4aeb18934c2": {"doc_hash": "263f660998d9471406fe5cf6acff260e0841b45eb2c0733a6f59c548954cfa72"}, "5028fb87-dec4-49f9-8d6a-0ee4ac093852": {"doc_hash": "ba04a2930c3d1e04f1a32f728f84a11c0d9462333d37739b988fa24061031236"}, "1a2b86bd-c055-4719-8917-2d16ddfdf24d": {"doc_hash": "61e4e013764dbb89fb1d4ef576f96e931177750e812ba6e61bcd2967275790e9"}, "d679c472-50fc-4e97-85c1-0cb5f883b2aa": {"doc_hash": "cea00cc1a609eaa772449eeea6498ec6ac89f9a15063dcae00002d992f0e1803"}, "aa5cbdf4-77d8-456e-ac32-af1f6abed965": {"doc_hash": "d964a066210be15e0a133210de953435fdd82b02fd73dbb9d8858820638481d6"}, "9be79619-07c4-4908-86f5-c7786f59947a": {"doc_hash": "923ca326352b54ac2142734c95fa9e9c7c2b2766425aa7dd5e59b15718fa9ce3"}, "229b6e18-913f-47ba-bb26-64b19bc43908": {"doc_hash": "387a6fe6f65a0d6846fa39a14f2cb8bac0dd8929e5d8d9739b65ced9c47d4b4f"}, "4fec7fff-df34-44b5-819d-092f564fa704": {"doc_hash": "f63356a664d3c8cb0975525a9f21ed2bf3af3f96a000a05f9df2ac4eb88f8c9b"}, "9d016e2d-8325-4c8c-8437-a6d1dc766db5": {"doc_hash": "da2fa1abc0c52edc8eb47ea92a31dd484a17aa4ee140caaf37f1e9c1718a35f0"}, "6cde3203-80af-4131-8e27-81093c08dc77": {"doc_hash": "a331bf158085b1a9f27fc9c0d00703139fa7d1d98d825b4c8a1c2c7e69bbdf44"}, "ba921fee-9b6f-4645-852f-24c24af62ee5": {"doc_hash": "fcbed82445783c6506d9ef151c0238e74043a2250119640d36b5c2c138c261ec"}, "975bea42-71b8-47ff-a7c6-52c6da9a3c2f": {"doc_hash": "4e067efe72b13c619836e283da905714253f22a39e1d463da1bcab8a34b244d4"}, "d113bb4e-601b-472f-b90d-44e6fb8d5c86": {"doc_hash": "f80ceed457716458a4e673f77216397c47a2fae53893d1ea3cc13b89d5ede1c3"}, "ba5a5093-94a6-4c1a-8ce1-c49f79347ea6": {"doc_hash": "b0e59e8e5b13513c9c2198eab1dd83a66ffc4782553ed2897860df6a175a8dd9"}, "6bf9a1ad-c76b-4a70-9040-736af6596ceb": {"doc_hash": "758d9efdd4e9e4f892a617bd1f04aad668040a17bc4f6d85f2f0f9e573078bdb"}, "752815e2-3e43-4b09-a7fb-3f3afe863afd": {"doc_hash": "600e46fcd0151157f9b550d0ada3bff6f69dff135ee79726867a4cfb682e15f2"}, "52b78121-7e7e-47da-b0eb-6dd474368b36": {"doc_hash": "5c22e6179a13baaa8405c76c9a35afac55630eaf04047c5d623f6fc3aea6cdde"}, "bd81c912-bb20-4178-b1e3-0df87dde5426": {"doc_hash": "ebcb5839add24bc721280cb6c70cd23280cf0e9e584e3f9d8c1b9305e2ef4fd8"}, "b2fe87d3-280d-4abd-8d2f-30bc085b2c9a": {"doc_hash": "2465d7ce39a84ab88143b79aa6d5e040b7fd37a9d88b0c793a14f2a162aee7ff"}, "7716f194-2b56-4220-9c4e-430c96d738f5": {"doc_hash": "d1932916e25ab01fab7ab18f0608a9ef4c67adaceeb9c07250230619fdc31200"}, "20023176-6484-4ab5-8d9e-1c664e10ce79": {"doc_hash": "e1fd41b8fe6769e978cb0f6d68cd230d15d05ddb0a1217b26bd6c27eb807d5d5"}, "d8c1c01e-7575-43d4-927d-a9c532a0273d": {"doc_hash": "c9d5daa150e4ad1d259494c1212d63778ffff9072d22039ebe701464b768ff4b"}, "49e850e8-753d-4145-b36a-2329929af481": {"doc_hash": "97de44164f37f1a75a4c9a632652bc283581ba3ef7ed50f9a20f3aa11df2c98e"}, "5f9601e8-0495-40eb-92a4-7ac4e58aac0b": {"doc_hash": "31963625d94d5e9888e8c057bfe9a2ab60d2c5749340745280ad4d6a64ce98b6"}, "adaa0fef-b347-4421-8220-cba702dd4083": {"doc_hash": "7b832283433006c294ff30ec7df4ee161871ad4ff0c98987ad7c24b9167486ba"}, "393cb6ec-d3a9-4529-a177-0980283db340": {"doc_hash": "2127f31c8de1178b5f3354bd3feb734a57d187fe6b9414c4b7190e4dd5d49f1c"}, "117b5627-6afa-46df-a9ac-b69ca5c1e556": {"doc_hash": "f30893c33c91437d2565cca86e5dacb446b4dac94a23e6860e9d3a6694bb72c7"}, "a3bb9921-16b5-4fc2-93ec-80c81821d045": {"doc_hash": "64b78bbb5372865b6064ad8c9949f889dd5fc2bf2368dedd72dcbf69cdd90b8d"}, "374ba5d2-d1ed-4668-983b-799dcddeae27": {"doc_hash": "f960981ccab2fbceed113c21e86b2166a779e33ce6f742e568ea97893891d35d"}, "29c9ab5d-8207-4f5f-98d9-df267fdb5c6e": {"doc_hash": "66ee4202f1e6c0149e305ebce4ecae01267ea41fcd2879630a0bc5c5725e6cf9"}, "4cf51b1a-4278-4234-9894-d38a43ed9a90": {"doc_hash": "97aafbc371bbca57996d1862752874cd8a78ec7dfbdde5bb0304ae04e6179aee"}, "6b150add-7ab4-4461-97f0-5a9b956647e2": {"doc_hash": "a968b6036ac1acb818cd127267b29b0fe95616a681eef729e1406539a02b555c"}, "e49bfc77-6f15-4c5b-aa01-24d06d0115d3": {"doc_hash": "72ec1ef426c0e8b0c6685d5724c9df375fe86c3d49d743907956269d5a41ad9f"}, "357511cc-c2d4-426a-b505-dcb29f767522": {"doc_hash": "c8c9b78c8868d3f43cda44484b805921e52c27ca8e2324c972ee323edbee952b"}, "15cb8b30-b27c-42dd-91f9-6577da4086ce": {"doc_hash": "b7a04c995a26e687019c55267a2d19b51e4e509f4bf985f0cafcb7f112ecb92a"}, "18258d2e-8b7c-43a5-8b4a-cf3210934de6": {"doc_hash": "6e93785555e14cc0fb0f9395b846befccec950e90421398e1f392f214487cebc"}, "2c3f08e2-b793-44a7-8ac2-afa86a417673": {"doc_hash": "eb6e738cb4cff6fbb102f8bdf2a21eb3ce3649fadde6216937605f5b79b1b781"}, "13f93e02-1bad-4e25-935a-7dd90e472053": {"doc_hash": "ae996f62d7530d725630ce8a719c764f0c94359c441a80a011b92e87841da76d"}, "20617c36-7f56-4245-8ca9-106687b9e4ed": {"doc_hash": "ac7e09a49902fd1f6a56cb5e4bc64c4c30458adcf2e8d1d7a125873b137ab5e0"}, "beea1a87-03ff-4e35-a7d7-cd1efb664e32": {"doc_hash": "a2dac6886c63aa1a4925956db6d721ab056ddb1f748da63986ae707dc00c0301"}, "680d946f-6933-4e2a-906a-654d78d485c6": {"doc_hash": "7b6dfaf62d1d77a654a0ac1414f736c6f3bc79b67eee0579eac8c62b976e0df4"}, "401f3a6a-41b6-41ee-a977-c004a98eb067": {"doc_hash": "c4d3737c02dbed62adec8804ececca91f6891b517d3d84798265259569294f56"}, "e89bcb72-c452-4c27-931b-7e91125c62af": {"doc_hash": "c305d305079ea1a99284969e78b61348b1f48256a93e8ea407847a209b77ec1a"}, "5ab029dc-0056-40a3-9ac6-30a8dc3559e3": {"doc_hash": "f6c804bedce4dde4e15e314cafcf5c3a5c6d9514ef52ba5a9cf241893e72bd84"}, "6d8c8247-18ed-4810-a605-72c5d8f7c0d0": {"doc_hash": "e82db8773bc349b84d780d9eb9ed777b93fedd16b18093c3c470362099dc5702"}, "bb6f9274-613a-4ef8-ad04-564001cb3c4d": {"doc_hash": "ebce59687f6975ec93d1d74e555b9f1865109d97a7230ed1d131e064a15d03c9"}, "e2d27779-6d93-45c6-bd21-6b9defba3fa4": {"doc_hash": "030471a56c2e32e6ace721141429975721c94adeb7219f806b28e59552b640f0"}, "3b1f2ce2-ea57-44a5-9f4e-0b9b9185f73c": {"doc_hash": "a08d8971ba6858b03d10ef2814744bbac3176a9db733b6b066345ce7fc114a94"}, "8eb7950e-eff8-4454-816a-99837b171714": {"doc_hash": "7d132fe33faa72bcc42aa0195a7d8906533841ca429bbfefaeec74eab8a5bda9"}, "e0fef81b-2224-400c-a730-16e21c85198b": {"doc_hash": "d109d9b677b8925ade30a3ced3e3de2c754cbf5a988b6f84d96b0c8c0368de8a"}, "9e56681c-beb7-4a84-ada5-ffac8d507ee9": {"doc_hash": "da2a9d8f60c4c7494bde6b413185f29de9b725b754d2574af571f7584c40d497"}, "fe521c7e-e8b4-4cc5-b395-3b0b82c9c569": {"doc_hash": "d27bdfb8e8e9def5d1fea39e244b53986258ced97c27114542ddbb10829a6164"}, "55eb17e3-3534-46d3-ab49-563dfbea41ab": {"doc_hash": "0d5cc0dbedbb55a5cbab61ef33b4250fa23e9bc4c0c6ee6963d921ea1417419a"}, "c9bbfe84-8c9a-422d-bc0d-31092018f5f2": {"doc_hash": "a6f85801c54fc315762fc949052721209915ca0ac6921dd43b22857efbe79946"}, "8217160b-9225-453f-a368-b589a206787d": {"doc_hash": "52d9ac628abb7a26cc9c1d3cb5d96aab852f753e607f46e3433edb2bd56d47bc"}, "f0f76446-7217-41dd-8102-d0eab63ab928": {"doc_hash": "9a711b88156e9f47105d09fc4d6b5f774856f01d675932d0d6457778a7dde5bb"}, "4d224074-18c2-4016-8010-232b17407065": {"doc_hash": "77ca589a2d77fc2900dcb16fc8cbe7f41f300d9001c305c5ef28c2b519b9282a"}, "d381e00b-9565-4607-bd96-e12c32174178": {"doc_hash": "318b852e7cd1d8ebd895a737cf30f61e12106ef1bdcc3cdc2835eee7726ce8b0"}, "d760de93-214b-4af7-b40a-adf7d2d67808": {"doc_hash": "51c0e762be6eb04c3e936329c87335deae5ff53a53d95570be9429ffaf1ce798"}, "86da5c77-71b8-47b9-bae5-57fffbe0a8af": {"doc_hash": "bcb480fdd6e503eae1aaaaa379d87edb5ffc8ca61224c5935a3a441a6e01c9d5"}, "dfbb6c29-58f7-445a-bc12-de7426968ceb": {"doc_hash": "c7b4c9e973e9ddf0c569e9907ca96b797b5fe13a90f08b1e39487e8e6bd53302"}, "9b3ad951-0940-4f23-b485-3dce681c6fdb": {"doc_hash": "d6f6519662977f4f83ef65bc0cc61989ae80923ac720a13ed401082b6c700edd"}, "3e5d6b6f-1e0b-4e2c-a720-28ce323585aa": {"doc_hash": "b5f844885cd113c8f237da366133d4f71fad9c974d3b9a8379fa4b242f61f660"}, "9b4e637f-2b8d-4ed7-9771-0392df077484": {"doc_hash": "c6b4d5a42ea481c442ec96e7f9a144e910f85574415310b299577885cc96656c"}, "366ecee9-4ca8-4b22-b8f7-456109e0290b": {"doc_hash": "3f43cc1037c78f38d24ee3711f0e97d0828f51fd91c3309364f7b7a1a683a95f"}, "7fbe6697-faf5-4478-b277-a0bb3168ebb5": {"doc_hash": "af3bd5a37ec594c664d20f6effc80ad60d85b0989d576aa47b38f03bf9da192a"}, "d64b618a-a2a8-46f9-838e-341c9ab91b2a": {"doc_hash": "aaa8e505b6635f0b0eef32ba5f73425ac437e7797813f0e7100d5be0ee12bc22"}, "997cda37-ca5e-4fe1-ada1-76db62fd55eb": {"doc_hash": "a82a81a7e5b33c0c72e3d1dd647942cf38ac9842e39f0369f5990d46045aad76"}, "fd51257b-dff5-4081-928f-3230efea4245": {"doc_hash": "ddfabe89823991e00fdd521546f64a825ae9328f86a6fff93cf20f82364fc5d0"}, "e0c9b6c8-d5cb-4e66-bd49-8a7cdb6d9899": {"doc_hash": "aed2d7ef301c568dc6961ac9c2e78c56bea638d1cf678c79626cb9645b847ee2"}, "46ef5e97-65f4-4374-8a40-20991775651c": {"doc_hash": "3a8f3188f32a0b2b68832450967503549a56cc55cd1dca1fb073f7ca668095be"}, "ca032878-3313-4906-8fa7-092cb864d91b": {"doc_hash": "9371e2e345192cff075d520878896202c801b3409ceeeed28a25612284266cd8"}, "98f431f6-a2e7-49c3-a058-19f508d4a697": {"doc_hash": "fb0b8d592ef94e9563d20a44ed2063b6e4cde142f8e5bc87c7e5971728cf7173"}, "10ba02cc-f43d-45ad-8b0a-627c37976ecd": {"doc_hash": "a0774ad70925cf3e3addef8c9dfeba92514a739d56bfb15bce1a955dbef54bad"}, "ed6f8eaa-232d-4db1-a407-3f2b9204740e": {"doc_hash": "7ab42f325ed04b0114fc0e0e8de5c95adae802199584453235bc37f3acc400bd"}, "12566ae1-6c1d-4d53-83dd-9f8a92cd589d": {"doc_hash": "c4080345ce4122aec06a58851e29912242f7a926ffd691eaa69160240fafff6e"}, "105d814a-3ff6-45d5-8666-d0c1b09236c5": {"doc_hash": "cacdcc99e3ce0b227ef81a47cf882e8a9e1ab15332af9afee15e6b1e6cf17045"}, "d43a3d71-79bc-4f19-beb4-9a2279fadce1": {"doc_hash": "09696ca2f9805f34441a04a83383209eef165ca1b5b11801969fe6b47a5aecb3"}, "30347475-d829-4651-807a-e2af387792ed": {"doc_hash": "18548f34cf6e85e5de14fb8eb04b807d45f740901413a3c722e2bb4556dcd262"}, "3a741f35-8044-4ff0-9a22-92c91913396b": {"doc_hash": "d7f517b61e0988285424d16f961ff4399834b7bec93bd3a6770ceef36f3b99c2"}, "2b7347f4-4104-4ef2-8a91-7615b9fea354": {"doc_hash": "0daffe5a7373881d27811945ad9ccb6ae626e847acedcb370d3df1ace79bee9a"}, "0fa826c7-f6ef-460a-bdaf-1c96e5c1c782": {"doc_hash": "b12af2a213ddfe688b49a89c4cd250193448cfced1499edbf04a9f0784b2c3fb"}, "9868ff8a-fa79-4f9e-9162-77d73c591944": {"doc_hash": "a7c0f9f9b90f604f99bb71bea43c264bcb905f0111f6656bdc3d66aebb39e17d"}, "2d21a2d9-c14d-4fb0-8ca9-f7da9cc59e86": {"doc_hash": "4cb09b4eba7fd374990e8a544b201dab163f4f639a97fee17515ea915b91834b"}, "9feda2cb-7916-4181-ab8a-e025f5eacb86": {"doc_hash": "63d5b63662c9c926b8e7677bfc690b538b1055e9e68ddfb153417396fde5c7e4"}, "ad59ef01-bbcb-43f2-94b7-82a5ec25eb02": {"doc_hash": "a081549ed5d91693a2f2c0f9e8da779c839af69f6f3414a1901536bc0d80058c"}, "c0678fff-d10f-4018-85e6-49f8081615c1": {"doc_hash": "23efe2f5bcf5a44b1f90b7c89718ff8bf69a36b40ae50fef44a6b7d96c297382"}, "1f8ae18c-28c1-4a8b-bf4b-9ef2c2d9905f": {"doc_hash": "9b43a59bfdf471af7e74d80a771db5516d42f802ca03b5d9249feeb7105a6567"}, "eba6d0d8-89a7-443a-affd-728f92bc8f29": {"doc_hash": "cf0f64cdf8d97cd3be475333c462ce7e710bffb9a3c044d899a79b05cf0442fc"}, "89d7aca4-811b-4064-b93e-11e4293fd880": {"doc_hash": "68e8985aa0336bfd36a7b38cb1cce5808cb33129be31bb4fe9fa043c611af487"}, "a37fd933-9557-4cab-8ca8-9831ba6bef7f": {"doc_hash": "5480d964b2321ebff4ba3c57432192163f5d06c5b78ea45ea11e86a291edc905"}, "d85e6c07-f342-459d-9814-360643069e0d": {"doc_hash": "ad46a5329d84980b60d02d09be56a464b204076c49c12850b3e30f5cc1d695f9"}, "c421011f-f926-48d0-806f-65164086660e": {"doc_hash": "d530e05238ce89b152d6bc146a82986b9ea387bbd708c29b6f614123e580aed7"}, "009fc9e2-66b2-4c46-b9cf-c7cbc02025bf": {"doc_hash": "35adab371d1056098ae26e8e2f9df00b48c966b23d9c1855f957995420fbe750"}, "b3434ad0-6a4b-4f5c-9257-0d207cc9bf8c": {"doc_hash": "e2d5d2b86b8ac6e2baf4a3708a2a9cf80a31a5a94126fc1f5459462cd0e446c1"}, "a58c715b-251c-48d9-915e-a5d58ca52a04": {"doc_hash": "f4b6ff31e4d29481c1678e3f1dd59674eb4048bf1bdf288ce265d71942d8ddb5"}, "d77102b6-39ba-4fda-89ad-8e805ce31913": {"doc_hash": "229708a3e67e623da28f73d2770242ce1b763ba3fa5a5f8805d287d6b3395005"}, "92bf58ef-8898-4573-915a-40a60f900fb1": {"doc_hash": "a8579513ffe07b212cbecc1bf3091d35047f0ddfed5bc439afca76d325cfe501"}, "f6b2aade-f614-4c20-9645-795dbe8080c8": {"doc_hash": "b9273671b5ef80ff5e1f39269346cb45a8b1c55d3d4773b5a6d66a7bddbf906e"}, "95e171c5-9daf-4f5e-a3c1-ca6506032202": {"doc_hash": "04879201ba68a65404c92a77a40a7b1c7adae2989258fd75fc8a4edabb573274"}, "514e0d12-f1a4-437c-8c28-dc7fc34bd1ed": {"doc_hash": "454b276146e1114732283eeb3f6fc8129d12789eb6083e7aa76e73fdaeceedee"}, "ae0ee819-0056-4fd4-9162-116599ff81ec": {"doc_hash": "db614889a27eb9136a4b1f7e8f3bc443edf346d24553eb9b3a68862dd99fa479"}, "df907850-1548-43ab-823a-bc3c26c3d15e": {"doc_hash": "3448e1de3745b3f889b162cb898876fa89656d6646cc97d57e2db8a7d2820d17"}, "39ea412b-6dee-455c-8d56-251d6a269237": {"doc_hash": "192f8c2b984e3441866d969ecb7935f6146f459a8484247114e85e031d3aeff1"}, "d6711024-e820-4845-9eaf-e3e4d24fabd2": {"doc_hash": "77c91a0672cdfc527e5ed489a6c3078872b022307ce55307d7bf79221634a0ae"}, "06a88d02-fe43-4815-877d-29a7760b1bba": {"doc_hash": "4913f4293f5da0f3bb2517f601b766907a4b01f26941b83f189112a1c5facb3c"}, "a6703883-5883-4ea4-b0d6-2420402bd717": {"doc_hash": "bc6b265e981a49f017991362cd605e526fe27390debe4700467a9ed88e571c36"}, "4dcb409d-54a1-4424-93b5-30fe5c588db8": {"doc_hash": "6e1a9f962ade9e6c042cf4829885a8a25fc64a7c8b9b5a5c918b1cd15579f80e"}, "914ad209-77c3-4a52-843c-b3e2c0f636e0": {"doc_hash": "ca2acea957f3f3eb01090cb5980e37e54bf5c8d2cedc8bbf1b9ac0716bbe77e6"}, "9329db6a-02f5-4a2d-8a42-d1c98a2ce4ce": {"doc_hash": "b8d64b903a5dff117e136bd4edb683002554e45aa6603bf546d574fa6652b36a"}, "8fdde9df-aaab-4cbc-93c3-d5b37d6b3f4b": {"doc_hash": "655802984bfa7c686611749fb031ab415414ddb391686c418c34543fc6aa2db9"}, "d600d3e3-4d74-4c9a-8755-0d92a9b1a62f": {"doc_hash": "c0669cbb9586384f35cd568d44b45f2c2346b0e9f79108c17a545ad4f20dad6f"}, "56b9c672-3cff-4fbe-ba4d-6bbc57a5310d": {"doc_hash": "c4523b737f8e802fec2c9ee9e32445bde8f3b568ff1ed760e249410982c39e3f"}, "44ec8bee-b6a7-4b4e-94fb-3f61e7330623": {"doc_hash": "c3007f7bf228df240de3baf4d6e3fa84c506b84ca5eccdffb1f767fbd0f2f12a"}, "3d93def9-58fe-4564-a3b2-f42dbb29c1ad": {"doc_hash": "a47dc9ce2884498e4413ab2eb175f35caf0303ef9339962bd274c59bfb11a78a"}, "eba31375-450f-4e37-8767-4e07a77df9c6": {"doc_hash": "e2483b1126a959ca8c50041642bbf9823e8355608d2af2d7eb287717739752d2"}, "023c2bfd-d788-44f3-9d99-e0a988c1085e": {"doc_hash": "e0b531494241b5a5aa3642d5e6fcc40e9e8b2e124e295b61fb684a498a6b7613"}, "3f19b669-8135-4ad4-a451-1b749261056a": {"doc_hash": "2e6571bf981331e04f5274dc6948c35142dae1729caea60fcb3056b8b679f825"}, "260502f2-6abf-4813-ae16-bcf28f6b494f": {"doc_hash": "2628fb6843cfe34342eb3c435131506468c821ca44352bffced3f793c0ca8cbc"}, "ab372910-0e5e-4bb0-acbf-8d6e76c93c23": {"doc_hash": "31e1a50664366dfde76bc139b349c8c049c17ab7e9ec9441acf434744f61d2c4"}, "9542b88a-dc23-459d-831b-a868e566791a": {"doc_hash": "aee5d4cbcb95407414c911719d1de6b74ff616f901721e03f8b49be3435b0897"}, "cbeecbcc-69c7-4b12-97a8-bd60cc92ecad": {"doc_hash": "4ecbf1c7b22324f22196ce0c33d3d9e32a8c0ca8274169ee042f11549b56e1e8"}, "643f4e34-4014-414e-9b12-dc862d7c9473": {"doc_hash": "d62f3d0500aa3819dcffdd87ad622cf0de44e6c08a0a2fc5d3b51b8bc17c00af"}, "24a3e9b9-b1ad-4ee4-9f18-061b8dbe8440": {"doc_hash": "17c38238e3ea4e0af0398b02ab8038f2c2494ca2dae98082bb6eaa9e954df897"}, "9722d874-72a7-4490-92bf-a4652f6449ca": {"doc_hash": "881e60133867030dae04054729011fccaba3f8110c7478af898837bf49f1f8a2"}, "38cc7271-0a7d-4ead-bbf7-3f556753166e": {"doc_hash": "8bee94c912d134d662e15859bf79302ee26eb533ed54a14ee413ddfc93748158"}, "50ca3d37-7d2b-439c-b773-19398cde035b": {"doc_hash": "843b8f6a3c9dbc1a6104dd93c05bc4eb996e824505c00675d85fae5a2d5be6ad"}, "89dc2e45-6571-46a6-9561-f1995ee977ee": {"doc_hash": "88f4f23a04844dccae2cd0dbea493d8a796f6666350ccc449cfaf9263f35fe61"}, "9f170c36-3765-4f17-bf08-93eabf3615ec": {"doc_hash": "871773ed237fdd949e06dac6e00ece4f6dfbd64546789887abc679cbddaee3a2"}, "1469ce25-7566-49fa-8aba-fbe0ede9d677": {"doc_hash": "68ea85cee1e29e3aaba6b9f70c8c28d218fe3c78312f9218195af7c2cec79a6b"}, "57360270-3d8a-4e22-9fd4-fbc9fb78789f": {"doc_hash": "6f320229434a146d96b3ea516d4f540e757af6571f20b67a2f176131e96a1225"}, "7e7c6386-027a-4849-9ead-0ac46c1082c4": {"doc_hash": "af75becffc991f6787ebbf56412fb35ada4ae33deebdcb0f0647781a9ab94887"}, "bf29f4ea-5e23-45e4-a4fb-8308f76e4b04": {"doc_hash": "3bf3c200ade3dfc36886ca32b675fa9e1b0a6b08e3e173c2390fe637bdb54d26"}, "a67a0c69-37d3-4dcf-a851-ba42db79d0ae": {"doc_hash": "134be2377e014e1b6ffa0a93432b8b5cb50c7633f11304a99f182516841089e1"}, "da15542e-e229-4442-b1fc-7688c1e7be6b": {"doc_hash": "32676be3b03039ed488ab1a14981e4945568399cf4669be5a84176595bc5d460"}, "02f0cce7-ae60-4d19-a666-ac5e53c94f05": {"doc_hash": "46d3979807492a787d0f748d714656827c9ed405b2b5f3c80762204934bd6e96"}, "f7dca085-e477-4667-874f-cb5a5d8faeb2": {"doc_hash": "1a3728e7fdfc151a65a759beaf1264c69512b72ba11f8f3e45cd52cf907f698c"}, "a5679258-9c9f-49ec-8269-040a82fe45c0": {"doc_hash": "a8afa43cacdfc24046a368c3c7d463f3b13f02dfa7530579e6d70e4fdfa649e4"}, "a71483fe-0252-40f4-8065-f69cbe55c3ab": {"doc_hash": "eb91c9cc2cf65fac08a00ee7c0e26411845debb00f7a0f3cdaa0d2b78460ee4e"}, "d8528268-6b55-43d7-839c-c66d4f012744": {"doc_hash": "f36d9442e4c67dd1736b9b694627f21e150005b18f69af20ee042f5234c080f2"}, "f0597b1e-6389-4e93-b936-4f433d2728a8": {"doc_hash": "ea3a043e8b3b9cfd9575f03f12f01df968ea0ae446479b8dbd08318569bd8521"}, "982995d7-f964-4e5c-9ea2-a6a296b1168c": {"doc_hash": "7ac86e8e301f5c7141b5adb5349ee79357b330b8e4f9b4ee9286df585a3d907e"}, "01d7e509-ce7c-4bfc-b523-13e70dd4e55c": {"doc_hash": "855fabc5b30b4539a62a477514d05e5cd18c9d1c96f6c47e7536ea420039e3dd"}, "3d1284ba-742f-4f00-99ba-ba391d2dc05d": {"doc_hash": "ca9d31cb8990aa7e8fffd8798330dcac9728b6214bf2e11a8afa3947247e8489"}, "5689055c-d65e-4c1c-850e-6988767ce179": {"doc_hash": "ec324958adf6b43c4d2e17d4720f74b763443ade12facb9f5a3fc97a6d0fead3"}, "4e5848ff-1a60-4cce-873f-9661a990882a": {"doc_hash": "4c1ae5724510ee411dc1ec8ba5dfd26142d789122263302b5c500c32ef8181c7"}, "27d969ee-3116-4ed1-929e-01b46afeaa85": {"doc_hash": "2a089c054acc2356e818e4c2577c7e9a623c05b4425e2640dec73062c3b584e4"}, "06a7289a-cc72-43db-8e99-34aba1bbddbf": {"doc_hash": "82126b5ffe0cd3e4ab3ea35e35beb5e65cb824ed4c0b7074c196730064d878aa"}, "75383dc2-f1d7-4da0-a723-cbf4ffac5fc3": {"doc_hash": "86c8341ed63719f1e4643a8570b6a7b580fefe57239afe1b9013b616d5bc0da3"}, "dcde70ac-d580-4a37-baec-34e5c68ad0a2": {"doc_hash": "ddf4a7ab58d6f754f02e59b17cdc3b742e2353172120e5673c51630c1ba41185"}, "fbcc267c-32d4-4041-abfb-14e9a2325b76": {"doc_hash": "9a478672b06e3a6dbecc5b53668df292e884b8569ac2e3d18949cac46e34aa52"}, "f0630758-a52e-4b37-bff3-8022ebc61c20": {"doc_hash": "5c9fcb9a8a8779520e77127ac1b12dee1832ee9979bf2c253a27d0f5f8b67d61"}, "34f5f364-de68-412e-956c-54db598213bb": {"doc_hash": "f719cc3fc371ae1377a9b2536d5e7c18c66cac3f1488e3bfdc307c4df062c02c"}, "feebbea2-1e93-43b9-949f-69b6b6d210f8": {"doc_hash": "584eac075111cdaf1906fc6e56bd73ba51dbdc839400a0ebdc0cec45ab7b5ba8"}, "e0bbe570-7182-45f1-94af-0aa5cd71c9ea": {"doc_hash": "7ce6e50482a1e4ce6fff9f95201a4ec8a5158dc8bef13a1e96aadc39aded45a0"}, "bfd9a388-f0b2-4ee5-a53a-344444954295": {"doc_hash": "52fe7c0bf13e820e0e33b693040c6b0a0d2497686389a199a84b94fd170d4743"}, "8804de4d-927f-42cf-8886-5e678eb52072": {"doc_hash": "6c70e5f76c5958af148e7278927ad68429e6cbf6ff3422b160d7c196f45e7d95"}, "3ea0f5cd-f5d8-4a53-a1b7-c251792bc30a": {"doc_hash": "d1f6c6c501a28ec9666ffb2b12d3a749d54a7e03874f880eb8bc2a5093b5a81c"}, "9ebaf473-8dd2-4c77-acb3-efde7aacea92": {"doc_hash": "7e120957ddeb07765735b7c8ef3bd41273ab881a647af1f6dd40c3661ef1c096"}, "b38b8103-9ad4-4a8a-bb82-aa128a7386e8": {"doc_hash": "6e91012af4cd6fc401c3133030b8a47fc070e512b3f77cb109447e2d36172ec6"}, "74bd25f0-59c3-4442-8315-10ffd2c17113": {"doc_hash": "942211f09a5e86fcf37bd74606a6df367092b85f37af956908a56d1f9b628943"}, "f2992f20-4a85-4ea9-b87f-d73c3abe30f6": {"doc_hash": "94cdaa860aac8fc00441ffe09528060d5cb8f49f9c509534ce7e280b048158e2"}, "6171c80e-32c4-4cfa-9d9d-21c6008eebee": {"doc_hash": "0a7bfe9ab73134bab558bde804904dd8780004026353470c3677c6b155a233b9"}, "0c983c27-a24e-428e-8b01-7ee379b826e4": {"doc_hash": "c2d7ff8d5869f185a2bd09687f390c80e493e0fe5a8d62bb69730ecb71f6a5e3"}, "6bf221cb-5621-4db3-a60c-c365a5f117ab": {"doc_hash": "bda34cda2e9911f23cd1860d521f3a1208a46aab2d915f458c3ba98eb37d6566"}, "e619bff8-4340-48dc-b342-850f2ad65828": {"doc_hash": "3b6a534844c2ff0f678f926388901a568355d16088c07d8a0076a9b7ef0a3cca"}, "e5df9d7c-adbf-4f14-a3cb-0900f21db8e1": {"doc_hash": "3cacc878c1e4da6a33c19f019ccac33ff1ec8927861e3473e191d89adaeeff65"}, "127f760f-e743-47ef-9aa9-8d1623aa0b1c": {"doc_hash": "481cd1e2cfffd39fc94f4433ceccca0522da2d8142569724e059b9bc4e903863"}, "b7fa1cd8-08cc-443a-b536-3d004397a1ef": {"doc_hash": "00887410bd90064f2ce9d316d17e73caff4ef075cc20ec1867f994581dcad513"}, "e5dc3e5e-b274-4c5c-8390-ac6c9645e0bd": {"doc_hash": "64084bc8dbf741cb85efbb52d5e03643438161736e660b130c3a7056cd7be94d"}, "3a532330-5add-4d57-8822-8eaa8566d70c": {"doc_hash": "45325e682b51a602c8489a851af4f0069ced59df2aa2f9001a25e9b5544a9af4"}, "8d790f7b-da26-438b-9610-cedebbe3167c": {"doc_hash": "29f8563642a2cecaf99ab58d80cea3683c3ea1976d33c57c30ba6c16e5079427"}, "93c62739-724d-4b84-a894-4d1829915335": {"doc_hash": "f752e9f39dd3f1beb7e8a842d5cd64d83db8d86b68446e024aaf2b38db34e89f"}, "b8c07ae1-7531-4f59-a33a-7aecc604952c": {"doc_hash": "de990b3b00e9c05e873b545069fbb37137547fcea0d957a211445f89b1053118"}, "4edd867b-07ef-4a38-87a3-ecbd0fc17685": {"doc_hash": "2d8561ab2909e0ffcf1da9621279cf09dc717f929680a5f84452761b2cfeb6de"}, "c2bc3153-203f-42a6-8202-fca086edafa1": {"doc_hash": "141ff60c4732fef99c17c432bf4c484a81bdcc69624bb974c2f003c164ae4a77"}, "dbe65b41-b652-42a1-b66f-80d2f8df2bea": {"doc_hash": "ee175f7a2ddd93062d6cade822d19e52b9dc80cde3ab995844cfe826575d8a01"}, "03dcbde7-5230-4348-b9cc-d12d81a2c869": {"doc_hash": "697509a1f043a77777edd9d090fba4447bf3f195a65d4aca2a5095c8fa376481"}, "a9c12691-0f49-4d17-b40f-a8efcdbb586c": {"doc_hash": "aac31eb4309d2b3842a361c95fd11a00bafce0e35e8f644b9de663749a3ef2b3"}, "b3760952-ea5a-4bb5-be63-bdd7ade742ec": {"doc_hash": "aaa3716edb4bfea81bdd847d692622d4c85aa52f2ba5e00893a0864e2f9fb8c4"}, "7370cdec-6d94-46a0-85f0-fc81472b53f2": {"doc_hash": "6cf25fe40e893ca250196f888f8d5e62603ba14cd5f45ce4309031ec0588f230"}, "1f20a2be-1257-4db8-939c-e0438e0a8452": {"doc_hash": "0a89a79ce0be5b66e5b9c48a0485938e7d98e5f39d2d253dee2ae065560e96bf"}, "086aee2b-5764-459f-86c5-ca72ef3a6dc5": {"doc_hash": "90a231f47090a50f12d73e1b5331428dc1f7623d232b2c4537c61e96e1c0f780"}, "5738874c-275f-4dc2-b1bf-29b05a8e6e86": {"doc_hash": "777d89d8b57757921df916afa2580e13a9766af56b63bccf59ff318c7e9e361a"}, "035495cf-4948-4143-b4b6-d03afb4f6144": {"doc_hash": "afad27d5be999e13926e31aba4d6e3f83ed807f168bb6ff6a0971a3bb4d8b971"}, "ae47c3c5-bc95-4cac-b1dc-7a8bf0ff9fce": {"doc_hash": "e0a3f97869136bd82d8dce110cedc72671c63877002a920b71641f99e80365f8"}, "f832ec61-b897-4745-b835-5158abc4b7c7": {"doc_hash": "f814c5ce4dacbe4c3d54b6bbcc235a1ccd6fe629075106397d8b411a0619422a"}, "e3cc393d-f9c3-4d3c-9f6b-1f118edcd88b": {"doc_hash": "54201a8ed1c04f2c37d7302454eb3d2c1489c972d846b3039ed2ab3978ff7261"}, "088db272-8b0d-4e3d-a324-7d4bf233517e": {"doc_hash": "5d624b0c1531aa2ed1fd8442d774b573d8f7d2bbd05aaa8fbf2cbf0b777594c3"}, "8faf3c04-6f49-4e02-aa35-14919129f4cd": {"doc_hash": "8ea2996bd114769f4804c43391b4abb883dfc6ba68ff296526e955be025d3118"}, "129ef60f-c486-4c05-beb1-5130b9e7be24": {"doc_hash": "d8a50b545c2a0d8d9fc0d31f194cf58c6bc2c44c62682be44193a2d57d1087a7"}, "de73d03d-7c87-41f1-a992-b4fa980f8cfe": {"doc_hash": "428350f22b23dbd81ca96ee26c2e077003471a597b3306aa7f95b698b5fa33f3"}, "7573be7a-9799-4a68-b74a-c53fde4c43c7": {"doc_hash": "e0c7b03af16838579f9ed1b97eaa656d827a4170e5f06a10b878643aead3536e"}, "47290b7e-4f9b-4dc8-aff3-4a4a75a459e3": {"doc_hash": "df7daa791bdc585db0fadc961a71562b48b99a5ac8facf80d4173495b883fd3f"}, "d18df3cb-bef8-4889-a804-415e03ab7086": {"doc_hash": "7b204f7cb4527bee0a522967d2f3b6b33bc1747d25aa35710110484bf6d2b61b"}, "81a22fd6-5773-4146-bc1e-c0cac30d8514": {"doc_hash": "06fa10ce6ce4ecf873cc72d28beaba8b1f217072edca911faec207ce7b6166fe"}, "b5910d2b-ac7c-48bd-a526-aabff5029769": {"doc_hash": "2f522b87ee9d0b289ed7d9fc813d683cd21386fb5ee4ee8293f7a397b6f036a6"}, "877cd254-b969-4020-818f-1d78ca2c953b": {"doc_hash": "5e3df868dfd78a4a807e6a8b8d94d4ad67c9bd5983173bf99280b880d6a5300b"}, "a847fb2f-95d6-4c67-8699-a2df88305780": {"doc_hash": "71e82b6b6a5193cc27b0bb5017a635cdd7a8191d05e12f3d39a59fc6812c15b5"}, "07808233-38ae-4ea0-97f4-ed949647387f": {"doc_hash": "703987d3593f485aece182e2a272ca2f114498b5ec30d71cffa88bdfba03ef1e"}, "c8dcdac5-e757-4371-b2b1-45f4f2092cac": {"doc_hash": "5afe4b22fe3ebb778af3d2d02b52fd0e412240ee596ad387b50697db2e9c2f02"}, "708561cb-b946-468a-8062-011d26bd70ab": {"doc_hash": "6049defa34bbc4df9aea12d0b903c0faa58e0e1f75421301bb85aeea94005cd8"}, "81aa97fb-da37-4c36-ba3a-15058dd657ca": {"doc_hash": "b54b80f7566f2316f2d0de54d5f4ea752d54e9dae41f347926124011af52ecf1"}, "fcb0bb9b-e43a-46b3-bfdd-64b1fd009dce": {"doc_hash": "a09a692ebdbe527654068ca63f989d5d3b97b74b654adf1a711d3c5f8c78d1ae"}, "34c077aa-02f6-488b-8c08-e64a26a7b253": {"doc_hash": "868c03e2d0f7cc55eb941b8b742f4141f675d4faf63473cca9e5b8790584aca4"}, "b77112c0-c576-49dd-b52a-1f5646326e8d": {"doc_hash": "76630bf7925ba13281a7fb7d82ad397bb1335dec8738304a635db1b19adc97cc"}, "1f9ddaa1-3f03-4773-9443-27bb153195b8": {"doc_hash": "0b34238c3851bc88d0a700b53c1fb4a81a2c3f9bd9db35810ed0c6f4af896eec"}, "a7ab9171-09f1-4033-ab67-c42d6c0522b2": {"doc_hash": "9acce6b27570cf4ff622c816d5580656f6a864002e9e72700cb24228d462cfff"}, "aa36d483-733c-4b70-8f29-cd0dc0064d2e": {"doc_hash": "d35c27e69e8f7e606cf241b963d7a89d0f373b1d038277557eba03a284843b02"}, "ddfe4c8f-3803-494a-98fc-9d391355d06e": {"doc_hash": "387e829360125568ec6f697679892f3c4544748d7f0e8782721f66e56ca74b8e"}, "f021f8ac-a087-45b2-a6dc-5d220082d90d": {"doc_hash": "127a980bb6339ba26cd6dd0ab51e82d35688256e4bd2dbaecc65afac7b1d046e"}, "5b6581eb-2f5b-4061-b17b-e1956bba6754": {"doc_hash": "ec818ef7a47f4d5495b156154c35069d9eba1a2208f01a63cd04e92b6991e79c"}, "24975b92-7a26-4eb5-a145-c17d069fb815": {"doc_hash": "02da3632e6453fb79d921a926fe3ad499cd108d6d6b935c61fc0b54334c0b58c"}, "31c0b408-3b8a-4d91-9664-6162d180fa9f": {"doc_hash": "7157883f01e7dd6a7eff7e33bcde5d98a28b76b0850767fa1a79f4a6e00a9a57"}, "d404ec4c-c113-42e7-a270-6da65b31ea8e": {"doc_hash": "9a4d164b08537564099a5df0e58a175bac3f3c9d31a5d4c0317d000dcf88c3d2"}, "a6a18a04-116e-44da-93bd-067b695befb9": {"doc_hash": "416e9ca7ed68f720ba6f195d24030f4e98e75fd7b978855d748d5f30842197d6"}, "e07ff4ae-9985-4891-ac52-9b3d5ea0997f": {"doc_hash": "07cc13018abdac0bcf87582a783987b22b1312176b5f9c7970383f26362592df"}, "9481fc18-7bec-4141-9ed2-9115c5ff6f90": {"doc_hash": "1a1deb9cb44f13117deb44ddf1509af37084cc9d92bf3ceaaf846aa91347a8af"}, "9baf27eb-4f98-480a-a62a-30bbd33b2c36": {"doc_hash": "a0f7ca157b64e3782affab65f0e610695b7655f618bcb54be5472e683ec5afac"}, "f3646be8-5fe8-4bdb-acb0-f4f35e7cf6df": {"doc_hash": "e96840fb47c35eb879aa471066aebc2dcaebfae58dcdaa8620167166cc5821d8"}, "9dffd154-6c4c-473d-a8f0-f8f7a6ea7ec1": {"doc_hash": "8aeae2e60070a2f02af82f163d07e6a59aa41fd21b53361cc1b3898b5e519724"}, "94fdbb72-5d7e-4c6a-8341-74f3eaa9e40f": {"doc_hash": "53350d516b3d2985a737b7051fadc5838a95b77653f56e3c5536571c2c3f6ac3"}, "1eea301e-a3d6-4853-b491-e21b2f9ec598": {"doc_hash": "167b7e1d647fc69841f1654ce26056864a88a0e4d42965827b2b5ab0f341c537"}, "218eb4d2-cb26-49a7-91f4-1eb905f6d371": {"doc_hash": "29e841b96bc1e37f310cf9b84a38856958c2956124342afc760ffe2e77b0ddf0"}, "98885822-5de3-4fd4-8504-ff15ac4f1c59": {"doc_hash": "e4676cf6fe1e657a8d1626804803757e780cef4064743d0809a1cd0e6a94be4f"}, "c0d6aae9-1a7b-49f7-be52-feb6710ae610": {"doc_hash": "6c625788b14c1c8b8a8f84630ce13692e33b3de435c41308b1a30d0f836e2de7"}, "c23944e8-5179-416d-a8a7-8fd8827379dc": {"doc_hash": "647ad84d917e5cc990c31becc0d98fd74783702fc577680ea84acaaaa8541695"}, "aa35d115-5cd2-450a-a03d-f40f487655dc": {"doc_hash": "23b907bd4ee11f33b27784516558801ca8c13f08c1e66e277f5ab8f029b1c304"}, "9053d7a5-bbc9-4ee5-b436-1c52ca084d85": {"doc_hash": "6283e185e4b1c5110b4c39afc7243a96debf1d035fc90389c2b78c6ff1f42459"}, "667caa6c-a289-40bd-9c0a-8c8612232c24": {"doc_hash": "760fe6def9f1d7e31fb17acffc0775a1aa25e3ad3cf713bcc82b22957152455c"}, "be48bce9-d730-42cc-82c5-2c4aa2696055": {"doc_hash": "fc9b3350901433d34b5591e0b1db81b68f3394d3e3a4319b205e604203610798"}, "a7792b4f-5209-475c-b165-803325c2bc5a": {"doc_hash": "e16e876f34219054f445c3cfa45364d4fe5cff35ee7d159052446ce4e2c3eaa9"}, "cd064d91-ac45-4600-a902-cd0bb1b5b3e2": {"doc_hash": "867486288e80d928069aa1c29e667cacc3de4401f693407bd288139e979db0e3"}, "114a59ab-728c-49b2-853a-cbba213b6ff8": {"doc_hash": "a5f78ec2d9460b66b303ddd4fc911f101b24564aa048f0b82413ecc5d9ae505a"}, "5db0336f-7694-408d-b1d3-eea1107c8799": {"doc_hash": "8db4cda2828df05ecdeeee5b72005acb00d322c6978bf53c789cf9512acec9a0"}, "23251ee2-03d8-40da-b2a5-925018444725": {"doc_hash": "8bfa4c18b3147fbdbb479b9ffeb62d6e369b05b6f773a6b900e59b1766a56d82"}, "e06c63fe-2a3a-4c7c-830e-b6b3bbd855fb": {"doc_hash": "b7c21a6360383aa4cbde9ae446b989497e375ec7051922c6eb0160c9409c6c14"}, "6f29e41a-f812-4162-ad45-37ac3cab1afd": {"doc_hash": "675368912eabacaf9eb517e054b2649c9b2371d8a5ad93e18285f06b18a10590"}, "51e07d18-ef1a-4228-a1b3-6fe7aa7ac4d5": {"doc_hash": "b275e3a4c4a84e6340d9c888c895ae0b18dafbc08a9536647af95762932c4792"}, "3ae4e3a1-2dfe-4ab0-93f2-ea1c34c6f108": {"doc_hash": "a0868de885ffc34dd6a35eac3fc96fb98d447e7ef249f8d7cb816bc67cc4eeec"}, "e974b134-6145-4383-bd70-dc312ac48902": {"doc_hash": "5a8719a1d1b5e75c92d8f45a0e6d75262d5328eaee7bc0b70c2a554828f04b27"}, "65cf492d-d45d-4d2f-bd7c-47b5daa06f00": {"doc_hash": "3f594d260c7e515acd7085860f34411cd0fdcaba0739fec06dfd0aa6f36933c1"}, "cc9c178a-c197-4331-8fa4-4fda3d5dad89": {"doc_hash": "808f166e5d516f80f1977dea7de901680994be1d1216bde1c447f7d8b8c768a2"}, "3e99586e-a37c-46c0-900d-d26fbae4bec0": {"doc_hash": "563283266a255037b1c585eacb201fc6d31924de7761edb99d0c6af28901a226"}, "1d140eaf-ccd8-41c0-be6d-4eb279622c7b": {"doc_hash": "a559142c99d5456787913df86ad07673aecdbbcafb2714fcc85f70dd5585950e"}, "10ca498d-155d-4986-8436-798a86a0e22e": {"doc_hash": "45677a501089581a3ee957a9194674e32c62c2175c95f879d5d5f8be6eb7b2b5"}, "00129353-93d9-4192-8c8e-57f16ed22367": {"doc_hash": "2a01186d9debe5600cf11a2fdeea42a65c3c6f46f783b2bfaf9a8982f1e8c99b"}, "7323d7d5-95ec-4636-af5a-2bfa7f54d943": {"doc_hash": "a82c8ffe2dd002dd636dc82eb8af09c76f3836c4255768d7d257facaa184daca"}, "cd8f94f6-d520-411f-8640-9b9da389ad01": {"doc_hash": "8bc2c21aeb3ce988fe34ebc554f9dd9bb071ff9bab34568836a1fcca74d2d967"}, "104302c0-1d43-4ae0-a1ce-0a98ce6b9a54": {"doc_hash": "7ad36c76e55a8a0eea87ec895457b1efe1b4d7770298e3ffdf6e5977d9d7ded1"}, "41c723a6-31b3-47ec-80c7-e805195c82e4": {"doc_hash": "b05123e9330d5b160b9e521f9c01218ba6ed306943970a0fe4f607bf5f66d884"}, "d9b00aeb-bbda-4a5c-87b6-4dea7d13fc5b": {"doc_hash": "1dd8588181982b3f6917033871f526b115a0c4ec20bf4a64e4d950698c3bd9a0"}, "9a1538c1-2492-44a5-81aa-c63c94caa618": {"doc_hash": "03fddd40af85dd1f0046a76b8866af3af308285ec51e048c8832a29ce28fa5c7"}, "9c19605c-cd7f-4416-8ce1-2b44d0ae735e": {"doc_hash": "4e1d6c723c76e05e0718a75dbd9c82163e5822fef7c629f0be34c11cc90be395"}, "7b9aaa04-641b-489a-9445-d3af27f4c1df": {"doc_hash": "d82eb233928afa3e8fe24d671cba0ba0a29816a1a675ef6f02429b7d98a61e0e"}, "df1fa265-80be-4603-9628-88c9597d0ad0": {"doc_hash": "d6d70617e90cef9e2172ed586444b93c0dca9db31871141a0fa8cd5d60790cc5"}, "7c61def2-3c1c-4c01-b76e-ce02f91404e1": {"doc_hash": "6ec999acdd417853599de6660710a64c3b17768679d50f9e92a2fe28605309f2"}, "aec0f15b-e05e-46b6-99ce-375434716ff2": {"doc_hash": "a7beba160f6075f10e8e203dfb4a4867e85b800b2e1f6174c7fd15fa60de5fc3"}, "2a909028-dc81-4412-8241-d944dbb5d3d8": {"doc_hash": "bcda75f2111332e9fafefc2933c8f77752f28e7f79cde19d4548269fb72589e3"}, "327b3dfa-5bfe-455d-af15-bca96e695756": {"doc_hash": "56feacd641ed1ff108bec28cae92b6c1d59f196a2b809df760cb48b0551982f5"}, "3e363369-24d7-49f8-8a28-fa580b125227": {"doc_hash": "ddca61fab0bc0fcc6f641557194c0968a6343837011cbb9e266bbb1ada54f785"}, "be853f4f-973a-4ce9-8a3d-06c3ae902409": {"doc_hash": "8ff8ea846fcf584431f843be26c79f480c30a5f3a6ca9c7c3bba83ee712553a6"}, "e6418e2f-e5e8-4474-ab55-88b33fc95a88": {"doc_hash": "389d4677061b96c695da9d7c2a372102730cee490d4207d3de3c90edcc9b0d62"}, "0dee2c1b-aba4-489f-8ffa-0167f405ec19": {"doc_hash": "0ce140e3f9b63888b5da4a723a1cd054f9cda0ba0874e4f61855758c8b5e35d0"}, "cce2af5b-4ebd-406c-b08f-8815a64e8ea9": {"doc_hash": "584755f0114acb790c3a0e809ed532d7996b98b0e4f44fea49a946867436e727"}, "c778080a-e532-40ac-ab93-8ef6ff0b3547": {"doc_hash": "30401b378d2a0754f4f2d8c19b24ac5b8d9d718a7ad036f0f41981b102af0a38"}, "fa329130-0130-4069-b191-9558e903c569": {"doc_hash": "068ab0e5047e7552fe662711acfd2190fe133de85e02071d7274427065e11d72"}, "3c20feac-bd91-4960-bd4b-34988cf58921": {"doc_hash": "acae851c2d1f51183a9de87d94e3e2e63e56588f5668aec1d4bd9e1abeb5fbf2"}, "e21afb07-9822-445a-833e-013f46bc321f": {"doc_hash": "9b9a45e5f82ec24f8cc9a5eeaae2192e0014bca6b0da200c78bdb76b48e0f040"}, "415b75ea-3f7d-483c-8a8a-f25984f59781": {"doc_hash": "3c98efd4a72757d97ae0eb90f2cc5e2db2342a306352f88262c295a0aa9d2ad3"}, "181f480d-f1b4-49df-a446-5acf992efdb0": {"doc_hash": "1b00dc05dba925d5c761b06452cc940e71779479cfae9a77991142dd13c3dafd"}, "69307d73-8208-4075-aa9e-60c12357ba3f": {"doc_hash": "11d45beab1abe071cfcdd57943aa8b8c99342d59e2aaa8e86c5c7fe7530b3588"}, "b86bf61a-9c54-41e3-b493-710dcbec0ed8": {"doc_hash": "b5a181d842c8eb6f51c5dff5b6d7a2035d22bdba2ed74d5a2df9f2f1015ceede"}, "5323634e-566c-4b34-859f-9cf4a80e5122": {"doc_hash": "9b4fe3d6d346595f6efcec2987ae2f5b679f5007f2d3700abc8585d83b81193c"}, "cc51f16f-94bd-424c-90e9-9cee2d881414": {"doc_hash": "e49ea0389a9d20154386f6021a1d9eac61877e35c4af9643f0c9afbe768cd9d4"}, "184dcff1-db72-4450-a6d3-e6eef2544683": {"doc_hash": "042efd1612fb9440c7087d0b6bacc998043a72ab3a8186ae4c3b68554b883558"}, "345062ea-55e7-4e49-9fc5-31a71d6a5f01": {"doc_hash": "6cc61ef2e848ab6a412fbd6c8379d0da7c6a69837ee0210f2688a9a74e468aad"}, "6c83953b-d084-4a50-9b87-b10dfef61d4f": {"doc_hash": "b2635055d3939878c0fb2949a2447a3556a64e08b77b80a63d7cf23f7c96a27c"}, "f1c27dbc-867b-4700-b3e0-7f6ecae1af29": {"doc_hash": "5c6501841c7f65469b0fc89a531d80b5508bb302bebc1417b11beffe9553efa3"}, "860c32f8-1fae-491a-a3be-b76f4d5a2a25": {"doc_hash": "306d3bd4a36ec2f3fb9fbdfe9491f87acd1e358c9dc6082ee4c53475c0f89b18"}, "2331cf5d-be9c-436c-8e36-aefa20d2401c": {"doc_hash": "6aa4a96b26da104531cc1957c1404be15a272f961d35bee03269946bd7bc249c"}, "04602e06-6925-4b8f-bfcb-2c9aa163acf8": {"doc_hash": "1550cf0913dc7e43cc301083415a0db3432b975e0ece0679889cd40c395eaff3"}, "19621c4a-6e17-4cc7-8158-ae43b4172ab6": {"doc_hash": "c588cf4d5e57188827d7316a8c45d9ff6abcc05a6749a02ec3dfac1e23068d9d"}, "055b9306-2ad0-4afa-befb-9e7ea22b2270": {"doc_hash": "d44fe206aa4a98e4bdd254227b212b64f622b727d183181aad158c7a108183a7"}, "f81610f1-fcc6-4290-9084-b7b7a2e2c5a6": {"doc_hash": "05c1109bd0cd9d8abc9833c28f2ce70026db160998d601cb452be60bd2160301"}, "42a483a4-f04c-4faf-8341-84e58ad68e79": {"doc_hash": "2615ddea2dc2b7898e0cf1452eef79fa5d7a4f8dfe083b5e4c81b0a21c7e668e"}, "48f71035-c751-4f8e-b0d4-c3c041aecf6c": {"doc_hash": "e62f1edaeb4c8c8ef17d37bd4a6c9a114f27eb29d85fac4f5d70f167692ed4eb"}, "a0976932-6ddd-4223-843d-a905386fa3ce": {"doc_hash": "561ec0c54206d0f5662b0f91314b65d939171e53655a5d5157a3109a1b160a00"}, "412a7fab-c1c1-4b27-8c07-21da1fd9a9e4": {"doc_hash": "9f274ca1f6cb2e38782d2478b7f9acd0e59f3872a6928c69edd5cf6f8a3651ba"}, "f178d07d-0e0c-4f1a-9aca-ca2633b50468": {"doc_hash": "d49de5b1443b8c50a48b4e5d145c6e61e691e13756db7e12ebf89dace8992f6e"}, "eaff1146-4d22-4bd1-9846-6b0eb75ea74a": {"doc_hash": "3bffa17a75a55bb5417233fd0214edc2a25b010af7c83c530b9b521055182cfe"}, "3c21cbd0-94d2-403c-a8ea-44ca9ff87655": {"doc_hash": "91dcc1e72dd43941f3b2f648c5506ee5de55242034eae4303fd0158fcc1ec181"}, "0d230ac9-76b7-4810-9fe1-f23a94e80c69": {"doc_hash": "a8a3a9fbd9010ec8a74656563f058c26b6d2fea4d60dcd7d829cdeb5286edddc"}, "42d817af-cc03-4cce-92c3-2a59092f883a": {"doc_hash": "c11526a37641f17599038dcb5831cb467667f18404a4b2e7e21c741bc17eb9d0"}, "f4559326-88f3-4138-92e8-01c25fef7abb": {"doc_hash": "60502e71c7688efad5a179ff3a13c120c61ecc36dbb38eb76e19d8587145b219"}, "6b434d38-2ac3-42ea-a541-910fa4b66e78": {"doc_hash": "ec61350e51e9f4d32e558a8fc1508c54074db260f65ef8babe09c341e167a11c"}, "32094063-fa64-4695-8860-22c4e06ddbac": {"doc_hash": "8a21196f496f2f35531d36e3327239e7f55c00b7bd12e894adf00fa568fa71ca"}, "ea2617c4-4154-4dc4-b3f1-4df529abeb33": {"doc_hash": "2505950c41a1d9b1dbb38436e2773c49a51ca2b00b92b834aefe729b14d5ba57"}, "35b8e87b-8a75-4dd9-ad6c-bee57bf85129": {"doc_hash": "9beb15151c1171cbacd4a8589a8576f236c7d9f4fb74cefebf863422cf7ea3fe"}, "bf9eb918-bf6e-4d9d-85c0-03c90ccd2576": {"doc_hash": "7af97c018a75b26d0a11ebf0b0a6e2e695758b58b5d47788f0fc5d6916573fd7"}, "1bd00564-4a13-47ac-a9d6-0d8f5a1ab342": {"doc_hash": "436fca9a9796d7f28c30199a4a1d3ce6f38880d043aeeec8e51f25558086cf01"}, "9b43ab2a-a287-4469-92dd-715869a0d10e": {"doc_hash": "c315cac4b8fcae74d601bc56f8f0f93f7a94dd6a27b663b20696c8e9d230a373"}, "076873b3-32ef-42f5-81e4-e07bc1ac8b2e": {"doc_hash": "95f96ec86084137bf991d85e36d9aef425ebbc3c88be8c3a85d735d6ec2ed351"}, "0871ba97-0496-4be7-9a3e-6dac3e94601a": {"doc_hash": "d9f417580d09a4eb092220916249343ac36dd6b7995ea38fadf9c65f2965ac8f"}, "3eb32836-1f31-462b-8949-43c92a79cbe3": {"doc_hash": "8cc184c0c6080da21ef6567d97912bbfa2bf00587a9c17e193217cac315cc737"}, "2e7c1c93-eb61-4a1c-9e34-b85e5f682b3d": {"doc_hash": "b46b70296bf1f9ea9be6ff67000129e6f2e778c27e7bd3e529a76bd06f9b0f65"}, "13ff403e-e7c4-409e-92c5-fbe4b9a327bd": {"doc_hash": "6d35dd631ef0c937f8beaeb66b11b8b115e9561ecb659393a410b19226a6e171"}, "6941a77e-c749-45fc-a48a-1e6c7603c248": {"doc_hash": "733cae39985e5435af5246cbed86e4da4ad6049ec63ba5cd526c0933450a8950"}, "da9a64d1-3a3a-4ec5-bfb4-5735e9306135": {"doc_hash": "7a7adde68134ff87440ecb528a5a62807dcf0332389f79c8a28eb725db18e2eb"}, "cde128cc-37fb-42d9-85a5-6858c55e25a7": {"doc_hash": "e388dffb58f630ea4bbdc1ea422145d28a3cff23f66390a239a33507123371d9"}, "ceccd252-2c95-4e7b-8ccc-c0c37aaf5f42": {"doc_hash": "0c425b4d4a6588ae74dfe11d64e61018170484b6e55c24f7582b7578a745087d"}, "d0edce96-0ce0-4724-a409-d3ebb40ea251": {"doc_hash": "e66e7052e8728527adee312153a513fde89def4ede7b734c4f2f271f0951dc70"}, "9ea13dc3-7521-4584-8ce4-91f17b7710ba": {"doc_hash": "b74e1acf797088cf876f45035a48ec4acdb05e9d155e72636d3eb73de1969acb"}, "03bbc9de-ab91-43cf-a178-14655580c71b": {"doc_hash": "7b40c904bd6f21123df6419f4dd45617832911eecf8ae20e325490884c122dd6"}, "6b534828-5cac-4f90-a41e-7c1b4c24a204": {"doc_hash": "536f769b63b8cfd091406169ae42d2d14fdbf67a6301ab25e692c54cc36ad158"}, "4d7b994c-6b85-4629-b3a5-2f0114c69a69": {"doc_hash": "2e93313ea768aa09c8d443f63cde2e91762c850132c20d00c62101ec2e17bc1a"}, "25770570-e267-42bf-b3ea-ee3edfea91b1": {"doc_hash": "59669d50ec250de6b30927c4f808ff6a76d28cc39155bb89a15b5daa59ddb219"}, "d2100424-b14e-47d4-8d4e-67e51a9c4a4b": {"doc_hash": "63b36739d3feeb9714012eb7b41472e2a6264d2ce2fb305c8fcb7d783149dfda"}, "e6e86a33-ba56-4249-88ec-c5945511b860": {"doc_hash": "a78e69c1b6440f77c2435dc02b38442febfe2c0301ff50ddc3e393fce8070526"}, "636abaa5-e064-4d9d-9e2c-271cfead0645": {"doc_hash": "ec94dfcb285c5e4a1dd09cc803654e15b14cb25fd8dc9b5cfa3affa73073b8ee"}, "63db8505-21a4-4789-a851-56803e0da499": {"doc_hash": "da5cfd50d25e4412fee577d3b837f803b19f0578dc01e3cd8d830b2aa0fcacec"}, "60790017-88a6-4d03-a352-fb605a70f76a": {"doc_hash": "f10801479b8556dc503e0dcc4a1ef942d4b06730563247181027817bb3b4a38b"}, "1469e8e2-7d22-4d4e-9e63-4fa4fde57421": {"doc_hash": "5f2d8e165efbd4f211ca51173010f8acac359251048fd64afecc69a09a057d33"}, "693c30aa-af1e-48a6-8973-b7eac99f46ee": {"doc_hash": "ea2f81a5096345574c5c6528d8f1b93857a19f6765633507b10c86a613b56970"}, "824ff52c-4e38-4750-a20f-bea9b33ef43b": {"doc_hash": "4d253069141bde580e887331262d987e98b0ef704afcc79c85031046a3e07487"}, "f57a5fbd-f3ca-4057-b090-ba2a8f8bb314": {"doc_hash": "bebc651f99362bb2693a6015db72da5086bf0ba4a29a8425ddd942216ab866cc"}, "e35e838b-48f0-4d5a-9d60-e526ade9a27f": {"doc_hash": "e4a5dd089b48ed449e285ee276185a79055bc174e1f6594c4bcb19329a47bf80"}, "99c39dc7-a000-4839-8ddc-8fa6dfb26214": {"doc_hash": "14d4d0d8ad1743519f6528f9bceedd8ab893c13f0f0e96b99e8b2dd4ad35577d"}, "9bd4cdcc-bdfc-4335-8088-5082f7addb1e": {"doc_hash": "2c2992fba8a37944a70bb709f7fbc43f850b7bd075b89949b41b7bfc989e941f"}, "4efcc1d4-cabd-4dac-8bc7-a030573f2dc0": {"doc_hash": "5df838398f9c97ed88767017a8bd4e58a5186227ea3d33e691240f153515f94d"}, "4dff1f51-2f7d-44e9-b59d-0f6d4e410fac": {"doc_hash": "8d3250b3017ee5f9d4d6b8251008992e174fca28a593667b0cc9a3a64a61950a"}, "ec87f510-8800-4cfd-9307-b8ed35a58b1a": {"doc_hash": "e832c5513a888f5175adbdaf3e1ea25cb4878444d5c5eb81296ae85eb418809c"}, "945b7eb3-a377-4bb5-a85a-196e4c8974f5": {"doc_hash": "7e542c9a1315718ae8903c36a2d9849175ced694f08489720f2718a9b9f2555c"}, "434675b7-8f34-42ed-a031-e7721f8a63e3": {"doc_hash": "fa337494b2f64ee1f0079f1ae00028ce66f410ff5612c0809d9c60691da4f6cd"}, "5a367987-1ac2-4066-b913-4be442ff7277": {"doc_hash": "3b72a8131b8ebedead84a07fc3544540b8be23fd5db5b44f15a8b6350c9922c7"}, "c99fa275-3e9e-4027-9c9a-8fc93ba1ba08": {"doc_hash": "47d6254cb87248c5963ed5a8bd19db323e3b9ea9decfd87255b5b9cec3ad6d31"}, "a726362b-9703-43e5-b715-3daa2496daae": {"doc_hash": "a7e5a7407797a503f32e8cc32eab38c14ed542d3619b66c85f634792428dcc44"}, "78fa39f7-fb98-4698-9bdb-8c9aeec7f76b": {"doc_hash": "ab7b4e799d36959ce62f82d1f1f83f2b808b6bdd6b5ab547a0dad00bf5293bc9"}, "24bf670b-55f4-49d0-b465-1d2dcf564b18": {"doc_hash": "29ce901208117f04a851ac494ce8dc215ef1de5d3ddb3124495aa7a922666c97"}, "03a751cd-12ff-42da-aca7-4c995e8e7273": {"doc_hash": "067d78d93141d03e9e31e4feea9cd7678f18186f42d2a5c1a2e46b90a8100791"}, "a2134412-3d8e-4f29-bcf7-26e226ca9503": {"doc_hash": "9f1144c808e64eb74d7eb2619ad21a279460a27ceeb434a8831b076461dc5f73"}, "2b696b53-b50b-4f4d-97d8-6ee5c0d2a4eb": {"doc_hash": "d815f9d46348ed5bc5f77dc5a7cb59f6ac8a56a111c66b00c9808ba294b5af7f"}, "f53b7745-7f92-47d5-a611-ecfe0d6de377": {"doc_hash": "a40b17578edb72244bd0bb65c185affaa1f04e545bd21a8b8d411eb60d6cfd09"}, "3b744cf3-158e-4ddd-90c2-c2f6f3b8864d": {"doc_hash": "826d3f8725c949fc4241133cdf4e9aa7a7d375c1649973c675c27e92ef3f53e8"}, "83325c20-279a-45b0-87c7-1e9fa8b8f004": {"doc_hash": "44478db1a023c76dcea6b84fee97f8543e7a01fa55e48599396a38340f9ca985"}, "da1c62ec-2636-4424-9800-b7f0cb1c92ad": {"doc_hash": "e76b223947f1d2e7f2258b870bbb261f6d23051afa4ba6d433b5ba8e620a19fb"}, "23ceedd7-57e1-42be-8905-7d96b813f318": {"doc_hash": "faa309d0fe92f3e8e902befac4eb2544a76ad9384370f345de4836e2d794ab20"}, "7f48cc91-9c3e-46f5-85c8-567291df5f20": {"doc_hash": "36c6ae69164b0895872ba9e49081cc4410e657d57383878edd34f0bc3db0a262"}, "e871de30-8532-491e-a792-180d7ee77014": {"doc_hash": "75e0875a37fa4c0d3d3be8eee61ebd0ea70f88e03e7b69ba40534e183854b6ed"}, "23d2c467-48f7-4a22-84a0-fe72036924a2": {"doc_hash": "3be337ea1ed16f86e492ba4e4a815ce36eccc8d32a23493eb744b5532f32e49b"}, "138865f7-77b0-4e77-a646-e9945b79649b": {"doc_hash": "1d1f47f418d92523e89731869ed8a1dad95634b3ba503b837a67a383438fe39c"}, "a0c02117-9c30-4611-9a04-2789d85a6782": {"doc_hash": "38d9aa8b391fd444c84e0480df1473bf2b9a3f4a4a6edab296111828581f0e2a"}, "2ac6849b-d9a1-42e7-8fff-2859fa9c34d1": {"doc_hash": "df7877725509f70329e15d66609f0b109717b4824a357138cacc37f63f5f490d"}, "275a1c0d-d39d-4fc0-989f-8fc8fd430d9b": {"doc_hash": "93aae3caec4a52ba6ebe7e95e62de982bae5420a35dbef2bd65f3ed7d2adc94a"}, "a47ec575-ab3c-418b-b63f-5d2a8f738cac": {"doc_hash": "bcabc2182bc49c61e37eba4e88cbb1d7acf8d83890c463cb6350f35dc35c4ca0"}, "78fab72b-a332-4216-9842-4dbf17e3c871": {"doc_hash": "ba3d39849afc427d091e6e18103386a4439031ca15b5dd43c7cd380aeebb112f"}, "8fdb09d9-4a84-4d9f-ad21-56bb090c6f0f": {"doc_hash": "4e8487c7367c3c3329dee795a8abd0a3e235460a169d31b6b74e2d2d5dd64164"}, "de6326c3-8f5d-402a-84f0-1d3b8cd968c8": {"doc_hash": "03f903ae91fa2e38e6a937a67f4a150290a7a0a31824e80f57ee214de5f886ba"}, "32d2ff3c-083b-4707-b558-9d7e94cda8c9": {"doc_hash": "d7bd156ef9b89d5ffbaa475442804a1dfaf0309c210fc0da62c8f0365cc48b38"}, "1393c641-8e24-47ac-a333-28fb99f2fce2": {"doc_hash": "9e83d051baf3267b21d43c5c45347e9e846390072238c5b1854fbe487a779914"}, "80080954-fc66-4edb-bdfc-35982c5c93cd": {"doc_hash": "d69086ad99b07bafbe1440ed2fdb72cd6d3264315985bdb1c6f04cc19c7ea8c8"}, "2b3bdc96-a2de-4efa-9967-a01a58900e50": {"doc_hash": "d7d25a2944336762d297677c3a2ce615b1a64abfc7ca60fca5b8dfefcbaf6419"}, "25925ec5-0707-4f25-874d-11816a34f621": {"doc_hash": "11b88d313cb4fe57c5f5ef0c5a11a6a5359c828b1f7170aebf9aabbddf66f3d3"}, "d4547b89-f042-4a34-9e7e-9526ea72964f": {"doc_hash": "663f93477c68dd2f9b7791496116e7a588618dd211494b69582967fb06de3b34"}, "d488199d-a5a5-4915-8320-ee2e8072addb": {"doc_hash": "588fcdb60947348fe7e9bb8e45e99a365f38df0e775a16b0a4072fd84e37cf52"}, "5f1cb4c2-ecbf-4d79-8994-902ffcce0731": {"doc_hash": "1e6cb2b0300877df8aa5ded7090366f9bedcf3c3bb9886e5e19cf91f4e78121a"}, "68d71651-8483-47de-b2df-196156f4ba87": {"doc_hash": "5aa10e7b0fbead8cae03c641076b7fa30f3611626193ed4c3ce5fd7a111c5089"}, "a2c6720d-624d-437d-b303-a798899684b9": {"doc_hash": "eaf56dc52b431b7080eb7cff71b1a92047f34f8e531b7c686814d05e3076aca1"}, "a63ff3c3-fa23-4c8a-9b12-0c9b76ff128a": {"doc_hash": "b635bb81fe0a606a541ee57e011ccdf659ca6478428a0b15cb6f8b9c269f1659"}, "b7018b8d-a764-4dcb-b8e2-17c5ee384e9d": {"doc_hash": "dd71627ef29544446ad19570269460b1a7eec6c91d6935a5632e91e42e9552ab"}, "a059e43d-b131-4725-81af-1599493cf769": {"doc_hash": "ba1bc93b37c0779d747451d96cb8c692e5c83ebb2de6dab1eee1277f4df351b0"}, "8707fba8-509d-41de-9f7d-f8c1006e27de": {"doc_hash": "ecf9dad0a22b67c68d00613aaf2392c47fde43ee32f65ca64fbb1c67b81e67c7"}, "cd22d62b-0d90-40fa-8ab0-26511e5675e8": {"doc_hash": "2fcfe85eee704f2e471f96bc9aa9c3de429d5af5210d36eebdcb28f9f035e0b4"}, "b896a6e8-3eb5-4336-ae98-cb78e86b357f": {"doc_hash": "52ab9036e0a0e51b5b6516e23ee003c7815a9bbc6dec7a57494bb760bc52bed7"}, "7f5d26a1-0c64-45b0-94d3-0c2e9aed4898": {"doc_hash": "08ce8d9ed558a2eaead177cca82e8bb05140115144fca3ebedfc3f4e4f6bd5fe"}, "c8fca6bd-03d3-4bf3-a23a-5a93ef07c027": {"doc_hash": "047cf01696def947f98d905771db75af927aec138695687916948a07daf23649"}, "46097bfd-96ab-421d-b6a3-de00c4b9694b": {"doc_hash": "204a343085b9f07eefb4b2ae34c983a2bdf80574979548fb41f06c2a557518a0"}, "6e4100ab-734f-4c5a-8386-b61029b126c9": {"doc_hash": "5fea9c6dc2cfacc108ae293d980b632eb7e31da9e7bfd377eaa98c0b0c9c7cf7"}, "8bebe3e5-0529-413b-b243-b3d499a873c5": {"doc_hash": "815d69831aa9310dd69a681f92a749ec09b1e9a3d82224690d3cd4a3d8a1afa9"}, "6a4cfe11-fc27-4b83-bcad-342a38c3f039": {"doc_hash": "d43d23c6ce1622181273ba4ccc758f5d8eab91f748e9fa9b6b546e8ea39f8582"}, "62ea4c80-a0ca-4665-a4d5-c4b0cc2cb7f0": {"doc_hash": "659eed4ddb3a41133cfb8365f1c01412e6532f751a3b0e698d757501d620c644"}, "6080e8ff-e7be-4981-aed6-01c683f169ac": {"doc_hash": "02a7d48d1e314d2d24cc061287e2e9a4fd3bf3bbcd8eafdd1f06f8236c49a308"}, "87d7aa3c-80fb-4c2c-8e92-eb6c67428315": {"doc_hash": "3589384c0e0abfc1338540f6150710bc35c4e0dededc339fef3f912da60e03cc"}, "3c310313-3c33-45ee-ad42-17dff9eae989": {"doc_hash": "25f15807b97bd532758384550bc03421abf254181ab5317c4b9259339becb401"}, "21e86423-e88a-4b97-b736-b0b0d7ab8efe": {"doc_hash": "a802a37fed1ee307e90be8396b1826434c1105135b5b0a39c4fbcb9e04ae4332"}, "bdd4f762-f7b8-4fbb-add2-ffa79a22ca37": {"doc_hash": "6ada347a29cc792a49af8a334ca4433e55d4c48c51766ccc36825e17fc7071e5"}, "dfa3cfcf-269f-43a7-a294-dbf998169be5": {"doc_hash": "b1fb0b82584ddbab4903f9fb59ff2e69a531c86898bdbe7aa1b73dcc2d477398"}, "508dc100-0972-4dc6-ae44-d57084fced3a": {"doc_hash": "69defdce2a5c0e9847c1f099f1af81e0534dbaa94892d97c4c5661a561773031"}, "507849b8-ed25-4346-99f5-7d108fc54753": {"doc_hash": "1da287fd24ddfec814c827606d39b4f7c8e201b2e17f136e108f3666e6998f66"}, "004efd65-2443-48ea-9d2c-c73983289e0d": {"doc_hash": "fe2486e98d50259561a8939afd8f6045bdcebc3809cf38c5ec37b6420d0a0a26"}, "f2c25fbb-ed9b-4816-b720-5ee7cf8c2221": {"doc_hash": "a095c48dbd922ae690c1b8d7ab0cb2cae9417b5e8f80e3f4d19e6d7de8733e16"}, "086565fa-f127-4e47-8260-022216a8a6c1": {"doc_hash": "a79e7f083a1f3379fd53dc2f9d15a89ce40e62a6866092b23b1af0d6e79ca404"}, "114b8ce6-75da-4212-9013-bef3907dd520": {"doc_hash": "cc2b704088cd619993d51463f1c7d01e2a6fa7fd53d7b5f7d966125627f30f34"}, "8c8fcb7f-2b9a-48b0-a7ff-8e843b2f74f5": {"doc_hash": "06080d4a5a4288e2c1933b57dd7ea22f6262f21324c50180bd99e6da676f869e"}, "633af932-0c41-4c87-8252-32bb7894481d": {"doc_hash": "56ab3f641216409cb104637f513ff96a2c03bf0a02e934c394d04f0405604fea"}, "dcca2fee-d258-4bcf-abbf-276e9244e1b4": {"doc_hash": "fcb041679fb90d5931b03d11009bbf07b5a20292a48f96234508bc9c959d5535"}, "6631ce49-9c9c-45ed-b570-66b6950ec48a": {"doc_hash": "22fd1db4f4070f6c9338bf10bb13b7e8dab3317caa78456b2db6912863f3db20"}, "9ac6e846-2e0d-49bd-a299-f608b265b393": {"doc_hash": "c22fd420604f25904319ab4efe0e01774897718058a27ed3d617143e4d425fa7"}, "ad7e60da-c33f-4f92-80e4-0d25dde15446": {"doc_hash": "ce43f0450a9711588f033aaaadebc45ac6b8c9f637b730f9d0f83c117c4381b4"}, "e1e146aa-baac-4e5e-b32f-eaccc391aad3": {"doc_hash": "f21fc0540e903293a6e77a8e751bc00629449b65e064b3bd964fb2d9f20b7785"}, "1499f467-6304-481b-a63a-cfa688140176": {"doc_hash": "eff0c14240f7ca8543c5d064b21e7a1ff4a13b53c23ca0648f484d442c46fbce"}, "ce7887fa-11d6-47ed-8b51-9eac3f4d80df": {"doc_hash": "f5122213749d6e0c2cc96a1b66c1bcd713e67927961a1a33ff7780e31aedb3a0"}, "758dbe39-d01c-43ff-9823-6cf8e62879f9": {"doc_hash": "90b3de80cc4a75ac654b33c0bcd5e12daf8af9a2db499843477e8d2020983d50"}, "d50d8d90-7c9a-4f96-9cb6-2302cd20fcf3": {"doc_hash": "e3de7779484c8845d4855ae9a85399e94c46ed4c2c4d6ed4c2d9a4b4a1f0afc4"}, "0247e755-31c2-449b-85b3-33650727f053": {"doc_hash": "759c1f4bda7037f51e59160d4032c7ce6a46b11eabaa1a7ef62b5f1aa0d1573b"}, "0fbbf768-8dce-44f6-9522-ee8750bac54d": {"doc_hash": "1fb9881486a6724d0f3b9eef11102ded42fe42eaf7e9152272eeeb4ad87e3402"}, "80da111d-306d-43b4-9811-3bd1f9a93c24": {"doc_hash": "48ec33070d1b691b20059dc18967569f7ff68f83e33be117166c5cdc48e16a85"}, "d6eb2dd0-1c37-4e68-8932-6eaaf36fd94c": {"doc_hash": "0d68b3691d9cfe29b4829f4b337aca609c12990089e276618213f8e5f5a8cbde"}, "78ade4ee-520d-4f5c-81e8-0c6f9bd532bd": {"doc_hash": "3d737599f04cf1f4f357a55ccb8d823ce089f0cedaf62b07c1f6332fdda441a7"}, "15f1f5c2-f546-416a-ab51-b72076e93bdf": {"doc_hash": "4fe69da0f1200232529f6920997243e39587c4eca5fe5cc403cf482af96399ac"}, "ef49c2e6-b8a7-4354-a499-2cba224dd3c6": {"doc_hash": "4847a0dfa3923fd2db5bd44b52a3d3fe389d79d93436aefb76755f4e8a84e09d"}, "121f9361-40a1-4d85-9f3e-21dd1e81f272": {"doc_hash": "75d60fa6d97098acf6296f304c0cc55150f4c7d5e5a258eaa13d5e9287bc9fd8"}, "07d0943b-9d24-460f-a58b-f2d5ff609048": {"doc_hash": "cfaf06a3b20fd5356a82a042ae75b76f9331664fb40ee5414b87f87daa390a58"}, "df1c1dc0-89aa-421a-93a7-f05576c40e0d": {"doc_hash": "8cd316ce2de078d9148582c825ea1e8648355ce7d5c29bd37023490a5781add9"}, "de9b9807-c0ef-41b4-a497-862040ccc0a7": {"doc_hash": "cd13007712490784015ec52134380926d688cac3130e1592bd6914bf080fd291"}, "0276bb85-a36a-40c3-9d81-ae61429ccef6": {"doc_hash": "c9143fcf7ba22bb390e78020f56c7cad136ad2e5f9fb69785306cbceeaf3ff08"}, "a4635b4b-7196-4b9c-a071-2bb83fc59786": {"doc_hash": "522cff4a43fac222ee0fd066b010782291f66b503d8962c9611a9c58f785e080"}, "dadde287-8b1e-4bb8-b813-b0a4f176316b": {"doc_hash": "091e9d2a14f963ba70904d6fbd5eeb0e94daadd2e64d0e5b1771b59055a98a31"}, "46840c2c-9db3-48e3-8526-ed50c89481e1": {"doc_hash": "a2ff1bca71d1c2fefba75551831383757cd06c03fc7e316aa598d9c4f47a48d7"}, "1add03c0-848a-4cb8-8bad-3265c8d61752": {"doc_hash": "40c6c7b2e250cbce0884b30313d25182735d422f2c5dbf1ae69c3763ab339eee"}, "e21d9c6d-8438-49bd-a5ab-90f5560a2ce7": {"doc_hash": "abf65f546e7f96f06dc59e8751a50ea09c884fc8e1c9d26f07ba0cc290173364"}, "8ea60a77-e6c6-42bc-b230-596bd0eb64ed": {"doc_hash": "7d103cbe20a57d3adbb526da4f9a9efe4d29c4001a67fb4a7b03dde5de61fd4a"}, "558ad263-ffde-42c6-b7b5-913533920fa2": {"doc_hash": "77a005e5e899bc43000fc312baf91acee47e5f02122fdf49bbb9fc5129e6c8dd"}, "3557d504-42cb-468f-9d55-834cf519c63a": {"doc_hash": "f770e057fa2014dea042765aa9939b4f6a727e28427fc9f09a12244b637a9f9b"}, "cd67c46f-a9d4-488d-9e00-99038ddd1b57": {"doc_hash": "c78c462db5d642d53c4c5c9ef61740c40ea39ec4eb45dc694ff6f5c59aed59ba"}, "c8327f63-39fc-4b79-b811-8ca9067e337e": {"doc_hash": "6697c1882b325dca0c065f2ed79cabf78e86cf02fe7e75c3ba566f68e443cc67"}, "bc8292de-1df3-4da7-becb-8b614abad96a": {"doc_hash": "3d6f9b8d291c9a741f0a5bdfa47e55c776d6587d5c0b2e24391edb4753518c62"}, "c72bef93-2767-43ae-a693-ae4e47eff9ac": {"doc_hash": "d7c7a5994a063a1bb50b8c00d67bcf1ddf75ac59fb5ad08a5f07e359ad24077c"}, "78f3dcf2-29bb-4b88-a975-a6429119e755": {"doc_hash": "81c75c3aff6da8299c096d87c966e7c41d9e58d5a6df557bef98ecbbc11441d4"}, "0d78ed61-4e05-4750-9e20-c7caad359760": {"doc_hash": "5019d6b0b761d8e4e578c728e50658a1f0d0682201454b49f40d71dffd8e776a"}, "e08a4edd-af60-4719-b1d2-e3c070c07a82": {"doc_hash": "a855c87ffe5f16bfb2ce86a04deb8628258917511de433f6c570bc54774e2cff"}, "247d984a-3c79-4e3e-be60-6b7050b69a65": {"doc_hash": "2724a3610435f7e486dee0f339937b386f3752be844b7b54cd63d46a243323c6"}, "ffeb173c-1a18-4e34-9cf7-ed5081d5c7d5": {"doc_hash": "fbee2ccc541889a0cafb9e49d8d8aeb3d655a77e09bd4b6b67768607c1b4d3e8"}, "87d61007-2221-4876-a1ac-60dd7acf8240": {"doc_hash": "5ab6784992831b45307bd0bd7e281c155d8228f0a83ba4f15bf8e39064d24846"}, "4e73fb27-a794-451b-8b84-ab0ff5410d36": {"doc_hash": "73c6e20a37c3a86cfb785893fa3d30883dc5e7793f9b91afef846252fe57292f"}, "77faf3d9-1103-4f77-9a61-498e5aafa985": {"doc_hash": "e5cd126a3090044b8e1c54050407fca4628ab4102350ad4f7df960d1c4e2a63d"}, "7951d1a5-4df4-4973-b4ea-935c3c12c081": {"doc_hash": "e1fe03af5443ed606a776e8ae9cdc4e09a0cf145198b34d91274c65c4a72f281"}, "51d7c345-f023-4f57-9f51-b04fc2432cc2": {"doc_hash": "898baae75c00a99235a30dcbdc9822cf665acb36d1c894ffc2308b772dbc1248"}, "94bb0a44-3fef-4c51-99f4-550737ce40d2": {"doc_hash": "74979817b6e4e4b1ab62a249b2e7f440f31c310cf97609aad4927f37e99e747b"}, "a9682377-c0ee-49ef-a23d-4d7e182419ef": {"doc_hash": "ac092515d4f70edab0dd1ef9c55bcb87d575e49a7fb023ce22f979dbcf4595cf"}, "6abc409f-37cf-4a53-8400-7ff57472ee2f": {"doc_hash": "84efc887676bb35164cd0e19a6f31b6715479b19ae21ed29dc25ee70e78f052c"}, "94ac2ab4-47c6-4d10-8110-0d238cb078cf": {"doc_hash": "01c0250d20891821ac858803825b4c0b9856fcfe68d5a9c4fdcb06a8c31176c2"}, "95a005ad-f0b5-4a3a-a0f1-16c992eb5d74": {"doc_hash": "cf09c049ca9dda0bdeaf840902a0cfde7f79aaf498e07f51ebba4ee3783c813b"}, "a02bcb24-35ff-4e4c-aafd-0c6b9b5957de": {"doc_hash": "ef77519d1fe8f5c16f3fdc9a3a1610cdcac5f8abd0ae497486d30b8b6d59a3da"}, "ab72c98b-4577-4160-9502-097e7e780f15": {"doc_hash": "f1d78af87a0e18975392e9ff5e92c65484530480f67760ab928e5d68a43a0032"}, "f7f7af08-1552-482d-b735-e1a3ce67bf28": {"doc_hash": "b9072a06cc43f0eb752a9fe8e9b39f2d3dfb7f4c2abf03a2ac634bf6fa83dfd0"}, "69a32055-d30f-4946-a47f-14a264f19eee": {"doc_hash": "dfc629e66f477b7c794f00e582d417cfd6bb8e369dbc7e9ecdbb66e8222cf41c"}, "acf7146f-75e4-47fa-acf2-3fe31fd6fe4d": {"doc_hash": "42759cc2876e960ecafd7e4c5475c258b111caefd38038fb4c13c7796dc47930"}, "5cdb6e55-b772-44b5-9f33-ba9307e9583d": {"doc_hash": "bb1abf5fba81a6bf4a3a2b1e4cdcce185c49e5ad59d0349fe51f638f6f39caa2"}, "4725e493-7f03-4188-9bcb-5e3ca2762b24": {"doc_hash": "9b7c0c2b664fbb13e978faa8a8f422b7314a16295158af9a7954a0cdaf1ff0fe"}, "ab2c3c79-d20e-4657-b26d-e36edc75c654": {"doc_hash": "d793db3bdbf8d8e715b2e33055489226e77b457dee3cdca629f0f1c8b46c4c30"}, "e7043aa8-4ada-463f-aea8-364ad491fcac": {"doc_hash": "f0d12c25732ed5698235ac1a97706c0416dce143804960459ce40a3ce4d55e5e"}, "ba4d27fb-10a6-49ef-8b51-6b27c61b80fe": {"doc_hash": "24893caec51284b9334139afd060cd494afe01762ed6fa16e90c8d89be74e180"}, "e55f865f-8e11-4f7e-b4db-59f0aa92da85": {"doc_hash": "f8e55b6c88dfeaf980a10b60dbf676055f0346a0ef9afa8ba6afb22218d618fb"}, "5ede3ff9-e7f4-4745-ad15-3ee087bfbdc1": {"doc_hash": "68b72d0b7b94670355f29b004f31645e0aac3a70e40f00a937c96f4285e7bf68"}, "5a22b1aa-b859-485d-bdb5-6bc47d2804fa": {"doc_hash": "4f4de71634a68ac1ce61f6f095b946f38016e966fbf3c21d3d5ec3c3b556243b"}, "24dab8f4-7064-41ee-80c1-6bd7cc23c3fd": {"doc_hash": "77c3f5614edea36f547606a5d12d5103d18e81863212678bfe42fadc36929e50"}, "0c73d0f3-876a-4b87-a42e-9c8d1b560bee": {"doc_hash": "b96f0f1e0b8a0c0a48001c60e736c8e344d6aed59d53ee338b43a1f1c5dde461"}, "3583205d-5450-4b31-8a49-4c0b5cb65b14": {"doc_hash": "e0ec4cc3a74e8f4bd7a9d020df1ab9d117d06e085eb4bdf000a0128645e66ab5"}, "39b31029-8c1c-4ada-a102-2d7631aa8471": {"doc_hash": "dd2a63809c1a1ad7a222ef24aaacab3ecce30e52ad48aba9e9aa6199ef63e212"}, "5cb561e4-ec01-4b82-a21b-9dcec146fa1d": {"doc_hash": "aeec1b4f9da2a8a266ed4377823f0aa664b3dcf6ebd05b41ecbcb0a52a26057b"}, "07286f3f-8e8b-4733-ae7d-b70ea7f4d0e4": {"doc_hash": "ebc8b38bb28ee7a8f9c48fd4538429bbe565c4aa78b5c67e88127b12682da0dc"}, "94a1ea6c-87e6-49d5-ae67-3e19b07ce9fa": {"doc_hash": "5c983d4150a73b7cf143d1c07aaa625f123e0727a04caa6feb45586def0d0398"}, "2609894b-b9b0-4655-8497-aa10c4708dd8": {"doc_hash": "f3e8a57340f4051d254d5680f4b8b9015f8f506bb35ed653635c0deaed677e66"}, "3b0b1a52-c981-4627-9a14-15d7cadbbcd2": {"doc_hash": "fb479cb1d362be018c31c730212687c9ec38737e7fbce9b0ac31b41b95cdce85"}, "60eb08b1-d2ac-4cb7-a94c-d177c8c958c5": {"doc_hash": "b06744f639c2df9219e0673890da560d2f1528326ce90b71ef1957a510993ea2"}, "df3c0f07-6a28-4edc-8094-cd7814cbb23c": {"doc_hash": "f8150989de0d5a70a3f7bd0a22f6201bb877a8c36fdfca9ab381e13b028f2e20"}, "26f4e3b4-6fa4-4365-9e8b-a0ea729102a3": {"doc_hash": "d27844384061e827c012de5c58b86022b891e9b8a923f59840942665bb0ff62a"}, "df2a3492-1771-460d-9f63-fa6cf8014eec": {"doc_hash": "60571da3db9ceb7953dc1523926c037a4e97ac5d2184c565889571f19026b8eb"}, "0b452979-6d92-483c-9c4a-e658f7f7c57e": {"doc_hash": "7a16cf3cc2c3cf61f6fa8029d74dd93d180e2b0f4692bb8ee8a88f154fbbe3ed"}, "81308c8a-2f9d-435a-8e09-775896c8e395": {"doc_hash": "ee81a4018a4780266cc90facdb023e94c862d8fd92eff3c4aea8dd0531c377e1"}, "1a5972b4-cd29-429f-a8ec-6b2ab6beb073": {"doc_hash": "51b13133ea9f64520df2d8ce83ad33e1084e93f39b1e42a8bf7a727cc3e8970a"}, "66e468b7-4c21-40d2-a900-0ee735401d7b": {"doc_hash": "c10794d9e97cc4f0696ce8778f63501ea5fbeca65e4fa96a11a9087294a458bc"}, "0e0cb180-f887-4458-bed6-35464a266f7d": {"doc_hash": "32cf77a8997a8fd3b425a9e96173aacc08f1d47567edf2e842e03ef45813faa9"}, "6cef2fb0-b427-4e6f-a6e6-14933765b29c": {"doc_hash": "84a0dc01c27bf5fc495f0f45ac34880e22edbcf7e5c0e99b6e4d9bd50a69dc9e"}, "01cb1b4c-cc47-4f16-bf45-7b5a6447f76f": {"doc_hash": "5103f73893757a1774fec31b960c4c2af2974e979c273a42da6ec19568a5ead8"}, "3c430dd1-ed89-4dc1-8514-f8865fbbecb4": {"doc_hash": "586926c7f0998b016d8d858c3ce54235056cf1dc81097bb6b5167ff07356bf72"}, "cff80025-df10-49be-9301-6b2836922236": {"doc_hash": "e58228ea1fac30da91d145d2a952351be42527972d4e9f32bd2407d50b516360"}, "749cd542-5c14-4707-b708-2d5f5ae288ab": {"doc_hash": "e5bf9bb3c8e4f4fcc6f6933ffae53d2c7187261c1eabb26b8f12749a6048f8a3"}, "bdde8bcf-c9c4-42a0-936a-d8cc8ec932e8": {"doc_hash": "6cc3ea426a05c04151f3871b2a52b40364cab9c4ee5ba789791ffd67083d4d55"}, "336abce8-ec2c-4360-a948-5e01dd0d7783": {"doc_hash": "5941607df7694b294118d43d3be44ae4c71eee1e67f4a3d8a401add97641cdb5"}, "384768ff-e2aa-40ca-912f-5b6416124c3a": {"doc_hash": "dee8decf6f0d7b20bb20210651f643523d1b04ea5ab51fdfbead69aeb9bddd84"}, "776d0b00-5b8a-4b45-b458-ef32f5193812": {"doc_hash": "c532d623ad6afb76f5251804b368d58299560f1ce94655a95b5f1be1ad20eaa2"}, "b4c149af-53d6-4255-9210-7d4d7357e3c2": {"doc_hash": "b71c6f327b4ca6fe5644334ef25aa932f5d2a1a04b2b321d83b259f29de2fd64"}, "462d23ff-7436-4a2c-ade2-41f55927ca03": {"doc_hash": "97f1e5f704be4eee24ae333b87bd74e36a69869f4673f73837dd1b438503b957"}, "414ecf77-57d4-413a-94ae-750508e5ed94": {"doc_hash": "d26aba8762b31362a12c8f59e7682f3eb03daf502e0470eb00dea1a60c209c68"}, "4171b3ff-2964-4db9-8628-002c92bce3b9": {"doc_hash": "3902ae7a7307a0f51aa204c6fe89dbf4c8f25878bc3fb297bcfd07c98f4bfff0"}, "af5f1c45-7c22-4c70-99a6-98d8cb2721bd": {"doc_hash": "f365d5f79f2c1e926fcae2f52efd3b99818b5a8e6f8c085d04766ea088175bd2"}, "2a48de98-0286-414d-a6db-3aee15c99be6": {"doc_hash": "09c68b04858cd3c1f9c6caa730431addf7e46d39090d543e74fc3802f9c32d0b"}, "3a8df7df-0ae3-4bfd-ac1d-42ba092c7d6b": {"doc_hash": "5288d8602834d1ecf55e72bb312248df106ff1d2df950348fb5702ceebc8193b"}, "ec850558-5fe6-48b8-b194-602252973974": {"doc_hash": "53cb4a9ec7e8c1eecf8768103d7c01b7c311e353ac2fe519f9985fd470cff3bc"}, "24a41545-a3fc-4622-a3bb-c00df3d5db67": {"doc_hash": "e8fc83ac2ad82677b11cb4613efdbd2b8ceca4072edb37f97155ea520a2a519f"}, "37d01a7f-8a52-4362-8b82-9c0def403bb2": {"doc_hash": "52372f4d820d92df1d19a5080bb8c4840413760ab34c9724f81d2fe4230270e2"}, "9ecb09c7-a8ae-4ede-bd71-ba6c1bed02a2": {"doc_hash": "17198ac5f239d40e4f9d3c038ae68705bd65315d3cc4ef41cee15db7e9830d34"}, "5dfdd7d6-b8aa-40f0-9540-53005d5051f8": {"doc_hash": "e710b25d5b5454a7cd2dc4a72c339fc1e1f703ea08437b4cede4d039b1168dc6"}, "ca0cbef1-2f62-4bd2-b5cd-e1c8567310c1": {"doc_hash": "9cc44d18ebe796b136889c2e598d2394ae94a23bb8cfada6792a434a0cebfaef"}, "ecede01a-446b-4293-b61c-d048af2c319f": {"doc_hash": "64ec383759adf12b7206cf43527f1caeaf3dc70ce800834fcc9d72cb76f4765f"}, "f3d745c2-a69c-4c86-b0fa-d7b548f01c3e": {"doc_hash": "6ebb28facbb788e9ceb951419d013f930a221bc53280090e4b288af25012dc90"}, "60bc563b-5de0-4d8f-9706-3cd073d7e0b2": {"doc_hash": "b6f591966d7cbe3c8b00bb6e8e05cb1193e69477f83fadc823ee4493f6b8a82b"}, "ce8a2086-3000-4a51-bb7b-29520c7f2ba4": {"doc_hash": "872ff7ac39936528c40290eabeadbbead51d8f93392733b686d6eedac1e123b5"}, "40876388-91ee-4964-a5bf-131db01c4e0f": {"doc_hash": "831cef305f57543741bad238d22de900cde4a636ca585bc0bad6d4e7693da81a"}, "fe42144d-77fe-4521-b31e-f0823544694b": {"doc_hash": "3ca47e7c03c7d67cb188e1ad943fe9dbccdb0a350bd45b9ae09e86b74133711b"}, "4f2454e1-59fb-4793-8932-fb2a993618a6": {"doc_hash": "4faddd1708707537999b52f41f823f593de2f6aca877e222bf2ba04cd0052db6"}, "b0974ac5-8ae1-4b2f-8a9c-69f0b6eac6e6": {"doc_hash": "ae4a7706e20151fbe14c3c37ce8e58497e0f41e83da0c3dbc2fac95d4d995cff"}, "226b529d-4b0b-49fa-a8b2-7064d3b5cbea": {"doc_hash": "f97023581a23d4570bee46d2c57dec570a09aa8df4bf45af45b351cb5e0051e6"}, "e6e5ddac-d620-4627-93ec-5337445784c2": {"doc_hash": "9243e0544449bc6d5fdd41e528b065a058bd50a22f9d679ebe2b1bf3834741ad"}, "232f29bc-c4a0-42ff-96a1-a90352605f5d": {"doc_hash": "7bfcbbc3f5a3ff0ae52f6b499ef2dde4efb2fc34edad96569cb12920243f9922"}, "b51c56fc-0a71-49e6-a1b7-10a32cebd706": {"doc_hash": "5e0769f500009d63deb2be747b906a5739e958feb4a3cc3075c819aa429532d5"}, "98ff0b8f-129c-47e3-b55c-809f905860e4": {"doc_hash": "2579680557a62cb562075ad9c14091ea02cad2d9b307912d1b669075ca8fdc42"}, "b5f65755-5547-45ee-b105-565be28f523f": {"doc_hash": "c7109b8c8c656b83c7d3d6c006c59fe776ae89dd8f9d82c939e0463a117067e7"}, "42ea1e25-cf2f-43a3-9337-11dc472a014e": {"doc_hash": "3d16620256ca28cec4e4e57c9108ed43a3123502da73589c7d641ddd5823bb9f"}, "18d36f4d-ca74-4901-9067-94bbd0efe45d": {"doc_hash": "a47cc75861908b7e421874700d0513e30fec6839eca3054d481f70029fd9315a"}, "d6e934d2-8c37-42a4-8778-736efd10fde4": {"doc_hash": "7125ae6f7b6764ae917df0a3bb2963371ae9459dc8658dcae8ea0d5d9789dc34"}, "96dff55e-3917-43d3-b8ab-99863b131ce6": {"doc_hash": "c2ac0e2626fb83f0f2e6e3e015592b09815eaddf8ae4b07b4650e62c17343953"}, "257468ea-ae7d-4161-ae66-83ce63718261": {"doc_hash": "8f8b1115864e7bf4d931f054d9a8d33bbb0136a4ddc680a52829a0f9b6c44415"}, "44fe6449-503d-400a-8f3d-3f275a100420": {"doc_hash": "899cb8ad8910cdbab3ed79a90b3685b26f8c379ae2850cadab851696d49c7513"}, "e2333efd-72b0-4095-8c0e-3b3fbe4692f7": {"doc_hash": "0eb23c61c195267a7ec40dc5fdba90797e24287895f7b395a4aaf2070ba931c9"}, "f3eabe6d-d169-4594-aef9-7f543d5556cd": {"doc_hash": "24c5b15776826280e4e237b9adb078219cb403528fffddd85b3a442b99e83c8a"}, "8c102189-e2eb-49dc-8454-45d03575fe84": {"doc_hash": "071abb3639ac7813f0fc9ed3e89a0e7c1286bc762cec4436ffa98193e7fe22eb"}, "4bf88be7-80ae-40c3-a395-bda7db450141": {"doc_hash": "091efd93d5452740028791eaedd350261991ea04076882556319316ea68e8d26"}, "3ff72645-dcc6-4428-9488-3871755a0762": {"doc_hash": "09ab3bacd48b5c5ff596fe45b275dfb08d93de42f9625a020d659310a76bbb68"}, "48a6d3cc-7119-4a71-96db-5735901c03c8": {"doc_hash": "0debbafd1915553754babe49277c26bbbacc73a675bbd91f7a3fc38107d77863"}, "4f5d46cb-c9d7-4864-a33c-6727843ac3bc": {"doc_hash": "71034fc4cb806ddf3234cedbbae0646223d7e0250d18f72d5ce4487d7378d9ba"}, "69063419-5029-4d09-8ddf-9562e50ffc45": {"doc_hash": "05958e6e31826b4a14b1a7250feb0f0def7cad7a7543b6931964f5e3b4e40dca"}, "6dc4e23e-5da1-48c8-83b1-bd800489482c": {"doc_hash": "b6dff4f80d5987f44de13be228dc472b2ff68b3b3e4c1152e1ddbca589942514"}, "a2d448fd-f3cc-4816-88fd-5053e26d4105": {"doc_hash": "171ae65bbe665b935d9645a4363068e95b16642cd26817e84967df90a80a2bc4"}, "12c79bfb-e559-47f6-9f99-2cf62da9e53a": {"doc_hash": "f42f60b206daab6e142700f9eda787118221e7411c2499523d7e4a299a2cabbc"}, "e126ca03-2a60-4321-b541-e649a37ccd4f": {"doc_hash": "7f680019db829cf1c7773ea82e927a2cbb1446a9c13371be7f13b1ab4c9a2f4a"}, "b0cfcc2b-ec77-4807-a009-1c1173cbab3e": {"doc_hash": "56bd2efa2d7eaf0c984bafccf0c6d81105a8565c3becb0dafa3c8c8917f8cc93"}, "45009599-a8bc-43fb-9a55-6d5aa5c7c19f": {"doc_hash": "d34e537714e8163696682fb185af575ae2ab8c54189ccaa9cff18c46b53c1192"}, "a39e3f8e-443e-44f1-a80b-3aed7b618597": {"doc_hash": "f5ad1834936ac4747e122e5b426511cb4b59592eea089f051b3c769e5baf6013"}, "e4572bba-8711-43b1-9198-cd474de46866": {"doc_hash": "38b8c353f6b635ce39afb274829d3e2fc76cf2a18da61e6a5b7dee3bc5c36f88"}, "65dfb233-3dcf-4356-a908-41ef6a66f5d0": {"doc_hash": "04c25104eef5bbac9194c99864f9c7a59b5cd91960dbb38d11f02c9799ceec7c"}, "e1164e5b-3b62-4f61-b926-a034caa7dfea": {"doc_hash": "90acf9d30a8881223e496375d7350e028052c00b74c3786deff45b6a6172729d"}, "35c0bffb-7b02-40b7-bfad-f8b7d9bea40c": {"doc_hash": "b41a6d232110177f288f083b0d60b2f6fab2fc8ec5228bd6d0e7136d64f9cebf"}, "22ffd56f-6035-44b6-9570-e26b64f2ce7b": {"doc_hash": "b95e3f17a4bd3f060cd9fcd613bc679cc40799e711b46d26af216ac190d11b6c"}, "a1d7a51a-d6c8-4a1c-ad13-c1ca3d0f03de": {"doc_hash": "67eada0fe5b94b3421669e3084ac36a3fccda390328de4fac5a6815cdc752501"}, "fc8d5073-29ee-477a-b1f4-7e30307ba454": {"doc_hash": "5ef12117dc2b31163b6896068bac0bbef8f4550f4c35252c6a8b71b36dfff619"}, "a8ef26c0-cde7-48ba-ab31-90be94e7cdd9": {"doc_hash": "2fca61db99a56a79a377e625809de73c2e63fb465cb608294b7ada2b7776a3e6"}, "9b5c4d08-b6e0-4ac2-87e7-29e2923c2a2d": {"doc_hash": "58fcb8927f678e15bf03e9c71328c53ff02729825b56016881cec50527ed2d52"}, "e11fd00a-4766-4334-9313-c1f86c914a00": {"doc_hash": "02ac1ec6a4e6fb79132b63db5645b7c62a69dda6001887469b78def09b15e92f"}, "7862bc3b-0436-4254-912e-5673e6133f39": {"doc_hash": "461755b32edbe221c36c8bb86d969dca9fa2bb8121bc3bc587aae8b2c8b61946"}, "90e68fd0-c37f-401a-835b-c203f5995f0e": {"doc_hash": "88741a892bf7c143adfd1d30e97719191a6faf424b0c6e37c5d162e893dde299"}, "21899607-b365-48d9-a6e7-931bda1a421e": {"doc_hash": "a63f3b4349134c97c0b26d0b37a19f2d962339f9e8fcf09f8080da6ad3854742"}, "cda036b4-0f2a-4fdc-836b-152edc0f19b7": {"doc_hash": "b146119393c744a213d4c8c09da55a4a425d73e8965a7bf7b1bef88c2db1d86d"}, "1e830ae7-5d66-4a7a-a47e-997f5ec4b79b": {"doc_hash": "60d14c46dc1dff225542f898f61b5810cd95eb0bd4c54a3f953e60f350329639"}, "34624f91-2ffa-4889-bdad-8284ef515811": {"doc_hash": "8f26cebb78ec9605fb42a05eea9596526d4edace8cf442582dcccf5b5c07d7f5"}, "9e697894-019c-4e06-9ff9-0e80c4b9d417": {"doc_hash": "b55a2d28b49662aa4785bebea4176c28220ded792fd3806a2f23736e60c1d5ca"}, "7b75a06d-207d-472e-a794-2d40ee948c06": {"doc_hash": "68174e1296d429ebed6130e1d0994716422dc50064357fcc42595d6c26afcf24"}, "3065eb16-5ab7-4da7-a614-33579b5501fe": {"doc_hash": "4bfd13253e9abc48e5724124df10804c5b00ea9178aee403a861ba9e3fdaf0f2"}, "b6519bd7-7c9e-4148-91d7-af69cf468b3d": {"doc_hash": "e2b3a66ea2eb342d53f2f94aa3c7a926fd815e91e4598a5d83706489ff4ba2a0"}, "c5b244f0-5ec1-4f82-9772-fe331a5e41f9": {"doc_hash": "07c403cbe0ddb900f7413e4fc00837ab60bd49ac244f2861588e158ce4c2302c"}, "677d206f-470b-4c7e-9c04-a9c0584bf4bf": {"doc_hash": "0231209d4479089131a022df86a2ab8a91058fadaa9a47a99a667cf99baf42b4"}, "1e0cabdf-3fdc-473c-b71f-ea6800595025": {"doc_hash": "76a725d20a102e1c62bdc05d6dc3d332073d90788d477b5d2fefa9204b739e3d"}, "b1997818-dff9-4017-acf7-faf2bbc1a2d7": {"doc_hash": "ab703c86f8ffc12d187f0601516c26f7b8a702ebad85b5121895da966849b2dd"}, "ee2a612c-1ae1-4b1d-b2c0-593ba514712a": {"doc_hash": "1bcc1a8b95d65c755090a5a3eec59d06e2723b284f93a74a6bc133a76cc8c546"}, "b6831d47-f333-4b52-b989-8fc3ae399f32": {"doc_hash": "e63f4c882ab19bad18efc360fedbcf7cbe11ef502c3843e9d087ea8c3e73c126"}, "1531f16e-236c-4df4-975c-cb4a1f276cae": {"doc_hash": "58fa7d4e5be4d5863bd7b15919c28f3a13e6a9c849211dea608960e24a2f266a"}, "993d37fa-eda9-45fb-94c8-3ee57f9751b6": {"doc_hash": "ee55b778509ad531de6071d5f6fe1405a5e62badde4080bf053bf956c051b351"}, "2cbb2d3f-68c3-49b4-8d01-f9855a055f46": {"doc_hash": "4b79920179467f52f4c6414a99af48a3dc606b543506a99ab7e88481ec5d1b53"}, "dfc67de1-e93d-4d04-9d1e-0d48266d789e": {"doc_hash": "6ee3196ebfc244ccdd260223377e93c27f20b591a4126f90cc2242bcffd14eaf"}, "ee1b9385-b668-4dcd-9855-43babf162488": {"doc_hash": "b9617ea05bd6e981e2a0c47c600225c26518873be80655e5303a5f273431db84"}, "a21c61ba-76cd-4646-83af-d52ec3cdc4af": {"doc_hash": "28989e524137fa28afe213859ed56db5da73396dbe014e3d8583fbc1562faaf9"}, "d0caeda5-7dc1-4f76-a910-0734bd5ca345": {"doc_hash": "3444f3a7d730e424ee36f5b9b81848845b6ec13c8686b80e2474eb78faa3fd50"}, "09a4c596-e330-4b3e-87db-31583e9b1ff3": {"doc_hash": "3134b12c09bc34717cbfa08d523e39ce0cc56a0473da428566223c8439b0d0ee"}, "9596f487-e87b-4e2a-ac93-31e50ea1b7c8": {"doc_hash": "729515d0881f7ac58d95257a30ef531c7f42c242d6255141569e95caa717a41a"}, "9be01ad9-3ff4-44be-aef2-dd4c7ce9f8da": {"doc_hash": "254a0b4aaa6a91a88cc2d28676a3964e082b28e766781e24d9f3f73568ea460c"}, "15795960-3957-4a62-b842-d68025b9b0f7": {"doc_hash": "0b91ebd23e5d566ffb0d98b1ae46ef5c9de1944154741bb2f9634e5b571bcb5b"}, "a483d805-ae51-4d4f-851e-f43b7694a986": {"doc_hash": "73c167d6ea64010ea35314290624882b6afe01c1bd9f57250366fb082984ce10"}, "2f301f63-42ba-48ff-b518-3a4b0331239f": {"doc_hash": "6112d289e9499e3440ecd3fa5d54c538209140f65157795c93da8c1aff3821c8"}, "a9f2669b-e1f0-4ed1-82ab-fc2ddc3176a3": {"doc_hash": "07424611e0c6e04e715b3377627995b940e137d2bd9bf349a8eb549efbc0a780"}, "72071ce9-8943-44ef-b0f4-173473900109": {"doc_hash": "f47afe721fb33b63ac0d0bbd6c0e32578a11a131f2423d6ce32048c7e7dcb693"}, "c2d0fa78-51a7-4f25-a286-f37e24004221": {"doc_hash": "be2501210cf0fbc4add2b20dc2c55b20f9e53a18ff56f72349ecae60eb2465b9"}, "463ebedf-6f3a-4a66-9c98-9167ba3904c0": {"doc_hash": "4554ba4b7cd2d964914925fc7452c30dd3b42413541b516251b7d01fc28ba766"}, "37809a6f-b2f5-45db-b29c-9a55ef6e2489": {"doc_hash": "f409c3bdb7b91689b214f63c5ea40586708e2ff0933e3acf420b5d256d9fafca"}, "693eaf89-71c1-4f60-95aa-352de08cc3ad": {"doc_hash": "e7a5afcf0351c061e0de98d6feefd9b1b5547a2f03febe854089b97123eb123c"}, "a635a522-9234-4c38-91b4-01eedb898e5a": {"doc_hash": "434e57efa6c343c3ad6147fb16815c907d893372519322b7945a4d00c30ab2d0"}, "fb0dcbb5-8062-4d93-96e1-513967316679": {"doc_hash": "4604be88ec5203e535bb553afcfe01b42a227e1c3de6d23c2962184c2c02d4a6"}, "daad47a3-2fbe-4a84-8a66-fd8f30d37b22": {"doc_hash": "c3d2efc69222b15820106f74e4b20910a37ce0b6fc511984f65e2104511d4fa1"}, "382dc190-350c-471a-bf5e-29f3d21b4183": {"doc_hash": "9a2b8638a7ba7ffd53eb6ad1814cd5cca6d7987114d5525b2cf27b44d3e802bb"}, "b19860d0-a8b2-4fd8-a497-08317d6b458e": {"doc_hash": "7ac3217da9c03d9e8d702816666e0170632bca0939ada251612a6a923c97eef3"}, "76b417b2-e951-4961-bb01-f9a807cb1fdb": {"doc_hash": "2a3a08e56f0c3d81b1fe6aa7fd570c9a0cf23e0c092b908857e1257cc25d60cb"}, "4603de5a-4ed7-4aca-bff8-efbad600648b": {"doc_hash": "25a9d4ed71ff7a2d5c6d8bf9753714ba66d036a232542bcbb5bedcac2810378b"}, "460b2792-0635-425e-a325-1cfbaabea87c": {"doc_hash": "fc906645e3f5b54a4bc2d2742ddba5611f9a6f655cdbaf5a39a1b570821a8e37"}, "230b0a18-d3d4-4add-ad16-c7d1796f37e1": {"doc_hash": "233718b6baa9bde1b28b0485de3b395b623e6dc17cc4e6c91e6e083317834fde"}, "41859b7c-0fe0-4414-881e-5e1e5dee2e25": {"doc_hash": "790bc96839b5160e1289f7d59a866eb7bc60e03ce6d217abb146fca13a815eed"}, "1c6a9a9d-ffd2-42c1-88cb-6576f7270649": {"doc_hash": "9c1b8f3bda3630f4b86f6088fa6ffe451e0509bbafda40c615920605602560cc"}, "31c2981a-30ed-4cf1-8620-e284f5c1a9f7": {"doc_hash": "c98e16a3a1880c00d9a971bd65c092bebba4ff543b57396dd448abb81a529d65"}, "c725e63d-eb03-45ef-b8dd-2ac5513d0869": {"doc_hash": "f318707125ad37c20dc4ec9e396f811487a59df8b47f257faff32ac98f5ea229"}, "d16ab139-677f-446d-bd7d-c91cb4b4ea09": {"doc_hash": "24b206312102ae5a927b65bb220af138a484ef86622d6db74904c466551f7df0"}, "cc4733cf-c374-4ab9-ac86-2c2d349f460b": {"doc_hash": "80f8e3462741c5ebb304be6f1b7d56c13b5df484567d4bb8d945dcad0f3f540e"}, "3215ecd1-ac16-4bdc-b6ab-67c0522f8f39": {"doc_hash": "13dca6a8be47fe675822876fb2e023aa8af80ba59d1c73f3d596c9c72f012778"}, "d141ff33-267c-419e-be58-effb86936228": {"doc_hash": "ac1a73c518e7b33955a258c805558af1c08c2c00716734dda4f641c7e482d761"}, "5efcbdbe-63d7-474c-933a-f574e37660ee": {"doc_hash": "e910b4fff59e67e2e3a796c642992fd95b59fbd989680caf2e245dc11a8e02f8"}, "4ed5e69b-0198-4c78-8bf1-9259f274f6e9": {"doc_hash": "2048706dd58fb34513489356aedb54f13141a88ffdd637996adff6ea3ac713a8"}, "8fc317ad-54a4-4fb2-81de-b2c218683806": {"doc_hash": "d969aa76be6087a64982bd18ad7600dbc14e21ed155c46e668638450d68779fd"}, "a0f7551e-0226-47d3-8902-27475db55773": {"doc_hash": "707bd56329e3d2109e03552c25c93059272e4671d7ccdcf7cdb0d5653576f133"}, "816dfe9f-d71a-404f-acb2-2e62cc31c9fc": {"doc_hash": "552547722e9f210f34973ef266f8021aeffd4a2f1cf39d93aaf4f15544b9d1f0"}, "47c5846a-8764-4cea-8c73-fe7222394144": {"doc_hash": "4e9e2f1531811041586166453c82b2118a35985f4bf11219a40bfdb63810e219"}, "1c075cc5-b177-466d-9fa4-08b5459bde7d": {"doc_hash": "dea1e9547148de7c0e1796c73959ec16daf58f58ee4a945096250f65d7019c22"}, "543d46f6-df78-4208-a7e2-19eac4abe0a1": {"doc_hash": "39d0e6072a5840b04818278205b101491407157253ca2899ef2c4475fd0cc3ef"}, "c5f27eb3-1472-4f01-b1b7-a9f2c59a6e14": {"doc_hash": "34b86c5e69640547f444e70f1392a72b60abf92b4607add0a6c1b570531120f9"}, "63f6f599-08d0-41f1-aa0b-7853d37680de": {"doc_hash": "5e06f2bea334f13bdc681fcb1494a1773e2bc90a17aed4a6750c6ebfd641abe6"}, "0f2f3811-f208-48a3-a8bd-ee2235511082": {"doc_hash": "65a42f87b43a785273d73eb999ac542885078291ca640544ce03f8f5c8a35172"}, "f903908a-bc35-4bec-abc6-893a7361d491": {"doc_hash": "7513ad48164857dea3bc0c7aa7b06dec4df6c0c64b1b1505596029a5b93229fb"}, "0559c94e-060e-4999-951e-d90b6b4ec9a2": {"doc_hash": "ff7bd90c0f762daceaf87cb8223874574359d5c0cdcaad1f0787f6ea7962adf9"}, "a9a5525c-0cd9-44d3-b2f4-91409f2af742": {"doc_hash": "56301e58c4bdef5e4b09a97579037f315a15e77497ef5018f3d0083974f1601c"}, "1e2056f2-499e-45b5-8779-8eabe6734ecf": {"doc_hash": "4b5fe6eedd897892484041daee1936e8f54d2cc882bc525f5edd7164a9248cec"}, "e878de0e-a3d9-4d63-a971-4cd1b5803615": {"doc_hash": "0ccd6d52858c8a618685abf33f85fd916cc8d46fc329804d59a6555e194c0e22"}, "81669650-a9ba-4971-abe1-0ccebe3dd724": {"doc_hash": "b6946abf763e295c9ccbf3a3face7db0e721b87eb472c67465f0bad3a1b315fc"}, "377c898d-7e9f-4bf1-826e-85fda05e57a2": {"doc_hash": "fb3f37474e54277604d81346b81a37a8973e24f2f151db04256ab5587c0f76c6"}, "c55afdb3-1a01-4b96-b04c-f20047f90e8c": {"doc_hash": "07f4a356ea24973c87a632e12fa1be1bdf7f33f52a90647fe3e5210ad4d6e76b"}, "ba6f5e33-35c8-496a-b13a-1cb45e6e9d26": {"doc_hash": "e610a450bced5ccf55cfa563d45c03153591190ff0f8a60e372781d8696d6cb9"}, "d5ff17a3-c856-4373-a805-fe3005eb7a71": {"doc_hash": "c626386253694e4f2bfffe88c64946218d4ea3eadb59d5e440555a9ee0cbb1dc"}, "dcff5e19-8243-48c8-8fdb-a69f22bce720": {"doc_hash": "a0d2080bd6862146fa4aa4dd40f4e91602910680af587ce334ab5bb58edc3660"}, "cba15e6b-ac48-4d01-92bd-11198429ce24": {"doc_hash": "b2cd5dc7ded7a87dd1930dc5331642aeacea49d4cd94f580e3569cdc64fdd240"}, "47ed7d38-b865-4b68-b694-6fef2ad83a7f": {"doc_hash": "f21d8c187db5eb4a9f197b7c5c1ce491c9af849054e387452041dceb2b0ee513"}, "063b52cb-0999-4696-a03e-954fc0cc234a": {"doc_hash": "83dc4d63e73d9c034e327d81bbfe9e4df87bbef4fe72129bf40bb797f6e1343f"}, "cbaa77d4-c12e-49f0-98ed-265aa167838e": {"doc_hash": "772126c0c4d37784f501ca5f336760c67a898047ad1927f112746886ad414a2a"}, "cb151eb1-aa1a-41c0-b412-c0412a1a4ed9": {"doc_hash": "b92be0f701a1e1675897753d56e72e01cc823b7fcc56f10e7efd3192e02f99c1"}, "79b48b04-8ebd-4436-8714-a18e48155ba4": {"doc_hash": "2b1f1968d15e170078941ce4ab021c79e8de776b75f024dbecaa726c2a2db52c"}, "9d4d3440-2785-4647-9312-c96b2ef9036a": {"doc_hash": "05eded15faf496181767681bcf7b9521c2278631478e9e7fef70123b0da17338"}, "9b9c3b6d-cfaa-40d0-8560-a57ba65fc468": {"doc_hash": "39589dbc9af8d1512520083d9b4f238facb7d0e31008f6c1f5eae918c54be9b2"}, "a54a31d8-ad0e-43a0-ad86-2d27768cb95c": {"doc_hash": "14a396ac44f3a661cb3ff421b2cb6ddab4a3ca36235d7ec548e6aad477faae8b"}, "31298161-4dc4-450a-9497-ba577031a9f0": {"doc_hash": "a8511e002fb339de4d6bb649ef8f4cd6fd96f308064b87a2db2e7477a1a7d548"}, "be33ca8e-f443-4cff-8917-48d588d3090b": {"doc_hash": "8be8631b8e65d438728e2e236792edc05b167808e9843de4fbc9acf209d521fc"}, "ebc0fad6-6550-44d4-b789-a9231f27064c": {"doc_hash": "b57004d802ccb317d618e58091784c137d7121863397bd8c47cfb8ba7ed3847f"}, "7084a685-83d8-4166-aa96-392f356434a5": {"doc_hash": "7fb39d89759a4d00f24c75f04295e3fa7a8c9f15211aa6cb7f6dcbb1b8968551"}, "f1bcfd1c-0e47-46b8-a3f2-c8e297c38e95": {"doc_hash": "f71067d04689e486c8716735cbbc82da6b6695a8c0a2cb4b18a1c22a206c43c7"}, "57fb5e34-7f4e-492a-ba50-00850d2825ed": {"doc_hash": "f3843f85deb3bd1cb4a7667cb9d23befa35b483fa0d94764317afe6a87810bb7"}, "fa9bea77-18b4-4d86-885e-66739e3ab9f8": {"doc_hash": "53703e258dd7c538f431c8deea1c85dd527c02512140d85830d7956885631342"}, "f1afef2e-28ea-4a5c-bf4d-34fa7874eed8": {"doc_hash": "e3aa1d1141f91417755d9b0692de3886c89409faa637bb98998c54ecf5413791"}, "95e7d944-bb77-4e58-a666-6474b8bcf00b": {"doc_hash": "df70882a2347d8f11bf441fc4dd2ada43d47c372dae19d6d014bd4427b4a6568"}, "2f63ee3e-f938-4ea3-bf53-8d3b11cde4a6": {"doc_hash": "e0fcfa6da8dad008fae0d43ee6fa14df29491fc8e1369cda3b31268389c0bd4e"}, "ecefb3dc-9971-446d-ac1b-859dc79a46c8": {"doc_hash": "1d076b715623a820c73ec3710f639caa3345c3e4052cf14dfd838f4fc3206569"}, "3ed2688a-a340-48f7-b8e0-290364f4523e": {"doc_hash": "0a12e0421867097d0b219327bb9fa7dbcd3f8cdadf47b7f6b875d533e167c268"}, "038bf8e0-7cef-4b5c-9eb8-27e6892cd040": {"doc_hash": "4e285f1dafc2603df70cddfaf16cd0f68033e77a617bc94723ae19b9887b4102"}, "a59ea249-c96c-4e51-a549-78207b5a38bf": {"doc_hash": "dfd618d377db11a335a16ae62a360cac3017d9183b5564e6cc8e96cac746135b"}, "66c60223-5c98-4811-8c80-751e492bee12": {"doc_hash": "575664585e0d6c45ba9095381d5b580cb5e79b60143a803281f4608b83e11bf7"}, "5fbaf4a9-bb83-4705-b764-7fa18079d8cb": {"doc_hash": "a8d5e0e0703dc9360115fb4c21d1b87b9208e5ecf7b1db6cfaf5e46a4d1c5d55"}, "70af5338-1745-4bca-aa86-7844d2eec1d4": {"doc_hash": "51024e9ba7c9d09bb7adf8becbad52a055eedbc5df232bb38f00f5f6ad0b223f"}, "7c3ead24-69b6-4d90-8d03-758c13653368": {"doc_hash": "4add8b21deae4e4a6c4819989800a2128244e2dacd4e49f20e97d8b7ef8a4e36"}, "5e2cbb88-6965-4df3-8963-b213aa51d63c": {"doc_hash": "0fcba8ed48f0ae12d2bcb5633b70fa8518f805c19c7637cb4c16071ce8f98484"}, "9505e518-cc79-4165-8303-86dd9d256127": {"doc_hash": "7baec82d760bfb84d3164ea2275601d29865aaf6b140ee4eb20f06379c727e69"}, "92e4c537-733c-4e23-adca-4c8103d9d2e4": {"doc_hash": "d6f09ce442626bc9f3ae8afcfe78c432842048a55d2841db5bda6707d95e9038"}, "c50d516c-91dd-42be-b02f-5891c960b1be": {"doc_hash": "d9a0d252a6de62eea346dc72938cd4e9003031fd9de0cfc73c34dd9659dc2462"}, "cfb83702-5ed4-4e1a-a30b-70165a53212d": {"doc_hash": "8990a534f265746de82af5c077bea21b1edf41841e85dc3db0e3e81c318d2cef"}, "4bfc9a7e-5144-47c7-9fc0-e3fe8c05c137": {"doc_hash": "a1d55b0b9cd18ffa5757ee5f483aa3eb2a2651614b6f06e715252f80b0401eb4"}, "8f1e0af0-532f-410f-a28c-1954f6c7e031": {"doc_hash": "7dfec5b3863bff86dcda62a5ec91abba8423f24d2dfb1a3c0698c8cac0a2bbbd"}, "7407440f-62eb-48b3-9d34-8a6ba12532cb": {"doc_hash": "632d9259386e117f704a65245b474bd809255e8f1d38491ffa6ab7cdf5210fde"}, "c6c39b15-a458-4fe8-8a59-d3b7b79641ef": {"doc_hash": "a10e5bf581bb2499cbe5e1361be778ca285e50c419d01b4ae25841652130921f"}, "1745d44f-99d0-4d3e-b055-92b27e5ecb7d": {"doc_hash": "46b0e8ba0e4c3181c4e048c4f1e7fc5f77ed5c523b13b2fce01c329a4772ef1f"}, "7c8017f2-b028-4e02-83de-fd7ad7e10925": {"doc_hash": "ee953b73c944db50b24d8fe367bdc2e6b4c4772ca14074f14ed7ffa018bee1ae"}, "5db5bced-031e-4adc-bc4d-17634d2ccec5": {"doc_hash": "11cca91ae4c075448850fb69292ff42b5e2068c91c3b7fb51ed7a1aea5faa82b"}, "4bfdd0b3-18b8-405d-84fb-ccfc5f48490b": {"doc_hash": "25bbec73623aaa76845b70cfad0de5b5cee4c166dc5239cccd8d19c05c4bbbb6"}, "5e0f0676-70ca-4f35-bf2a-7471428972f1": {"doc_hash": "0d478f8d29da3042898dbf60d4287f9e65857da2ce1c087c5b00025dcc5b38aa"}, "02c3045e-942e-4fed-9d9a-205bf3708177": {"doc_hash": "3c74330254a1d820985dabcb527216cb2d9e6523c4f47ce04d5917341809fdab"}, "ac22a433-f284-4c89-8527-9c97f81dcabe": {"doc_hash": "d563f56ae41068e65ff5a42fb37ba46fe1e86631c807ebfd85a4e44d401a0b2b"}, "776c361f-2d56-4134-92d6-721b1a74b7bb": {"doc_hash": "53074d04ecf18eeb4662efae4ffe72c442d37dac57b44bf82f98678164232617"}, "bcc9205d-6149-40b2-b74e-ef50462d9f59": {"doc_hash": "d0c7357468198ab11970db85c4a13a79a90ce9b3602145e6ae68ac627638d499"}, "0565530d-301c-45ac-aaa0-44b1d8cdb36a": {"doc_hash": "d744c3fbfd6a92f12e5db5a4c192f524f7e98f4b65c1c840e53668c1fae286ea"}, "90473aca-452d-468f-92dd-bb27d3d4191b": {"doc_hash": "e2f6492fca845a26822431a54ca9eeac7976a6cd00d7b8f1f2958af0ee5bea3c"}, "4d91befa-f6ff-4a94-8f35-8d9d70194f8e": {"doc_hash": "c076e491d9e7d8b5d8672a47a151c15f0d424b84e1f489bb7e2d5058b73f98f0"}, "40811b3b-4b90-44cd-8288-a0e58a632068": {"doc_hash": "0ed87e30e093f7d2db735b4da9021827a4c8369e5960956c2498de553b03e4ca"}, "f18533ec-40f7-4f2e-bb74-f837928f1582": {"doc_hash": "0899c451d3e4fdb6d228191ca30e5031437f8577d6b2d02bec9b06ab1720031c"}, "93bf7c7a-d3c9-4d3f-89dc-36e0225a6131": {"doc_hash": "897139a0abad3b9528e3bc871eaa59090e8d9820346267cc9b51c143dcfcfa30"}, "da28e9b1-4c67-4b7d-a3b7-02c716f15884": {"doc_hash": "3c701b228971c8737843f7d44b09f8625730c9837d02d8d24ba725765a1f6d1b"}, "ae4a396c-fd92-497c-b2ce-50ceba4cd2ca": {"doc_hash": "fc6bf8509971c46cff29c30fa69704247e3cc185f4ce2c4d5d50a22a92cf7ebd"}, "f0175172-52d1-4e1f-b9ce-3653697804d2": {"doc_hash": "9eeea49d9e91dfa2c58dbb8f63776eb66d391aa676460bab96f464b64b0fbd03"}, "6fc42ca3-9179-403d-adc1-34d1a2cac95d": {"doc_hash": "3d72f9dafcfce14970e113c9f3d1a3813a852e7078d89aaf3a8482f635957440"}, "a28ba738-07a6-4228-a914-c5333d4b10d1": {"doc_hash": "60a4cc61d1a860402afd1e11ca7b47a00a347ab9357761624ae5cbf64c739961"}, "a465c11b-032f-4d8a-84e6-475f5e026c12": {"doc_hash": "442804c8ed22224524abadee7e197aced090ee64815dbde449601fff4241613d"}, "66bfe2ad-b7c3-4a94-b565-31f95ccda9ae": {"doc_hash": "98d2207458764b3143163eef478c03aeda5790cbc6ad761802694514cb4a6ee9"}, "4f410207-d907-4f28-b2b3-10f9973edbae": {"doc_hash": "f9ad5753de66af7171a87f3839b769e5c6ab4a01a6ac2614fe929e56366777ed"}, "970fdd93-4f95-465e-b78f-23f9a42f749f": {"doc_hash": "772d3bc56acc1f54e293cbebfaddb84002f6b02c0b0bb30a714a8a64b54ca0fb"}, "e373ec7a-cf77-4dbe-8ac0-87e1def9cb7e": {"doc_hash": "2f5b5ee36a9b76eda21b4e1a1305d4e633c43ce0b06922327d0cabcdd0b9f7b9"}, "7463f9c0-325e-47b9-a5de-fc6dd92946bd": {"doc_hash": "de1ad28a33d541a01f4c0ab797f622e3edbf023ce08b52e2240a64745cd0373f"}, "0c863ddf-b040-489b-907e-1b3cabea62e7": {"doc_hash": "af552d9e792e4f16f2c2507ec6d7a729395a9547322ef9d23227ed80058c99a8"}, "134da570-79fa-4e90-8ac6-1fc22abbd5bb": {"doc_hash": "ed3c809c92ec0b5437d67743bbe39961f8d39e5967abbcb83b33a77b236b5994"}, "5daeb425-4a9f-4bd8-9174-758c37177f13": {"doc_hash": "36c9530a07b8c0f04eb24c245a4405cacad3552ec6acf60ba14e14dde1643297"}, "47277464-fb86-42b1-a160-a0cf8235ec95": {"doc_hash": "356b0f60650ce90192222fe8dabc845fdb056fa785099269e7ac1fcfc8aceb23"}, "9fef27f8-1a57-4fa2-bd44-289942713981": {"doc_hash": "17d816d449d5de47b76ee1a49469af36676f8e8da4cde83b731602d5d541f6f0"}, "95cf5097-407a-4607-96d5-e471e34174fb": {"doc_hash": "3db2cf027c722413b3200f2964d6858cf1a5b85566fbc5a0914bc92fcece5af5"}, "fb4b34d3-279e-4b6a-916e-e2c1ae1676c9": {"doc_hash": "157bbb6080c315366196f1a4da4bdc4196146f6a83016e288dd29afcf309ce14"}, "a61514eb-9daf-49b6-90fb-58e4585e5e36": {"doc_hash": "6bc151ca046ad8ccafd16855f09b6b46255f715f8cb856a7688e516a351b8979"}, "75f9b52e-83bb-4c03-a327-a65faf58304b": {"doc_hash": "915138058ae45c5744b2a84f257a09ffd3206bc3a7a9685acbcd152d0dc1cb4c"}, "4335e411-a543-41c2-bf42-364a8c482cf8": {"doc_hash": "7bd07f1086ecf855592d70eb751e695882d8fa0610712eeb7e1c2e441f76dae6"}, "d815c595-b5d1-4918-94da-e8f92bf2d95b": {"doc_hash": "fc64e9ed99b30d56c13d796bcef96b7a2e7dd27d19649fe87713c2f05bc6b099"}, "31ba72e0-0cb9-45fb-bdf8-37d3661d7afe": {"doc_hash": "68ac1b36385193eed3f8bb9f999a78ebce82e2fb79ff8b5949993a9319a600c6"}, "9e1c853b-10c6-4a43-892a-404777e6f766": {"doc_hash": "c052ba1f16504a41f35822ee942fed2c232233710406bd62188b26ffb3f69e96"}, "6654c66c-1993-47ff-9a43-d03f063dd893": {"doc_hash": "d44497bcda5f16d86836ca65959df35bdd9692b8babd4287cc1ffd93dca7c92c"}, "85d680ec-46d5-4908-bee2-5b642800c54a": {"doc_hash": "180a6426cdad69fc04af4ed92fb40efb3ea6ffb99616ca1ee6e3674ce0170e7c"}, "01591232-3e55-487b-819e-5433b570998f": {"doc_hash": "a4e50d66415fd12403d7817d796efd6fbd0369ca80c2e90c261402f94fa33250"}, "7c461718-0a2c-4d28-a6c2-54cddbbe36fa": {"doc_hash": "954f5e179191ede242cc6fc3fd5a97e982bd6c939806918f275ec4923a18afd6"}, "a6176669-729e-43df-9c4d-3e9938a9d8b2": {"doc_hash": "7055025b7e69fa2703a7c9a024886571b141e41f54f30815848119b35970aaf9"}, "0766d2d3-fc00-416f-bd84-d51be4430048": {"doc_hash": "d6587ca452c15ee5e10e60aa96435645dfc9114cda7141f58715264c3d14528a"}, "66cd6f43-e0e2-4e31-91a3-6af0685ad24e": {"doc_hash": "ae7f1b1bf2b4a2bfddef01d387c358b5cc4ef3130a6e46d02e94b0fca9d030e8"}, "febd6f07-4102-4322-a244-85c462a8074e": {"doc_hash": "135cf1e0628eae010d42b703f67cfed2fc7c75232f9150e47113fb7bad58d4d8"}, "d309e2b0-159c-4762-811e-5dc5f466c4a4": {"doc_hash": "fab5f5dcde0394deeb7797887bce5e1e9c0efb2be054a6389104ee9a6f11251b", "ref_doc_id": "4536c7a5-f8a1-49c6-a684-2bc5c5c8b362"}, "7b470071-5400-423e-bb72-46aafe894580": {"doc_hash": "de4c7fd47df9a7151c93ba1c4f157ff77ac3e444ce449dee97413d708caf238a", "ref_doc_id": "b8e0fd88-9c5c-4bee-8d5f-34c7cfddf61b"}, "5bf2afcc-9668-499c-a8c4-3425fb05394b": {"doc_hash": "0d7146c4ec75c1d31b8bd3c55675705aedd85c434febe8aeeb958f9b15768f8e", "ref_doc_id": "dcb8d134-6b29-4205-9f66-2571af10521a"}, "4e4d811d-b2e0-43ad-8e12-5f28d42c3a10": {"doc_hash": "3e5a3136b76227151a439aa0d3074edcfbc14d904542602f38d94391c1fe6232", "ref_doc_id": "44e6b813-b597-4855-8c73-abd185bdc9ab"}, "6f5993d5-50dc-4fad-a6d3-6b599a2d3ae1": {"doc_hash": "f5c41f14108cb3f3968235476b9e80b401250eb7394c618bc51280f94c73d943", "ref_doc_id": "090f6cbd-7594-4c59-ab80-cdfa9103caf3"}, "aa3ef838-0ecc-4ef0-858a-0978e528c581": {"doc_hash": "ec18919b143c2d95b466e45e61b4d8b9afbc624e2fd20babb89c59d3419cc7a7", "ref_doc_id": "4828d225-5d1f-4e35-b4fd-717e3351c219"}, "9127f353-b2b0-4728-a732-0de7296c043e": {"doc_hash": "f180f1e8922c2641423ac268a3a59fd38981a6487ba6894409c2a063da0597f7", "ref_doc_id": "7078060a-ea3a-4282-9c23-db78c9d21dff"}, "54a534e1-3c1c-466c-90da-a09a3870ebd9": {"doc_hash": "0be49e3dfc8397ae20b444c53f849c294b1ab2c54b054a0440ac6d0effb3aeab", "ref_doc_id": "1484d1dd-5f29-4f11-927c-a575f7810445"}, "c3b5ee34-c8dc-465c-b9df-b4711eaa07fb": {"doc_hash": "930bca57faca3cf2628c570024734022bd9136724b6d2b950c61774dcf4af960", "ref_doc_id": "1c2ffb2b-2ff1-4786-8c1e-6a2206ee767b"}, "7f8a6a0b-f398-400d-83c1-7f638c5ea1ed": {"doc_hash": "e81217dd37c5d9e743190c3eb4f9d5447886850aca7c0f6ca5f79eb069657b16", "ref_doc_id": "37543027-c634-4a4f-91cc-dfdaff6de13a"}, "9bb4d2df-62b3-4dda-b8e3-4eac95e186d6": {"doc_hash": "49d7a88a2652517f6ddc29bbb75bab2bdbc33ff171a725c0e0c9703c6675c26c", "ref_doc_id": "f7ba0b1a-e60e-4015-b8de-4b4ff07d3b44"}, "0e7c5f44-aeb1-423b-b605-3fc02cf668e9": {"doc_hash": "618b8a90c26868a5d13701e4a43600775d135ff5d7d81ec16e0d9a379171d492", "ref_doc_id": "16f976f9-6952-4ce8-b03b-fcb350f08f01"}, "81a30b8e-c842-4830-8055-cb1d206eb2f1": {"doc_hash": "9ab750afdf4297843fc9ffa65017845fa06b868b080a5f8ac74932326628128d", "ref_doc_id": "5dd7398c-23f1-4e80-92e9-da81baaa2f7f"}, "638c9691-c4ca-4365-a7de-942ffb3c8c1b": {"doc_hash": "b68803a320a49ed5e6ad6dd9fbec0a305f570af15f6293ade15e6689aa4be490", "ref_doc_id": "2fad2dca-54a6-4c85-b947-124bf62f5a6d"}, "2d88d7ca-4e2a-432a-9583-e8fd6c76fabf": {"doc_hash": "c23260cfb460a168adc9bb4f6c268b43086d46a19ca3135ccb3183612aeaf3a3", "ref_doc_id": "24880012-18f6-456d-af2b-076a33f5067c"}, "5944387b-7d5c-43c7-8959-a83970997ecb": {"doc_hash": "a4448682bed82c05fde02d9121a100e28f3fb8145bf522e669854e38714d68e0", "ref_doc_id": "63719f8c-6ce3-4d45-b06a-14e0f1334343"}, "9dbfdb02-df96-4cad-a69d-3cedcbdb99df": {"doc_hash": "115b3cb7957719d77aa2c62f63d67aae220251943c0c8951b3e4f711d0232bbf", "ref_doc_id": "d68c272e-e910-4430-bd9d-5a33c35064fe"}, "f7fe4a39-6a00-414f-b7f6-826a11a87b72": {"doc_hash": "5e1660402d89589e0d4bcc62a2ad33469c2c933bd820fcf439f256882812eefb", "ref_doc_id": "1a41dd19-ac4c-4f83-bd47-daf1a2d21ef6"}, "a7fe926c-482d-4374-a1ef-8f171e038f8e": {"doc_hash": "11c97f1681b34519bf215a6b6f78c4f54bbde9bf22b573b0c815a183ce64b462", "ref_doc_id": "e6f86a9a-b581-495f-8243-5ea667154734"}, "74dea28b-9c0a-4217-8cc4-67cb46b92759": {"doc_hash": "1bf770896ba11a6f0486766430f6b11a63238f9fdaf4c480b6dcde651911b3a3", "ref_doc_id": "2ae52e95-7e2b-44bf-97fd-e28f183ecf1d"}, "1b5c4a5e-7d87-4769-a332-2899afb908dd": {"doc_hash": "f2ef8618bf66db944bcc1395a6afb3298444bd371f439c4983b9bb15733aa393", "ref_doc_id": "b1065af6-39c3-4a18-9bdb-7c6c134d20d9"}, "aedecc0e-3e40-4d09-bb60-e571a0263a24": {"doc_hash": "21eef70a776b00022a417c4aa2e0087a94454b340d5d96f6536c80c997bfd06d", "ref_doc_id": "eb66606e-d697-4ccc-ad77-d8228b4bb745"}, "a10a9382-80b9-4e23-95bb-f87e667dc552": {"doc_hash": "886c219efb630abb78a783a005af3363761ef649c5743e1e3e3f55dffff61dad", "ref_doc_id": "ddde86fc-815b-4682-8fad-1f5189243770"}, "86e02bec-5f67-451f-8bf1-c551a48c700c": {"doc_hash": "b7da13266762448b8da32de4bbd8b6619fde4977712fe3022ea3c162dd466553", "ref_doc_id": "477640e2-4f9b-4613-962b-409368857896"}, "5f7c8912-8806-4f1f-9f0a-b5723b6eec7c": {"doc_hash": "84777ec9c1751827021fcc3556c7772911e2cc2c616c8e835f4f3f3ff3e7e03e", "ref_doc_id": "59d84232-09ab-4b2e-8973-665b464d8278"}, "e603d02d-ae0e-4b9c-a562-c688baef6385": {"doc_hash": "7c290a8cd0470d157d70a5486ffb294d716341a70b028f612b8de0e9f4635fd1", "ref_doc_id": "4a42ac7a-14b5-4066-849f-68b1bd25395d"}, "9494501e-3430-4719-844e-2da439a99205": {"doc_hash": "0357bbd151e33d1af7f2ab68471c2526f61dfdbbd4fb5aa1eaa18ea5e85a66c9", "ref_doc_id": "1b061e34-9fa7-4aa7-8fce-b16fb7f0617e"}, "9c77689a-846d-4edf-a0bc-3de6ca2e40fb": {"doc_hash": "eabc4808f26295aa6bcc3943acbdb79105bbb56de9ee574a178c4db09f9e1887", "ref_doc_id": "b327e644-bfa6-4c8d-8917-1952346384a5"}, "9960b106-e385-4f4f-af51-12442ac44635": {"doc_hash": "15a5bef8aa5dd5d2cee20df9fadc9e3f5ca5f00bf89c525aa6fafd3575d8d5c8", "ref_doc_id": "3b80bc31-f6d5-45ee-8d44-54714a155751"}, "d75c3b67-8eab-4785-be62-69533a8cf716": {"doc_hash": "77f82384e3788d33b004978d2d8383351e1d52d78cfad66a1c2f3c492a67a8cc", "ref_doc_id": "3b80bc31-f6d5-45ee-8d44-54714a155751"}, "5e3f4c80-e66c-4242-91e1-e55f0777e9bb": {"doc_hash": "fe8f29a60a91a37e33b888d1b8db4746caec3695e6f2e6956e464f33e9ddc96e", "ref_doc_id": "c863b8d5-e3fd-4a57-9c4e-0ed9cc10fae5"}, "e1462f50-d16f-4dfa-b286-72062460870c": {"doc_hash": "5b64196d8001f62f7e48383ac7e2a85c29db5f2f9e65373a9e2e5f467e5950f7", "ref_doc_id": "01db5cee-01e4-435b-ba79-11ad2dcc85a1"}, "53354811-2f7e-4efa-bf1b-b38c21f6d882": {"doc_hash": "26a83c85efa443756be73aea96c289e330cc5eefdb6304566cb75ac1b787bf68", "ref_doc_id": "bc5bdfd5-1f27-4c78-8c43-05609d3dd81c"}, "11f9c439-458b-4c05-bab9-d5b7bb85ff07": {"doc_hash": "dde897dc5ef74d33c986e5d559cea62c52121920061186b02686a3bb0d629282", "ref_doc_id": "e3c1a094-d8a2-47cf-b4bf-cfa98da8ef0e"}, "52f3c867-069f-43ff-9e8d-28427e4b4ac0": {"doc_hash": "5891e79129a300d5773a3dc3cc65028f81ded462a4b99cf7f02233696aad6148", "ref_doc_id": "e4ae379f-9d63-413b-8afa-afc20b5d0840"}, "f50ec48a-2bd6-493d-afad-aa8d488b4e1e": {"doc_hash": "d3b12621a74676641591280dc80537bf3e467e139f3cb9fb667cb1c96f7b6f91", "ref_doc_id": "0902737a-cecc-43dc-a42c-f1170e797f3e"}, "5a064a9e-3536-496a-a879-dcedb35b0f66": {"doc_hash": "9d900b42b177e2b4a05e0aaa237ebd55da0a7a85a1ef5c1bf22060c9c9c5da85", "ref_doc_id": "1dd89492-3c6b-45cf-bf4c-0f0846bd5e6a"}, "2abb7291-582b-482a-9690-d68abd48619e": {"doc_hash": "36d2228d3a1dbe90d6b9ef67989b6edd6aa962f1119d608e68889f297e5c1140", "ref_doc_id": "453afa2a-95c5-464a-ab4c-71d860b2f67e"}, "3d82f039-4ee2-452d-b6a7-d5561e2854cc": {"doc_hash": "5d47ffc4474dd8e46e260b57a39958f7d18afa61f8b7d1323fab0eb094781ae8", "ref_doc_id": "5dbde026-bebb-42ed-b237-366ab5b3815d"}, "65d6c4c8-708b-4cee-a3e1-79b9d88e6a46": {"doc_hash": "7d338aebe13204edc74d75a43d9405342f5ade386410e5c050fd1d14c5620db4", "ref_doc_id": "4bc1f1b7-8730-4a4f-8e64-705677c17aad"}, "96ae10a3-3e55-434a-a9fc-29bf3994780f": {"doc_hash": "13af101350976e28264f1c5556279062adcebba7c817b9244558cf634c1dcf70", "ref_doc_id": "4bc1f1b7-8730-4a4f-8e64-705677c17aad"}, "e056ae5f-1b79-4e74-8fda-d124bf45f28d": {"doc_hash": "1539d814c35d66817701a67734c09e5cee2da2da33cec9c597bb604d0f1e63d3", "ref_doc_id": "86c64624-4863-40cf-a897-99aada3d293e"}, "1787b3bf-8484-42f5-9e3c-123532075e09": {"doc_hash": "a8374a568f0db37729a55aec5b4adc96937d25852d63f9403f84b692b7faa143", "ref_doc_id": "86c64624-4863-40cf-a897-99aada3d293e"}, "d7f2211e-3ab3-4cdb-bcaa-0834dc35de19": {"doc_hash": "434a7b52cb35bac8daa08cf7708cf2fbf257992924697947338acef2e8617a5a", "ref_doc_id": "ead21676-478c-4016-8130-55d7a1b30667"}, "6f7923d3-d1f3-4acc-9ff5-c8fd6a3b0aa6": {"doc_hash": "c3c8b0e8a7f421f1aa51703966725aa3e8b4706e5630d67f68be96a2cf631708", "ref_doc_id": "07bf2223-6f67-4480-9464-061c9446a7ba"}, "72900278-f191-49f6-abfd-117594e73859": {"doc_hash": "a758e4b060a423375fc6cd8912cb29dcbb2a3d181adbd8c9c9571d32200f3cf9", "ref_doc_id": "3e310d24-ca9b-406d-afa6-ca08e60a881f"}, "b28491b4-a24c-4960-a6f8-3a607e4bf97e": {"doc_hash": "b471e3b8094946ba29c0e1f5be471b5e24200e875ffc555b5c2157b74871d3dd", "ref_doc_id": "a7edf12c-ddf8-4bd2-9d1e-74fe6714b246"}, "9ff278e1-9fa8-4fdf-9cb0-681c4435c7c2": {"doc_hash": "8cc68ba328895de6b2ac51f191381347b1f5f755daeafd657c429316d201ede3", "ref_doc_id": "1cd7ed3d-28fc-486b-a305-fe41714edd67"}, "0ade37bd-3aaa-4a62-93ae-bd818203bd28": {"doc_hash": "efc21db147df4182cf3ff6d57e1bc5f3d63e8da8fc531cfc05a17c6b7cc8fee6", "ref_doc_id": "9a45a111-0d63-4a6d-a051-ef74ab85bd94"}, "11f88103-34d2-44ab-ac8b-7e9e1738f9f2": {"doc_hash": "789b81edfcfe2bc7da238f62499152350165c6c6d582bd79190815c8acad8a46", "ref_doc_id": "5727633c-2a70-4b63-850e-f9a827e549c2"}, "6a7619ee-346c-4a47-931a-cf535877e28f": {"doc_hash": "16121edf64f19ef3667148581c0e1eeb1cefb56054de5cb2650f2f7fba09672f", "ref_doc_id": "3301a21a-1eac-4e82-a4f8-d1a7799151ac"}, "7d176641-205b-4e70-95e0-11dabb434b0b": {"doc_hash": "0e5e9085bf9d24122e8cd541ead21adce63ce28bf2f36cc93d31e8f3e1f39d6c", "ref_doc_id": "8577f61f-7da5-4b39-aa64-93207290cb2f"}, "ec2b1ff7-edf0-45f2-9a4f-5e5b05ec5821": {"doc_hash": "86bd7cfa7f3e64974c37e19d846199b6f3d9a8cf8b8943ed7268fc72fa4296d7", "ref_doc_id": "7d021290-03b8-4928-ae52-30e37ea681e1"}, "842b0cef-7ec7-439c-a04b-fbbbae3da790": {"doc_hash": "5ee458dbe40450ec316a6a10997fa46ef9d02076aa0dbb6db8717c4f7a805c26", "ref_doc_id": "04296aab-2a9d-4182-80b0-9d6fd5485bfa"}, "7609548b-f30b-41e5-afcc-8b6b8e2aedcd": {"doc_hash": "30611f2dab6c26d3ba5e6d99e7796c168173030e8d0614ae7635dde424033b2c", "ref_doc_id": "13f8f39f-0fd5-4540-9645-4f5c7e4dca54"}, "9b06b38a-6cbe-465f-9e35-a4db146f5a89": {"doc_hash": "337ee5f0d3d7b40b2511861ae7c24dba9978fb5eb935fd8f20579ae370133a54", "ref_doc_id": "752f075f-b7f3-446d-83b1-9aa5b36e58a3"}, "898b42c3-5d28-4e96-90b9-e5b5aeecb592": {"doc_hash": "3565a28cea842bccab56074582ff676c375bde3ce56cc3a7c61814cb291318ea", "ref_doc_id": "1b057de8-418b-45c3-945b-de77c1d90051"}, "e8353196-347b-418d-992d-8746e5a407ed": {"doc_hash": "d815da0113137b0529890a06ae06e6e9a03421e0cff14e036d480ba587b424fd", "ref_doc_id": "5e3b5a88-532c-4bf3-a6de-2e3ba09049a4"}, "23e195e2-4f0f-492e-9a5f-f8bd0294ab20": {"doc_hash": "1200997680bb4ee086bf36980fd62469cfd4b141208b6b229b773c051f7de23d", "ref_doc_id": "d4f7dce2-6393-4313-bc0c-2cdfebe762cc"}, "925343d8-a08d-47f7-8440-e30cf09cc867": {"doc_hash": "a2c138d79b6a274fa97e2c2574e6c3ffb6fe764330fa92309cd7dd2f02b091a6", "ref_doc_id": "cccd72e1-8f73-41d2-b15e-b5ec34e88f6e"}, "518dce73-3313-4479-aaaa-5bb55ef71efc": {"doc_hash": "0d93731ef1455b79d850a1b44d987b8551f81c9da345a7d262f1b26657ec8039", "ref_doc_id": "e187c352-dbdc-4526-8a11-acb8819f1e88"}, "835d7195-762f-4f3c-8014-83d4520db493": {"doc_hash": "e66d5561573a6f0585fe2b053ff29f1b3e32ee6eea7dcd2baa18e656ed28fc53", "ref_doc_id": "f2316407-e14b-4c19-be75-42bc7b59b074"}, "ddc948bb-5fc7-4fbd-9aa2-895943dd2f07": {"doc_hash": "6efba0bb12b748cf087531d5119c596c0a5051a03f1ef65751cf275e8f04853e", "ref_doc_id": "2777322f-b9ce-46e2-b8d4-c17b971e1b72"}, "ed87ddb3-110c-4ea5-984e-98d31f33b6d3": {"doc_hash": "17225b402bb733f0dbf9ae55151a8cf7789f675f65a2c74f727f36a1be15969e", "ref_doc_id": "85466ec0-cd68-485a-ac5a-e4faa41257bd"}, "000b7117-126c-403a-abed-aa13b0a0d299": {"doc_hash": "5d581896dbaaaa0ad95c0a53ded3be44dd5e6a1fe174af3aad3ef11c15b64fd8", "ref_doc_id": "6a785e8e-6fcb-4f83-93e9-663da5167de6"}, "8264139e-4817-4af1-8158-2d444714022d": {"doc_hash": "38605c6a58ce835d35a6cc472fb720b693cfc4c06646d4af3036ea9a8601f648", "ref_doc_id": "5f614161-3f67-43c0-84fd-d1814299e861"}, "81e0b601-5751-4cf3-b905-845d4661f46d": {"doc_hash": "fd9ce39f8fa1c03d23c07a453ba606162dc4bbdf6d9d1583b00c60dcd8290342", "ref_doc_id": "cb003932-8052-4708-a030-7392202b9adf"}, "072c7972-46a3-46c6-8d7c-926dfb698e7b": {"doc_hash": "88f3c0e579b3b764398c276801e1e22df9b79350596e51c007e9315eccff9927", "ref_doc_id": "04edc4bb-4ad9-4bd4-a7dd-93add88a3521"}, "0a0e1fa2-4b1d-4741-9dd7-11aacc076305": {"doc_hash": "ea5cd98335b6b7a4229dc8429cc6c409d68f54b76ae3f963a4268852decbee81", "ref_doc_id": "b564ceac-4cef-4a26-9c80-a23be11dc10b"}, "13f557cd-d4d4-4908-ad7c-82603d0bc21b": {"doc_hash": "2c5f5a430eaa9592473329c7b0e698a8e1e9c1fd3df8af0c4446930db98e57b1", "ref_doc_id": "32cc05f1-2a71-4f76-a2dd-21b48a0f732f"}, "b8d5a8bf-ed1a-4499-9d67-f2c0c0da3889": {"doc_hash": "b0107c77faa0885d95f048cc3d11cb36eaa3d31d1f3522fce988f15d2e817df6", "ref_doc_id": "f2589de3-8eaf-4cb4-aa97-0364ffa07d21"}, "16f515ca-0dd5-4dca-85ab-7e7e85e0977d": {"doc_hash": "e4ae3a1b7fbf10702da421d50fbc23398f5000f6b37cf77e1dbf1625407b26f8", "ref_doc_id": "cce6f646-7384-487c-b324-309fc6affb77"}, "f90568da-45a5-413e-9db0-5c55f1f40766": {"doc_hash": "31d47c6439d5780406b551dc02f64a8d3ad8deb44b33c0bc04db653f7b5aabe0", "ref_doc_id": "b6bad8bd-bdbb-4ad6-a3b0-4b2f6c32cc30"}, "f7af7fa3-0968-46bf-8e5d-bd93caa02d5b": {"doc_hash": "bdca984fe8949826514bbdd4e41c420058ae7439b35efa56e6acf7ba77085e3b", "ref_doc_id": "3554f076-0cf7-4007-872e-53ad1157c837"}, "65bb1aaa-83fb-48b3-8e44-0302c2011fe3": {"doc_hash": "f70f318e896696cc1fcdd9138b270763db293eef378f81560fc08a0260f76d74", "ref_doc_id": "1ab8f553-673b-4e15-a1b3-9ce906842891"}, "99d5bb5b-f7c2-4f9f-874e-53ec082be9b2": {"doc_hash": "cf26626764b9b8226650736298292e090252e360b516bd0c31e26c0cd6cc3217", "ref_doc_id": "d987d3a4-06d7-4953-9805-66d59b44e91c"}, "1cf03328-e574-43a5-a3cc-ece84c14fa1e": {"doc_hash": "ec459fc2f3aa97db8c7d35e24d74aafaf72233f6049a96b93e61fdd69f86d740", "ref_doc_id": "7bf72344-40b0-469b-b6ee-81ad3c35aa5a"}, "890049a7-f634-4c57-84d6-09709e3d5823": {"doc_hash": "3a78eed90f68da9e9cb5c9216bef574dd7580c2ef5631cf6d14a13cccbfd51b9", "ref_doc_id": "c14d73e6-7c07-489d-a20c-b75f6cdb00c3"}, "2c0c93e2-99a9-488f-a364-be8a10159c85": {"doc_hash": "5d823a597f391c2e17f3ca3da3a8beb681b432e68d6c8769e0d36429b28ecbe1", "ref_doc_id": "f336b233-6662-4dd3-9adb-17a39907b54f"}, "8a64f27d-be93-40f9-a922-11f1879a4d9d": {"doc_hash": "06a385cad239267f8f2fde7bb58543185f026be383c0411ce2a13faa60d2ad4c", "ref_doc_id": "82429d40-80fd-4194-bfee-b641afe43cdf"}, "2a7f6739-0a1e-471e-b6e8-e0b3b4b69f23": {"doc_hash": "c7e2a4ebe79133e934325bde718289d6f22622e431fa52f2d4bda1671ec0a06c", "ref_doc_id": "ef6a1017-7adc-4f8f-82fa-3b8a87431952"}, "884aabff-0470-4f2c-a48d-725bd776eee9": {"doc_hash": "d58fc92584fd45455af9d4d03c8e93386b20eab76679eef0491835e5d31fdb92", "ref_doc_id": "13d1e588-85e5-4d85-a5fb-c9e94b74d89c"}, "5837d3dc-1bf6-40ed-abce-b23d102a9aca": {"doc_hash": "1d9d19f6370c092273fc1a723720dffe511799ef894ab888a9bfa7645af0d870", "ref_doc_id": "9ef26203-762a-4b72-8726-f5367480317d"}, "171c3ced-5bcf-41bd-8367-fe16e37d118f": {"doc_hash": "eae79ac0bb54e6aa6c51f3ee0dade41d8c7dcca19651e1f2ae49892719e4c199", "ref_doc_id": "10c41412-5362-413a-ac6d-784a2258db5b"}, "210f3d60-6df3-42fe-b51a-d948e60dfecf": {"doc_hash": "6667ae549b19f636f4669e788a8e5a9566c8ac589b74f17c3c24f0b34d2d5f7a", "ref_doc_id": "8acec875-a1d0-4812-87c9-12141bdcde8c"}, "67c5a110-26ed-43ac-8964-667debcb272c": {"doc_hash": "218886456a5d583d5e20ef410a22795ad37736981ab188904db4dd0e3e7cfc2c", "ref_doc_id": "a306a787-2b16-4671-b764-4821848409fe"}, "e25e6f70-00fd-4f99-878f-2adb5797e7f7": {"doc_hash": "17ca4fb17edb7a6befdec8f6bd4cba6dfdaec1955be63c50bf6b538b34c4920e", "ref_doc_id": "95582803-7714-4dfc-a935-817b5ddb574f"}, "ada70517-d3a1-42ff-9533-c94cc25f5dc0": {"doc_hash": "56d46265eb543fc606c42331a69a6effbe4ede1ea5ed7faacbdeb9c59ce8095b", "ref_doc_id": "83d42ba2-d396-45ff-97a2-1a713a34b7a2"}, "23fd8d25-1218-4ea1-9031-8e866813b324": {"doc_hash": "5e398082628ad2928f03079fb5266106a8fc8621d6d6051d5d79171497864ce4", "ref_doc_id": "8ffd8653-1c20-45b5-a9d6-2444054ff836"}, "ad48ecd1-f18c-4d01-95db-b4c60873d1f7": {"doc_hash": "5112ac9502787cf6b99ad872bc68055df280e48dc46d36bd1524075b8c6eb9c0", "ref_doc_id": "f0533645-d4d0-4a93-a302-190251cd23a2"}, "ec586ece-4aed-4be5-be92-145c68956464": {"doc_hash": "52ebfe5250eb7bd8e9f08090668e298191d07936656a68f81acee82e29f69262", "ref_doc_id": "ef8895c9-e158-4328-8bb0-2808888628e9"}, "1d0953af-8efa-4a68-8a8f-9043546bbc9c": {"doc_hash": "3f5b9963ec0bb57ec75c0b3c727c54bf8a8bf5b69e365a0d533d5394c93337eb", "ref_doc_id": "a738b865-19f4-40ae-8ecd-17704b1880a0"}, "0fffa81d-2126-40d7-a32a-66055ae15991": {"doc_hash": "d72a095e0787d461c9d2f224862b346cd5bd5cdf66d25b44fb6ae16e1628a7eb", "ref_doc_id": "74b9126a-4fcc-4a57-88ca-2afc34d8526d"}, "c8f5991d-ca30-4f36-8e4d-9491f3c015c7": {"doc_hash": "79b9ee090c647c70ae358dd701fc2ebb52c7aad4b16c8e0a320c45ef8c6fa9ec", "ref_doc_id": "cbdccf59-e8d9-424b-8ca6-f7a16e015737"}, "d8619a5d-3bbe-4475-8baa-727716389c54": {"doc_hash": "d8d3b2c6ce38782b5118871e9861507c01af41a3cea3f87d44d1118e484a4670", "ref_doc_id": "d1cdb3d5-03f1-41f6-ad61-3bb8d2200581"}, "9ea4855d-88a4-41d5-b917-23f3228c7140": {"doc_hash": "0e3e366d6a1e3b5298416dcb986b0a7f3517e3c14d5b96fdb36cd2fc6ad4d660", "ref_doc_id": "885b3087-a36d-442c-9748-d0dc6c9d6dfa"}, "ff559108-9ae7-44a9-8f1f-f56a73a6f845": {"doc_hash": "0eccc70245efbb57ade2b55748e92dda40d6341e54511deed1dcded16bd4327c", "ref_doc_id": "61671732-245a-4392-b420-0ba6ad322ff3"}, "3ea709c6-8702-45d5-8628-edf4341bb8a7": {"doc_hash": "2fac6a04c8d1143a00b87dcd89477049777bba9610a5de0e9e7db7692ecbd31b", "ref_doc_id": "9775e379-01ee-4811-afca-34f66c2ce5cf"}, "f120f79a-a0c3-4f8b-8ed0-180a56f83c44": {"doc_hash": "a2e55d01b32a60b89f5b54b2c228c5a52ab22ac6b6a5c8e394a401fd8f6d62c4", "ref_doc_id": "dacf3b98-0f27-48b1-8f36-c5876bc493aa"}, "336b7d6e-2727-4270-9311-65f938627af3": {"doc_hash": "59a87ecbf82e8ec19393d00f8084d214abec34aea51945faaa01371a8a419b81", "ref_doc_id": "c4bbe220-e335-42fd-8d45-3babaf36e6d7"}, "87820f8d-32cc-4c8a-b0c3-887a40b52943": {"doc_hash": "484058896e61ee077883750c0896776b166d7ed9fe284e030858e3c06eb5fa8d", "ref_doc_id": "c4bbe220-e335-42fd-8d45-3babaf36e6d7"}, "009e0002-e57e-4029-a725-45b6d512eacb": {"doc_hash": "3669ef4629cf6a45123a7fa31899fafa0c81e3c50d3108e230825bb9be2d2e77", "ref_doc_id": "fe2c398a-a70a-480e-a9ba-5c310d24d1d3"}, "dbd48933-4c27-4c91-bace-3562cb0abf7a": {"doc_hash": "cbc30336b1178002dd9ac6f0428c81f70270e9d38c18ad0e45d2eaecddd232cc", "ref_doc_id": "0c348d79-8048-43a4-afe6-1923171d4c80"}, "8d4ab7c9-516d-4a13-88dd-4ee847b5a1b7": {"doc_hash": "9069cf48d34449924a9a1170e6da99f5ed419f83ef53e9c017402f9bf9218b24", "ref_doc_id": "bf1e24a4-fa67-4d33-b1f8-86f8cf06c7db"}, "7566accb-13b5-4f67-ad12-d34dc83d8690": {"doc_hash": "6892a508f6cdcb8d1fda331814ef998225cd8fd88e256002aaeb65fcc7c00aeb", "ref_doc_id": "30ec26a6-82c1-4566-bcdf-1452c417d567"}, "c6157a54-a39c-46cd-868e-0cdedf70d707": {"doc_hash": "89d96546f1f1cd1e81e70ab6625ef427f9525c6385c707d2eb61205783cc0ac9", "ref_doc_id": "9fcb5435-78c7-46ac-bdcb-690fec057055"}, "db933f85-1138-4661-818c-8d795b12d1cc": {"doc_hash": "4d3e98bc87bdb366ae15f2007c005703e182b8541f33643b245b659e197c95d4", "ref_doc_id": "f017f507-17d9-4e64-ac1e-3056163f7b08"}, "3e3c1613-f69e-4958-84e5-39656662cb81": {"doc_hash": "97411b8108986c82872d1c7a7941d16ec7cf5af914f4efa0f2e3c8949413c05b", "ref_doc_id": "eefc82cc-e904-4d89-a023-bca35633a97d"}, "58687f56-e150-4871-80ad-949c9fec49ab": {"doc_hash": "a07189e94d89a2a171f59f739d885e2893a86c5ba9700b33677f56624f0c9422", "ref_doc_id": "09e818fc-385c-40cb-93f7-712fdc1b278c"}, "f0d6ae37-fe7a-4230-b381-9b4b54f17336": {"doc_hash": "e54d41e085aec7ffe0781270c7a21a01b3b1786fac13f59c916bbe5cf802be6b", "ref_doc_id": "30edcdcf-0697-41f2-9946-196bc9ba443d"}, "f9ae405e-8bbf-4bb6-a374-55ac499efff3": {"doc_hash": "9c20bca27eb21ff9912367707b5be031d7c53dfe6fb061ee1653181c76c3039c", "ref_doc_id": "1a6cdde4-18c3-4946-a53f-dae2a6d0f588"}, "efec72e5-115f-4a57-b63c-70d72eb5fb0c": {"doc_hash": "b0d85c4593619cf46d77bf8066c399c6862ea6cf9d7bec87715e0bb71bd1f697", "ref_doc_id": "ad2cfc73-37bb-4b7b-8287-97522bc256f6"}, "154e534d-9007-413b-ad76-31a27c70c1a4": {"doc_hash": "41892d718cb404bd9dfc0574c700ebb8ff32af6c53fa81ff432b500c525ceb86", "ref_doc_id": "e60b55ef-bf2a-4951-b66e-a215a4162631"}, "6472b42d-1fc2-4204-a085-a91e9e3e77fd": {"doc_hash": "7fc1ab9167f0ee4a3cbebda12cdd1d3afa6f4c51bc573c8816d186d568ace5c8", "ref_doc_id": "9e7d1fd9-0ab5-423c-b6fb-10464d6473dc"}, "a5e294a6-d3f6-4560-a5d6-eb01847c4275": {"doc_hash": "522aecd1f385bb82082f54d98385538b37f08f1333e5819e368ea40da8ee7da4", "ref_doc_id": "a4dcecf6-1b5e-4629-823c-f817d01251cc"}, "8fedf6c8-e429-4977-8b3e-668544d9716b": {"doc_hash": "e408e29dc2642d555c39c15ae203521b12b1eaaa33444421535558348df1f16e", "ref_doc_id": "02911eb1-2714-4d45-bf2a-4fe19fc55871"}, "73f306e7-edf9-4126-98ad-923a8e39022f": {"doc_hash": "10ab72e5e69364f72f773ff4bf7d93537340b5d4d325a96d6401b509c86d542c", "ref_doc_id": "6f6de8f1-566a-4a1a-bc12-b7a11691b387"}, "03df2935-407d-427e-a42e-a3fd633559cf": {"doc_hash": "c9d68634c0f57d2d4f09d8fdbfd4aa2ab26a57bb7a03ddac7cb218d416d007ef", "ref_doc_id": "49a431a9-503f-4da5-8753-d2ddf82c09c0"}, "f91f877c-47fd-4727-80b9-11b0855096a6": {"doc_hash": "7fe869fec9316d8774d88805f1a06083a3d5670617c820299484bb797c8e6667", "ref_doc_id": "309537af-1378-4104-8f65-94d2640eb42c"}, "4ee02e6a-4e64-469b-bec0-23f120bd140a": {"doc_hash": "881a236b0f2ca9e2cb57cffe36ef9d848652357942645d228408cd06eb50042e", "ref_doc_id": "b7bb677d-5c59-4983-b2b6-c2b90239a7d2"}, "ebb702b1-bf3d-4ebc-9803-f3d64062d14c": {"doc_hash": "8ef82ddc48f9a707cc4bea3e748d46c8ad818fc5da4f0c5f2147b6d6e6bec684", "ref_doc_id": "2de9dc72-a627-458f-9305-fe7108028a51"}, "45407d03-1f95-4dfe-85b9-8aad40068924": {"doc_hash": "77996b3176b80ac4ef93a92872609a2f004712c135c62b0763c6312be97e3d1d", "ref_doc_id": "c6dc1253-7056-4dd8-a98d-da1ea0cabc43"}, "013cbf3b-168f-43e5-988c-0c119b990d7a": {"doc_hash": "f2daa8262de83b1014f9a8293921669c20ddf558e245650c75ee6a6813031750", "ref_doc_id": "833bb4ed-8f5b-4f6e-98a2-8981f3fcd4f3"}, "b1dba3cb-33ab-431f-b2c8-55d2dc74a442": {"doc_hash": "20bb405bd0cda48290751c31117dd0ffa3247815a228d0fdb6bfbb74570233f7", "ref_doc_id": "facdb65f-d37a-40ad-8360-87994a1e99f2"}, "112d3444-8043-4126-9254-6140993fc310": {"doc_hash": "a28304b6110f9da0ffe876bed628de4a4e33279641bd05cd9a14915d72c347a4", "ref_doc_id": "d2f989bf-23df-4a52-aca4-fdaf3c61e40c"}, "071edec4-d744-431b-86ec-9db1db5c5aef": {"doc_hash": "03bacadbb0db74f770e06bec6cbf905e7c4286a4bb907d77d94bcf2464010a07", "ref_doc_id": "859dcc04-6c25-4e38-a92e-ab31569fb10e"}, "c914225a-7fe2-437f-9100-e91a8d5edc00": {"doc_hash": "ee7dcab555c60f46d086b5fb5a67cef8aff4dcf32d1c219f28f872979eeb6c45", "ref_doc_id": "a0758f96-3e2a-484b-96db-7cde00181ef7"}, "e76ed89d-629a-4d20-88cd-531dddf6eb41": {"doc_hash": "68b43a85a7c0f8bce3ed65ca1596f8626cea11a631e5d1c16a5ecb9fa6a7b207", "ref_doc_id": "19f9203a-c83f-454f-98c4-7fda199da842"}, "220bc180-6b42-44b7-8024-d0a1b9f93173": {"doc_hash": "fcd616d775318050549eac53caa0d0bd52675d07c35106265fe919db575a4a72", "ref_doc_id": "57837dcc-6cb4-4636-bd65-75849f1527b8"}, "f0a30b99-16e7-41b7-b3b6-ef30e67777ce": {"doc_hash": "2abd4d08733e743d88ee5a2be68b62c4f7299112d377b37d93925e66e2412d21", "ref_doc_id": "01fc81ba-2b6f-494d-a19e-5ff325ee76d2"}, "5253cfee-3f87-45b1-adc8-6976c33ab3c7": {"doc_hash": "b73ccb4f2d121b49edadc695d348a0157b0f0602bb3812c4a4c107ac8c7a775d", "ref_doc_id": "01fc81ba-2b6f-494d-a19e-5ff325ee76d2"}, "5eb2d40d-0b6d-4dfd-b345-52988e864863": {"doc_hash": "1020cd1936396582ee63ff3db3644b13b1a29dcf835308e6b7da4538117dcc5a", "ref_doc_id": "9ed539ad-4de5-49be-b369-8be2de44fb0a"}, "6bc29b05-15b2-4b2e-acd5-85d808044379": {"doc_hash": "9a06affd609e592218e177d7b62895f1ae0a47c68e5379701ecc6f1b2465fe5d", "ref_doc_id": "bc786873-541c-4b3f-85c7-0955ad2f451d"}, "b748a419-773b-42f4-a160-81034e18d135": {"doc_hash": "48571d81208932d18c255ed574a94a7466f20cfbafa74f2985a0486fc17bee7e", "ref_doc_id": "e87cca45-641c-4d94-86e0-edc884c57306"}, "fea787c6-736a-4c2f-9b44-d47778cac787": {"doc_hash": "2a55eaccb634e2f29e9ab2d526c37733aef343fd97e0fbc3687f7a23021a3822", "ref_doc_id": "26f23882-bf36-452b-af54-54b53ed5960a"}, "179b3807-9368-44f0-af1e-af74a1faca28": {"doc_hash": "4365b48859dec229bfcc7c385f6c90b91c6104af1372ca76fdd4f017c43a6843", "ref_doc_id": "4ae098b9-96ea-4d5f-8223-bcfb092929cd"}, "60b8661c-efd8-432d-a143-8ecfbbf3edcd": {"doc_hash": "43a479966479e5cd4788d693259a9c8277e38b03775df159f3a1141ff789b442", "ref_doc_id": "3903c9a9-23fc-4532-ab00-8b72b2b6c86d"}, "23f95865-cf3a-4d94-b3ed-87e0a00d5299": {"doc_hash": "e5e8f142a12ae65cb637cb7c98a5c6fbb76634893accd1efdb1d513957a66e75", "ref_doc_id": "4bdaae58-2b10-452b-aafb-2f17de3f6bbf"}, "11d2a024-ac9d-4451-ae00-146eb1a781d5": {"doc_hash": "e8d6a32b112e80c877a680f06459d87f9da488e4d8f68fa20d825cbda2eb00fa", "ref_doc_id": "4bdaae58-2b10-452b-aafb-2f17de3f6bbf"}, "2690e8f1-0d9d-48fe-9464-64e9be7f2fdf": {"doc_hash": "4c4f273f297d581093a8a9f11b75503311d57d12eafa9d2452bc14cbe1dafd40", "ref_doc_id": "49c4b941-19bc-478d-909e-9a948b55b01f"}, "a4538c45-9cc6-4cde-9176-f5d8ef9d641c": {"doc_hash": "e0167c6532c719b6cb98ee4fd4dff2d94cdcd9af919d59340a7ec9db07d2aa23", "ref_doc_id": "654bd8d8-b21f-4ffb-bfd6-72213b3647d7"}, "4979f2f0-b279-495f-b7ba-d66e56e902d1": {"doc_hash": "306adc27b22fbd6e381f5ab1393974d8b9a517c38c2e40fa9920b7c775c5c246", "ref_doc_id": "080d7dbc-6178-4cd6-af31-e968bc1c3968"}, "f769df96-a3c8-4aed-9271-4a5f9bdaf536": {"doc_hash": "4198fab5e67999fe6ae50e650cc828dddbf50b83da661b7335be4b0f261296ce", "ref_doc_id": "10bb9270-5549-4eb1-a5f9-a531e9b25c0c"}, "759ce702-6918-4bb3-ae74-f21c19f78a8a": {"doc_hash": "87ddde35e319e4414a8991a71b4485099f51ece331f34ff90dfc18c9575e3904", "ref_doc_id": "ef4ecd3b-89e2-4a16-a5ef-20558ce1fc7d"}, "9d2d8d50-c7d1-4645-8d13-9f83c1400161": {"doc_hash": "24497870e281a8ad226b4223780418ec2f9708665fae9ca9426a7ee63721a9d5", "ref_doc_id": "61773825-8cb5-4f7d-b774-aa1b4f79353f"}, "0b7622e2-aa2f-48e6-8942-f5d76b87da44": {"doc_hash": "40e826083aa556d6ba8465931f36795541641ea682d1b7958cc91e710aaf2131", "ref_doc_id": "384c3c45-4c1e-4d8f-8008-4a5a3d99a820"}, "f508d885-8a23-4195-bf24-c1cd60e2063c": {"doc_hash": "a726f0d209e47e856848a95378664e0ea0f7f6caa006f78ce0d74b7607139dc6", "ref_doc_id": "b4a2fcfb-fa1c-429b-ad31-67e32e895782"}, "c3faa421-db77-4c2e-83d5-bfd28e3e4e11": {"doc_hash": "639df1e09ebbfe8835883592a1b41d2802bb5c8886640eadbdcce45e3b513b48", "ref_doc_id": "19245fe9-5920-4588-b097-3e3037210b38"}, "38acc63e-1d3b-4bf8-a406-a3eccd07da18": {"doc_hash": "f57b3ab7f286a24cf72c51b773728340da447ec8f599d91252057e4fef2d9d7c", "ref_doc_id": "0222444a-79c4-409b-ab08-8cc11b5350d1"}, "eeb21716-7d5b-4820-be79-1c896039f5ff": {"doc_hash": "ade30a815be6a83be9b03e83bf89732136b0252990d1d4b39d6db848f5f9a4ea", "ref_doc_id": "381adc2c-39d4-496a-b659-c8f9e006baf9"}, "87abc490-c3bd-4135-8ccb-7b01e64b9dce": {"doc_hash": "b70ad2ac4680119b73bb9e4e3276da81853048463c5ee02031d6ca1955565a50", "ref_doc_id": "e669b8a5-8b94-401c-87ca-c455bec2cccf"}, "22e02dd4-7e74-4b48-9cef-362395414e29": {"doc_hash": "9eee2528f0b65b48b5ff70844b3a0218b0813d6f263b0cf7561268633fe4c98a", "ref_doc_id": "04e0ee8e-1549-4fd0-81b5-8362d5063f1c"}, "a36ac4df-bee2-4a9e-b518-ce9c1611c037": {"doc_hash": "f24f74d783f4fee1b7819a221bc8a4b06527fe465443431fb6c550717527eca1", "ref_doc_id": "fa3dd9c2-37d8-4212-98bc-ff33a78d13ef"}, "dacaac01-2f84-44ba-8426-4e8694381653": {"doc_hash": "7768cdbd289e8f1dc7c88cd0c2b743217388d1e78b961a206e65947247fcdf4e", "ref_doc_id": "e6f6cb78-0499-45b4-b641-dcf9ec1313c9"}, "b2d761a4-a95c-4224-8cf1-ec16720bf831": {"doc_hash": "062aea63641a0dfe43b25163acdd3d2463bd3463998dd6b70b70d50552cd28c5", "ref_doc_id": "1051bc8e-760f-458d-a7c3-8607998f6544"}, "fd3f0856-28df-4ba9-ac9a-210687af160f": {"doc_hash": "2d4599c3e72bd23b494e35ee55dad47b190c013bf3574c3b9079184654636c86", "ref_doc_id": "3716dcb5-ef79-418e-9cef-fc42d6698941"}, "484ac50d-ff47-4260-b14f-2717093fafcb": {"doc_hash": "4d94f46a35ce4d397c968cdb17e91cb0e5339d01d618c52d6996099119937235", "ref_doc_id": "a9ad9932-f173-42bf-a2a0-274329934761"}, "ab95a1b6-f6a2-43ab-ad33-dbb78c6c0d04": {"doc_hash": "643e3c79702f3c4bf59b0161cb17cc64186537bd6128766943c71f85e3aae77c", "ref_doc_id": "23b4b4d3-c20a-4125-aaa3-3001c1391991"}, "da9de516-30a6-40d7-bbf1-252182cc593d": {"doc_hash": "85845f6c66ed14db18ef5ba49213448aa4a8ecdb6ae62c9671192198774bf643", "ref_doc_id": "36983539-293c-4fb5-ba1c-498c660d378c"}, "8f1eb2f7-4888-46a0-b529-4a7eb3d5fa25": {"doc_hash": "312a6909684f9883519f4e67fdee37e3b804982af520339ade9a1c7c1722dd1a", "ref_doc_id": "4e41c544-0e85-4158-9a71-03caf334c5d1"}, "31cc5e95-0380-4683-83e0-de0839d844ce": {"doc_hash": "948722028d03ba49860b5c2f75b28d85ca85f1cdfc3396bd0b1ee707899f9022", "ref_doc_id": "0fbb0971-ca86-4553-99fd-24290ea96b73"}, "62ac95de-0c07-49a1-948b-c7830e94a273": {"doc_hash": "f54e510ad36ae550e4dc164991b9588f629f6064f64aed1f86f7a0553b15f4dc", "ref_doc_id": "5ac865b7-d61c-40e1-a8bd-193b81176674"}, "0d57ff7b-7339-4911-841a-8bf0148067f4": {"doc_hash": "aece1f405ccae134d4493a1c4e3d9aa3feb9d416485416c990a881395cae3f52", "ref_doc_id": "bc5e2b1f-acd1-4d64-8129-5adf07008f1a"}, "f42c6431-d698-48a9-82f2-b6c69ca42235": {"doc_hash": "26b367ca32f2bcaa0823e15b37252bf1671de800e85bf8ed96694e51a5f3a4aa", "ref_doc_id": "e5acc09e-b152-4060-9ac6-7b1db967cca3"}, "5dc98b08-ceae-479b-8827-f1abc460c90f": {"doc_hash": "3431c30e39503690985cf8d0586b697308d5182b0abcb95922f0445b05532d0c", "ref_doc_id": "050dc063-032a-4c64-a2af-45edc8873841"}, "a878079b-f288-422a-874c-7dbea044a803": {"doc_hash": "39a6c3855e1e137bfa3cbac8dbafc6ee864a09c1739063d9f7cccc1b94e0a182", "ref_doc_id": "6f4e2028-596c-4f3a-9e3e-2554cd28a671"}, "3aebffd5-5f9b-4f75-9c1b-fe6cf474a26e": {"doc_hash": "55a95c1a8d5290d4149f6f6e134f494e550eff6db3039ac3eaf19f379ca23a89", "ref_doc_id": "225e94cf-350e-405a-b3e2-61df0ec86773"}, "f1622148-d0dc-4719-a93b-03b6c14603ff": {"doc_hash": "a9d67eb09a5ed9bb072fbcb4c02813f15fd04fca39e6b89c22c3c5d7b0f47c56", "ref_doc_id": "6d6c2bfa-f8d2-45aa-bf85-01619cc04fc9"}, "ec3fb8c8-6feb-4e67-8b96-c3df4f051896": {"doc_hash": "2f9d1c3f251a3fd7dd1f0378861d5bb2559959721b4a4c78716b1e317cd65c00", "ref_doc_id": "467a2faa-e226-478e-a1af-a51c2b915c56"}, "ba0cbae4-fa99-403b-889d-23e7125a701b": {"doc_hash": "e8752fd7bf14f428903a93fb8939cda7dc61954829387df007c3de62e8a7cfd3", "ref_doc_id": "9295b091-d5ea-4707-90d4-5ee7c350b671"}, "2259b1f7-ee78-4467-ad1e-59d7afe9f521": {"doc_hash": "d5e54c511b6496ac0e6627965b720da59850cefea8a36e1dd261918273520cf7", "ref_doc_id": "ffaf2043-50a9-4108-892e-686ccc034040"}, "8ac91f58-2f65-4ef0-a3be-57b8f184922a": {"doc_hash": "8fbe21defeccdd47a358b59e729b723f569183b474782cd6933d932120189975", "ref_doc_id": "311b2664-abdf-4d5a-8a5c-bcd3d84dad1b"}, "325cd1de-ecc7-40b3-9dba-5576cfecb4c7": {"doc_hash": "f05c8f74783a993619a6679a6db56519a1675445748d202755742bccee39d7eb", "ref_doc_id": "1aaf53aa-d230-4f36-98df-5dcbf12a7122"}, "129b86bc-f928-43d3-a81b-ed56094a5fb7": {"doc_hash": "59e2d1be1f6e51e100162fdfa8574d39af7dd699fedf8d5814b77f2c88035e94", "ref_doc_id": "1aaf53aa-d230-4f36-98df-5dcbf12a7122"}, "44b1842b-bdef-48c4-baa0-4d3ec8d67778": {"doc_hash": "d59be6ea103910ebe948331f307cb42510b8e20e112954e5624da817d31f8d17", "ref_doc_id": "186aae32-e1a3-40db-b9a8-1a5546a1c5d6"}, "8556cc11-140c-4e2c-8597-8d0b17924cef": {"doc_hash": "a02bfe9df4b1ee0947a643590e05a78825fc7b776a230d472172bbd7fd1a1e46", "ref_doc_id": "bbf2c993-92ac-4d0a-a0e3-9abca7772803"}, "46073802-2153-4625-8066-84f5759459d9": {"doc_hash": "89b0cb141b7de363b1dec24e0bff7a472cd74b4426a756a7d1a13dfa441c110e", "ref_doc_id": "3f359dd5-73f9-41b9-a83f-52233b605e52"}, "1e584c9e-9282-4090-a4b6-53b7e6e85283": {"doc_hash": "40ce151c3c35c16c2d1e5e14148b6ec1703906ad534bbd368b861a8f328321b1", "ref_doc_id": "6967c86c-1a7a-4622-b37d-c149cb25b9a4"}, "4cacccf6-32b8-49d8-ae5c-611df2293acd": {"doc_hash": "b08354662e5cd257f1c2f532922388f2b8423358a8edf6fa908a6065a28f1ed9", "ref_doc_id": "ca796061-17d2-4a54-8690-7a689866464c"}, "0f8b91ef-d661-4b3d-a30f-b1fc1685c398": {"doc_hash": "3f8d6aaab26aa8e479ee2938f274222b4f2555f882c376c9bc3021bd591bd125", "ref_doc_id": "c36bf82a-afcf-435b-a3d0-a2da3b23dfec"}, "6b8f034e-ad9a-4543-9af9-54c6bf4874a7": {"doc_hash": "6c76dc00620c52981fc37a77fea16bf224061edb597d80b27625bbaa501166c2", "ref_doc_id": "784e52ed-599c-4027-af5e-595073e8c393"}, "9d216aad-8fc4-43b8-8ede-8a5498b9f123": {"doc_hash": "8ee7f059fbcd80d15fa23a42bec1f35573cc4a07a759a65f5964e2985b464548", "ref_doc_id": "07a5fd13-ba12-4aea-b14e-520f3bbd5ad7"}, "8a6c743b-2d3c-418c-ba56-4c42fca45a19": {"doc_hash": "4c9819c046aabcba11757dcd6d4d744e945a476be19c1e02f0059dc0e5a3d962", "ref_doc_id": "9f269857-45fc-46a1-bf17-446c6772f562"}, "3f447eb0-f55a-4e82-9c57-9639348c2062": {"doc_hash": "5fd9ba105e31d667cf27867af90003a77182c9b4ee6631a5f39e35ad844e8fe4", "ref_doc_id": "0330562b-976d-4a14-8514-faadd4b93e9c"}, "4917786c-3b91-4bc7-989b-40c6bbe8d73c": {"doc_hash": "b1b727916c179af2ab470c8dee462c018a604dcb809a54a7200bc5cb4dfd2744", "ref_doc_id": "223d09d7-7f17-4a4c-9b8f-38a5a78bf3fd"}, "2a44c392-fb76-4735-9e81-6ab41fdda4f9": {"doc_hash": "79683ffea35c4a79a3e53872c96f9818273c06cc2c12b7688e06c966f4c1b6bd", "ref_doc_id": "bab5d1ee-f912-489c-802e-f05a01e9e615"}, "a6862ba4-21fc-4b4f-8f7c-3a0e1111a7b3": {"doc_hash": "fc0205905c80fd8a0bb99ad0354b3d71e58876cef3211f532ddbc306ddbc7ecb", "ref_doc_id": "add48fdb-f87c-4242-afbf-d6c5855f31a1"}, "e45b2d47-3ad0-4906-b6a4-dab3a2f99b34": {"doc_hash": "cc19145828543c4df6b9eebf675fccdf1f2ebfa35a821cbdde28f4fac12a9b42", "ref_doc_id": "22a839b0-dd01-46cb-b359-e664363c7b65"}, "9c1bd46e-70bc-4fdf-9a8f-3500f6bf7ba0": {"doc_hash": "51f994c313f740e37153a71c7260c042fc5f4126bf466cb05c6a67c01884e6ab", "ref_doc_id": "8205764f-8b54-4ccc-bc44-d96bec6e74e6"}, "fb8a82a1-2a91-45c9-bcdd-9f6de6df59bd": {"doc_hash": "f626b69bbf8c916c8eea7cc528895c841c0f264456a80170b12054f4c304389f", "ref_doc_id": "e17503da-2fe7-4b9e-ab95-ec5cd4adef92"}, "f6531598-96b4-43cd-a905-41c98c647d1c": {"doc_hash": "f81cc621882e541a3b174cb595838000ec49609b763d604be0d14aadd15522d9", "ref_doc_id": "16ac06f2-a3b4-43e8-b3d1-5f3690d392d8"}, "2f8e5cbc-d709-4f97-9eb3-c33c4f6089b5": {"doc_hash": "dda35918a7bd8c1ef34dd3354505fc1d3ce289c06ff2705e2fd3c5dbdb4daeb3", "ref_doc_id": "4098719c-bc0b-43dc-a9a9-8dec11ca74ea"}, "aba44502-f6a3-445c-b105-92557e2cb376": {"doc_hash": "415e01f1b09a5418368ba06f0229e0f4291a6bdc7e9f42ea7672149c69c049f6", "ref_doc_id": "db0f6059-bc1e-4c5e-9470-6d80717499c4"}, "ac9137ef-7c1e-46e3-9143-beafcd3da67a": {"doc_hash": "a151ba4201e9d7f0db9bb0f6b2a0201cb710803918e6b4f3af921dd9ac46a32c", "ref_doc_id": "395d74e0-4a3d-4909-af58-21190d5aac47"}, "c292920c-cb99-4c20-8d68-9dcb732d5bac": {"doc_hash": "0d0431ea64fdf82caffaf4c067449121f7c7b301144656e65bc145f6fbda6dfc", "ref_doc_id": "6eec134f-e7e0-4127-9590-0435c418ab26"}, "9eb68db3-8351-4f6a-8d06-e7feef6f823c": {"doc_hash": "6dbdef6d37fb47fa486d637a17bf356c9fee576a62447b88bc177d0311d3b831", "ref_doc_id": "8e68cf70-da3d-430c-8652-0dfc6b229d81"}, "9e11a70c-7933-49b4-a24e-f25595f47383": {"doc_hash": "565fb74c5ccfc51519bea7da803e771963a53ac2f0cf1de9eeb7d534ee846b17", "ref_doc_id": "5c91be46-4c92-468a-a62e-5a58aa1ed438"}, "c03da7b4-34e5-49da-bfbb-c4ce47db7701": {"doc_hash": "c0517aecd7b5bd68bdac1d18b329e770f18a104a1e6cbedd4f75927d65aa0790", "ref_doc_id": "aff23f75-465e-4de4-9621-545c33fd25db"}, "22584e2e-1751-4180-9ea8-cccd1ce346d7": {"doc_hash": "c1ab0be56fbb9892fd6bf168293c3da5100edfb79ac256ec60e6fa57653124f2", "ref_doc_id": "31f40556-d89e-4618-a099-21378c60ab41"}, "c795783e-813d-4782-ad07-1d63c3c0a16a": {"doc_hash": "75230314ccf2287dde4a7519f45c7bb8c54458a718e45fb5f72db40e9823fb5c", "ref_doc_id": "515ce81b-4cb9-4c33-8692-d963dc07dd1a"}, "cd1c2873-0830-4be7-bb76-f2bd378549be": {"doc_hash": "9364c4c6d6b921517dcb8795a319af749970ae2fd9068bf8883be1dbd78112af", "ref_doc_id": "cf7dffa8-b7ae-4665-b417-e3c40fbe1eae"}, "be998169-9cb9-44d2-981d-3b067fcb16da": {"doc_hash": "fdcb58701b4662ded95ac7edffd991e82b4a81e979cf0ba3e21f50026c7b9828", "ref_doc_id": "2ce169af-9c75-4954-bd8c-61e9e547d4d8"}, "88bb1d0d-10f9-47af-98bd-7b2ebca567a0": {"doc_hash": "f075af929f3bbbbee1274a4b3126a20bc48cceb4c9ec0352af92048739204972", "ref_doc_id": "88efc990-3a38-4ce1-bcbc-e0dcc9dbf796"}, "d3687edb-7690-4a3d-81a9-fc5713f3ae3b": {"doc_hash": "e1fb0352c16ef54084d409c0a7c6b0b8e86604c1d6a11aec42fcc2a0874fd510", "ref_doc_id": "9e7f1bb1-68c7-46e9-a1cf-6bbacc756325"}, "69f65619-31a5-436e-8514-5a3358d7cc8a": {"doc_hash": "8f9794c59a413a310fa761ac3cf3e56acc9d876c220afa4f1b94c97492c0fcf3", "ref_doc_id": "f2e4249d-e15d-405f-97f6-d8018e31a218"}, "a339d175-9f2f-4286-8df8-b827aa8052e4": {"doc_hash": "827964a421a3eaa463b9821caa09150a6dc30b3ddfd46c37f782c0ab4dd86d54", "ref_doc_id": "df0bc6fe-91d7-4636-8ca4-3cb82145452c"}, "5c356633-8bd2-4c3b-96cd-dc3090a51ee2": {"doc_hash": "b8b8961a0e199dcbfc4a4ae811424615d192ba1edda2e132083c488be3f08f79", "ref_doc_id": "1b6692f0-8a9d-41a3-a424-2ab79a89e903"}, "d035fb34-e0bd-4473-b28c-e077f6366d26": {"doc_hash": "4d552aa934fce7e7e597a7814fb38653f18a208fd734a2226efdcb64e1d28807", "ref_doc_id": "4532fb0b-cf8b-4269-b405-503f8fb21bfb"}, "4d64e628-d162-4f7f-b951-aab596d6ac8a": {"doc_hash": "e15036e86785139319010d4f67582802ad7004f0136b6b6c2cf9d0c923182413", "ref_doc_id": "ca0defeb-721d-472e-ba3e-e8c97b63728d"}, "315b0654-5bc1-4674-8414-2c3e87a31f7a": {"doc_hash": "ceb53152e0073cac778c699ea2667e4b8bf81bb120071cbc780c9693a885c9a0", "ref_doc_id": "a7a37174-b2de-4619-83cb-e3b5b2880308"}, "3d0ba866-d086-4bd5-870d-5b2f92d40455": {"doc_hash": "c03814a1a101150706d2a7e1c4fd18c0bc6d0c9bd87339546022b3f6931bc9ec", "ref_doc_id": "a650ba24-99fa-4529-a655-6a9758b749b4"}, "6582dcb7-595e-40a3-a6c0-1aadef7ddf84": {"doc_hash": "1b294c88fe0331856c5e18960246c17eee44100d7a81c898001add2bf350597d", "ref_doc_id": "9aaafd07-0dbe-46de-a807-db2bddb5a1ef"}, "c1e0c52a-c5b5-4370-b827-d53c2b3a867c": {"doc_hash": "e2f5c3afc8a789fef020ebd8462d7f39d78bbde4170d9c727c31e753280ddcdc", "ref_doc_id": "a7bd2634-f8bb-4d1b-ac1b-35dfa5812c95"}, "6a611048-b180-40c6-bd2a-02336d3e8f15": {"doc_hash": "eb90671ecd8e2fd8a553bc0cfef20028eb2d618f12580aae82e60dfffaeaf4fc", "ref_doc_id": "d34d95b8-067b-42f3-b33c-37f03d4c5084"}, "350e660c-cc0a-4404-9499-c244ad0d4894": {"doc_hash": "c35f3ff4bc3b9590b412fcfca110ff15a6f677ae7b6d95c08ce5ba8b1ca21c93", "ref_doc_id": "c5600311-5653-473d-9907-f058f7dc1ef7"}, "02b27095-f917-4771-a801-c877a05f42cd": {"doc_hash": "266cf08d4885581d2129f6d7e2b7325636f29790355a05574139b993176fb92e", "ref_doc_id": "f82acea8-6960-4f77-a05c-8f0c29235005"}, "3ac32094-2721-4188-99f0-daeee4218072": {"doc_hash": "89ee5d4bcd0610ee5b457f48dfa86a2b75c734218b1d16d493da8f9be7f687c6", "ref_doc_id": "80a4a387-9259-4822-833d-f441f61427c0"}, "5ddd90b6-0ef1-4a86-b1bc-866f8a652e91": {"doc_hash": "3778b2177e09326885a3a8e887b19eb4f42764c7ef300e1f98ddb1997040e6da", "ref_doc_id": "5042599c-c5b2-41c4-865f-294fd1925747"}, "6d31e838-0687-4217-bea7-3fb781aa3955": {"doc_hash": "e06a0012501f84f79d3deea9c761d982dcb29c178bfdfb5e982b8b80c3adda6e", "ref_doc_id": "2e6e0ddb-3fb5-43f6-8ff2-6ff2db2bc415"}, "086d644f-2fa3-4f06-89a8-eaed7cd72d66": {"doc_hash": "5131b4735036f72b438006ab59c03659550c32323f355c0a9618cc5b346f5dfc", "ref_doc_id": "97fe2a42-c7f5-4791-ad62-fed15a8a09af"}, "46b636c7-e330-44a9-9aa0-780a8766a29f": {"doc_hash": "ff66f4f481d9345d245ef91800e6f6ba20370adbb2d8b6c7b4823a8db6b7eee2", "ref_doc_id": "c47da29f-03e2-4faf-8ef2-3ac153b0b948"}, "cd21c50f-3f89-4a54-b70f-7407feb6c49d": {"doc_hash": "adfacf2b1bad8265b2355cdfae18ec9b4db1449fd159bf6ed292d2d279e59ae2", "ref_doc_id": "921179c8-13e4-4498-a53e-7da71168f8c1"}, "0d9138ab-2b79-408f-9a80-d54b2858e3c0": {"doc_hash": "62630af1d3bc204747715191d78ed36a8d909a4f47a82c64f69814e9511e5970", "ref_doc_id": "820b7bb8-8cc0-4e8c-8361-b073814eccf6"}, "2b8574ae-5832-4318-9b35-9bfe1848d4d3": {"doc_hash": "40f69c2d88bd7796d89a37c38630397da74d08f5166d5cde9677b72662ff060a", "ref_doc_id": "1a5bd254-3c5f-49e4-9bfa-0ea7c3d3b5d6"}, "048e91f7-1f34-4108-8461-7357f411ec8c": {"doc_hash": "c523f996152b654596641229fcc179733d0cc27c33f53e9decc8f493eaf886ee", "ref_doc_id": "9e634128-7380-4a31-a476-e59b006ae219"}, "fdb3d070-5f97-42dc-b203-42e13a390eb3": {"doc_hash": "9303bb9bec1ca9692336aa22d58f04df5bc52f9791b9816084b7d083f320df8f", "ref_doc_id": "c95dadce-0036-46f6-b922-f1f7b144ab7b"}, "79964e7d-753c-4bcf-9ccc-0857a8ec6fdd": {"doc_hash": "1f0ea1e5f21593bd2d88e8a1a15bf67d6c55e143ae72ee2e54fa9115a5f4cacd", "ref_doc_id": "b282b006-a3a4-4a9a-9568-1d3813d96331"}, "36599981-7c10-4754-bcbc-fa8c3a4c5250": {"doc_hash": "b30fcd93708f124315c1f37790e08d84fc2ceb59e02badacdfec521f41686a56", "ref_doc_id": "5083885a-9e33-4ae2-be1f-52c17e1fa7f8"}, "768cde1b-338a-449b-ae05-e9bf33a98c95": {"doc_hash": "96d408b47f58b79774a41d7754588ffc1c9fd2f86128c638a0cd581907594be1", "ref_doc_id": "09a94798-b5dd-4e28-9466-2b11935e44c6"}, "437ca213-3e31-4af5-a4af-ba1545617685": {"doc_hash": "0e1fa2c470a8627b0d480a186f370c359979947ae3e6278a101444d310baf052", "ref_doc_id": "a85ae421-1251-43ab-8257-3fab2e49558d"}, "208ec19a-4dd1-4e8f-808b-3ee20326c850": {"doc_hash": "5e435aee6b975be2a888b6baecc939e11b54008386f6340c46c720657bd67cac", "ref_doc_id": "4f75d18a-c65d-463d-9461-119a7a3b82fe"}, "dba5a09e-73ff-4b8a-8324-6d947a264f4d": {"doc_hash": "22d00a0647ee8aa8ab8f90fe787ffc3972f5d3873eb4ee1d1dc3a5fe5a1e2290", "ref_doc_id": "f716064f-54d7-4f7c-870d-db6731765726"}, "146f4ac1-4a75-400e-b4ed-a42d86c03abb": {"doc_hash": "fc2c5d130f51027b6486264dc24c1b663165a8b68caf716c8f8b6e9b2f3fae71", "ref_doc_id": "74b779e1-c56e-49a1-8d6f-f85520d7b423"}, "afbdbf0b-6cb8-4278-a79c-ebba78488041": {"doc_hash": "cfaa619ece89cb4a0fd69191c593f45cf813d7061137836c3d3b5dfb1bee35b8", "ref_doc_id": "da89ba99-0217-4f36-bd95-dec10a8a8807"}, "9c3c0c97-2d33-42b1-8414-2833b98aa0a0": {"doc_hash": "74096bee67e24bd37a117d8d3d8e18c6098b55b45697010a57c641c7d60b2eb8", "ref_doc_id": "fe17b061-dbd2-4cf9-a76d-aed523ba3e70"}, "ac44f9b3-890c-48cb-9525-3c59b89daa19": {"doc_hash": "14f72b349e10a186b9402e25d4248a98daef6353271147b562849c33695759a0", "ref_doc_id": "d2de1fa2-3ff9-47cf-a2e0-0ebc5f0b3ab6"}, "bd98800b-5875-4fb6-9ab1-4824d1d8fd91": {"doc_hash": "87431c88c3200786c5e49dafe5272c9a15fb04d606167d2f4c39ec8a99941323", "ref_doc_id": "884cb8a4-2841-4183-b584-7ff5cda2f74e"}, "effa2022-a3d1-4a01-93b9-897f0367d2b4": {"doc_hash": "b53e571012709ba127d7b0b63e8bebfff21b81d7c11efd3290fbc1a03d5de11a", "ref_doc_id": "3c8f4483-6048-46d5-934b-4b032c978045"}, "88c0f168-4f42-4fd8-8cdd-2252ca91cb35": {"doc_hash": "276cb9c9ee38ccfa8fe28e0cfc22bfcdf6fc2fb28607d3f2de018dfc1e6f783e", "ref_doc_id": "4b4ab300-c2c6-4867-a345-ebee1456000d"}, "56690117-6aed-43c0-baf0-21866cdea389": {"doc_hash": "300c3e727dcf0a8140c0521a128a8d3a04dc261602124ce5a65e540ecb0ebc79", "ref_doc_id": "43eaba79-dcfc-43a2-86d9-e67d4fe5b27a"}, "a2e94e84-706f-4a8e-84f0-76447c6ade76": {"doc_hash": "02b7ccba0b79986e5134f0d8f7668c81b886918664044fda03bc089c0c1d0764", "ref_doc_id": "af36c7fe-2446-4921-9a75-d542a14d1818"}, "d48b967d-868b-453b-94ba-7d2db382b54f": {"doc_hash": "69b58068294d0ba13820656f4c64830cb7bd4b303d03f91511fc794a9106ff09", "ref_doc_id": "807f6830-5174-48b0-85e2-1e4e94baf25e"}, "ce03992b-30f2-42f4-aa58-5e12f9caca19": {"doc_hash": "8e8a0045513dda26d94de89010ce20400931ef9f63dd25d2f708991800d1606c", "ref_doc_id": "4deca681-0f42-45ca-864c-a891f789d3a0"}, "0a3db01c-a9db-471c-bab3-85a7345788c0": {"doc_hash": "10668657bf09a0d19ddc1d97588fa058d7580faea632d41d20c4bd44c5987a7f", "ref_doc_id": "a3c57a4f-3b7f-4752-854e-1402f2d8e1fe"}, "e116152e-ccd1-4eed-aa75-3f3b9803e491": {"doc_hash": "89c4a0d6ad2175f0482f832f97a6fbb24a6ba49a9d12e111a1dedf912c8d2d39", "ref_doc_id": "cecc755e-4e1f-4326-b872-70d8416a8089"}, "8ef4c21e-70d7-4943-a4b8-cd45d2202813": {"doc_hash": "db2634daf3470bae3276423787fa4960fc5e7410f11685b6ea5b7c4eae3874c9", "ref_doc_id": "d6cd24f2-26db-4ed8-a41c-977b84d21f43"}, "36039e26-b65d-4e63-8df1-9e8924b4c2d3": {"doc_hash": "ad3d91ff2d78ecc46f8efeafddb32895e64b5fc5c05080689725552ff74beb39", "ref_doc_id": "3cab2bf7-6485-4244-a1f2-66a920a972d5"}, "399e1b13-9b90-4a13-ba9d-7e770c8316b8": {"doc_hash": "e68c5b583087440b3964b135aa50dc5a37a20c6c6d3412625bcd502b2bf44458", "ref_doc_id": "b545e59c-7d2e-4083-942b-1bb5a07252d9"}, "5146e307-0663-4bd3-a4b0-2a78e3c6b455": {"doc_hash": "8dadc201e4d53dcde875c02feb9b7a0b1ff62ea73964d14af710429c61a1e56a", "ref_doc_id": "174a73e0-48ee-464f-b096-d42386dce72b"}, "2dce3d28-64d9-4aec-b228-7be44916c007": {"doc_hash": "b650e2e1871418b2d57bee7fc21180f568990a07b865113919bbfe5f2748f477", "ref_doc_id": "b4256e63-cadc-4267-9e50-0d9a3ac6e583"}, "054cc4bc-ca4e-4932-8ed2-f176ac82593c": {"doc_hash": "dc7a42485eb7b5d8910c78ead41ef4425b405053e69b09fa6f5365f23956af81", "ref_doc_id": "58a98e6c-6583-4c89-9d2a-4f6e3470136c"}, "582fe9b4-52be-4449-a8bb-1b0c9424c05a": {"doc_hash": "ea9c144f17f6ee2df6f9841a80f9997c81daac2322ceab84478bd9f493929b1c", "ref_doc_id": "dedd53a2-9955-43a4-b487-b2079a3558eb"}, "25954946-06bd-44e0-85d5-cbfa29f7b6b8": {"doc_hash": "2ad860a4a1fe3d3dfad3aad1f28ebc1265c2cd8e3331ff2d0a530bb7fd00a1c6", "ref_doc_id": "5f68319b-4c0d-4d78-8e72-fdaffcc68721"}, "97d8ef1b-2cdb-4bbb-bb15-0b00107dee59": {"doc_hash": "4fd401c3be8f82d7177741f087197d26d9b3a9c7cbddc73931461cb01c19f477", "ref_doc_id": "10c3b9d1-171d-47f2-8fa3-91ed85d01645"}, "d7d70d22-97a1-4573-9ecf-253d1d3bf1e0": {"doc_hash": "8ce892e425222f50a1b4142887c9d9b6abd167131540ab70e7465a63aaf17daa", "ref_doc_id": "544f69fa-b053-4b1c-9703-fa89c2a02c28"}, "d1bbf49b-2281-451a-b7fc-e320974bf014": {"doc_hash": "41a7f48257e0a44880592ffb1279c8ab988658d9d1e976c4756ef28dd93d8b1a", "ref_doc_id": "fd7499f4-2259-44b6-9b27-42746c425901"}, "6218d87e-b417-4a6f-a01e-a0d228cdd9d4": {"doc_hash": "f001f0122be965d1321f6124615ce81449f0a562f40f87bb741a3bc9acbeabfa", "ref_doc_id": "966bacbe-d9e7-4dda-b7ff-7e730254403e"}, "c8c48b14-9549-469e-a855-d6ca729d02c4": {"doc_hash": "9b6a5727a30781210ae21d76f9cfa2a20f47e9179a121a5959f8fb8b5f07d695", "ref_doc_id": "ef812af2-ba1c-4900-82b0-4ff292578afe"}, "aaa35494-00df-482c-ae36-408b50eeba13": {"doc_hash": "4dbf5601625e6dc239a227fb027e481ded7dbf0209cc2739c2dc8868cff51097", "ref_doc_id": "510c1dcf-5ff9-407d-a25b-6f6fce06cb11"}, "c086ed68-dc79-4426-a026-ca1d4361b5c3": {"doc_hash": "5b84f3ef8d61366cc33aa692693e1391296167e9ac1fd385de09b3f5fee2fc4a", "ref_doc_id": "8a81d30a-fb05-46f2-b486-3923c7966585"}, "f2ec1d4d-ef35-4f48-960e-14ff324b773b": {"doc_hash": "fd7e2956e7ed9d2ecc1c3e590912b0a6f714edf5a54a02d6d42e8d6561cd825d", "ref_doc_id": "45bbce71-1d4f-4777-9b76-469978086d5f"}, "a3651ada-701c-43c1-81c1-c68827a22ba9": {"doc_hash": "ead4f499a33a734c247991d7c77ba5702d16ba97033de2c478c2c61294ebe143", "ref_doc_id": "31f37692-0992-49b9-8919-c24d914a667f"}, "6524a92b-3aa7-4d49-aab4-b26473ecb489": {"doc_hash": "b6192ed136b6ef82758c122a13acbb9af27592882e0cb09b637e327b3c231e2e", "ref_doc_id": "c6f9c487-c132-4e8f-9115-a0247c8a6bb0"}, "e04a8cff-3fc4-49b4-ab5e-ae34962a56f7": {"doc_hash": "097026420b23ba02d98e084658a08d96a967691ecc35d22d5068cd65a523e533", "ref_doc_id": "6c73d408-bf30-454d-876c-020652c30d26"}, "292ebe4d-026c-4028-9f7b-d8e70bf4dc26": {"doc_hash": "ea287858b9278418efc8af2182154aa5e3104eea01925d173957e581206ba19e", "ref_doc_id": "e5fdc819-83a7-4408-b9b3-d9603860111a"}, "1875fec4-33f1-439b-8717-6d8abeaa6b35": {"doc_hash": "c8662a92810a1cb6d93e31873d3f11ae59eb4d0509afe5423da5d1b24a710e18", "ref_doc_id": "7c0e5279-d099-49a9-a1a5-c6bbc4de70dd"}, "3def36cc-7ce6-4b6a-8073-a398a5ba7416": {"doc_hash": "ef9a51f94bba0965ee6626e5577c83ea36f9dfadb34c6ae0d93f3a34eaa3cd4d", "ref_doc_id": "9b745e95-5f45-484e-a2cb-f1f51ec7d7c9"}, "c865e206-e2c6-41bf-ad98-e9132218de45": {"doc_hash": "2c32e2437f56aa557bc1aa06cd5058aacb02870dea26d99c7a92d3baa84db397", "ref_doc_id": "dacde70f-6303-498f-88c4-228258ad41d6"}, "0aa5601a-76f6-4cba-8d45-a59a9c7487ce": {"doc_hash": "44757af8dcb0e447b17292a3911dcb9934c6921325101ad5cde007e92e86c0ca", "ref_doc_id": "c643571a-869b-41aa-b4b7-642c04a97188"}, "266f9258-2e26-41bb-98b5-148e40dbddd2": {"doc_hash": "66aa0a89631c771972c0039c418c1bea3bb65a635a61d09b03358c993452783e", "ref_doc_id": "544b24e7-9c5b-4ad5-b763-a94d9c2f994c"}, "c4662c05-8b90-4253-afa8-deb2f3bf7d04": {"doc_hash": "d5334e583caf2d9304f3e4f090a60c4b03de1687601356429f2e073d9b6bd4d1", "ref_doc_id": "4ac916dc-319f-4d53-98fc-291a6745fcd1"}, "cba63cd8-c1e7-4c53-9efc-ad0c6248575b": {"doc_hash": "831e24743029b5c072af4e7ab98f8203e868f002b8a090f7c0191bab128e2373", "ref_doc_id": "4b3cc256-c207-4841-aaf4-6aeb02f3594e"}, "8e9a420c-457a-4ccc-8fef-a33a80b742ef": {"doc_hash": "20a3da7a0835675a512325f80aaa1395b81c742ce39b829ae7fbef2aee730e08", "ref_doc_id": "6510f538-9d4d-445f-8c3e-8beac6916d13"}, "a4d96eca-a09e-4053-adf2-909de068a966": {"doc_hash": "a5023307fb8aa26e02d5c5d21209faebd6fc76b16ae2f4c534494457d4fd7e5f", "ref_doc_id": "6510f538-9d4d-445f-8c3e-8beac6916d13"}, "0ce22cc3-d2f0-4f13-aaa7-a6499b2e5c66": {"doc_hash": "dffec1862a444a867d9647853fdc8432b5ac833d9233d533ded1413ce8171879", "ref_doc_id": "482d3eae-6f93-424b-a9bd-f48f4f155571"}, "83ca32df-ebb5-439e-9950-9d1b38d734e0": {"doc_hash": "1094bfde340a5c3fe9a840a1e1f06a8051cc981dffcd9f51e8ffdbf11853a9f6", "ref_doc_id": "482d3eae-6f93-424b-a9bd-f48f4f155571"}, "7c6df006-37c7-4905-b5e8-862cd798a946": {"doc_hash": "c75187386f85bed0ddb9938eec3ad4bf2d9ae8d9a0eb06861881774950ac4705", "ref_doc_id": "3b3bae26-2679-4d69-b4ac-241fad854b4a"}, "ed5c060f-3acd-4c08-b953-cfd0ffc4eb7f": {"doc_hash": "17a6ac6bfbf4b70f46f4fd35e132136349680e01dc6fcc2f352eb89b6a35dad2", "ref_doc_id": "b96b03ce-619e-4b51-a791-a81aeedb0b2e"}, "4f19a4dd-2c70-498a-8739-6f7347008a6d": {"doc_hash": "3afb3b4ea7c1757f5a9cdb3addd27e77d2ee08104dd55ea9489f8920c2cf8899", "ref_doc_id": "0f560b38-6656-42ea-9cac-25ac01665a69"}, "1c4df0fc-d6c1-46a0-b2f0-b0048b80b31d": {"doc_hash": "59e91432df746d6480b30cfee04f92add9ace6666f1c856c425b28074e6dc130", "ref_doc_id": "9219484d-514f-46a0-99fa-8a83302f3717"}, "770b0281-0bc7-453c-bfde-45051bf615f4": {"doc_hash": "467d287782ff818c4dd0810b609c0f241db543f19abd1f8d7ff65202e4678056", "ref_doc_id": "03bbb391-4b4b-4d5d-a7fb-4563444c9d3c"}, "e9f2d3c1-ea76-4ef5-9b7b-6a4dd16b1460": {"doc_hash": "29a6ff3e6f1b9aca8145af0a72487bc405f3578626deef43f26b5c2be88a92ce", "ref_doc_id": "59d89076-9535-4e90-b0bd-1f17a9a40fd5"}, "ef65b35f-6994-41d8-9b53-d42c9d901d82": {"doc_hash": "69d1f0ffa00980fe6300bd4c4e710a8e54394294579ad5a7cd6e4a654b25ade7", "ref_doc_id": "5ced7010-2d4c-47d3-a51f-4f9d3c421a23"}, "9c14e2fa-59f4-4276-a693-040506d7a050": {"doc_hash": "2780fc54112f7b53791bba54acaa77faad986b2347ee6aab2d801398166baea8", "ref_doc_id": "a706f6f5-e5ee-4ff7-830a-4ee3707013f4"}, "3917d8fb-1219-42f9-bfff-a8c4fd32de3a": {"doc_hash": "189988d8e26eff0e6be0d9ed55ff7421080bc95bf516bbfba9de228aa5f51fdf", "ref_doc_id": "4805c533-3b25-4edc-bf61-49a4bccb5ecb"}, "1bd2f048-fa74-4899-afb8-6cf350ad8360": {"doc_hash": "86e1b2064438dce02a5015b5c3d4f878d193f73add2105ae26402df33bcf887e", "ref_doc_id": "e52e8c07-f7f5-48a8-ac35-02b9add8bd47"}, "11552297-9775-4182-877c-cdd447200c6a": {"doc_hash": "747b6129ec2fa788766be9c28e7a2561fec9aa9c4939ea8b7b608d3a447163f2", "ref_doc_id": "9c59b63c-fe5e-4b6f-9fd5-b1049d2baa06"}, "5359b1df-7b03-4348-858d-0f38480af92b": {"doc_hash": "67921f0672bd12ac34abaad5d0a6882a9b037232014af24c9f44a7cefd690874", "ref_doc_id": "a7efc45e-2821-4e4e-993b-36224131874a"}, "acec41fc-1d9c-4fa6-825a-f4af1b11cc95": {"doc_hash": "41b43cef4c70175a28cc5ae215e39e9322ca29812926f7a6bbaa197eccfa532c", "ref_doc_id": "8aef6527-0a81-4f37-bee1-eec9b48a2eb6"}, "ba0ffb7b-ba0a-4742-b09e-29a347f58953": {"doc_hash": "773dfc028838f8f61940dd3aa37106d1734b3570870da3b4c3d2f9bd302ce3b1", "ref_doc_id": "81eecd6b-b598-47bb-b934-87e50e9ec70d"}, "bf856344-20bc-4910-8446-84ac2d0af108": {"doc_hash": "b5c160cbd9c43af982f61d942fec453006c975d3fa846ad0f6f2d4841276fad9", "ref_doc_id": "84cb59ad-8699-4c1f-a8d3-5c769454edd0"}, "16bea5c7-26b3-45f3-a36e-d40916854ca7": {"doc_hash": "ed214848e7f4a4c78ad9b3412c56e2c792678a258d4ac25cc8abc8e3ba915292", "ref_doc_id": "fa4c7ccf-727f-401a-93e5-7211d33e0564"}, "23627685-7dd3-422b-a345-ed6ce85f3dd1": {"doc_hash": "8f6c63a0931b200fa4abffc09c45f70110c48f4c2875e2ce620a897d7e609d3a", "ref_doc_id": "4b842583-60ab-45f8-9251-7bcc388758a7"}, "ebfad792-9703-435e-97a1-29407e16dcdd": {"doc_hash": "4897a87f48db6abf9551d70e6fac32ff7c80e68323c2683a39807a14b607b76d", "ref_doc_id": "b9346e9d-e13f-4afd-bdca-adeedfd3fc61"}, "19cb383a-6e7d-45e7-9a77-5d34751699ec": {"doc_hash": "cabaa45e4c1ae4c8c40803a1bab13e5109dba82c60c794a5dbd4b93a7c18c82f", "ref_doc_id": "436fda78-8e7b-4ded-a029-eb6d6a121339"}, "cf2802a1-d684-46d9-9c84-564caff4eaba": {"doc_hash": "5dfa3ef804f7207d9ff6801c2651bae0c91a35d8809794d8359e7d4db15e5da5", "ref_doc_id": "a775a1dd-094f-4d00-8f39-f1cc79afe210"}, "62594afb-fb73-48bf-a325-b47fe8340cfd": {"doc_hash": "8420c1324a10ebc8e063029107b9ac4343a7cf65db494bb18ccf47a1a967d077", "ref_doc_id": "a383b9ee-818d-443b-aedc-6a61db937df1"}, "968bea49-ccdf-437f-bd83-1ed8e24a6c35": {"doc_hash": "1c8e406a417314cdf686bba2a806ada64d45295ce8fcfea41a297d62e6fe527e", "ref_doc_id": "6373c8a1-70fa-4cf0-8028-a46de1e70f13"}, "d036c21c-9f61-4b53-8c16-36a7d3f915f1": {"doc_hash": "fac2cda3ff7a28d888a9dbb5e2fc54d43de4521ce200489ba13f219e88a51eba", "ref_doc_id": "11eaf81e-caac-43ec-817b-ff6cfc101f98"}, "71bdcd9a-c8b2-44be-a385-de930f68a9b6": {"doc_hash": "f954d810a7904ac11ede2dca42d3b67841cd6e74dfcc0a50591b5fcb2a9d2dcd", "ref_doc_id": "56282b31-05c6-4fad-b366-5c27e8e7705d"}, "ef9029fd-114b-43c6-a537-77f1fec04d95": {"doc_hash": "3a8b74caaadc81c650bb45159e240eeb53d7e70b1d617761b9f52cfa60bbcc83", "ref_doc_id": "40ffceba-1735-4058-881d-47ed34d9435d"}, "62cdc4a0-c6ad-431f-8f82-cba2dcdc15bd": {"doc_hash": "05d99acf7dcf1203aee4476b5632da9c04dbdde3fb863e572ff0a844799b300e", "ref_doc_id": "f7d2b211-732f-4d96-af71-8f3d76bcec6f"}, "f82596c3-c19f-40f7-8828-b84ffe88b6fc": {"doc_hash": "6b930269ec89bcb1601d82a17a7c788df144a1a6dbb3055738e0205f363cc0e5", "ref_doc_id": "ccd87f54-0401-44d3-a6d9-4e7d0f15e92e"}, "93596e62-e3be-4ed1-bfc4-94a314039bf6": {"doc_hash": "64b279e562c0b796ae88857b5b2e768d08d62cfc129565a6d79ac9c9fb11c28a", "ref_doc_id": "bcfcbb84-3773-418d-b919-584da9309e02"}, "3b357ffc-b856-4212-81b5-0609dabab13b": {"doc_hash": "c4c1058da54f592c144ca228fcf56c6d8026451b4be20bff9f30e8d17c983630", "ref_doc_id": "e961ed54-2513-4b47-8af9-3d930b6c4c2a"}, "ae916781-e6be-4272-9c54-45db2b9a664a": {"doc_hash": "90e9a1dff240ed611c15e06340324a2349929743a1c2a79e6bf325c23999004d", "ref_doc_id": "c88d1f96-f076-400d-b3f8-d2aa917ed864"}, "c08db8e3-ab5a-4c10-a9ee-e2bb85709daa": {"doc_hash": "517238f0138b2710c7882fb6e864e56800df34a70283a8b85803f42792c1c9a0", "ref_doc_id": "23bd0390-9873-4f79-b39d-7986091b95c9"}, "9a36e625-f683-4a1b-bbec-697b992794f7": {"doc_hash": "78f926e5f3d456624f31a91f598a29c511d9411b6a066308456fc33996207959", "ref_doc_id": "e4cb947a-e679-4dc4-8731-da11ef37cf79"}, "33a25cd7-cf85-4263-a8f7-102d86cfdadd": {"doc_hash": "6cadd9f345ab8472411f96b0e6c9c82c92610de99510fca13a4163cf62ae585f", "ref_doc_id": "ffd50294-da1f-49db-a69d-b11603a71f48"}, "7fd25ab4-ea61-47f9-9033-ea67f0d49324": {"doc_hash": "3e235e1595abf124f2a7a63025a279f2e4e2436333b5f3bb66b3ff7e5aa4aedf", "ref_doc_id": "61965537-de19-451e-a2b8-9a50a00ea209"}, "75a33a43-b930-4877-846f-c5d310c1c613": {"doc_hash": "881217efa3eb547a4d28dbdc0e2e7b3e33e8ea260b0d45263ca4a04977818297", "ref_doc_id": "3cfd0ae8-d695-43f3-b76d-e9aad7687d5f"}, "7720db1a-981a-439b-910c-7610f516658c": {"doc_hash": "76e15a8af864512f6afcc77d8fec77c6f246ab9b7144ac3d919ac6bbc9e54c67", "ref_doc_id": "66b580d7-8fc7-4173-a9b0-017b9f33f715"}, "67261a6f-041a-4255-ac1a-372398279eb4": {"doc_hash": "3b3039f127f219eb94ed89a369cebc38fc53fcad768a69b036e8ecedc78826ce", "ref_doc_id": "0d870915-aac8-4d37-b3a2-5d0d8e5684fa"}, "057d0cc5-390c-42a0-9179-9aa280b54655": {"doc_hash": "5f30bdf8a10777b606f882721c29c62b20637689c00c58363766a4cce38d286d", "ref_doc_id": "250c7ab8-5d0d-4b6e-8f13-ddf200acb4de"}, "b830e29f-0025-40bf-871f-5a248ee05e11": {"doc_hash": "30e3753ffabec366638a5cdf14ec37d174a9a57d632a21ae0fb204cfec3e0464", "ref_doc_id": "0b4c10e3-330e-4e9d-abb6-2270e73d033c"}, "f82950aa-13a3-4d92-8581-3f337b8ca2b3": {"doc_hash": "0a0f4f8b1c417ea6e1486cd0b2547731a5d626826eb37d7a7f3709b2332002ac", "ref_doc_id": "218850bc-f4bb-4d34-9605-5e32f0eed11b"}, "92714847-823d-4e9b-a692-ae772e3100ef": {"doc_hash": "e10f213ca26eaf38a1a7df8c86eb68b53fece797b48acddb092f862ce7c7753c", "ref_doc_id": "3d966de5-0ad6-4fc5-afa8-d5fb5bea8dea"}, "fe6acd69-aeca-49b2-8e58-abb529861667": {"doc_hash": "29921aa7110658fb6edf1275971d2481883e26cafa793a89971de20f41670d24", "ref_doc_id": "d46063ca-d326-4e2e-8d41-3d1e45e3e916"}, "ea08f880-5959-4f42-843a-759909ba4627": {"doc_hash": "9d31a37839a91a8dde85830adb90164456793e42996a945dfa0f5002a155231c", "ref_doc_id": "618f0b0e-0280-4ebd-b425-573356244342"}, "6bdce02d-1170-4c34-bccc-cb1ce2ee6e95": {"doc_hash": "eb0b3ebeed7359a55b6cb86afffcb1c06b599bea1faba2c00807a0a13b3d0b10", "ref_doc_id": "6b93020e-4ea3-4496-99e1-afbfeaa282c2"}, "4af395e5-fbed-48ef-a802-384fc9e326b8": {"doc_hash": "d78a948fe25f197cca191968f0995717044438be12ce9bdcc4f1cb391b1c5b32", "ref_doc_id": "04411f5b-c85d-4e3a-afbb-8f8ca753af40"}, "2354cce8-c467-4733-8f9b-7a8e46a8902c": {"doc_hash": "d98e087e661e84e2baf618fef8d92c24ebbb7063d402b30fd64031c54c443927", "ref_doc_id": "89279d59-07b1-459f-bed9-7601d10cf5ff"}, "c8df2a36-4b2c-421d-8de4-58bc4ff3a7b0": {"doc_hash": "edd914c1f376d63acdc697dc6ef3665bcf3a6b191df7b211d6e5f96173751336", "ref_doc_id": "ef37630a-9d87-4041-8339-9d48ef7f8923"}, "9dd70010-7db0-4566-875e-8974383537b8": {"doc_hash": "14e6638ab4582fab7afdc4e761342b8f05ceb2ab40072f73cbcc3f286bd03cbd", "ref_doc_id": "7fe7fa3e-23a2-4076-bdf8-e92d32af9bfe"}, "b785d575-d7a2-472c-8328-30337dedc998": {"doc_hash": "86c2dc426b3321c3ea0534076976f40311272a0ea3ca47cb966ec4135104ae52", "ref_doc_id": "26aad095-9fe3-487b-b7cd-233458e193e1"}, "7459cb47-7189-47c2-a2e6-f9e8ad28f77c": {"doc_hash": "47f201014ce8bc867fb699ebca1cfaa4db2c2e7301ad2772cc4ee7febf6994bc", "ref_doc_id": "94cc97c7-300c-4ecd-a8a8-afd424e6fe58"}, "3e0c3e02-8db7-4ea5-b8c3-05cec088f1e3": {"doc_hash": "078f4cb35a460303abd218412dfb619efeba5ee45369387c7eb70127000e70cd", "ref_doc_id": "32e6b1a4-8f47-4d5e-ac52-0b5af7f73a06"}, "da8fad0b-a3e2-43b1-b2db-0cc2680e9654": {"doc_hash": "16ae14e423138b24cc9fb247f09326cc4fb281fee1e39d45b6aac8a4e60e1cc6", "ref_doc_id": "cf9febae-13d4-4a70-bcbd-b5b361261269"}, "34f48f9b-b30a-40d4-8b21-d1df1f577275": {"doc_hash": "26bd75d0501021e33e4cf13a3fbb1450acde76729ddd66372acf3a87c98ff1bb", "ref_doc_id": "f843f40c-ec1f-4f08-aae5-447eb2f53fd0"}, "cf3addc8-8a38-442f-8b55-0a9bc128f7e7": {"doc_hash": "f6b285e3122baf16584a7fa59de47b8ce84324fe7a51b5e432a0222acacedfbd", "ref_doc_id": "afb7f9b4-0557-4b6c-abde-0615f548a017"}, "d436f246-9f9a-4f36-a242-1dc088c921b4": {"doc_hash": "c160c1118137058ebc65eb62b2142d7f0ba4888a5847d67b99f37c62574c2759", "ref_doc_id": "44cf9109-923b-4e43-a620-986b8a529727"}, "69b170a8-a1f5-4ca8-aaf9-82fed26ce484": {"doc_hash": "2831c6be1f74d4ee5385420549df3feb1400067b89316b70fa7ac38b0d65027f", "ref_doc_id": "2017b307-5093-44d6-bcdd-85767ec7023e"}, "b745cec2-2f12-41ec-8bb2-9369706c16e2": {"doc_hash": "3ec918b75c28b81615d33ffa9c2fac9a1e600c20ff2dff11f9e648cf92f269e1", "ref_doc_id": "a13f7229-c6d5-421c-b873-6f6ba0ea357f"}, "0e3720f2-238e-4ad1-98df-2e3216f0877a": {"doc_hash": "7d7a9e45772108fcda597a6090a4998e939dd5201e6d8cb06f28ba6f7c1676d5", "ref_doc_id": "258369db-6c9c-40de-9132-6b93d5c87879"}, "e9baef76-3520-4219-b948-3749a65f49ab": {"doc_hash": "a57d6bf1f5fb500e8aaba2b5e05a6a1ccee2b5ce25f89e877da598fbc1f897b5", "ref_doc_id": "d60374bd-9b21-4e85-8ae9-70ec300ee0d4"}, "771ec08a-ead4-4e8c-9fa2-d371b0c0747a": {"doc_hash": "cb83526305190906bb74b35c8ae0f0ce06d26ca102aad9a6e3c6da81c2c80ccc", "ref_doc_id": "16e4c4dc-0fd1-41a0-a1de-8edcfbe03f0d"}, "25291b76-c034-4202-b772-b21b04a00398": {"doc_hash": "660c80922a5b82aea47abdc9c05cf4719310572cc5a0f315409fb86136c34afe", "ref_doc_id": "0576b29b-5e00-4809-90de-a5d8d4ed643e"}, "92ff0a4c-3152-4152-871d-2ce28215f8e7": {"doc_hash": "b047639c863fd93a59d41e00f2e941ba35a6d606f7f66ee70e7a97c8a863a244", "ref_doc_id": "62f5c672-f3bf-4871-9ba5-1fab45527137"}, "2a657811-d7b6-4d58-8bfa-d2938b2a519b": {"doc_hash": "d8cca9289a427da243899699731d4fe09b90a42ff448fa58faadb9fb980ad6e6", "ref_doc_id": "59e085da-64aa-48e3-8376-04ff018abdcf"}, "70345a82-0217-471c-9031-5119e047d3a1": {"doc_hash": "87d2b16b1abedb61cfcbfd66f17594abb7bc3a100983259edbe3adaed126e33e", "ref_doc_id": "6c1b0711-7477-47a6-b17d-b611cc0e5ee7"}, "b04974f1-8e5e-439b-9d24-f6ae9b26b059": {"doc_hash": "14aca307d2ff2df28c9d8bbed44beb3be73dfe8009c2b7d7d3e4d724543fdca0", "ref_doc_id": "0ceaf771-8c0c-4a33-a6f5-f5456143c647"}, "5b8b1ec9-54a3-4031-8944-f5c76a2b07ec": {"doc_hash": "d18151be03226e7822e9c73ce785d065289e77c301afb15ec4439179a8a8c7f6", "ref_doc_id": "e0b19272-5427-47cb-9bb9-95139ad8c3fc"}, "e302e844-2ebe-433c-b00e-7b25cebe466d": {"doc_hash": "4af63c3c8478cc1a6b8087c690e0aef01e6e8c2297fa745f3cf02cc9a3c7afb1", "ref_doc_id": "360f886a-27c3-40fe-83bf-2306d46050a1"}, "a1f2a676-06df-4fc9-a467-6660c1abebed": {"doc_hash": "9c600eab7d281a7778c38a26aebcb370ad434ab346babd14b656dfca72f7b1cd", "ref_doc_id": "5c49e22a-64eb-48d5-8876-811a6a5d8da6"}, "babd7430-5d88-48a5-ba0b-769f201af186": {"doc_hash": "27f02cf3820032f458d4bcb9ba829df1dd56de9ebdf8172be8b41d0911ccd726", "ref_doc_id": "59813012-8b2e-4709-863d-a9216907ec7b"}, "0de7fc24-190c-493e-ae68-fdba07b744d1": {"doc_hash": "3d1cac10e6e7aa4bb29b4723293a8d1774f2833fcd4f618c7a1cff454d20ce47", "ref_doc_id": "934b3f04-0fd5-415c-b746-ad733055737a"}, "5ebc8cc2-b0c1-40be-b08c-f63e1bf12ee0": {"doc_hash": "fb2c39b4234dd7b02cabbae402c8aa26583e32252f085d7598f7d50dfa7b7275", "ref_doc_id": "749d9153-134e-40c8-8fe7-cd55fc8e56d9"}, "8ba6fb9f-3903-4293-9514-9eb8adb0f1a0": {"doc_hash": "eb5fa0167e104a8b47b857d664fffe6ef5c4d999107c1619beee79a709ef28a4", "ref_doc_id": "84e62828-a4af-46e5-b397-637ebe5c1f77"}, "cd9203a0-bbad-4dd4-97b1-7747acb75b4b": {"doc_hash": "589b25398e1f1873df211b4f16be63441b957511457ae1c938f0531a718c04a5", "ref_doc_id": "d2b7d5a7-f229-44ec-bb73-a1f5acd69a3d"}, "8cc2d788-d523-48d7-87ec-40546b6a86f0": {"doc_hash": "884c277d1b6973e41ad9fc5c30fd021a9ddfe287bf2e951379b45db467329187", "ref_doc_id": "97ea8c55-3378-42a5-8d9c-d8a90eb5bf38"}, "1867fd7b-0296-4971-bfdc-a5288f55211b": {"doc_hash": "d267ee623af3f2a0160c3615f7b302a5917dc6386f39a5b2ee9e302e5f77d55d", "ref_doc_id": "6bbb5786-d069-4820-8cfb-ef41df5ebaf5"}, "f6dacc57-4ba9-460f-a22b-74d8d1aa919c": {"doc_hash": "790bd546ef9b4e016db0874d08eb186b9f692a964a52baaf0e30d108017dbbde", "ref_doc_id": "bff0204d-9979-4181-9a8b-13f87a5515dc"}, "37acf63e-e4ef-4feb-9786-bb13dc868781": {"doc_hash": "77b3f86221e616d234157ed9974e97255cedad9abd389b04f23b4f48ca8c4747", "ref_doc_id": "1849de7d-16ee-43e9-a046-b93ae74bd7c9"}, "2e04d189-3a71-4b4d-9ae4-8d1c837f4d39": {"doc_hash": "b785e16f889d5f3a9d6d01b1b0a2205c0a55bee47ec43c02ee6db98d279564e0", "ref_doc_id": "8f90fb16-e21e-420d-a1f1-2a1a328443e1"}, "3eab93a1-37e0-42f4-b0bc-cbacb783683e": {"doc_hash": "5bf15cd8080a698ec5ed33b6ac97aee90fe7fb3acbe4aa893b10785a9d03a580", "ref_doc_id": "45e3b0aa-015a-49fe-a240-fea8a328564b"}, "3da22e1a-3ecd-44c8-8b67-c4f3fa32fbfd": {"doc_hash": "74da2da02223ecd6628feb7f12eb2b65aa2c7fa97f0f445a4309a51176a3ab62", "ref_doc_id": "b9b2128b-d471-41b7-8004-9fb4f8c646b4"}, "c827e761-8ff6-4a77-8916-ff445c0ae97f": {"doc_hash": "0d50a062b57eaffb56800acc42fe16ede0eb289b30038bc3c7024fac19dd4aa8", "ref_doc_id": "f9e923bd-c5c7-45b9-827c-077cebe35dac"}, "65e3eab6-3a3f-4c9d-87fb-a8934fc64a02": {"doc_hash": "33c751f22c215be4613a039802344667120ee68218a5da1022298a5b4ecd4401", "ref_doc_id": "44d3251a-2d18-44bd-855d-d8cd31ac32c9"}, "f9e86776-5bfe-4cde-b500-95eca73208e6": {"doc_hash": "2fc574012fb2be50d1d267c88a3250241ca579b37942650d6138b1895d76ac98", "ref_doc_id": "c4bb568f-006a-4adc-a56f-5ec5b54f3438"}, "77ef3256-49b7-4f23-8640-a3a986a374bb": {"doc_hash": "ca66566bf43500b501e64a30dd8a61066c79e7a2cac06c441eb33925f285607f", "ref_doc_id": "e31c649e-73b0-453e-8092-0f94482cd098"}, "7cbe2f49-3d38-4f08-953a-54ff912c91d8": {"doc_hash": "9310dee8c89fd829adc2129a518fd786316b719a73aabc11ea957a382c7a187f", "ref_doc_id": "b99d4fc7-9452-4a88-a056-e71f2e9c8bfd"}, "8bcfff8e-b465-40a1-a6a5-77110cf7f91c": {"doc_hash": "64a1bc37e6801ded3419aee3bdf310e36d16e3b875b6682b46c4087d73116cd0", "ref_doc_id": "29a23499-5b04-4646-b1ec-73d6ea9241ca"}, "f2ef8d67-7f54-4bdc-9e43-9ce946af1b6b": {"doc_hash": "2539e927999852f33d95c32c8fc8f44a4f694ff3c1aacb571717169030337a44", "ref_doc_id": "416e82dd-6bc0-4ce3-97ef-ea6400ede39a"}, "a3d30657-60cc-4250-be6a-7fba88f9dbe0": {"doc_hash": "14154bc6c9bd76663484d712134fb274cb91ba18e3cb86ec1cfafec6d13a5ed3", "ref_doc_id": "5b8f4140-266d-400b-8e44-0a1add4f54ce"}, "b720dfda-1526-4c85-81e2-46b4aad1de7f": {"doc_hash": "8f379dffc3a9b8395a5f3e9372c819f900a3d07d8262b0762241d97472236d7b", "ref_doc_id": "42bfff9b-9c25-4385-acf4-244125f691e8"}, "8a4dd8a2-747a-404b-9513-4fe7830d30f4": {"doc_hash": "6e014e6925f31107c3c57c3e92b06da4f334e500a6a479c893abda47e8a7827e", "ref_doc_id": "2ccd8a58-b19c-4aa3-bcc2-c8b922fc1694"}, "3abc471b-6f18-4eac-b6ea-c18b4ec1a19a": {"doc_hash": "194d244cbe27d5a462ba9f6e92b24e755839407103a94713774975823793413b", "ref_doc_id": "2ccd8a58-b19c-4aa3-bcc2-c8b922fc1694"}, "a4c9f06a-62d0-4080-aaf2-760c78cf0400": {"doc_hash": "69cc2aa6479becf37cd5cf6d3d15370be7b1f6ea4e6bab7423234eef00537ff4", "ref_doc_id": "9d57e201-fe3c-46ba-85d6-f7559fbb1d0c"}, "554aeb20-bd3b-4e16-b481-6498d189933f": {"doc_hash": "44f985a68452cb4c1508e84a296c44933a59d822c3c0dd64bbccc03a15814519", "ref_doc_id": "ebff97c3-a7e0-4422-a33d-ec441c202fc3"}, "704aea51-1dac-4b3e-8f7d-e569d47bceb0": {"doc_hash": "9f24e9b8ce5d10c1152f29a6445725762a9810e640e4676bc9f0a329357b0aec", "ref_doc_id": "f7b53843-b7ad-494a-b357-28eda3ae9bc7"}, "fbce9b0d-19e5-43b2-a508-d1880a608def": {"doc_hash": "4a910ec3c8965cec6bdc94317532a9609d35f15d92cdd08d4df16128ca5fbc4b", "ref_doc_id": "cf8444cc-83bf-4fb5-824a-9311ba0090ab"}, "437e32e8-aa13-4b29-9877-c683b522e84a": {"doc_hash": "5ff29e0eac0a878b28a5e509a11958a3412b32450f4f5e47b5310f7068dddeaa", "ref_doc_id": "6cc43358-0eec-49fd-b048-dbc55893946f"}, "f244d19d-0a15-422a-9e61-3065b17cf690": {"doc_hash": "fa20ce910b45496a72470223f78b187f80741b97bb1fba47a97939ed30cebb02", "ref_doc_id": "1918193b-cc28-4ce8-bf80-30cc3f5c6c6f"}, "e31a00a8-2539-4b3a-9754-64267526b91b": {"doc_hash": "0e5513fc0961c5536fbe491af36e92cc39a759cf583fa33164c9f4c8d6bd1056", "ref_doc_id": "837f3afc-a706-47d5-9f1d-10d0b84b427a"}, "6225ff2c-d242-4f5b-a40b-e2217e03a1a7": {"doc_hash": "c10c09162acf9d6a2e0adb4e2271d931a26147bc606502a18c60571083c66d55", "ref_doc_id": "8461dade-a8c0-4999-8679-7110164daafc"}, "2e76d6bc-049b-40d1-9ca3-f969631c63b0": {"doc_hash": "d917042dc9e8f193af92aac0d78601c965972a8ede1f23b35d1f7784a2f3539b", "ref_doc_id": "6f5e62fb-5ea4-4e2e-9826-12f28138f0ab"}, "5942814d-cd56-47d3-8982-29bfe3186185": {"doc_hash": "d7b289c71513bfc15a312666f9817024217bcef814d4657d4504c570ba26c200", "ref_doc_id": "56776356-42dc-468d-8fa1-bf8805380591"}, "65415d54-9f43-43a6-85a1-48bf1e9d6212": {"doc_hash": "f2bdc5da2fcbe3733afbf964d030b7ce4e98b7ddb39e969f0321bce7cf5faaa9", "ref_doc_id": "47792a3d-13a2-4ab1-8dd2-137025fe3bfe"}, "41599352-2737-4c08-84c4-e2bf85bccad4": {"doc_hash": "df71db93871e1108faad7ed663f9fee1717c3fed061896ff192253692cc4c82a", "ref_doc_id": "e093c856-b912-422e-813e-50e2b05f092b"}, "39c6f6f6-c75c-4b2a-9e20-401866e441ec": {"doc_hash": "c1e37aacfbb01e039ec5bcf6a5e909cf3258669c26e1a9a131dc25b0fb99e544", "ref_doc_id": "1411bed5-47b7-4ef0-8938-f750b1ce02cc"}, "fed53ac8-ba52-4852-b451-2607b685d940": {"doc_hash": "a657696a04d29fe680a1e958bd61f23eb6cf80c9d248bc0947062cc3115921e4", "ref_doc_id": "abf5a3d4-e5ee-40c4-8c58-acb5e30c45c0"}, "3f8c937e-de43-4299-bb46-41244b9da479": {"doc_hash": "24c1fa4b9b392f00a23482b2da291891523e363af52f3fc84820e5968c5cb9ad", "ref_doc_id": "2effd3c2-524f-445e-9ba4-82c6a58828b2"}, "1159d90e-6316-4341-aabe-d1c0bae59e41": {"doc_hash": "6ff58a5a0f7b5b63cec697fce0666d7b9f689b03794f1de00fae2dd0fc4cadb1", "ref_doc_id": "7104ddbd-03f5-4a85-9515-a888ea1d0515"}, "84a4427c-5493-436b-84fb-3f058676a05e": {"doc_hash": "7c235946b54020e23a1de862209e7b250dbe965bb18ea11fc64a8b6c17883132", "ref_doc_id": "5ba809d3-89d1-41c0-9909-d1133f1bcfae"}, "6745e4fc-928e-43cc-a218-ef44b8df1cf6": {"doc_hash": "0da2ebad263ff5e9f8c2f022660572ffd8217d3c53cde8e4050462a7e2e4504a", "ref_doc_id": "2fe869cf-e6cc-4ddb-b046-c581b98dc151"}, "8d69574d-6e2c-4683-b6f2-8c6988e9587e": {"doc_hash": "f5bfae21901bb04ba783ebfc710130da4ad3ba0b6014ccc992650a8d2ba91de3", "ref_doc_id": "c5fbd5a8-c1f1-4f2c-a045-cfcb044df77c"}, "85ccc68a-0ab0-413d-8a3d-b2f911747cba": {"doc_hash": "c92a285dd9e91fe005d2f3f3f7755d35b3024c517d5dc829cbf99508f5766058", "ref_doc_id": "e6007b0b-793f-433e-a0fa-f93addf09297"}, "4f344f1a-0f87-4601-a5bc-ff5dddee4ad6": {"doc_hash": "ed79265abc5e8e20cd2a7eff11b84d814f1237bdf293d469ee6b48e9c40c53dd", "ref_doc_id": "641ee814-2572-41d2-b321-e25ad41c3bc6"}, "3549f939-c86b-48a7-bb0f-f31ce6a19f3a": {"doc_hash": "18441cdbdceb83869437072fdcf60e9a6b91a25a3d3ae305151e7b28273bb28d", "ref_doc_id": "d004f951-b0b3-4224-91c4-bf85499b7d94"}, "2d77d51f-5986-4466-b65f-528d8fdf5342": {"doc_hash": "370907b48abb353e4694da6eda2a56c432defb6539548424fb76cb8bbc3558b8", "ref_doc_id": "4f833ec8-0fae-4892-ba47-eeca1f1902d4"}, "d0e5f6a4-ed7e-4391-8565-725b90229ab7": {"doc_hash": "e4c7e27e693bf9a619a3bb3c00cbb2cbcf2deff88d981a14506cac02febc35e6", "ref_doc_id": "9f5de443-543b-4b9d-b700-59fad19d7868"}, "b79cc9c9-5c3b-479d-9562-4f02faaa730f": {"doc_hash": "0ab224f192c425b5c2eae2d68289ed3485090e2a443094433d375b67635a2bb6", "ref_doc_id": "d9f8bddd-72e3-46b7-b52a-77642dffc75d"}, "d9be35e0-ab5b-4242-8b16-49179da3d0e1": {"doc_hash": "0efbb4eb0ab8abf9ec7817f6548b30176e594c884c8af146fd8d438d16405053", "ref_doc_id": "080cfcdc-cdca-4926-82e5-f8cd1f79dc37"}, "09a606ca-d949-4811-b9ad-b9dd8c113d01": {"doc_hash": "bc9277bebfadf21c60faf1b9efb78e1ef7e2ff1794a5b2f5abdd79c4f05568e2", "ref_doc_id": "32288a3b-aae2-4dc0-a4a3-b98e9bce57a0"}, "220b96c2-9a76-488c-8457-6f25391d39a4": {"doc_hash": "9848a1543f13a2c5f9c833de0a058827f0347cb2de1c641a33c520afe2809cf1", "ref_doc_id": "8ef8f965-8653-401f-9fa8-637eb4fe33e9"}, "9dc15862-6691-4c7a-8219-11a627df5bd2": {"doc_hash": "c66281b8579682fdd79b0d57cd0f0707c4be463a4ca98ea909debb67971818cf", "ref_doc_id": "71407cce-75d1-4a79-8154-a6b18d91f9da"}, "34034b7d-2c67-4d2e-9c4e-eb7624f5f729": {"doc_hash": "890a5a9a0d81e9d7ba60585e6c31dfc41c22ba958c36353fd09c60716a6307f4", "ref_doc_id": "71407cce-75d1-4a79-8154-a6b18d91f9da"}, "cdd23294-2f78-49a7-9a07-4fc8f9424ce6": {"doc_hash": "ca22856cda255429d0d1342242ed11260ef818fd76ce341261724fa597e1aaf1", "ref_doc_id": "955870ca-cea4-4b08-80cd-025aca2b84f4"}, "bb4bc1d2-d443-4ce5-9645-9c0b84e37509": {"doc_hash": "58e91091e32bcbf1f62e8c66d739915458d45eb87be6c7addf594cb9a4fb3f31", "ref_doc_id": "0d3f70c7-c292-423d-8064-a7053216c696"}, "39e9e6f2-3334-4914-99d7-cf6c5e0bc4a5": {"doc_hash": "80c70bb5fe2389bab95a31093cb0fde7120e9f766155db5cf63e322d0445c915", "ref_doc_id": "35cb2e3e-6a10-47a9-8ab8-ab061f10a990"}, "4904b475-fa7b-4706-8738-f464032dca15": {"doc_hash": "d53471a8d572baca0b01e49a636d1afeaa01c93f33fc3d3416653e8ac518cd01", "ref_doc_id": "ca1a4570-f7ed-46e7-8254-4c674ec8a5cf"}, "29662bd4-7ed3-47ba-8534-8ce0bec03f77": {"doc_hash": "98c3ff635f0d4f9fc867efe037924cbab0ff7689b91a197d775d2e5ba553b135", "ref_doc_id": "4afc3a2d-9cf7-49d8-a199-49157562715c"}, "f26681f5-fc07-4a13-a5f4-59af4ac8a224": {"doc_hash": "a77166cba1441476b82508fefa3fbb32872a7edae6a458b490b127a6c06205ba", "ref_doc_id": "b0e5d0dd-0cb4-4ad4-a216-7b6fc7dd9993"}, "1ecdef50-d72e-4f5b-baf6-7ca6efe32c48": {"doc_hash": "15d19aedc7ee9e18543ef34715bb566164a9d54775869863bc0891fad575a66e", "ref_doc_id": "f0854f3a-1b23-410e-bbee-8bbcb3a95b43"}, "00ed1be2-3370-4ac1-b265-8a1f2d26609e": {"doc_hash": "600af43e8fb941efadd542160833ca41801caa3d2ad9952250e41e6a86f21a27", "ref_doc_id": "56a34ccb-1230-4398-a1be-4047b59759f4"}, "b6145b9a-7f0c-460a-82b9-4e90dc6fe9f9": {"doc_hash": "fc9cf1806f7fd8dc8941d90093f86cc450c798fee2a0693421507b7e55b369b4", "ref_doc_id": "118f0783-de88-4784-88d5-e6569a952627"}, "e74199be-f8be-4647-8dc9-663184b01061": {"doc_hash": "b06951c0cb20a5d0a439c7a8cf1cc6da9aa3f541ebb6e855ae1d974763e9e72a", "ref_doc_id": "588789f3-a7a3-4a83-a060-9cbd07ea0570"}, "fd29379e-dffc-4ab1-9368-624ccf9e0459": {"doc_hash": "41726b4f3fc4c137112f4677a5b24611ab4ba92c3a3965522f8fae36a3aa74f8", "ref_doc_id": "84a4b8c7-feb1-405b-ae25-381c480e5879"}, "5cf7a6c1-c544-47c5-bbe0-3718b56d3b05": {"doc_hash": "1cd642e3482d9bc9299831e981aa64879f198f80318ae9fd91c32273205ca945", "ref_doc_id": "e3b0d3e7-f660-4b82-9078-d74ebcd64c49"}, "4d128bce-5e7a-423b-9cef-30322a6a5317": {"doc_hash": "4abe7d922822836571f522d3eeb295d4595a1324cde06a39763d5722a5a3e1af", "ref_doc_id": "a961b99b-1ffc-4136-9c88-d0210f832534"}, "a2010ea5-3d5c-4356-bbb8-f529d87eb631": {"doc_hash": "ec6e4619b4ab14f3756b5e433ab58f52aeb69716ac10b90595296b770398975e", "ref_doc_id": "d15252dd-f92c-4529-9570-fb05f318160a"}, "7c6a516f-c027-4dcb-9535-f51590333168": {"doc_hash": "ab1ff147b348670025e683cd35a5358cd412c96292ea1948de94677dd01109f0", "ref_doc_id": "cb3ceb9a-38a3-4639-8970-f43b4b0531b1"}, "42f88e03-98d5-4c8b-8408-b1da23346926": {"doc_hash": "820410c714a5399b329c91d1e20c8507c535b9fc6ee1b68491131ab26f638688", "ref_doc_id": "19e41f82-7ad5-46e5-8be5-0bca1d7dc047"}, "cd32f49e-5ea2-473f-baac-516dd5474591": {"doc_hash": "740bd019ff29adfc6a837bc408ce9fdc1a5fb2a3f8458093f1152e313e8c2efb", "ref_doc_id": "b41f90d9-db7a-4d0e-b68f-9ba91b67d8a9"}, "c3aeee3b-f4f7-4446-8936-0a81647cf243": {"doc_hash": "28d6a41d8a9376e690fe77d8512c585bc70430a348c82b778f4dd4a3d77159ad", "ref_doc_id": "af45d2f4-a6cd-4e50-87b3-6dde7094047e"}, "84216000-3711-4ffe-b8cb-13db9ec15e03": {"doc_hash": "8467033889fbe5c69011d9857664d6e9f6a34e53a470d7740eb38de8ed2c8a5e", "ref_doc_id": "5eca12dc-cab1-4271-bbe9-d6e0d19058f1"}, "bc7533d6-01e1-4728-bb88-a45a5155dd1d": {"doc_hash": "7b62ed9040e1291f2dd509f3f45b0acc19f4b5b76c29dc225fbfcb4d9411bf09", "ref_doc_id": "31453792-fe49-4abe-a39e-fabc3df8f5de"}, "0d47bc0c-e5d8-465e-8e47-100e25880498": {"doc_hash": "9fb138bda2399413a6e7c2eaec04edbd5697a7dea5fe57143024cc8c09cfdcdb", "ref_doc_id": "cd6e6069-8236-4141-b1d9-e425e4df6260"}, "38255058-e2c7-4956-bf79-a65765fa792c": {"doc_hash": "47a395fb61ea0c5fc8f8098ddacb7a847c485e6255687f39c686bdd462f2f493", "ref_doc_id": "0cd937f5-7c18-459f-8ecb-2f7a0e6d68a7"}, "9b00abd3-5df0-4641-9803-38e3f4e805d9": {"doc_hash": "cef8fc9ac4866e8ccbf4064a1c826e4ad075a164f02b0667e6556e3cf3ef47cd", "ref_doc_id": "36e6279b-6442-4137-ae8a-3811045f78d7"}, "7e39ea01-fa49-4469-b181-8f768118c04a": {"doc_hash": "1718b452449d9979b045e31fa6589799fa3608fd8f16ce263585ee418a3e9dd0", "ref_doc_id": "d886fb8f-e41c-4d5e-932c-b34d342149d4"}, "b72fa594-82ae-4802-83cd-93fd89b9e746": {"doc_hash": "3c36cd89bf581a4cbdf15a1af3cc27ad185d8dd55b180a5096388881e2e049e1", "ref_doc_id": "cf6c7754-2bf2-4c11-b784-bb3cb24be9ca"}, "d0c0e1b0-a723-4421-ab83-87e870ce6cd5": {"doc_hash": "9d2d05aed5111e65a50c894a20cb1fa817a44fc742c1934dc12fa13736f1bc96", "ref_doc_id": "2f4b08a4-94c9-4b13-85c1-af90c0027bb6"}, "c0c8d48a-575d-40f1-920c-8d380e89ca45": {"doc_hash": "e21aee9f313559089826b382d2a38925873fdd01f56db3b43cdab043873a33df", "ref_doc_id": "f77a0e64-a9f2-44f0-b89f-cedfbef10fe2"}, "3a39838b-7d47-4c33-988f-9d8f4aa99a4e": {"doc_hash": "0f75ad95946f376386e23fe7919b8e92e0e4c0d9ee177a07f5a5966e782967c2", "ref_doc_id": "0bba286e-cb34-4520-98f9-10da3bfd851e"}, "19670c68-a810-4000-839b-4140f28e6bcc": {"doc_hash": "c101680db3d1370ce510e4ee3a2e2f25b4ad766eb68f07e076670b958d8de770", "ref_doc_id": "a99c9c94-831e-43ca-99ad-2215ae11f7ad"}, "09b23eb6-db52-4b2b-b416-35c480ed479c": {"doc_hash": "71e76d368eb707a1559bef189c7395821dd5d2f41d13a84cc164a800a9fc8e22", "ref_doc_id": "bcff4d9f-5fe1-4fee-be8b-dc7f31c150df"}, "92ea0eab-6000-43c9-84af-69b9d0df0334": {"doc_hash": "7abd168466553766b6b3b91a573f475778e935c4936c415d2b3507a9fef2f1de", "ref_doc_id": "15010ef0-c017-44da-9b50-b2a34972e3b0"}, "0f26c1c1-a7f2-412a-9944-d649961b9f6e": {"doc_hash": "a15f0d680522c761ccd922749629829178f699c176132195c7f0037a2c6e55f5", "ref_doc_id": "d79e78f9-6978-4ab8-8a86-d729d345e751"}, "dd95c1a9-f26a-4793-acd8-a1f771ad1f29": {"doc_hash": "1783e38a53ed64d0d7ca8a8b311364dee4647d0345b1bd2cae50d7b2e2e49648", "ref_doc_id": "4bfc82ca-f567-42d4-95e5-b3c63ecfed6c"}, "5b823ed9-a08a-40b5-8f18-c1c1d6fc2cca": {"doc_hash": "1e35c6dc16e8a6b8d3957c2cf3db1a2bfc664f784ea3b72c3b033b395bdec0cf", "ref_doc_id": "17358d04-2a13-450d-8d23-17f1e0fcc891"}, "087dfdac-5912-4754-8220-85c06326c33e": {"doc_hash": "1a94fb2877342f889fc66a098ab0170ae7d00f72985ad89acdc65249d98e1691", "ref_doc_id": "590250cd-1555-4994-8c35-cb304b1c97d6"}, "35dbbaec-1000-4614-962e-1693ce8a5617": {"doc_hash": "2a3b1bcd331f1c18675424c86b0771f373adc4b2504c4c263bd901b11f46e8e1", "ref_doc_id": "a7eb9891-3e6f-45f6-8ffd-6a7eba663823"}, "ff45f6f4-c140-4a3c-b3f2-976f68362bc6": {"doc_hash": "6808d95e97c2c496d573f44abe8f40fe6d869e79f952e4a081a54c6d586eb8db", "ref_doc_id": "290bf3d4-2eac-43c0-8719-0913776aeb58"}, "21fe6da2-3ffa-41c4-ab0a-c6ba0758eb95": {"doc_hash": "558c5ab6ec61dddd49d08223bbafd1b81730cb644f2c30f5c7c7a888bd8577af", "ref_doc_id": "f2979cca-f3f1-4c85-9dc7-6b71909e5c11"}, "5db1624f-4c2e-4def-85e6-cd469831783f": {"doc_hash": "ee381026017f012cf0ec2d7552bc7d2e1d08e96cb945e7fb4ac602782f71e368", "ref_doc_id": "2f7566b9-b47d-4f73-b863-f0675de59f27"}, "5cef2e1c-3a6b-46b4-ae02-8f3c2b8f3f03": {"doc_hash": "fdca7a491ba81e272596dda71b0c54d24b3f2f0cc9f04ab3e252a81ee3af1187", "ref_doc_id": "93fda818-e244-4274-8a21-6eac4fc8af1a"}, "c1c88df8-94e5-46b0-970d-fec734b6a456": {"doc_hash": "5887ac2dbfaac2fb4e779196844bc5d798a972ec2f40a1b4286dbc1361b65128", "ref_doc_id": "d08e6245-3ca4-43c1-9ea1-1d826c39ab76"}, "037ff7cd-faf9-4039-b272-002847098c25": {"doc_hash": "5016c8d70276df60ec45d1d3ad7209dc4d6d9e92604adb67f91f7f5d503b6801", "ref_doc_id": "c287ac8e-5547-4afc-85a2-55c18929302e"}, "2e29f716-3177-4d18-81fe-b32ff6cd0d42": {"doc_hash": "4447657a44b6c3b39320d75a4cf753dcf1390388ee3218863bc52f8eae008adf", "ref_doc_id": "0295e345-ddfa-4a1b-8eff-425927b618e9"}, "1ef58c11-1c14-482b-8b62-370669a9a15c": {"doc_hash": "16f5675fd602b38e3deb3244406b4730bd2dbf72c7ba2d2b4932beb6a378c52e", "ref_doc_id": "5ae8a322-d326-4a55-8302-b1faff5a537a"}, "3840c9a8-bb2f-435a-bce4-f2518e2298be": {"doc_hash": "6463f9978544664c41c7785d2378e5502f8be66081a3501558a055d4f63fe8ad", "ref_doc_id": "8582b286-0da6-4138-ad08-3107ffd7f79a"}, "e110b059-13fd-4311-bd10-e0f6a7cead5d": {"doc_hash": "a4a5e135dc4988853fefacebf6d42d51489eb5666c8823ce79db905791621a6b", "ref_doc_id": "95099e15-a51c-4805-b7b5-a42074066edf"}, "2d4e8f86-d9f8-428b-81b2-507a024bc577": {"doc_hash": "af591d0e62f5c86969f2957df3ef8d1e6800c4077fc7142051e897006cd57063", "ref_doc_id": "6b777d8d-aef8-4d8e-bebe-a087999fbd2f"}, "ff5edc85-32f4-408e-89b9-0fa7f16c65d7": {"doc_hash": "435d919f5461eaf160d13d02a82b2f8ed142484083d183ed90b48bc6cf5e4cfa", "ref_doc_id": "fe58eac7-671d-41e3-a5a1-fc342d177fe8"}, "bb068039-d703-4177-bcd7-cfaf2ba87af6": {"doc_hash": "6bcc609e612d7af771ecb402f8fb339d1f818462a65b94d753ace6d3c67cdd4e", "ref_doc_id": "9ece048d-fe7a-4e23-89c9-3aa0e609a4d9"}, "bafd7fe2-9f21-481d-9e6d-0421a103b230": {"doc_hash": "b9300da1de6d4ef6fc36e451ce10dab9b8829a1869c37936d658781978949186", "ref_doc_id": "d6a934ec-1504-4a8e-b92d-a15167b22b64"}, "2e10f53b-680d-4721-b124-8a90470bf9e1": {"doc_hash": "46992ee0c2d94c18554a420997cc27da3f3d92bf1b53b66d46e0eb77c592f48d", "ref_doc_id": "5ff7e443-9744-483a-b578-aa5a0d27ac6e"}, "1ed8d1ae-6f9a-438d-82a6-3176fcf15f7c": {"doc_hash": "8356df9b6a38eee7720aa4afb719f174609e2abda286e60b9258d546aeed7fef", "ref_doc_id": "631f9317-f065-47d7-8911-eb035681c3c4"}, "5e94b18e-d90d-4287-b91b-14420ca0c388": {"doc_hash": "7200064717924b786cc44b080efab64160099dbc907379c4cf6daf54983b7270", "ref_doc_id": "e5ec2d86-962c-4ade-a6c0-31b4412b800b"}, "c34a5a78-09cb-40e9-9a41-38ed6cf6a093": {"doc_hash": "a1adf851eaa1350f40bb07739549e178ca2cd05bb2a54ec8a7e5d7a9858d8032", "ref_doc_id": "ef9fb24d-3767-4090-be5b-8220237b7c08"}, "884cf616-caaf-437b-a58d-a869d578c1d1": {"doc_hash": "aa4e318a7acbfffc83e3ae6db1d71a61b07eb60fa71bd4ba17f77e8be12ad63a", "ref_doc_id": "13f9dcfb-473a-4a25-88cc-a3645d3b6bef"}, "ecb2f3d8-14d9-4929-9e00-f7b2c22bcf15": {"doc_hash": "b204800c01b6de812dc3a648b24e39b6fec7f56ed29dd1e510b5a9c75f641d3e", "ref_doc_id": "e754db18-3a4e-42f0-a851-9eb873b16211"}, "bcddde01-8764-41de-9b6e-6fad27bf1b0d": {"doc_hash": "da27793b5267d95a0900ce7fe2bec6030a38b5ed302973d942b16f6211a7184a", "ref_doc_id": "64b810b6-fb40-4562-86f3-39406f51d672"}, "1c0a927f-a2a9-4277-b944-8f01e0a3fafd": {"doc_hash": "847f77bcca9f35da14d167ba7f449900ba409994d5db1d10da7bf1d05f008d45", "ref_doc_id": "12c0f22c-492d-45bb-adb3-2195637e15f5"}, "47063983-667a-4ebe-a082-e053b0472887": {"doc_hash": "dbfd7fe69a8718c55ecb8236c653e13adf912c69fca4b7e7003071e4816f98f5", "ref_doc_id": "8da80870-f31e-46d9-99d6-dce3b78796f4"}, "99e40e95-7ad7-458c-a9c9-7d3637373c43": {"doc_hash": "db2d38804d6a55385d7d07767dce15b57f83b7d7c9837d05070a032b190e2ff0", "ref_doc_id": "37d4574e-cad4-48bb-8b69-db9c5a148303"}, "f3937a51-edd5-49c2-ad76-baeeddbb98ae": {"doc_hash": "e2ca4bb28733b96c8bc898b59a1d24f79872919110c9be4ae91f4214b7441293", "ref_doc_id": "f69c2141-d86e-4bdc-925c-6d8f9931b193"}, "251dbc5f-be3d-46c5-b787-eb912317726d": {"doc_hash": "333a210e2d92a56db27a4ad141878363ba374893d036604e7e4d8f7fe1235366", "ref_doc_id": "b7f1b4b8-4e57-4dd7-8c25-03bca6ecdb2c"}, "9f6b5c3a-aa0c-43cb-896a-c87f0ef71104": {"doc_hash": "def4c3084df4581445bd433f58c044bb6d5f0af368a09d3541abfdab50a1cf68", "ref_doc_id": "51da49e5-6763-4acb-87cf-876d154928d9"}, "805b6d5f-1dec-4763-bf3d-318df8061aa3": {"doc_hash": "e64f5f71b05186f48df90077d87736b5c2819312e0c2099eebe7533c7b610a4e", "ref_doc_id": "9cee441f-2b4e-445e-8fae-3115bc05d523"}, "bac08d9e-9d1d-4bf2-a234-aae972675994": {"doc_hash": "e0e754e61f324df53f9e47553cab893f25f1bdd5bc01f71732b23fc9979abaa5", "ref_doc_id": "28c40e9c-1430-48ac-88ea-6ab22cad52d2"}, "6dc6e153-30b0-4a10-bc23-4b20495e0431": {"doc_hash": "7ce28b2218b1b724da56f43b8b23c2183a61025a9d986a4e587d58d0e56ba3bd", "ref_doc_id": "ac3462f8-06a2-4f85-ac0e-e0653d1b4538"}, "42cb96d2-bf79-4acf-b708-cc0fb03ea4bf": {"doc_hash": "bfb659ac7dd505c552b6ade9a83c5a08d4da2a13a077cead958b108d0deb6251", "ref_doc_id": "14d54e81-6d48-4813-81d2-158dc456e8de"}, "b62e5a4b-d542-44e8-bfdd-389780c87a95": {"doc_hash": "c2d34a337d41dc66abc92b2de402acfb728f9e3c8dd17d6feb68a2ef83f00ea1", "ref_doc_id": "7f82ba6f-0fd0-4977-87eb-b14ed646812d"}, "7c33220a-e72f-4a21-9153-075a124a07ff": {"doc_hash": "2fd1b8b7be30387a3f8ed90fc0e64e9ee0282f8676551283c582a551e500f65b", "ref_doc_id": "8790262d-3f30-468b-9bff-de566cb7c570"}, "6a47ec3c-5055-4089-96d5-169ae3f4ab3e": {"doc_hash": "cf0b28002d69d802569521e92a0d5dfb0fd4667c7ab3270d5e09bfcecd61b25e", "ref_doc_id": "8ac6cb8e-d80a-4c22-8d7b-35f2cd0b7500"}, "ba6e6b92-0baa-49cb-94dd-312564b564b8": {"doc_hash": "5e618758b218418ddf91b4a8aec4cd7453dbafe9f1e8f0ca2057edb5121244fe", "ref_doc_id": "f9b74f6c-594f-43b3-be3c-2636b36f7b74"}, "a7730fca-47c4-43d4-bde4-e3e92e2ca435": {"doc_hash": "eb7cd043a9e47cbf2661e70df689d0e98150a73a10ee44e3088ab3facce3d124", "ref_doc_id": "e860fbb1-9133-4256-8a33-592f8e569053"}, "9f733625-5e72-4c55-8cce-bbbd92dfa9df": {"doc_hash": "4aac22331f72b3edcc7c3f49948a22492bb0aa4540f52dc17cd92af015c4f639", "ref_doc_id": "fd951588-6bb7-40b9-b69c-66e04fd7b003"}, "1f95c5d5-a972-45a3-b432-1992a5791ec0": {"doc_hash": "263f660998d9471406fe5cf6acff260e0841b45eb2c0733a6f59c548954cfa72", "ref_doc_id": "71f392a5-e16e-4f81-8ae2-c4aeb18934c2"}, "efc52289-b9a4-4d1e-8a5d-4d34e31d44b7": {"doc_hash": "ba04a2930c3d1e04f1a32f728f84a11c0d9462333d37739b988fa24061031236", "ref_doc_id": "5028fb87-dec4-49f9-8d6a-0ee4ac093852"}, "c45cbb7e-c0bc-4880-b1b3-0249d30cc7c4": {"doc_hash": "61e4e013764dbb89fb1d4ef576f96e931177750e812ba6e61bcd2967275790e9", "ref_doc_id": "1a2b86bd-c055-4719-8917-2d16ddfdf24d"}, "18997e9f-1a64-4181-ba31-3411692b1280": {"doc_hash": "cea00cc1a609eaa772449eeea6498ec6ac89f9a15063dcae00002d992f0e1803", "ref_doc_id": "d679c472-50fc-4e97-85c1-0cb5f883b2aa"}, "dc66946a-e8dc-4c79-9ff5-78c72ce07ef4": {"doc_hash": "d964a066210be15e0a133210de953435fdd82b02fd73dbb9d8858820638481d6", "ref_doc_id": "aa5cbdf4-77d8-456e-ac32-af1f6abed965"}, "c0f4ba56-8deb-45fa-abfd-d896a4fc85a7": {"doc_hash": "923ca326352b54ac2142734c95fa9e9c7c2b2766425aa7dd5e59b15718fa9ce3", "ref_doc_id": "9be79619-07c4-4908-86f5-c7786f59947a"}, "8c63957e-caf8-468e-92ca-c9bffa87bc37": {"doc_hash": "387a6fe6f65a0d6846fa39a14f2cb8bac0dd8929e5d8d9739b65ced9c47d4b4f", "ref_doc_id": "229b6e18-913f-47ba-bb26-64b19bc43908"}, "b6490be2-c886-4817-9564-6e844c819768": {"doc_hash": "f63356a664d3c8cb0975525a9f21ed2bf3af3f96a000a05f9df2ac4eb88f8c9b", "ref_doc_id": "4fec7fff-df34-44b5-819d-092f564fa704"}, "58be316f-9724-43f6-b92f-9216f49c519e": {"doc_hash": "2feba669f44e1f2b9b6b82bf41ab9a97171bdabd3d29c45fde8ce3405292cda0", "ref_doc_id": "6cde3203-80af-4131-8e27-81093c08dc77"}, "e06bdb89-aff3-40b9-ac7f-98446cbfd50b": {"doc_hash": "3dac364707bfc31f89a98c92ad9169bf58a73cececa37177169c76779b14a69f", "ref_doc_id": "6cde3203-80af-4131-8e27-81093c08dc77"}, "112efbfe-7845-4273-9609-d13137a2b4da": {"doc_hash": "fcbed82445783c6506d9ef151c0238e74043a2250119640d36b5c2c138c261ec", "ref_doc_id": "ba921fee-9b6f-4645-852f-24c24af62ee5"}, "285ea26c-c168-48d1-a567-80254914332f": {"doc_hash": "4e067efe72b13c619836e283da905714253f22a39e1d463da1bcab8a34b244d4", "ref_doc_id": "975bea42-71b8-47ff-a7c6-52c6da9a3c2f"}, "a1e47307-802a-443c-a3c5-5b879b52cc46": {"doc_hash": "f80ceed457716458a4e673f77216397c47a2fae53893d1ea3cc13b89d5ede1c3", "ref_doc_id": "d113bb4e-601b-472f-b90d-44e6fb8d5c86"}, "008ac8f6-b876-493d-8c16-69ac59680201": {"doc_hash": "b0e59e8e5b13513c9c2198eab1dd83a66ffc4782553ed2897860df6a175a8dd9", "ref_doc_id": "ba5a5093-94a6-4c1a-8ce1-c49f79347ea6"}, "54415658-387a-4a4e-b1df-ba3d8cf13d4a": {"doc_hash": "758d9efdd4e9e4f892a617bd1f04aad668040a17bc4f6d85f2f0f9e573078bdb", "ref_doc_id": "6bf9a1ad-c76b-4a70-9040-736af6596ceb"}, "bd4256fa-cedf-40cd-8f57-8685d9cb76bd": {"doc_hash": "600e46fcd0151157f9b550d0ada3bff6f69dff135ee79726867a4cfb682e15f2", "ref_doc_id": "752815e2-3e43-4b09-a7fb-3f3afe863afd"}, "7a359c96-1f90-4392-857e-74ff5a025294": {"doc_hash": "5c22e6179a13baaa8405c76c9a35afac55630eaf04047c5d623f6fc3aea6cdde", "ref_doc_id": "52b78121-7e7e-47da-b0eb-6dd474368b36"}, "b92a7b28-9f3c-471b-a3a8-89aa972e75ba": {"doc_hash": "ebcb5839add24bc721280cb6c70cd23280cf0e9e584e3f9d8c1b9305e2ef4fd8", "ref_doc_id": "bd81c912-bb20-4178-b1e3-0df87dde5426"}, "0d388ed5-60c8-4c76-8666-fbc2a6257e5a": {"doc_hash": "2465d7ce39a84ab88143b79aa6d5e040b7fd37a9d88b0c793a14f2a162aee7ff", "ref_doc_id": "b2fe87d3-280d-4abd-8d2f-30bc085b2c9a"}, "996c0089-e096-40fc-90e6-a649439f172e": {"doc_hash": "d1932916e25ab01fab7ab18f0608a9ef4c67adaceeb9c07250230619fdc31200", "ref_doc_id": "7716f194-2b56-4220-9c4e-430c96d738f5"}, "826b90ae-3086-43db-b6e9-5b93cf3a4dbb": {"doc_hash": "e1fd41b8fe6769e978cb0f6d68cd230d15d05ddb0a1217b26bd6c27eb807d5d5", "ref_doc_id": "20023176-6484-4ab5-8d9e-1c664e10ce79"}, "3a03e341-ab40-498c-8a34-a8cac64d97e6": {"doc_hash": "c9d5daa150e4ad1d259494c1212d63778ffff9072d22039ebe701464b768ff4b", "ref_doc_id": "d8c1c01e-7575-43d4-927d-a9c532a0273d"}, "44f4e8f1-eb3f-4679-af65-e1f9405fd1ca": {"doc_hash": "97de44164f37f1a75a4c9a632652bc283581ba3ef7ed50f9a20f3aa11df2c98e", "ref_doc_id": "49e850e8-753d-4145-b36a-2329929af481"}, "87a08bb9-7c8a-4d98-abfe-7d4ecd3f558d": {"doc_hash": "31963625d94d5e9888e8c057bfe9a2ab60d2c5749340745280ad4d6a64ce98b6", "ref_doc_id": "5f9601e8-0495-40eb-92a4-7ac4e58aac0b"}, "f2755fa0-28cf-43b1-9f87-9df9be602eda": {"doc_hash": "7b832283433006c294ff30ec7df4ee161871ad4ff0c98987ad7c24b9167486ba", "ref_doc_id": "adaa0fef-b347-4421-8220-cba702dd4083"}, "e051d8c0-7178-4216-8d9c-99a6a749d131": {"doc_hash": "2127f31c8de1178b5f3354bd3feb734a57d187fe6b9414c4b7190e4dd5d49f1c", "ref_doc_id": "393cb6ec-d3a9-4529-a177-0980283db340"}, "b3db7605-335f-4e53-a772-ad893c07fa62": {"doc_hash": "f30893c33c91437d2565cca86e5dacb446b4dac94a23e6860e9d3a6694bb72c7", "ref_doc_id": "117b5627-6afa-46df-a9ac-b69ca5c1e556"}, "67cb04fc-08f4-4f16-a639-748e1c3b4840": {"doc_hash": "f960981ccab2fbceed113c21e86b2166a779e33ce6f742e568ea97893891d35d", "ref_doc_id": "374ba5d2-d1ed-4668-983b-799dcddeae27"}, "966e5bec-4129-4d2f-9e25-74860e7731bd": {"doc_hash": "66ee4202f1e6c0149e305ebce4ecae01267ea41fcd2879630a0bc5c5725e6cf9", "ref_doc_id": "29c9ab5d-8207-4f5f-98d9-df267fdb5c6e"}, "039eab44-b642-42c4-81ab-cd82828751c0": {"doc_hash": "97aafbc371bbca57996d1862752874cd8a78ec7dfbdde5bb0304ae04e6179aee", "ref_doc_id": "4cf51b1a-4278-4234-9894-d38a43ed9a90"}, "3bf2a62e-f064-4e5a-9d27-9ed92d13e16e": {"doc_hash": "a968b6036ac1acb818cd127267b29b0fe95616a681eef729e1406539a02b555c", "ref_doc_id": "6b150add-7ab4-4461-97f0-5a9b956647e2"}, "19a70e81-b38a-4d02-b6ea-134cb2de6e02": {"doc_hash": "c8c9b78c8868d3f43cda44484b805921e52c27ca8e2324c972ee323edbee952b", "ref_doc_id": "357511cc-c2d4-426a-b505-dcb29f767522"}, "197460a7-3d41-4746-ad27-0c6f6e6a1ea7": {"doc_hash": "b7a04c995a26e687019c55267a2d19b51e4e509f4bf985f0cafcb7f112ecb92a", "ref_doc_id": "15cb8b30-b27c-42dd-91f9-6577da4086ce"}, "398513cb-b3f0-498e-9991-1d97093cbbfc": {"doc_hash": "6e93785555e14cc0fb0f9395b846befccec950e90421398e1f392f214487cebc", "ref_doc_id": "18258d2e-8b7c-43a5-8b4a-cf3210934de6"}, "cfde4bef-448b-41a3-8e10-1735dd7af95a": {"doc_hash": "eb6e738cb4cff6fbb102f8bdf2a21eb3ce3649fadde6216937605f5b79b1b781", "ref_doc_id": "2c3f08e2-b793-44a7-8ac2-afa86a417673"}, "da5e955d-6ef6-4ce0-b4a5-5034597a9b23": {"doc_hash": "ae996f62d7530d725630ce8a719c764f0c94359c441a80a011b92e87841da76d", "ref_doc_id": "13f93e02-1bad-4e25-935a-7dd90e472053"}, "2a1c59dd-31fb-4379-848c-897872c8e515": {"doc_hash": "ac7e09a49902fd1f6a56cb5e4bc64c4c30458adcf2e8d1d7a125873b137ab5e0", "ref_doc_id": "20617c36-7f56-4245-8ca9-106687b9e4ed"}, "b20126be-997f-45b2-b3d0-08856a278747": {"doc_hash": "a2dac6886c63aa1a4925956db6d721ab056ddb1f748da63986ae707dc00c0301", "ref_doc_id": "beea1a87-03ff-4e35-a7d7-cd1efb664e32"}, "6eb4f5da-c68d-4086-bf6b-e52fb3754a39": {"doc_hash": "7b6dfaf62d1d77a654a0ac1414f736c6f3bc79b67eee0579eac8c62b976e0df4", "ref_doc_id": "680d946f-6933-4e2a-906a-654d78d485c6"}, "eb4bcc82-976f-4f4e-914f-2e18368393aa": {"doc_hash": "c4d3737c02dbed62adec8804ececca91f6891b517d3d84798265259569294f56", "ref_doc_id": "401f3a6a-41b6-41ee-a977-c004a98eb067"}, "d18c8779-d1d2-4083-990d-46aac9258978": {"doc_hash": "c305d305079ea1a99284969e78b61348b1f48256a93e8ea407847a209b77ec1a", "ref_doc_id": "e89bcb72-c452-4c27-931b-7e91125c62af"}, "a4b6201c-a8f1-4790-8182-763a0d45bb2a": {"doc_hash": "f6c804bedce4dde4e15e314cafcf5c3a5c6d9514ef52ba5a9cf241893e72bd84", "ref_doc_id": "5ab029dc-0056-40a3-9ac6-30a8dc3559e3"}, "4d0b6992-3be1-4c12-876d-7a845e7138fc": {"doc_hash": "e82db8773bc349b84d780d9eb9ed777b93fedd16b18093c3c470362099dc5702", "ref_doc_id": "6d8c8247-18ed-4810-a605-72c5d8f7c0d0"}, "61833f17-15eb-482d-bf8c-c0fd0b6567eb": {"doc_hash": "ebce59687f6975ec93d1d74e555b9f1865109d97a7230ed1d131e064a15d03c9", "ref_doc_id": "bb6f9274-613a-4ef8-ad04-564001cb3c4d"}, "6365e49d-afef-4da3-9342-61e260f74fec": {"doc_hash": "030471a56c2e32e6ace721141429975721c94adeb7219f806b28e59552b640f0", "ref_doc_id": "e2d27779-6d93-45c6-bd21-6b9defba3fa4"}, "42b23314-3cdf-4993-96e4-187f13154b21": {"doc_hash": "a08d8971ba6858b03d10ef2814744bbac3176a9db733b6b066345ce7fc114a94", "ref_doc_id": "3b1f2ce2-ea57-44a5-9f4e-0b9b9185f73c"}, "b2fb7ba3-5c27-4fe5-b711-0204e8703256": {"doc_hash": "7d132fe33faa72bcc42aa0195a7d8906533841ca429bbfefaeec74eab8a5bda9", "ref_doc_id": "8eb7950e-eff8-4454-816a-99837b171714"}, "a7593103-0bdb-402a-b0f4-abf6c269af73": {"doc_hash": "d109d9b677b8925ade30a3ced3e3de2c754cbf5a988b6f84d96b0c8c0368de8a", "ref_doc_id": "e0fef81b-2224-400c-a730-16e21c85198b"}, "bde15604-7e37-48c8-ab90-2ed521b2f7f9": {"doc_hash": "da2a9d8f60c4c7494bde6b413185f29de9b725b754d2574af571f7584c40d497", "ref_doc_id": "9e56681c-beb7-4a84-ada5-ffac8d507ee9"}, "07b14f4d-054c-4a84-9f05-17904b7710e3": {"doc_hash": "d27bdfb8e8e9def5d1fea39e244b53986258ced97c27114542ddbb10829a6164", "ref_doc_id": "fe521c7e-e8b4-4cc5-b395-3b0b82c9c569"}, "be32b610-eee8-4a72-a38b-187468488aee": {"doc_hash": "77ca589a2d77fc2900dcb16fc8cbe7f41f300d9001c305c5ef28c2b519b9282a", "ref_doc_id": "4d224074-18c2-4016-8010-232b17407065"}, "a2bfd2bc-7c3a-436a-a5bd-5b4448eebb22": {"doc_hash": "318b852e7cd1d8ebd895a737cf30f61e12106ef1bdcc3cdc2835eee7726ce8b0", "ref_doc_id": "d381e00b-9565-4607-bd96-e12c32174178"}, "0cd36c6b-d231-4442-8aea-8ddf91948570": {"doc_hash": "28ab6041c14dd556d85142ffd9253911c5c0b177dee936692b072f78703bfa8f", "ref_doc_id": "d760de93-214b-4af7-b40a-adf7d2d67808"}, "a0aeb945-9db0-4bfd-9214-f6f0f889df70": {"doc_hash": "59c9d3ba0480f50dfb34765f4b8563bcb2492d2a168628b8f96bdec88b3aa43c", "ref_doc_id": "d760de93-214b-4af7-b40a-adf7d2d67808"}, "e68a1a5e-0748-4a1c-8d95-148e642f09b8": {"doc_hash": "3fe18074d01ed21792146d5414e3946c6ad68b6d397dfb408c357f4dc4f2d7af", "ref_doc_id": "d760de93-214b-4af7-b40a-adf7d2d67808"}, "11a593a4-999c-43ab-8c28-fb61beaeeab2": {"doc_hash": "c64947a1df52fac567f5b22303e7719faec1f63890931fa62064f2afbbdacc93", "ref_doc_id": "d760de93-214b-4af7-b40a-adf7d2d67808"}, "667c4f0a-15e2-4ecd-af2c-b417ec276108": {"doc_hash": "ef1666c54d14361a771855b0e1bb9a9bef32f48af5fd798e02521980d6de26c2", "ref_doc_id": "d760de93-214b-4af7-b40a-adf7d2d67808"}, "d3224ec5-4901-4e91-b952-b6b0d073ea07": {"doc_hash": "bcb480fdd6e503eae1aaaaa379d87edb5ffc8ca61224c5935a3a441a6e01c9d5", "ref_doc_id": "86da5c77-71b8-47b9-bae5-57fffbe0a8af"}, "31943ac9-6514-4b11-9ab4-16ef93e5a8a5": {"doc_hash": "b5f844885cd113c8f237da366133d4f71fad9c974d3b9a8379fa4b242f61f660", "ref_doc_id": "3e5d6b6f-1e0b-4e2c-a720-28ce323585aa"}, "9de2a99c-2c10-4b37-a263-35c612ac1909": {"doc_hash": "c6b4d5a42ea481c442ec96e7f9a144e910f85574415310b299577885cc96656c", "ref_doc_id": "9b4e637f-2b8d-4ed7-9771-0392df077484"}, "ee022ded-f9e0-486d-9ca6-4f4bb618ec8b": {"doc_hash": "f5474c488d2260e6518f5e740b1f1fc1354c11b5c50f2e2b40976818994d31ba", "ref_doc_id": "366ecee9-4ca8-4b22-b8f7-456109e0290b"}, "ea1702f5-dc3b-4d0a-9a4d-0d05b3715831": {"doc_hash": "0f4286f63f1fd150f35736cde0da46a938ada0fa3a8f5f2efabc80a7b6f5cb0b", "ref_doc_id": "366ecee9-4ca8-4b22-b8f7-456109e0290b"}, "cbb34b17-31fa-46ca-8240-6701e936bb5c": {"doc_hash": "af3bd5a37ec594c664d20f6effc80ad60d85b0989d576aa47b38f03bf9da192a", "ref_doc_id": "7fbe6697-faf5-4478-b277-a0bb3168ebb5"}, "60ee3c0e-fd55-4305-bfa0-7f12a9ba1db3": {"doc_hash": "aaa8e505b6635f0b0eef32ba5f73425ac437e7797813f0e7100d5be0ee12bc22", "ref_doc_id": "d64b618a-a2a8-46f9-838e-341c9ab91b2a"}, "0d5afc54-41b0-47d4-b93f-d90cf5bf1b9d": {"doc_hash": "a82a81a7e5b33c0c72e3d1dd647942cf38ac9842e39f0369f5990d46045aad76", "ref_doc_id": "997cda37-ca5e-4fe1-ada1-76db62fd55eb"}, "a242925b-5711-452d-bdb7-8ef423133aa4": {"doc_hash": "f715e45e04083e39ce660f99cb6ea62b54b6d4455fbd60e89470c8d597706828", "ref_doc_id": "fd51257b-dff5-4081-928f-3230efea4245"}, "2686860a-77d9-42cc-9786-d490cd244a94": {"doc_hash": "2f756e53d85b51062257d5b17442a25fc300f4ac89cda76f648c0c572d121b20", "ref_doc_id": "fd51257b-dff5-4081-928f-3230efea4245"}, "16de8c9f-3aba-4328-a7dc-1c84c4339618": {"doc_hash": "aed2d7ef301c568dc6961ac9c2e78c56bea638d1cf678c79626cb9645b847ee2", "ref_doc_id": "e0c9b6c8-d5cb-4e66-bd49-8a7cdb6d9899"}, "58b89eb8-874d-41a6-bfa2-38ba2dae3742": {"doc_hash": "3a8f3188f32a0b2b68832450967503549a56cc55cd1dca1fb073f7ca668095be", "ref_doc_id": "46ef5e97-65f4-4374-8a40-20991775651c"}, "7207c704-40a1-4b59-803a-2fee1f146691": {"doc_hash": "9371e2e345192cff075d520878896202c801b3409ceeeed28a25612284266cd8", "ref_doc_id": "ca032878-3313-4906-8fa7-092cb864d91b"}, "f03f1576-0741-4693-968f-cf4a2b80dab6": {"doc_hash": "41752b537b805b5a40d8fbfb311c2712f825e87f82537480cbc44ad1caa3da9d", "ref_doc_id": "98f431f6-a2e7-49c3-a058-19f508d4a697"}, "9863c3a4-6838-42da-94ad-83f2a407a015": {"doc_hash": "5167986a462f480e34482e6cd1f30fcd8dcb7cc4d91b6e4a64c8c68042ae1408", "ref_doc_id": "98f431f6-a2e7-49c3-a058-19f508d4a697"}, "85a31859-f378-4f6b-8506-7b862f739090": {"doc_hash": "a0774ad70925cf3e3addef8c9dfeba92514a739d56bfb15bce1a955dbef54bad", "ref_doc_id": "10ba02cc-f43d-45ad-8b0a-627c37976ecd"}, "9078ea14-2971-43c7-a15c-322715ab7c0a": {"doc_hash": "7ab42f325ed04b0114fc0e0e8de5c95adae802199584453235bc37f3acc400bd", "ref_doc_id": "ed6f8eaa-232d-4db1-a407-3f2b9204740e"}, "e55a28d6-15d3-4010-8762-e2b7056e5b83": {"doc_hash": "c4080345ce4122aec06a58851e29912242f7a926ffd691eaa69160240fafff6e", "ref_doc_id": "12566ae1-6c1d-4d53-83dd-9f8a92cd589d"}, "869779ab-6817-41b3-a233-3d14f8c8e7ac": {"doc_hash": "cacdcc99e3ce0b227ef81a47cf882e8a9e1ab15332af9afee15e6b1e6cf17045", "ref_doc_id": "105d814a-3ff6-45d5-8666-d0c1b09236c5"}, "d5fc10e7-53e4-4c48-92e9-732aa15b1040": {"doc_hash": "09696ca2f9805f34441a04a83383209eef165ca1b5b11801969fe6b47a5aecb3", "ref_doc_id": "d43a3d71-79bc-4f19-beb4-9a2279fadce1"}, "71ce9552-8830-485a-88ca-3c24590fc8a7": {"doc_hash": "18548f34cf6e85e5de14fb8eb04b807d45f740901413a3c722e2bb4556dcd262", "ref_doc_id": "30347475-d829-4651-807a-e2af387792ed"}, "d6621d66-2f81-495c-9b2b-65063cdabdb1": {"doc_hash": "d7f517b61e0988285424d16f961ff4399834b7bec93bd3a6770ceef36f3b99c2", "ref_doc_id": "3a741f35-8044-4ff0-9a22-92c91913396b"}, "4f552d33-03d0-483b-ab9c-d9a897b137c7": {"doc_hash": "0daffe5a7373881d27811945ad9ccb6ae626e847acedcb370d3df1ace79bee9a", "ref_doc_id": "2b7347f4-4104-4ef2-8a91-7615b9fea354"}, "cfac342b-2f49-41a1-99ad-30f47649702d": {"doc_hash": "b12af2a213ddfe688b49a89c4cd250193448cfced1499edbf04a9f0784b2c3fb", "ref_doc_id": "0fa826c7-f6ef-460a-bdaf-1c96e5c1c782"}, "3226d0eb-4dc4-40c5-82c6-d8368e4a506e": {"doc_hash": "a7c0f9f9b90f604f99bb71bea43c264bcb905f0111f6656bdc3d66aebb39e17d", "ref_doc_id": "9868ff8a-fa79-4f9e-9162-77d73c591944"}, "2cf09e2e-1eff-4c08-9148-770a16ff27ce": {"doc_hash": "1478db6a320a927a79694133484bf999b840af35f3c939167ae2cf66e2505c14", "ref_doc_id": "2d21a2d9-c14d-4fb0-8ca9-f7da9cc59e86"}, "6ae63a60-700a-44ce-a3ba-ff3d1d220d2e": {"doc_hash": "f4e952c93d3db4b4d1f5f7030ce65abb8d53f99adbbbc35b355ed7034912d475", "ref_doc_id": "2d21a2d9-c14d-4fb0-8ca9-f7da9cc59e86"}, "fdb94132-8f7a-4314-a971-8ffb3546b9ab": {"doc_hash": "51ead4755f122f501f1507fc34f017645deaf2862b56268c358a8d5c7724f454", "ref_doc_id": "9feda2cb-7916-4181-ab8a-e025f5eacb86"}, "a58564b1-972b-4a44-ab5a-af0508dafde8": {"doc_hash": "7dc63ef0202213e614133f32899eb61f7889a715afa68e24aaf3243293aa5008", "ref_doc_id": "9feda2cb-7916-4181-ab8a-e025f5eacb86"}, "154b239d-a900-4c93-a8ee-49b1e06651b9": {"doc_hash": "a081549ed5d91693a2f2c0f9e8da779c839af69f6f3414a1901536bc0d80058c", "ref_doc_id": "ad59ef01-bbcb-43f2-94b7-82a5ec25eb02"}, "6e2153ef-8f10-4da2-963d-513bf96bf2bb": {"doc_hash": "23efe2f5bcf5a44b1f90b7c89718ff8bf69a36b40ae50fef44a6b7d96c297382", "ref_doc_id": "c0678fff-d10f-4018-85e6-49f8081615c1"}, "53849443-d9b0-4c63-b3e2-fc9b45b720f7": {"doc_hash": "9b43a59bfdf471af7e74d80a771db5516d42f802ca03b5d9249feeb7105a6567", "ref_doc_id": "1f8ae18c-28c1-4a8b-bf4b-9ef2c2d9905f"}, "f15fdc14-12c1-4928-bc5d-d2b5bfcccb46": {"doc_hash": "cf0f64cdf8d97cd3be475333c462ce7e710bffb9a3c044d899a79b05cf0442fc", "ref_doc_id": "eba6d0d8-89a7-443a-affd-728f92bc8f29"}, "d6ef5232-a3ec-4cea-863c-cc6cdfa53ffb": {"doc_hash": "68e8985aa0336bfd36a7b38cb1cce5808cb33129be31bb4fe9fa043c611af487", "ref_doc_id": "89d7aca4-811b-4064-b93e-11e4293fd880"}, "c7d3c1b4-f38d-4769-987f-0c5cc060ee9b": {"doc_hash": "5480d964b2321ebff4ba3c57432192163f5d06c5b78ea45ea11e86a291edc905", "ref_doc_id": "a37fd933-9557-4cab-8ca8-9831ba6bef7f"}, "9ad5e653-6a22-442c-9b4f-55fc842928d9": {"doc_hash": "ad46a5329d84980b60d02d09be56a464b204076c49c12850b3e30f5cc1d695f9", "ref_doc_id": "d85e6c07-f342-459d-9814-360643069e0d"}, "f547f0c1-48d9-4915-a559-b915099768a1": {"doc_hash": "d530e05238ce89b152d6bc146a82986b9ea387bbd708c29b6f614123e580aed7", "ref_doc_id": "c421011f-f926-48d0-806f-65164086660e"}, "c0942f2a-24b1-4f8c-b0fa-9d86c59ed22a": {"doc_hash": "35adab371d1056098ae26e8e2f9df00b48c966b23d9c1855f957995420fbe750", "ref_doc_id": "009fc9e2-66b2-4c46-b9cf-c7cbc02025bf"}, "0983cd3c-221c-4e95-9673-8e8178b73cff": {"doc_hash": "d05acd37d6adaa7c502a7d4c8d33d78fa5092f6b30464a3c4b6cb1361a4bb113", "ref_doc_id": "b3434ad0-6a4b-4f5c-9257-0d207cc9bf8c"}, "973cb306-f3f4-4f56-ad07-faac69cd9646": {"doc_hash": "268a6f66ed52bc021800418f20f3d0a50811ccfd0860706a5dae49f6b987d7e3", "ref_doc_id": "b3434ad0-6a4b-4f5c-9257-0d207cc9bf8c"}, "11c24e56-649f-49c9-8089-8514099dc111": {"doc_hash": "f4b6ff31e4d29481c1678e3f1dd59674eb4048bf1bdf288ce265d71942d8ddb5", "ref_doc_id": "a58c715b-251c-48d9-915e-a5d58ca52a04"}, "54c8c7f5-b676-4b45-8604-29382816b200": {"doc_hash": "229708a3e67e623da28f73d2770242ce1b763ba3fa5a5f8805d287d6b3395005", "ref_doc_id": "d77102b6-39ba-4fda-89ad-8e805ce31913"}, "24082785-35a7-46e4-b4d7-28f78524d38a": {"doc_hash": "a8579513ffe07b212cbecc1bf3091d35047f0ddfed5bc439afca76d325cfe501", "ref_doc_id": "92bf58ef-8898-4573-915a-40a60f900fb1"}, "11f220c1-1db5-4391-a680-317ad64416c6": {"doc_hash": "b9273671b5ef80ff5e1f39269346cb45a8b1c55d3d4773b5a6d66a7bddbf906e", "ref_doc_id": "f6b2aade-f614-4c20-9645-795dbe8080c8"}, "1b66f01d-2b6d-42e5-b374-0fe3200e705e": {"doc_hash": "04879201ba68a65404c92a77a40a7b1c7adae2989258fd75fc8a4edabb573274", "ref_doc_id": "95e171c5-9daf-4f5e-a3c1-ca6506032202"}, "bd3584a8-8699-4b2f-b8df-d933804cc7f6": {"doc_hash": "454b276146e1114732283eeb3f6fc8129d12789eb6083e7aa76e73fdaeceedee", "ref_doc_id": "514e0d12-f1a4-437c-8c28-dc7fc34bd1ed"}, "13217e5f-1750-4171-9948-7e1621561e38": {"doc_hash": "1b764fbf9b2291807a6d5d4d7fcd15b8adb621674609703e94ee588d5600c7ab", "ref_doc_id": "ae0ee819-0056-4fd4-9162-116599ff81ec"}, "5878cb32-b662-4691-916c-5cc3ed2825f3": {"doc_hash": "0c1d1c91007112ba6af8b97c24a76e7b9827d409fc0456361ca70e1006341b72", "ref_doc_id": "ae0ee819-0056-4fd4-9162-116599ff81ec"}, "fcbd8e4e-fa18-4895-9ddf-a6fb42aa5502": {"doc_hash": "3448e1de3745b3f889b162cb898876fa89656d6646cc97d57e2db8a7d2820d17", "ref_doc_id": "df907850-1548-43ab-823a-bc3c26c3d15e"}, "af543220-f827-4be3-b884-663b1f721236": {"doc_hash": "87b9f44d67d48374f16ce003a95560bcd104975644448cefe7aa767bcde25bb3", "ref_doc_id": "39ea412b-6dee-455c-8d56-251d6a269237"}, "257ce1e2-82e7-40d4-ae7b-13cf733adf76": {"doc_hash": "0b53738143a179074c9528f1302ef9db6863537d2ee2fc9e725ece7c3e9779e6", "ref_doc_id": "39ea412b-6dee-455c-8d56-251d6a269237"}, "28665762-0c23-41d9-8832-93c980aa3210": {"doc_hash": "77c91a0672cdfc527e5ed489a6c3078872b022307ce55307d7bf79221634a0ae", "ref_doc_id": "d6711024-e820-4845-9eaf-e3e4d24fabd2"}, "ca2f55f4-194a-4efb-9b57-c512f4e30199": {"doc_hash": "4913f4293f5da0f3bb2517f601b766907a4b01f26941b83f189112a1c5facb3c", "ref_doc_id": "06a88d02-fe43-4815-877d-29a7760b1bba"}, "c57aa113-b013-4d52-b245-c47032c5fdc0": {"doc_hash": "bc6b265e981a49f017991362cd605e526fe27390debe4700467a9ed88e571c36", "ref_doc_id": "a6703883-5883-4ea4-b0d6-2420402bd717"}, "919db0b7-824b-4e73-9a33-b76939d1c8b0": {"doc_hash": "6e1a9f962ade9e6c042cf4829885a8a25fc64a7c8b9b5a5c918b1cd15579f80e", "ref_doc_id": "4dcb409d-54a1-4424-93b5-30fe5c588db8"}, "791a2a1f-fa4b-4b99-92ce-9dad973f8557": {"doc_hash": "ca2acea957f3f3eb01090cb5980e37e54bf5c8d2cedc8bbf1b9ac0716bbe77e6", "ref_doc_id": "914ad209-77c3-4a52-843c-b3e2c0f636e0"}, "5ab61c14-7c2b-4e11-b7f8-eb286b235f3e": {"doc_hash": "b8d64b903a5dff117e136bd4edb683002554e45aa6603bf546d574fa6652b36a", "ref_doc_id": "9329db6a-02f5-4a2d-8a42-d1c98a2ce4ce"}, "8a6f8dba-9ace-4bbf-a565-511e18620cab": {"doc_hash": "a493ad8b412fe80bff6ebb6874871196000b82a4e9b08b68858206f8bf187a76", "ref_doc_id": "8fdde9df-aaab-4cbc-93c3-d5b37d6b3f4b"}, "9c47187b-c473-4369-900b-5401efb8bec1": {"doc_hash": "1c04922c395f2b433a0191f805be908f9f237d02df7e1e22a485bd12961b05b5", "ref_doc_id": "8fdde9df-aaab-4cbc-93c3-d5b37d6b3f4b"}, "651db6e2-eb3c-4cfb-b36d-9a107307eea2": {"doc_hash": "e0c63edfe62110352fdf72694f60628da9c6894aa6df8070e2ee13089d0e5947", "ref_doc_id": "d600d3e3-4d74-4c9a-8755-0d92a9b1a62f"}, "a8074fde-379e-4f43-bbdd-5ff2316881bb": {"doc_hash": "1b901eec772768943599ab9c5f2408c881cf3b552f7af15ab2c0a1d5a0d152f8", "ref_doc_id": "d600d3e3-4d74-4c9a-8755-0d92a9b1a62f"}, "6e917c32-4d6e-4aa4-b972-5e74e3146ad2": {"doc_hash": "701e386c10a5ee887dac4f1a100b354a062ce5c5751cd2a606c44b15191b2bc2", "ref_doc_id": "56b9c672-3cff-4fbe-ba4d-6bbc57a5310d"}, "2b4b29b2-4be6-48c7-8160-a1b849aa4a12": {"doc_hash": "58d632e93d1b2a68fefbd00e04b1b80a7b4fcf5a04bb95e8b54934e56753c0c4", "ref_doc_id": "56b9c672-3cff-4fbe-ba4d-6bbc57a5310d"}, "a791b139-ee4b-410a-9df8-876575a52b13": {"doc_hash": "1dab21aa163a4a142043eba0355932125e089adc402ed7ba83ee0278f98a5350", "ref_doc_id": "44ec8bee-b6a7-4b4e-94fb-3f61e7330623"}, "dd475cce-4efa-4e2f-a705-10d20954da0b": {"doc_hash": "2fa4b5862edcaf29b644afcb7469f9b70fae6601bbb5605b27e57646dcd84ad0", "ref_doc_id": "44ec8bee-b6a7-4b4e-94fb-3f61e7330623"}, "bc89fc15-8557-47b3-9b2d-40c3d287faf2": {"doc_hash": "a47dc9ce2884498e4413ab2eb175f35caf0303ef9339962bd274c59bfb11a78a", "ref_doc_id": "3d93def9-58fe-4564-a3b2-f42dbb29c1ad"}, "4619c404-bc29-4bad-87c8-975c4cbd888e": {"doc_hash": "e2483b1126a959ca8c50041642bbf9823e8355608d2af2d7eb287717739752d2", "ref_doc_id": "eba31375-450f-4e37-8767-4e07a77df9c6"}, "40379dff-3627-4a73-818b-d9926a647d15": {"doc_hash": "e0b531494241b5a5aa3642d5e6fcc40e9e8b2e124e295b61fb684a498a6b7613", "ref_doc_id": "023c2bfd-d788-44f3-9d99-e0a988c1085e"}, "98e9afc0-f51e-49e4-af16-26e6ff202b3d": {"doc_hash": "2e6571bf981331e04f5274dc6948c35142dae1729caea60fcb3056b8b679f825", "ref_doc_id": "3f19b669-8135-4ad4-a451-1b749261056a"}, "2cda68ce-e5f6-419d-aa20-ce007dcca89d": {"doc_hash": "2628fb6843cfe34342eb3c435131506468c821ca44352bffced3f793c0ca8cbc", "ref_doc_id": "260502f2-6abf-4813-ae16-bcf28f6b494f"}, "9c2629dd-53d5-49dc-b73d-f6877853df01": {"doc_hash": "31e1a50664366dfde76bc139b349c8c049c17ab7e9ec9441acf434744f61d2c4", "ref_doc_id": "ab372910-0e5e-4bb0-acbf-8d6e76c93c23"}, "1dfcaa14-71ad-4309-9cc5-7b1adb968674": {"doc_hash": "fd359c17e28c37eb79a76df09223955e88ba25b09b7c33ce050f82f80c2a6dcf", "ref_doc_id": "9542b88a-dc23-459d-831b-a868e566791a"}, "2a388a6e-eb61-4f43-a39b-f3b070326884": {"doc_hash": "92fe1e7db29fd76fbc4eaeed3d456b14b798d26b73c60aa897d3cace4def6ec6", "ref_doc_id": "9542b88a-dc23-459d-831b-a868e566791a"}, "89ef4e8b-eece-423e-a094-e5839aa63dfa": {"doc_hash": "4ecbf1c7b22324f22196ce0c33d3d9e32a8c0ca8274169ee042f11549b56e1e8", "ref_doc_id": "cbeecbcc-69c7-4b12-97a8-bd60cc92ecad"}, "18f7ec40-2df9-442f-b4f4-85d834c768a1": {"doc_hash": "d62f3d0500aa3819dcffdd87ad622cf0de44e6c08a0a2fc5d3b51b8bc17c00af", "ref_doc_id": "643f4e34-4014-414e-9b12-dc862d7c9473"}, "b98f6cb3-5780-433e-9908-73da6e0ea863": {"doc_hash": "17c38238e3ea4e0af0398b02ab8038f2c2494ca2dae98082bb6eaa9e954df897", "ref_doc_id": "24a3e9b9-b1ad-4ee4-9f18-061b8dbe8440"}, "ae460863-8b0c-4bd2-a91c-a6e4a3ba4f9a": {"doc_hash": "881e60133867030dae04054729011fccaba3f8110c7478af898837bf49f1f8a2", "ref_doc_id": "9722d874-72a7-4490-92bf-a4652f6449ca"}, "f0744fe7-df50-429d-941c-f7263318e962": {"doc_hash": "8bee94c912d134d662e15859bf79302ee26eb533ed54a14ee413ddfc93748158", "ref_doc_id": "38cc7271-0a7d-4ead-bbf7-3f556753166e"}, "807ca88b-e79e-42c6-b912-f75436a0c99f": {"doc_hash": "1ae7915554281e62cde6ba295bca94c884a5f8c95d469744438d184d50c10505", "ref_doc_id": "50ca3d37-7d2b-439c-b773-19398cde035b"}, "a1fa33f1-5366-4ece-bbb7-8f0941218ff2": {"doc_hash": "0d5ac8c11fe45ca70b62b2f4c316536b70b7d9e5f002641231b80e28d0971d63", "ref_doc_id": "50ca3d37-7d2b-439c-b773-19398cde035b"}, "0e26515f-d2fc-4c7b-a103-d8140ce7599c": {"doc_hash": "88f4f23a04844dccae2cd0dbea493d8a796f6666350ccc449cfaf9263f35fe61", "ref_doc_id": "89dc2e45-6571-46a6-9561-f1995ee977ee"}, "a97bed54-5d30-4c9c-8a9d-45d91e3731aa": {"doc_hash": "871773ed237fdd949e06dac6e00ece4f6dfbd64546789887abc679cbddaee3a2", "ref_doc_id": "9f170c36-3765-4f17-bf08-93eabf3615ec"}, "6a924746-c8ec-4a1a-989f-299fe63496a1": {"doc_hash": "68ea85cee1e29e3aaba6b9f70c8c28d218fe3c78312f9218195af7c2cec79a6b", "ref_doc_id": "1469ce25-7566-49fa-8aba-fbe0ede9d677"}, "7a0db42b-293f-414b-a4ee-d093e896e75e": {"doc_hash": "6f320229434a146d96b3ea516d4f540e757af6571f20b67a2f176131e96a1225", "ref_doc_id": "57360270-3d8a-4e22-9fd4-fbc9fb78789f"}, "bf70ff21-322b-4115-b60a-8fa480876486": {"doc_hash": "af75becffc991f6787ebbf56412fb35ada4ae33deebdcb0f0647781a9ab94887", "ref_doc_id": "7e7c6386-027a-4849-9ead-0ac46c1082c4"}, "d76a66d4-173d-442e-a957-8ff3f85e3c59": {"doc_hash": "3bf3c200ade3dfc36886ca32b675fa9e1b0a6b08e3e173c2390fe637bdb54d26", "ref_doc_id": "bf29f4ea-5e23-45e4-a4fb-8308f76e4b04"}, "b35aa57a-8fbf-4a98-a804-985e332e159e": {"doc_hash": "134be2377e014e1b6ffa0a93432b8b5cb50c7633f11304a99f182516841089e1", "ref_doc_id": "a67a0c69-37d3-4dcf-a851-ba42db79d0ae"}, "0deeb4d9-44ae-4069-84ec-355af3e9ae4e": {"doc_hash": "32676be3b03039ed488ab1a14981e4945568399cf4669be5a84176595bc5d460", "ref_doc_id": "da15542e-e229-4442-b1fc-7688c1e7be6b"}, "32f1c308-54ac-4256-8c7b-17db572c7f90": {"doc_hash": "4f405d582baac8a2fbb72c46e8329d430636b5866fa48d24cd34e7e0105da2e7", "ref_doc_id": "02f0cce7-ae60-4d19-a666-ac5e53c94f05"}, "e658db25-fb30-4c84-a222-af11f367afd4": {"doc_hash": "ffd4248030881af43eff999cca96f5ce7c54022bcf9c2e3716aa10c76f8bfc97", "ref_doc_id": "02f0cce7-ae60-4d19-a666-ac5e53c94f05"}, "e95488fe-cdc8-4f3a-9184-c9dba1e556b2": {"doc_hash": "73a7a6e318b518886cfad40105d33036df1860d32e4acd152bd1e4ea41b30436", "ref_doc_id": "f7dca085-e477-4667-874f-cb5a5d8faeb2"}, "5b04157e-cb0b-4993-b122-5f09434fc5ff": {"doc_hash": "10c2ac58441fa63d560ec5de0fa971156a09e48f189b8d05e943b643f0e516c8", "ref_doc_id": "f7dca085-e477-4667-874f-cb5a5d8faeb2"}, "2989c3cf-edf6-4f54-847c-9f3294bc8b40": {"doc_hash": "027abad7500ffac5638ee037e4e6afcb2bf3bfb33d46c1625921dfb035855d93", "ref_doc_id": "a5679258-9c9f-49ec-8269-040a82fe45c0"}, "696e25a9-1801-49c2-b4de-77ca20657b83": {"doc_hash": "f7f1f1b9efea1d8ae2566aa7712404f57ee3b7fc1039d4e48bd098f0d4813dd0", "ref_doc_id": "a5679258-9c9f-49ec-8269-040a82fe45c0"}, "317ee7fe-3eb3-463e-85b7-5be19faf5582": {"doc_hash": "f36d9af4b71228a93a8492234d1bc1034e41ae6583f3e7ea33b46f7d5032f001", "ref_doc_id": "a71483fe-0252-40f4-8065-f69cbe55c3ab"}, "0d015a0e-5c1d-4f7c-a7e4-fcf57217c326": {"doc_hash": "207910963aca3b9d00be1464953e115e9bc5bb203977447a10327ee816ce9b92", "ref_doc_id": "a71483fe-0252-40f4-8065-f69cbe55c3ab"}, "bd8be6f9-e479-4a92-8a17-87b5e1e434f3": {"doc_hash": "f36d9442e4c67dd1736b9b694627f21e150005b18f69af20ee042f5234c080f2", "ref_doc_id": "d8528268-6b55-43d7-839c-c66d4f012744"}, "4701cd83-0d32-4e58-b992-d75ef1ba5ed8": {"doc_hash": "ce19ee60bb55aa6db151bd4bbc7664ead4809d18a8978122088b7b1f27e9969b", "ref_doc_id": "f0597b1e-6389-4e93-b936-4f433d2728a8"}, "3147f1ad-9d87-4f84-a019-ca00fbeae987": {"doc_hash": "f9bd8af876cf4ff19750d4793a34db6a498998ac1bfd82abed097c4fea123859", "ref_doc_id": "f0597b1e-6389-4e93-b936-4f433d2728a8"}, "68564dd4-60d4-4be3-b647-9bedd2724a81": {"doc_hash": "29abc6f1dcad0c73e187fb21b3e4365c9f37eabccd9d30bea07b5abeaeff58ff", "ref_doc_id": "982995d7-f964-4e5c-9ea2-a6a296b1168c"}, "e60d16a9-af1a-4305-8705-99d2e716bf6b": {"doc_hash": "ef8ac6ac471ef97903c6ab014b14cc8a62474349a9c706409770e97ab2909ed9", "ref_doc_id": "982995d7-f964-4e5c-9ea2-a6a296b1168c"}, "8d31b1b1-39a2-4ace-baf9-dce0100c425e": {"doc_hash": "a779fb5272e28801c777a0a8e988baa2a53e53f47c4cf0a8c0c0d5de24bd9851", "ref_doc_id": "01d7e509-ce7c-4bfc-b523-13e70dd4e55c"}, "b749a7e6-ab93-4284-997e-d9c906a05fc3": {"doc_hash": "4d7a145ffe88d7c5631ffcc22822b45529f45c984c05d72547851013b49b5347", "ref_doc_id": "01d7e509-ce7c-4bfc-b523-13e70dd4e55c"}, "472e3e50-ece6-423f-a941-04f1be0ca11f": {"doc_hash": "ca9d31cb8990aa7e8fffd8798330dcac9728b6214bf2e11a8afa3947247e8489", "ref_doc_id": "3d1284ba-742f-4f00-99ba-ba391d2dc05d"}, "52d692d4-a8b0-480e-858c-8e64fbb79acc": {"doc_hash": "44bbdec367755c658c29ee98df7ee34579a2b486660b3f832b6ecdbd5441cd40", "ref_doc_id": "5689055c-d65e-4c1c-850e-6988767ce179"}, "dd401094-5e8b-46d5-88b2-0ce9857c54b4": {"doc_hash": "eceb78b598d2583cd37194dc48b8afa302b29e34b0f87bba8236d4da048b5b0f", "ref_doc_id": "5689055c-d65e-4c1c-850e-6988767ce179"}, "0889fa44-16e9-4800-b2cf-c432fb2744f9": {"doc_hash": "82d4f64165c1c3bb3a7dc9851ffca90e5864d09fc134e94f2df3cb1e64df3447", "ref_doc_id": "4e5848ff-1a60-4cce-873f-9661a990882a"}, "68699bd1-6840-4d04-b460-926d83735e7d": {"doc_hash": "5916d861285fcb70a15b819c29f257b4ec7a693e41ba625312967c0add25806b", "ref_doc_id": "4e5848ff-1a60-4cce-873f-9661a990882a"}, "f9cc017b-dfdc-4f47-8c03-deff3d646b29": {"doc_hash": "11bd817b2282a62bd28aed4f58566a82c7c4af91ace5cfca89911a11b9d81b44", "ref_doc_id": "27d969ee-3116-4ed1-929e-01b46afeaa85"}, "34829c26-0c6d-4cb2-b035-14c27c0f3d96": {"doc_hash": "7e5a174d6fe4d3f50152919c5e682781e1986a9b4350b3390cf6be84bd178626", "ref_doc_id": "27d969ee-3116-4ed1-929e-01b46afeaa85"}, "26e931b5-4ec7-4900-86fc-931eff0dbdf4": {"doc_hash": "1f9c70f71259bfe0be7a356d2e5a575a1f2a81929205fc0d3e9d6c64d87376f3", "ref_doc_id": "06a7289a-cc72-43db-8e99-34aba1bbddbf"}, "0b24766e-aa5c-477a-a3a3-3df909b5867f": {"doc_hash": "c915f26a0bd215c6334c894e5ed721245a6ec608aee971fe3ed2f561ef8d33c4", "ref_doc_id": "06a7289a-cc72-43db-8e99-34aba1bbddbf"}, "f331b363-fcef-4443-9871-81e664147dcf": {"doc_hash": "86c8341ed63719f1e4643a8570b6a7b580fefe57239afe1b9013b616d5bc0da3", "ref_doc_id": "75383dc2-f1d7-4da0-a723-cbf4ffac5fc3"}, "2a06301b-9034-43fe-bba6-0cddf5ef7659": {"doc_hash": "0288dbeb111f58e9277a44e41752c70704fa4587dd710db5b01cc3c771843b39", "ref_doc_id": "dcde70ac-d580-4a37-baec-34e5c68ad0a2"}, "f7af74ad-d187-4e4f-b244-590bf30cf669": {"doc_hash": "b923e0f9ce08e8e3c4272bcce2cf41be9116775a521013f960fa9b55772cedf5", "ref_doc_id": "dcde70ac-d580-4a37-baec-34e5c68ad0a2"}, "1a94900d-3e19-426e-96bf-9848d9b22f90": {"doc_hash": "c8dc03a57dce67687701b7cf6e45091c3f66a3aa1b5ca9b637c0c6f7e9257272", "ref_doc_id": "fbcc267c-32d4-4041-abfb-14e9a2325b76"}, "ee1286dd-fb20-4dd6-a51e-d693604d4ea6": {"doc_hash": "f15acdf2905a86fe786eb128a1c7905f77f0de0521f39beeea65531d1504090f", "ref_doc_id": "fbcc267c-32d4-4041-abfb-14e9a2325b76"}, "6f00b9d0-2613-4d7b-85f0-ba1bda3c561c": {"doc_hash": "a38a565fcb7839a42f2942431824ce4e4de1d97daa1b4fc3214194dc1df318a8", "ref_doc_id": "f0630758-a52e-4b37-bff3-8022ebc61c20"}, "af822332-d017-4192-b151-4220227d348d": {"doc_hash": "ad485fb89a200ce5d8bd8898c9833d33edf4bb5a730ad3cd225ecd2a89bdcd6d", "ref_doc_id": "f0630758-a52e-4b37-bff3-8022ebc61c20"}, "4da48a85-a147-4e03-8ef5-030f1a64760f": {"doc_hash": "552680be80138b58f2baa5319158e15cca26873916e2feabc986682aab48251a", "ref_doc_id": "34f5f364-de68-412e-956c-54db598213bb"}, "bdcc64ad-2a26-410f-920f-69ee30fe3d63": {"doc_hash": "2238b787332ac9f73060a1bb4c7ffa4cb53d14d59d456a5fe80f8449ad71cfe8", "ref_doc_id": "34f5f364-de68-412e-956c-54db598213bb"}, "bee95db5-0e83-4aa3-ab01-3f28bb8dccc0": {"doc_hash": "d11da6ea2db98abb02b9079740b94d0974162a2d95777fa56075a8f70de733f4", "ref_doc_id": "feebbea2-1e93-43b9-949f-69b6b6d210f8"}, "0a3d38c0-ea0f-4145-9615-3b82d549f6d8": {"doc_hash": "ca4a608ad960f0745f1927788556bb5b749f9fbb097534f816752a89db390969", "ref_doc_id": "feebbea2-1e93-43b9-949f-69b6b6d210f8"}, "51f96d84-1330-46b6-b069-3653d9fc708d": {"doc_hash": "66b2c93d86c56a417884dc20d8947e24dc2d1a2f25fd8111572950767f0e47c7", "ref_doc_id": "e0bbe570-7182-45f1-94af-0aa5cd71c9ea"}, "63eff1f2-a97f-4003-958a-cb4f29a2d877": {"doc_hash": "21e47f7d53e4cb3f092ed62c792e1eae4946e7a363c602367da92c14c7cc69dd", "ref_doc_id": "e0bbe570-7182-45f1-94af-0aa5cd71c9ea"}, "1d871056-f983-4c8b-93b8-e43c1a334410": {"doc_hash": "5f3e9dc46603190d40ac94515a8b6e6bc87bdcc1b38eb89361427fa258c2d22e", "ref_doc_id": "bfd9a388-f0b2-4ee5-a53a-344444954295"}, "2cf6efad-df50-465f-8d82-c491f955a233": {"doc_hash": "0ec6c63e50575ee3d3ce62bbdba6dc1aad01d268e79f40a3deb90f62b9d4911c", "ref_doc_id": "bfd9a388-f0b2-4ee5-a53a-344444954295"}, "2cf246df-ce82-4ccb-81db-3c1cbf29f64a": {"doc_hash": "64bec98604e75870b45902e9f6a0392ba7885bd0780a6809fa1821ef4bb5e993", "ref_doc_id": "8804de4d-927f-42cf-8886-5e678eb52072"}, "e3ecc5eb-6da5-48dc-ad96-10412191e3b6": {"doc_hash": "0c12d1dd82dac57da7bfc4c8d75252ee3a4d7d9d55e3350338007736728494b7", "ref_doc_id": "8804de4d-927f-42cf-8886-5e678eb52072"}, "801b2a31-eafa-4271-852a-5cebbd3af022": {"doc_hash": "f99f11a10d7278b7bd4f36ed14c4c5853112572fef033b864d652efd5524cc1c", "ref_doc_id": "3ea0f5cd-f5d8-4a53-a1b7-c251792bc30a"}, "8b47db3b-e8ef-4889-a9ea-8da27020524f": {"doc_hash": "f7cf7b6ad3fc1806456300a53f4467f1266a01524cc911ac13a61c2227ce2a9d", "ref_doc_id": "3ea0f5cd-f5d8-4a53-a1b7-c251792bc30a"}, "2317efbd-e9a3-422d-b664-9d92ed5ed9af": {"doc_hash": "42d5aa3fac0d6f52e964b33d25fa417ca4db4518b858fd00eff36d84db0c329c", "ref_doc_id": "9ebaf473-8dd2-4c77-acb3-efde7aacea92"}, "9bb90168-2063-4620-9e9a-55c3fea55e28": {"doc_hash": "919d05be14a48ee226407bea6df7fde9ce578c118dd25b56542e4489f7e1b2cf", "ref_doc_id": "9ebaf473-8dd2-4c77-acb3-efde7aacea92"}, "ef4c1c90-64d0-47d3-9a32-26a8e7ed95c0": {"doc_hash": "224c4619e922c0b9b75c2ac885310b43c6ca4dfd4b5153dc258ab3400b4e9206", "ref_doc_id": "b38b8103-9ad4-4a8a-bb82-aa128a7386e8"}, "0ab7c261-fb8d-40ae-9048-e3efe1b044c3": {"doc_hash": "08bd78e602ef640a807b4872bccf73223c35ccd8d2b4c8f37574dd187cf9b56b", "ref_doc_id": "b38b8103-9ad4-4a8a-bb82-aa128a7386e8"}, "9b4f2a56-e040-4aee-a9df-ab91e4361aa8": {"doc_hash": "942211f09a5e86fcf37bd74606a6df367092b85f37af956908a56d1f9b628943", "ref_doc_id": "74bd25f0-59c3-4442-8315-10ffd2c17113"}, "04ff110a-e221-4369-bfd0-5b62217dd734": {"doc_hash": "94cdaa860aac8fc00441ffe09528060d5cb8f49f9c509534ce7e280b048158e2", "ref_doc_id": "f2992f20-4a85-4ea9-b87f-d73c3abe30f6"}, "80c740ed-1697-42f9-ad11-6c30c4b06b77": {"doc_hash": "0a7bfe9ab73134bab558bde804904dd8780004026353470c3677c6b155a233b9", "ref_doc_id": "6171c80e-32c4-4cfa-9d9d-21c6008eebee"}, "74851931-da80-4837-8177-f594448a38e5": {"doc_hash": "43ad18348c5d0f7111d24a0daabfe837053e846b1ea7451e565432585b30e2df", "ref_doc_id": "0c983c27-a24e-428e-8b01-7ee379b826e4"}, "40e53e01-2cb4-4d99-8ab8-75b331c01e14": {"doc_hash": "1a77afb0ea0398ce7b1ed22e6d3bb6c636a7ffa9c4308d6081dcc187efa64b81", "ref_doc_id": "0c983c27-a24e-428e-8b01-7ee379b826e4"}, "f645b972-019d-4ca5-9b92-96df346a9d79": {"doc_hash": "323d0485fca8ac713f29d66ed88db5a01e129a220eb6a751567afb9458169753", "ref_doc_id": "6bf221cb-5621-4db3-a60c-c365a5f117ab"}, "ace4100e-f1f5-4775-8de9-11c8a33d857b": {"doc_hash": "ed54835dd0bc4add28f06c30881b3efaa57debb3ad441e471a3c8337635931fd", "ref_doc_id": "6bf221cb-5621-4db3-a60c-c365a5f117ab"}, "055708d8-7f94-477d-bae1-f5fd3ff7f397": {"doc_hash": "5e2ccf434861b91555046eb38fda31610a0213725a8d66cd167afe6419dee7b6", "ref_doc_id": "e619bff8-4340-48dc-b342-850f2ad65828"}, "e0d330c3-c7a2-451c-b207-e0cf59e0569c": {"doc_hash": "b7a40278daa567d13f66f1d207fca034ba85363f6a10ba8269649980813b7f59", "ref_doc_id": "e619bff8-4340-48dc-b342-850f2ad65828"}, "6e8dd6d2-da80-477d-8854-47a10378b4f0": {"doc_hash": "3cacc878c1e4da6a33c19f019ccac33ff1ec8927861e3473e191d89adaeeff65", "ref_doc_id": "e5df9d7c-adbf-4f14-a3cb-0900f21db8e1"}, "a339e548-1962-4b3e-ad80-47d72f1b85b5": {"doc_hash": "481cd1e2cfffd39fc94f4433ceccca0522da2d8142569724e059b9bc4e903863", "ref_doc_id": "127f760f-e743-47ef-9aa9-8d1623aa0b1c"}, "295ab6af-6dc3-4f28-ac96-6a3d2b013fef": {"doc_hash": "00887410bd90064f2ce9d316d17e73caff4ef075cc20ec1867f994581dcad513", "ref_doc_id": "b7fa1cd8-08cc-443a-b536-3d004397a1ef"}, "10c47816-8de9-4aa1-9c26-4dd07e7b144b": {"doc_hash": "64084bc8dbf741cb85efbb52d5e03643438161736e660b130c3a7056cd7be94d", "ref_doc_id": "e5dc3e5e-b274-4c5c-8390-ac6c9645e0bd"}, "0982f878-f68f-4a5b-87fd-b365e2ed36b5": {"doc_hash": "45325e682b51a602c8489a851af4f0069ced59df2aa2f9001a25e9b5544a9af4", "ref_doc_id": "3a532330-5add-4d57-8822-8eaa8566d70c"}, "813bb6e6-a453-40a3-8250-5a86af88b2f2": {"doc_hash": "29f8563642a2cecaf99ab58d80cea3683c3ea1976d33c57c30ba6c16e5079427", "ref_doc_id": "8d790f7b-da26-438b-9610-cedebbe3167c"}, "6d89c1d0-2fa8-4201-be3a-dfcf45ad37d8": {"doc_hash": "f752e9f39dd3f1beb7e8a842d5cd64d83db8d86b68446e024aaf2b38db34e89f", "ref_doc_id": "93c62739-724d-4b84-a894-4d1829915335"}, "234b3a34-b16b-415a-8461-517de762eede": {"doc_hash": "de990b3b00e9c05e873b545069fbb37137547fcea0d957a211445f89b1053118", "ref_doc_id": "b8c07ae1-7531-4f59-a33a-7aecc604952c"}, "604655b7-0d62-4221-b227-0de177954e6d": {"doc_hash": "2d8561ab2909e0ffcf1da9621279cf09dc717f929680a5f84452761b2cfeb6de", "ref_doc_id": "4edd867b-07ef-4a38-87a3-ecbd0fc17685"}, "06e46a1a-005a-48aa-a3dd-4d26f27bb302": {"doc_hash": "141ff60c4732fef99c17c432bf4c484a81bdcc69624bb974c2f003c164ae4a77", "ref_doc_id": "c2bc3153-203f-42a6-8202-fca086edafa1"}, "5b11a152-14b4-4c01-a345-bfd97e311ad3": {"doc_hash": "ee175f7a2ddd93062d6cade822d19e52b9dc80cde3ab995844cfe826575d8a01", "ref_doc_id": "dbe65b41-b652-42a1-b66f-80d2f8df2bea"}, "1d0bfbda-8793-46af-89ed-49365740d75c": {"doc_hash": "697509a1f043a77777edd9d090fba4447bf3f195a65d4aca2a5095c8fa376481", "ref_doc_id": "03dcbde7-5230-4348-b9cc-d12d81a2c869"}, "c6fe0850-3b74-4552-9f9a-7de5d4825168": {"doc_hash": "aac31eb4309d2b3842a361c95fd11a00bafce0e35e8f644b9de663749a3ef2b3", "ref_doc_id": "a9c12691-0f49-4d17-b40f-a8efcdbb586c"}, "c50edbac-8c36-4ea9-8a81-dd288b1d4422": {"doc_hash": "aaa3716edb4bfea81bdd847d692622d4c85aa52f2ba5e00893a0864e2f9fb8c4", "ref_doc_id": "b3760952-ea5a-4bb5-be63-bdd7ade742ec"}, "5e2a3730-bd5f-4011-a5d9-32fc82184426": {"doc_hash": "6cf25fe40e893ca250196f888f8d5e62603ba14cd5f45ce4309031ec0588f230", "ref_doc_id": "7370cdec-6d94-46a0-85f0-fc81472b53f2"}, "3ee580ab-4408-4249-8840-4b9dedc31146": {"doc_hash": "0a89a79ce0be5b66e5b9c48a0485938e7d98e5f39d2d253dee2ae065560e96bf", "ref_doc_id": "1f20a2be-1257-4db8-939c-e0438e0a8452"}, "349027d5-7bf3-4277-a3e4-d7b66eaeebb2": {"doc_hash": "90a231f47090a50f12d73e1b5331428dc1f7623d232b2c4537c61e96e1c0f780", "ref_doc_id": "086aee2b-5764-459f-86c5-ca72ef3a6dc5"}, "1ac83e14-53c6-41c4-81da-2b5b86053aa9": {"doc_hash": "777d89d8b57757921df916afa2580e13a9766af56b63bccf59ff318c7e9e361a", "ref_doc_id": "5738874c-275f-4dc2-b1bf-29b05a8e6e86"}, "e2185805-90e5-41d5-937c-67aa9bdc48b1": {"doc_hash": "afad27d5be999e13926e31aba4d6e3f83ed807f168bb6ff6a0971a3bb4d8b971", "ref_doc_id": "035495cf-4948-4143-b4b6-d03afb4f6144"}, "1ce7acb2-9e33-4740-9ae0-67558380cd12": {"doc_hash": "e0a3f97869136bd82d8dce110cedc72671c63877002a920b71641f99e80365f8", "ref_doc_id": "ae47c3c5-bc95-4cac-b1dc-7a8bf0ff9fce"}, "79a3745e-1d78-4ded-996d-b09971c14d6b": {"doc_hash": "f814c5ce4dacbe4c3d54b6bbcc235a1ccd6fe629075106397d8b411a0619422a", "ref_doc_id": "f832ec61-b897-4745-b835-5158abc4b7c7"}, "e1c8753d-fee9-4101-ae7e-8c251770d409": {"doc_hash": "54201a8ed1c04f2c37d7302454eb3d2c1489c972d846b3039ed2ab3978ff7261", "ref_doc_id": "e3cc393d-f9c3-4d3c-9f6b-1f118edcd88b"}, "85610445-3361-4556-921c-50e92adf755f": {"doc_hash": "5d624b0c1531aa2ed1fd8442d774b573d8f7d2bbd05aaa8fbf2cbf0b777594c3", "ref_doc_id": "088db272-8b0d-4e3d-a324-7d4bf233517e"}, "c509f7d7-14d5-4f06-9bc2-0689e259509f": {"doc_hash": "8ea2996bd114769f4804c43391b4abb883dfc6ba68ff296526e955be025d3118", "ref_doc_id": "8faf3c04-6f49-4e02-aa35-14919129f4cd"}, "25ce4d90-ff5e-4074-8da6-bd1bf136b636": {"doc_hash": "d8a50b545c2a0d8d9fc0d31f194cf58c6bc2c44c62682be44193a2d57d1087a7", "ref_doc_id": "129ef60f-c486-4c05-beb1-5130b9e7be24"}, "b28404ab-736e-485c-ba80-479395cdb79b": {"doc_hash": "428350f22b23dbd81ca96ee26c2e077003471a597b3306aa7f95b698b5fa33f3", "ref_doc_id": "de73d03d-7c87-41f1-a992-b4fa980f8cfe"}, "8bd3fddc-19b3-4748-a1ee-231454b0d538": {"doc_hash": "7b204f7cb4527bee0a522967d2f3b6b33bc1747d25aa35710110484bf6d2b61b", "ref_doc_id": "d18df3cb-bef8-4889-a804-415e03ab7086"}, "efd7971e-40b7-4dff-915b-f94f40e27c0f": {"doc_hash": "06fa10ce6ce4ecf873cc72d28beaba8b1f217072edca911faec207ce7b6166fe", "ref_doc_id": "81a22fd6-5773-4146-bc1e-c0cac30d8514"}, "5ad08e7e-53df-4765-8201-0b580a04f964": {"doc_hash": "2f522b87ee9d0b289ed7d9fc813d683cd21386fb5ee4ee8293f7a397b6f036a6", "ref_doc_id": "b5910d2b-ac7c-48bd-a526-aabff5029769"}, "e9fa399d-4add-4ef2-8fb9-31153ac4cae6": {"doc_hash": "5e3df868dfd78a4a807e6a8b8d94d4ad67c9bd5983173bf99280b880d6a5300b", "ref_doc_id": "877cd254-b969-4020-818f-1d78ca2c953b"}, "356c1e4a-1a5c-4f8c-bfd0-39369d18619f": {"doc_hash": "71e82b6b6a5193cc27b0bb5017a635cdd7a8191d05e12f3d39a59fc6812c15b5", "ref_doc_id": "a847fb2f-95d6-4c67-8699-a2df88305780"}, "7777690d-cb9c-4f4f-ae04-62c5f2aaf994": {"doc_hash": "703987d3593f485aece182e2a272ca2f114498b5ec30d71cffa88bdfba03ef1e", "ref_doc_id": "07808233-38ae-4ea0-97f4-ed949647387f"}, "2e5e0bf6-f699-4bee-b90c-8f3784f9f104": {"doc_hash": "5afe4b22fe3ebb778af3d2d02b52fd0e412240ee596ad387b50697db2e9c2f02", "ref_doc_id": "c8dcdac5-e757-4371-b2b1-45f4f2092cac"}, "81da3871-0a12-4cca-974f-28b014f3c001": {"doc_hash": "6049defa34bbc4df9aea12d0b903c0faa58e0e1f75421301bb85aeea94005cd8", "ref_doc_id": "708561cb-b946-468a-8062-011d26bd70ab"}, "8f925daa-77e9-4e49-9354-decd2e4043ef": {"doc_hash": "b54b80f7566f2316f2d0de54d5f4ea752d54e9dae41f347926124011af52ecf1", "ref_doc_id": "81aa97fb-da37-4c36-ba3a-15058dd657ca"}, "e93b2350-d67c-4721-92e7-0f9a07393779": {"doc_hash": "a09a692ebdbe527654068ca63f989d5d3b97b74b654adf1a711d3c5f8c78d1ae", "ref_doc_id": "fcb0bb9b-e43a-46b3-bfdd-64b1fd009dce"}, "49ccbc19-8c14-4113-9366-f6e10390bf82": {"doc_hash": "868c03e2d0f7cc55eb941b8b742f4141f675d4faf63473cca9e5b8790584aca4", "ref_doc_id": "34c077aa-02f6-488b-8c08-e64a26a7b253"}, "16eb342f-da23-4729-b10e-54893821a438": {"doc_hash": "76630bf7925ba13281a7fb7d82ad397bb1335dec8738304a635db1b19adc97cc", "ref_doc_id": "b77112c0-c576-49dd-b52a-1f5646326e8d"}, "f29d0ab4-df7b-45fe-ad39-a726f18b3a30": {"doc_hash": "0b34238c3851bc88d0a700b53c1fb4a81a2c3f9bd9db35810ed0c6f4af896eec", "ref_doc_id": "1f9ddaa1-3f03-4773-9443-27bb153195b8"}, "2b72a8db-8d7e-419f-bbf4-43b072cbef30": {"doc_hash": "9acce6b27570cf4ff622c816d5580656f6a864002e9e72700cb24228d462cfff", "ref_doc_id": "a7ab9171-09f1-4033-ab67-c42d6c0522b2"}, "36674254-95ee-4613-8471-541055e283aa": {"doc_hash": "d35c27e69e8f7e606cf241b963d7a89d0f373b1d038277557eba03a284843b02", "ref_doc_id": "aa36d483-733c-4b70-8f29-cd0dc0064d2e"}, "4b55be42-c577-4a54-acc7-5cb026667660": {"doc_hash": "387e829360125568ec6f697679892f3c4544748d7f0e8782721f66e56ca74b8e", "ref_doc_id": "ddfe4c8f-3803-494a-98fc-9d391355d06e"}, "e2555100-60b2-45a9-bc13-3dc8042638a4": {"doc_hash": "127a980bb6339ba26cd6dd0ab51e82d35688256e4bd2dbaecc65afac7b1d046e", "ref_doc_id": "f021f8ac-a087-45b2-a6dc-5d220082d90d"}, "aa25a05a-cc3d-4bcb-ad66-ef3c7b68d46d": {"doc_hash": "ec818ef7a47f4d5495b156154c35069d9eba1a2208f01a63cd04e92b6991e79c", "ref_doc_id": "5b6581eb-2f5b-4061-b17b-e1956bba6754"}, "1108eab3-c0eb-4d6e-b2a2-b394f2c51cec": {"doc_hash": "02da3632e6453fb79d921a926fe3ad499cd108d6d6b935c61fc0b54334c0b58c", "ref_doc_id": "24975b92-7a26-4eb5-a145-c17d069fb815"}, "6525a768-43c3-4936-9b7e-0756cb4ecc69": {"doc_hash": "7157883f01e7dd6a7eff7e33bcde5d98a28b76b0850767fa1a79f4a6e00a9a57", "ref_doc_id": "31c0b408-3b8a-4d91-9664-6162d180fa9f"}, "25b69f63-b54e-4faa-89de-708574a74935": {"doc_hash": "9a4d164b08537564099a5df0e58a175bac3f3c9d31a5d4c0317d000dcf88c3d2", "ref_doc_id": "d404ec4c-c113-42e7-a270-6da65b31ea8e"}, "a29262a0-0c93-457f-9f78-e2b792f87d79": {"doc_hash": "416e9ca7ed68f720ba6f195d24030f4e98e75fd7b978855d748d5f30842197d6", "ref_doc_id": "a6a18a04-116e-44da-93bd-067b695befb9"}, "1e1263b7-4f81-414a-a712-033484814215": {"doc_hash": "07cc13018abdac0bcf87582a783987b22b1312176b5f9c7970383f26362592df", "ref_doc_id": "e07ff4ae-9985-4891-ac52-9b3d5ea0997f"}, "81e1fe4e-e413-4662-b18a-3f3ccb03aa1b": {"doc_hash": "1a1deb9cb44f13117deb44ddf1509af37084cc9d92bf3ceaaf846aa91347a8af", "ref_doc_id": "9481fc18-7bec-4141-9ed2-9115c5ff6f90"}, "e0522904-5bf0-4d20-a40a-59f674d3c525": {"doc_hash": "a0f7ca157b64e3782affab65f0e610695b7655f618bcb54be5472e683ec5afac", "ref_doc_id": "9baf27eb-4f98-480a-a62a-30bbd33b2c36"}, "8424883b-7390-4784-bfd3-6b9f1630ebb5": {"doc_hash": "e96840fb47c35eb879aa471066aebc2dcaebfae58dcdaa8620167166cc5821d8", "ref_doc_id": "f3646be8-5fe8-4bdb-acb0-f4f35e7cf6df"}, "d6237a1d-5ad5-4c21-a054-614b89d98b6f": {"doc_hash": "8aeae2e60070a2f02af82f163d07e6a59aa41fd21b53361cc1b3898b5e519724", "ref_doc_id": "9dffd154-6c4c-473d-a8f0-f8f7a6ea7ec1"}, "81501a0e-addd-4a42-bb9f-d1749de4aeb2": {"doc_hash": "53350d516b3d2985a737b7051fadc5838a95b77653f56e3c5536571c2c3f6ac3", "ref_doc_id": "94fdbb72-5d7e-4c6a-8341-74f3eaa9e40f"}, "5105b182-ea99-400d-a52f-68d568ee2f0a": {"doc_hash": "167b7e1d647fc69841f1654ce26056864a88a0e4d42965827b2b5ab0f341c537", "ref_doc_id": "1eea301e-a3d6-4853-b491-e21b2f9ec598"}, "b10aa813-49d0-4a2e-9194-1a0430c7e8cc": {"doc_hash": "29e841b96bc1e37f310cf9b84a38856958c2956124342afc760ffe2e77b0ddf0", "ref_doc_id": "218eb4d2-cb26-49a7-91f4-1eb905f6d371"}, "ac624d69-7811-41bf-b881-f4e2ed01d9cf": {"doc_hash": "e4676cf6fe1e657a8d1626804803757e780cef4064743d0809a1cd0e6a94be4f", "ref_doc_id": "98885822-5de3-4fd4-8504-ff15ac4f1c59"}, "cc17dc9b-0355-449e-8ed7-2572286979d6": {"doc_hash": "6c625788b14c1c8b8a8f84630ce13692e33b3de435c41308b1a30d0f836e2de7", "ref_doc_id": "c0d6aae9-1a7b-49f7-be52-feb6710ae610"}, "42dcd03c-fcd1-42a5-812b-0265ab79c43c": {"doc_hash": "647ad84d917e5cc990c31becc0d98fd74783702fc577680ea84acaaaa8541695", "ref_doc_id": "c23944e8-5179-416d-a8a7-8fd8827379dc"}, "1d5d79c5-ad65-4b56-a432-f8b7b103baaf": {"doc_hash": "23b907bd4ee11f33b27784516558801ca8c13f08c1e66e277f5ab8f029b1c304", "ref_doc_id": "aa35d115-5cd2-450a-a03d-f40f487655dc"}, "45eda351-709d-43c8-b8ee-9c01a4cc1828": {"doc_hash": "6283e185e4b1c5110b4c39afc7243a96debf1d035fc90389c2b78c6ff1f42459", "ref_doc_id": "9053d7a5-bbc9-4ee5-b436-1c52ca084d85"}, "f9917544-b17e-4dad-93f1-5f30d226d5fe": {"doc_hash": "760fe6def9f1d7e31fb17acffc0775a1aa25e3ad3cf713bcc82b22957152455c", "ref_doc_id": "667caa6c-a289-40bd-9c0a-8c8612232c24"}, "3025f9eb-0959-4e8a-9ed1-038827e44300": {"doc_hash": "fc9b3350901433d34b5591e0b1db81b68f3394d3e3a4319b205e604203610798", "ref_doc_id": "be48bce9-d730-42cc-82c5-2c4aa2696055"}, "243a18c1-dd8a-4cc5-8df1-8d95dbaf951d": {"doc_hash": "e16e876f34219054f445c3cfa45364d4fe5cff35ee7d159052446ce4e2c3eaa9", "ref_doc_id": "a7792b4f-5209-475c-b165-803325c2bc5a"}, "a133ecfd-c511-4137-8298-79897353e39b": {"doc_hash": "867486288e80d928069aa1c29e667cacc3de4401f693407bd288139e979db0e3", "ref_doc_id": "cd064d91-ac45-4600-a902-cd0bb1b5b3e2"}, "f9a45f8d-66b3-4b24-960e-e9239f9b1b9c": {"doc_hash": "a5f78ec2d9460b66b303ddd4fc911f101b24564aa048f0b82413ecc5d9ae505a", "ref_doc_id": "114a59ab-728c-49b2-853a-cbba213b6ff8"}, "d48e1d12-27b2-4812-8815-666c63648495": {"doc_hash": "8db4cda2828df05ecdeeee5b72005acb00d322c6978bf53c789cf9512acec9a0", "ref_doc_id": "5db0336f-7694-408d-b1d3-eea1107c8799"}, "b8bd003b-61e9-4713-b19a-4a1bdea38ac9": {"doc_hash": "8bfa4c18b3147fbdbb479b9ffeb62d6e369b05b6f773a6b900e59b1766a56d82", "ref_doc_id": "23251ee2-03d8-40da-b2a5-925018444725"}, "0b0dbdaa-e8ca-4866-91e7-c7adced2904b": {"doc_hash": "b7c21a6360383aa4cbde9ae446b989497e375ec7051922c6eb0160c9409c6c14", "ref_doc_id": "e06c63fe-2a3a-4c7c-830e-b6b3bbd855fb"}, "b38cdebe-b5a9-48d0-b99f-deeae0cbcfdc": {"doc_hash": "675368912eabacaf9eb517e054b2649c9b2371d8a5ad93e18285f06b18a10590", "ref_doc_id": "6f29e41a-f812-4162-ad45-37ac3cab1afd"}, "261d514a-785e-4fbd-811e-059580094b87": {"doc_hash": "b275e3a4c4a84e6340d9c888c895ae0b18dafbc08a9536647af95762932c4792", "ref_doc_id": "51e07d18-ef1a-4228-a1b3-6fe7aa7ac4d5"}, "36e450af-fd4d-426f-8443-9d19151ec92e": {"doc_hash": "a0868de885ffc34dd6a35eac3fc96fb98d447e7ef249f8d7cb816bc67cc4eeec", "ref_doc_id": "3ae4e3a1-2dfe-4ab0-93f2-ea1c34c6f108"}, "d7e162e0-54ba-4234-94a1-5d053ddfaeab": {"doc_hash": "5a8719a1d1b5e75c92d8f45a0e6d75262d5328eaee7bc0b70c2a554828f04b27", "ref_doc_id": "e974b134-6145-4383-bd70-dc312ac48902"}, "1f55c7b5-30df-41fa-bdea-c7893b9c181b": {"doc_hash": "3f594d260c7e515acd7085860f34411cd0fdcaba0739fec06dfd0aa6f36933c1", "ref_doc_id": "65cf492d-d45d-4d2f-bd7c-47b5daa06f00"}, "bd072fe1-c636-407d-b2b8-3629cd723a77": {"doc_hash": "808f166e5d516f80f1977dea7de901680994be1d1216bde1c447f7d8b8c768a2", "ref_doc_id": "cc9c178a-c197-4331-8fa4-4fda3d5dad89"}, "0cd01362-f17a-4f91-8608-4943028c4e08": {"doc_hash": "563283266a255037b1c585eacb201fc6d31924de7761edb99d0c6af28901a226", "ref_doc_id": "3e99586e-a37c-46c0-900d-d26fbae4bec0"}, "3a1ba42b-8b87-48e2-9f86-d7b3a478a6cd": {"doc_hash": "a559142c99d5456787913df86ad07673aecdbbcafb2714fcc85f70dd5585950e", "ref_doc_id": "1d140eaf-ccd8-41c0-be6d-4eb279622c7b"}, "feed908e-f583-4be7-b350-f9204d833002": {"doc_hash": "45677a501089581a3ee957a9194674e32c62c2175c95f879d5d5f8be6eb7b2b5", "ref_doc_id": "10ca498d-155d-4986-8436-798a86a0e22e"}, "dbdb9e72-01c9-4912-a90a-976a13858cd8": {"doc_hash": "2a01186d9debe5600cf11a2fdeea42a65c3c6f46f783b2bfaf9a8982f1e8c99b", "ref_doc_id": "00129353-93d9-4192-8c8e-57f16ed22367"}, "c854a73b-ade2-4c22-a68d-fb62d116b52e": {"doc_hash": "a82c8ffe2dd002dd636dc82eb8af09c76f3836c4255768d7d257facaa184daca", "ref_doc_id": "7323d7d5-95ec-4636-af5a-2bfa7f54d943"}, "1fc3fb3f-693c-48b6-91f6-db679d5f0bf5": {"doc_hash": "8bc2c21aeb3ce988fe34ebc554f9dd9bb071ff9bab34568836a1fcca74d2d967", "ref_doc_id": "cd8f94f6-d520-411f-8640-9b9da389ad01"}, "bc47bc62-bdbb-4bc6-82da-57f7bb750019": {"doc_hash": "7ad36c76e55a8a0eea87ec895457b1efe1b4d7770298e3ffdf6e5977d9d7ded1", "ref_doc_id": "104302c0-1d43-4ae0-a1ce-0a98ce6b9a54"}, "6c53b6c1-8c40-491d-85d3-b8f5d3d86de9": {"doc_hash": "b05123e9330d5b160b9e521f9c01218ba6ed306943970a0fe4f607bf5f66d884", "ref_doc_id": "41c723a6-31b3-47ec-80c7-e805195c82e4"}, "e5c104f2-8850-428e-9e0e-53e0cce18c24": {"doc_hash": "1dd8588181982b3f6917033871f526b115a0c4ec20bf4a64e4d950698c3bd9a0", "ref_doc_id": "d9b00aeb-bbda-4a5c-87b6-4dea7d13fc5b"}, "37a6620b-4114-47c8-b597-1ebab602c11e": {"doc_hash": "03fddd40af85dd1f0046a76b8866af3af308285ec51e048c8832a29ce28fa5c7", "ref_doc_id": "9a1538c1-2492-44a5-81aa-c63c94caa618"}, "5197d6ae-05b2-44cb-84a6-0930e4d7a673": {"doc_hash": "4e1d6c723c76e05e0718a75dbd9c82163e5822fef7c629f0be34c11cc90be395", "ref_doc_id": "9c19605c-cd7f-4416-8ce1-2b44d0ae735e"}, "58a1df65-3a98-452e-9047-6790b58aad76": {"doc_hash": "d82eb233928afa3e8fe24d671cba0ba0a29816a1a675ef6f02429b7d98a61e0e", "ref_doc_id": "7b9aaa04-641b-489a-9445-d3af27f4c1df"}, "51f336cd-2feb-4b27-8151-e715ebbb5949": {"doc_hash": "d6d70617e90cef9e2172ed586444b93c0dca9db31871141a0fa8cd5d60790cc5", "ref_doc_id": "df1fa265-80be-4603-9628-88c9597d0ad0"}, "1feb12bc-6744-4ce1-9b04-0676fd2a9b4a": {"doc_hash": "6ec999acdd417853599de6660710a64c3b17768679d50f9e92a2fe28605309f2", "ref_doc_id": "7c61def2-3c1c-4c01-b76e-ce02f91404e1"}, "4ce04832-7d92-4d98-b75c-b0362623ff41": {"doc_hash": "a7beba160f6075f10e8e203dfb4a4867e85b800b2e1f6174c7fd15fa60de5fc3", "ref_doc_id": "aec0f15b-e05e-46b6-99ce-375434716ff2"}, "ec91d208-9eb3-4ef5-943f-3d220a402eea": {"doc_hash": "bcda75f2111332e9fafefc2933c8f77752f28e7f79cde19d4548269fb72589e3", "ref_doc_id": "2a909028-dc81-4412-8241-d944dbb5d3d8"}, "989fcb88-a4cf-4fb9-aab9-8f3ec29981a3": {"doc_hash": "56feacd641ed1ff108bec28cae92b6c1d59f196a2b809df760cb48b0551982f5", "ref_doc_id": "327b3dfa-5bfe-455d-af15-bca96e695756"}, "03144f58-a22b-44ae-8fef-f6cb3fda2d81": {"doc_hash": "ddca61fab0bc0fcc6f641557194c0968a6343837011cbb9e266bbb1ada54f785", "ref_doc_id": "3e363369-24d7-49f8-8a28-fa580b125227"}, "59dd00c0-ab06-4060-87a6-4843e83a07ea": {"doc_hash": "8ff8ea846fcf584431f843be26c79f480c30a5f3a6ca9c7c3bba83ee712553a6", "ref_doc_id": "be853f4f-973a-4ce9-8a3d-06c3ae902409"}, "ed9d357b-eef7-40cf-b1b8-9cc9fb8e5772": {"doc_hash": "389d4677061b96c695da9d7c2a372102730cee490d4207d3de3c90edcc9b0d62", "ref_doc_id": "e6418e2f-e5e8-4474-ab55-88b33fc95a88"}, "0cb4bfd2-811d-4591-83f6-c03f4068615c": {"doc_hash": "0ce140e3f9b63888b5da4a723a1cd054f9cda0ba0874e4f61855758c8b5e35d0", "ref_doc_id": "0dee2c1b-aba4-489f-8ffa-0167f405ec19"}, "be8c18a5-785e-46d0-88bc-e7567f899220": {"doc_hash": "584755f0114acb790c3a0e809ed532d7996b98b0e4f44fea49a946867436e727", "ref_doc_id": "cce2af5b-4ebd-406c-b08f-8815a64e8ea9"}, "4bd75d11-54a9-459c-bb61-f0bb033fa1fd": {"doc_hash": "30401b378d2a0754f4f2d8c19b24ac5b8d9d718a7ad036f0f41981b102af0a38", "ref_doc_id": "c778080a-e532-40ac-ab93-8ef6ff0b3547"}, "9df86eb3-6b77-428c-a518-da2e357e9826": {"doc_hash": "068ab0e5047e7552fe662711acfd2190fe133de85e02071d7274427065e11d72", "ref_doc_id": "fa329130-0130-4069-b191-9558e903c569"}, "d614dc29-5315-4670-9714-84cf74769c5b": {"doc_hash": "acae851c2d1f51183a9de87d94e3e2e63e56588f5668aec1d4bd9e1abeb5fbf2", "ref_doc_id": "3c20feac-bd91-4960-bd4b-34988cf58921"}, "5ce62330-7800-43a3-ae5d-e60b62bb43b0": {"doc_hash": "9b9a45e5f82ec24f8cc9a5eeaae2192e0014bca6b0da200c78bdb76b48e0f040", "ref_doc_id": "e21afb07-9822-445a-833e-013f46bc321f"}, "b6c5ed46-d393-4eb1-a875-022e4e7e7b81": {"doc_hash": "3c98efd4a72757d97ae0eb90f2cc5e2db2342a306352f88262c295a0aa9d2ad3", "ref_doc_id": "415b75ea-3f7d-483c-8a8a-f25984f59781"}, "ce90e5c3-d282-440b-ba95-2a7d678b071a": {"doc_hash": "1b00dc05dba925d5c761b06452cc940e71779479cfae9a77991142dd13c3dafd", "ref_doc_id": "181f480d-f1b4-49df-a446-5acf992efdb0"}, "62dbd8e3-0420-45f2-be5b-49c9bf68e4fa": {"doc_hash": "11d45beab1abe071cfcdd57943aa8b8c99342d59e2aaa8e86c5c7fe7530b3588", "ref_doc_id": "69307d73-8208-4075-aa9e-60c12357ba3f"}, "799d9c18-626c-4e20-b34a-a53b9658b9ae": {"doc_hash": "b5a181d842c8eb6f51c5dff5b6d7a2035d22bdba2ed74d5a2df9f2f1015ceede", "ref_doc_id": "b86bf61a-9c54-41e3-b493-710dcbec0ed8"}, "c4890488-911f-4da0-b7d0-5d5feb8a4649": {"doc_hash": "9b4fe3d6d346595f6efcec2987ae2f5b679f5007f2d3700abc8585d83b81193c", "ref_doc_id": "5323634e-566c-4b34-859f-9cf4a80e5122"}, "1b9a4a62-2e8a-4759-bec9-119d2c8a0513": {"doc_hash": "e49ea0389a9d20154386f6021a1d9eac61877e35c4af9643f0c9afbe768cd9d4", "ref_doc_id": "cc51f16f-94bd-424c-90e9-9cee2d881414"}, "478cd9a0-e867-48d0-b27b-d55fae8db294": {"doc_hash": "042efd1612fb9440c7087d0b6bacc998043a72ab3a8186ae4c3b68554b883558", "ref_doc_id": "184dcff1-db72-4450-a6d3-e6eef2544683"}, "508dc4bd-20b4-4505-8d40-ec48a99ead71": {"doc_hash": "6cc61ef2e848ab6a412fbd6c8379d0da7c6a69837ee0210f2688a9a74e468aad", "ref_doc_id": "345062ea-55e7-4e49-9fc5-31a71d6a5f01"}, "4903a4b6-b6fb-451f-9863-61fab0731588": {"doc_hash": "b2635055d3939878c0fb2949a2447a3556a64e08b77b80a63d7cf23f7c96a27c", "ref_doc_id": "6c83953b-d084-4a50-9b87-b10dfef61d4f"}, "d21efa2b-1ab0-40c2-9603-ac25de701b30": {"doc_hash": "5c6501841c7f65469b0fc89a531d80b5508bb302bebc1417b11beffe9553efa3", "ref_doc_id": "f1c27dbc-867b-4700-b3e0-7f6ecae1af29"}, "b8f7c502-99ab-45d2-9887-307685d11f56": {"doc_hash": "306d3bd4a36ec2f3fb9fbdfe9491f87acd1e358c9dc6082ee4c53475c0f89b18", "ref_doc_id": "860c32f8-1fae-491a-a3be-b76f4d5a2a25"}, "d51ac964-a70c-4c43-933b-b4586212aa5b": {"doc_hash": "6aa4a96b26da104531cc1957c1404be15a272f961d35bee03269946bd7bc249c", "ref_doc_id": "2331cf5d-be9c-436c-8e36-aefa20d2401c"}, "46642ad1-f56e-46eb-ba38-152d33eb857c": {"doc_hash": "1550cf0913dc7e43cc301083415a0db3432b975e0ece0679889cd40c395eaff3", "ref_doc_id": "04602e06-6925-4b8f-bfcb-2c9aa163acf8"}, "7c56c090-44e5-4227-b65f-126130d5709c": {"doc_hash": "c588cf4d5e57188827d7316a8c45d9ff6abcc05a6749a02ec3dfac1e23068d9d", "ref_doc_id": "19621c4a-6e17-4cc7-8158-ae43b4172ab6"}, "b4db25a5-6f7b-4db6-b56d-ba74f312ce6d": {"doc_hash": "d44fe206aa4a98e4bdd254227b212b64f622b727d183181aad158c7a108183a7", "ref_doc_id": "055b9306-2ad0-4afa-befb-9e7ea22b2270"}, "2845c38d-1caa-4daf-98b7-1c6fd5ac4cea": {"doc_hash": "05c1109bd0cd9d8abc9833c28f2ce70026db160998d601cb452be60bd2160301", "ref_doc_id": "f81610f1-fcc6-4290-9084-b7b7a2e2c5a6"}, "f1d1c9ac-e182-4e49-88be-d9cec680dcba": {"doc_hash": "2615ddea2dc2b7898e0cf1452eef79fa5d7a4f8dfe083b5e4c81b0a21c7e668e", "ref_doc_id": "42a483a4-f04c-4faf-8341-84e58ad68e79"}, "21d74570-c9e9-413b-81be-2c3dc3a864c7": {"doc_hash": "e62f1edaeb4c8c8ef17d37bd4a6c9a114f27eb29d85fac4f5d70f167692ed4eb", "ref_doc_id": "48f71035-c751-4f8e-b0d4-c3c041aecf6c"}, "fa64e6d9-aff4-424f-9b86-8f8918f5f36e": {"doc_hash": "561ec0c54206d0f5662b0f91314b65d939171e53655a5d5157a3109a1b160a00", "ref_doc_id": "a0976932-6ddd-4223-843d-a905386fa3ce"}, "ed1c2ecb-3d7a-48e6-88f8-090d2d84e9f8": {"doc_hash": "9f274ca1f6cb2e38782d2478b7f9acd0e59f3872a6928c69edd5cf6f8a3651ba", "ref_doc_id": "412a7fab-c1c1-4b27-8c07-21da1fd9a9e4"}, "363d7670-73a6-4e25-a6c9-fca1d5f12986": {"doc_hash": "d49de5b1443b8c50a48b4e5d145c6e61e691e13756db7e12ebf89dace8992f6e", "ref_doc_id": "f178d07d-0e0c-4f1a-9aca-ca2633b50468"}, "7909aab6-3932-4fcb-9a33-84218320352f": {"doc_hash": "3bffa17a75a55bb5417233fd0214edc2a25b010af7c83c530b9b521055182cfe", "ref_doc_id": "eaff1146-4d22-4bd1-9846-6b0eb75ea74a"}, "8ef7b1e5-1e54-4b0d-948c-f8bfafa92767": {"doc_hash": "91dcc1e72dd43941f3b2f648c5506ee5de55242034eae4303fd0158fcc1ec181", "ref_doc_id": "3c21cbd0-94d2-403c-a8ea-44ca9ff87655"}, "137cd0f4-6b7f-4990-9077-ffadc3c67f36": {"doc_hash": "a8a3a9fbd9010ec8a74656563f058c26b6d2fea4d60dcd7d829cdeb5286edddc", "ref_doc_id": "0d230ac9-76b7-4810-9fe1-f23a94e80c69"}, "e410cc59-d085-44cf-8a2b-7908a609685d": {"doc_hash": "c11526a37641f17599038dcb5831cb467667f18404a4b2e7e21c741bc17eb9d0", "ref_doc_id": "42d817af-cc03-4cce-92c3-2a59092f883a"}, "e0b55df1-ec6c-4398-8622-85405068e0b5": {"doc_hash": "60502e71c7688efad5a179ff3a13c120c61ecc36dbb38eb76e19d8587145b219", "ref_doc_id": "f4559326-88f3-4138-92e8-01c25fef7abb"}, "dac7318e-6c74-4b88-b04d-c317e11339ff": {"doc_hash": "ec61350e51e9f4d32e558a8fc1508c54074db260f65ef8babe09c341e167a11c", "ref_doc_id": "6b434d38-2ac3-42ea-a541-910fa4b66e78"}, "8ffb72cc-e0f5-473c-9e12-4742cea7dfa1": {"doc_hash": "8a21196f496f2f35531d36e3327239e7f55c00b7bd12e894adf00fa568fa71ca", "ref_doc_id": "32094063-fa64-4695-8860-22c4e06ddbac"}, "1d10d145-a211-4325-964c-6764b0e548b0": {"doc_hash": "2505950c41a1d9b1dbb38436e2773c49a51ca2b00b92b834aefe729b14d5ba57", "ref_doc_id": "ea2617c4-4154-4dc4-b3f1-4df529abeb33"}, "b0a5720f-37b0-4434-8a5f-8f31b83648f1": {"doc_hash": "9beb15151c1171cbacd4a8589a8576f236c7d9f4fb74cefebf863422cf7ea3fe", "ref_doc_id": "35b8e87b-8a75-4dd9-ad6c-bee57bf85129"}, "b915dfaf-bf10-454a-8093-9ae8c923093d": {"doc_hash": "7af97c018a75b26d0a11ebf0b0a6e2e695758b58b5d47788f0fc5d6916573fd7", "ref_doc_id": "bf9eb918-bf6e-4d9d-85c0-03c90ccd2576"}, "67bd0b8f-e8d8-461d-b0fb-a6f016623f71": {"doc_hash": "436fca9a9796d7f28c30199a4a1d3ce6f38880d043aeeec8e51f25558086cf01", "ref_doc_id": "1bd00564-4a13-47ac-a9d6-0d8f5a1ab342"}, "af329d5e-0812-45de-804c-a0d6e908cc56": {"doc_hash": "c315cac4b8fcae74d601bc56f8f0f93f7a94dd6a27b663b20696c8e9d230a373", "ref_doc_id": "9b43ab2a-a287-4469-92dd-715869a0d10e"}, "e89acdd9-e4ad-41da-aabd-3a9d9cb749bf": {"doc_hash": "95f96ec86084137bf991d85e36d9aef425ebbc3c88be8c3a85d735d6ec2ed351", "ref_doc_id": "076873b3-32ef-42f5-81e4-e07bc1ac8b2e"}, "c7c00819-2d91-44db-8eaa-12a40c7c256e": {"doc_hash": "d9f417580d09a4eb092220916249343ac36dd6b7995ea38fadf9c65f2965ac8f", "ref_doc_id": "0871ba97-0496-4be7-9a3e-6dac3e94601a"}, "5a85a3cd-9735-4482-abc5-b3f2006e73ef": {"doc_hash": "8cc184c0c6080da21ef6567d97912bbfa2bf00587a9c17e193217cac315cc737", "ref_doc_id": "3eb32836-1f31-462b-8949-43c92a79cbe3"}, "355a5f10-cf03-4583-afaf-29b5cfafc1f5": {"doc_hash": "b46b70296bf1f9ea9be6ff67000129e6f2e778c27e7bd3e529a76bd06f9b0f65", "ref_doc_id": "2e7c1c93-eb61-4a1c-9e34-b85e5f682b3d"}, "42b85f6a-a640-4a39-adc0-84f622c7bd5a": {"doc_hash": "6d35dd631ef0c937f8beaeb66b11b8b115e9561ecb659393a410b19226a6e171", "ref_doc_id": "13ff403e-e7c4-409e-92c5-fbe4b9a327bd"}, "76dc2b01-9372-4245-a0de-7122a91e3d0b": {"doc_hash": "733cae39985e5435af5246cbed86e4da4ad6049ec63ba5cd526c0933450a8950", "ref_doc_id": "6941a77e-c749-45fc-a48a-1e6c7603c248"}, "aad90a0f-1566-403c-b132-b3ef43ab58ef": {"doc_hash": "7a7adde68134ff87440ecb528a5a62807dcf0332389f79c8a28eb725db18e2eb", "ref_doc_id": "da9a64d1-3a3a-4ec5-bfb4-5735e9306135"}, "8ca083b1-8da3-40d9-ae5a-cb34c38c8e74": {"doc_hash": "e388dffb58f630ea4bbdc1ea422145d28a3cff23f66390a239a33507123371d9", "ref_doc_id": "cde128cc-37fb-42d9-85a5-6858c55e25a7"}, "f18d6853-6c5c-4b8a-afde-55071a58e330": {"doc_hash": "0c425b4d4a6588ae74dfe11d64e61018170484b6e55c24f7582b7578a745087d", "ref_doc_id": "ceccd252-2c95-4e7b-8ccc-c0c37aaf5f42"}, "de86728a-6452-4376-beff-146d1e5ba894": {"doc_hash": "e66e7052e8728527adee312153a513fde89def4ede7b734c4f2f271f0951dc70", "ref_doc_id": "d0edce96-0ce0-4724-a409-d3ebb40ea251"}, "ac22adbf-d1c6-4ef0-b892-8eb512eedaca": {"doc_hash": "b74e1acf797088cf876f45035a48ec4acdb05e9d155e72636d3eb73de1969acb", "ref_doc_id": "9ea13dc3-7521-4584-8ce4-91f17b7710ba"}, "2ab5c10d-481d-4aa6-91ef-aaf4d1cfd026": {"doc_hash": "7b40c904bd6f21123df6419f4dd45617832911eecf8ae20e325490884c122dd6", "ref_doc_id": "03bbc9de-ab91-43cf-a178-14655580c71b"}, "9499f986-aa6a-4b21-a6ba-8972afbf4399": {"doc_hash": "536f769b63b8cfd091406169ae42d2d14fdbf67a6301ab25e692c54cc36ad158", "ref_doc_id": "6b534828-5cac-4f90-a41e-7c1b4c24a204"}, "43e555ef-a8c3-44ab-8d5c-dba3f2e83198": {"doc_hash": "2e93313ea768aa09c8d443f63cde2e91762c850132c20d00c62101ec2e17bc1a", "ref_doc_id": "4d7b994c-6b85-4629-b3a5-2f0114c69a69"}, "498f781f-9405-4ee9-8471-2d43e1e45555": {"doc_hash": "59669d50ec250de6b30927c4f808ff6a76d28cc39155bb89a15b5daa59ddb219", "ref_doc_id": "25770570-e267-42bf-b3ea-ee3edfea91b1"}, "1279f856-82ec-46f6-a447-ad7a599a6085": {"doc_hash": "63b36739d3feeb9714012eb7b41472e2a6264d2ce2fb305c8fcb7d783149dfda", "ref_doc_id": "d2100424-b14e-47d4-8d4e-67e51a9c4a4b"}, "4dad07c8-5c29-4af4-9a63-925c5af7d24c": {"doc_hash": "a78e69c1b6440f77c2435dc02b38442febfe2c0301ff50ddc3e393fce8070526", "ref_doc_id": "e6e86a33-ba56-4249-88ec-c5945511b860"}, "549b43eb-2f8f-4455-b247-de913cd3e17d": {"doc_hash": "ec94dfcb285c5e4a1dd09cc803654e15b14cb25fd8dc9b5cfa3affa73073b8ee", "ref_doc_id": "636abaa5-e064-4d9d-9e2c-271cfead0645"}, "114f6e63-f2b7-4302-b6cd-2f099778efbe": {"doc_hash": "da5cfd50d25e4412fee577d3b837f803b19f0578dc01e3cd8d830b2aa0fcacec", "ref_doc_id": "63db8505-21a4-4789-a851-56803e0da499"}, "ecbc2516-8222-4b57-aff0-242125d1cec4": {"doc_hash": "f10801479b8556dc503e0dcc4a1ef942d4b06730563247181027817bb3b4a38b", "ref_doc_id": "60790017-88a6-4d03-a352-fb605a70f76a"}, "301418c3-a7af-4f39-a698-c85bee52e037": {"doc_hash": "5f2d8e165efbd4f211ca51173010f8acac359251048fd64afecc69a09a057d33", "ref_doc_id": "1469e8e2-7d22-4d4e-9e63-4fa4fde57421"}, "c7c06382-63b5-4e85-b65a-55b840a5b1b9": {"doc_hash": "ea2f81a5096345574c5c6528d8f1b93857a19f6765633507b10c86a613b56970", "ref_doc_id": "693c30aa-af1e-48a6-8973-b7eac99f46ee"}, "00eecb98-85ba-4fb8-8cf5-6756e405b9a5": {"doc_hash": "4d253069141bde580e887331262d987e98b0ef704afcc79c85031046a3e07487", "ref_doc_id": "824ff52c-4e38-4750-a20f-bea9b33ef43b"}, "912b3fc7-a3a3-4136-9bb0-f78d47a6ac12": {"doc_hash": "bebc651f99362bb2693a6015db72da5086bf0ba4a29a8425ddd942216ab866cc", "ref_doc_id": "f57a5fbd-f3ca-4057-b090-ba2a8f8bb314"}, "f45b9ea0-2ff6-4081-986e-00c2d40fba4b": {"doc_hash": "e4a5dd089b48ed449e285ee276185a79055bc174e1f6594c4bcb19329a47bf80", "ref_doc_id": "e35e838b-48f0-4d5a-9d60-e526ade9a27f"}, "7ed72470-ec09-495e-84a9-a1d7eeb90ba9": {"doc_hash": "14d4d0d8ad1743519f6528f9bceedd8ab893c13f0f0e96b99e8b2dd4ad35577d", "ref_doc_id": "99c39dc7-a000-4839-8ddc-8fa6dfb26214"}, "36189eaa-0809-4f77-a9a6-8c0310ee3d48": {"doc_hash": "2c2992fba8a37944a70bb709f7fbc43f850b7bd075b89949b41b7bfc989e941f", "ref_doc_id": "9bd4cdcc-bdfc-4335-8088-5082f7addb1e"}, "7f9a3cf2-b823-41b8-8e93-709afc490b0e": {"doc_hash": "5df838398f9c97ed88767017a8bd4e58a5186227ea3d33e691240f153515f94d", "ref_doc_id": "4efcc1d4-cabd-4dac-8bc7-a030573f2dc0"}, "e8f3d5eb-9804-41e3-a09b-866af40bb43b": {"doc_hash": "8d3250b3017ee5f9d4d6b8251008992e174fca28a593667b0cc9a3a64a61950a", "ref_doc_id": "4dff1f51-2f7d-44e9-b59d-0f6d4e410fac"}, "a0e9e368-78a1-4d62-9d17-6c8ebd462943": {"doc_hash": "e832c5513a888f5175adbdaf3e1ea25cb4878444d5c5eb81296ae85eb418809c", "ref_doc_id": "ec87f510-8800-4cfd-9307-b8ed35a58b1a"}, "bc3286cd-2a1e-4cc4-8f33-23d351e9ee5d": {"doc_hash": "7e542c9a1315718ae8903c36a2d9849175ced694f08489720f2718a9b9f2555c", "ref_doc_id": "945b7eb3-a377-4bb5-a85a-196e4c8974f5"}, "15b3d481-01a3-4315-a917-73eab8018c92": {"doc_hash": "fa337494b2f64ee1f0079f1ae00028ce66f410ff5612c0809d9c60691da4f6cd", "ref_doc_id": "434675b7-8f34-42ed-a031-e7721f8a63e3"}, "cf489f58-1df0-41b4-a125-3f5d36223964": {"doc_hash": "3b72a8131b8ebedead84a07fc3544540b8be23fd5db5b44f15a8b6350c9922c7", "ref_doc_id": "5a367987-1ac2-4066-b913-4be442ff7277"}, "0e72d7ce-69ae-42d6-9664-aeaea91cfe47": {"doc_hash": "47d6254cb87248c5963ed5a8bd19db323e3b9ea9decfd87255b5b9cec3ad6d31", "ref_doc_id": "c99fa275-3e9e-4027-9c9a-8fc93ba1ba08"}, "e8569ca7-3931-4eb6-89b9-8a42301f5777": {"doc_hash": "a7e5a7407797a503f32e8cc32eab38c14ed542d3619b66c85f634792428dcc44", "ref_doc_id": "a726362b-9703-43e5-b715-3daa2496daae"}, "18c7d6b2-32a4-46bd-882c-e4aedc7ba081": {"doc_hash": "ab7b4e799d36959ce62f82d1f1f83f2b808b6bdd6b5ab547a0dad00bf5293bc9", "ref_doc_id": "78fa39f7-fb98-4698-9bdb-8c9aeec7f76b"}, "b0daf8e6-d5f0-423a-80a1-fb99df57c45d": {"doc_hash": "29ce901208117f04a851ac494ce8dc215ef1de5d3ddb3124495aa7a922666c97", "ref_doc_id": "24bf670b-55f4-49d0-b465-1d2dcf564b18"}, "2abe43eb-d385-42f0-9e6d-308bef91b460": {"doc_hash": "067d78d93141d03e9e31e4feea9cd7678f18186f42d2a5c1a2e46b90a8100791", "ref_doc_id": "03a751cd-12ff-42da-aca7-4c995e8e7273"}, "c421ae8e-4e55-4c52-b7c8-44f746aad846": {"doc_hash": "9f1144c808e64eb74d7eb2619ad21a279460a27ceeb434a8831b076461dc5f73", "ref_doc_id": "a2134412-3d8e-4f29-bcf7-26e226ca9503"}, "5e61c914-e60d-41ca-b980-3b330eacb402": {"doc_hash": "d815f9d46348ed5bc5f77dc5a7cb59f6ac8a56a111c66b00c9808ba294b5af7f", "ref_doc_id": "2b696b53-b50b-4f4d-97d8-6ee5c0d2a4eb"}, "a80e5fb1-c2c1-469a-91a3-ffa14b038b22": {"doc_hash": "a40b17578edb72244bd0bb65c185affaa1f04e545bd21a8b8d411eb60d6cfd09", "ref_doc_id": "f53b7745-7f92-47d5-a611-ecfe0d6de377"}, "d39c2688-4f24-4049-bb96-3115fc30d07b": {"doc_hash": "826d3f8725c949fc4241133cdf4e9aa7a7d375c1649973c675c27e92ef3f53e8", "ref_doc_id": "3b744cf3-158e-4ddd-90c2-c2f6f3b8864d"}, "63998638-a523-41c9-9e09-d9ff08c5a2e9": {"doc_hash": "44478db1a023c76dcea6b84fee97f8543e7a01fa55e48599396a38340f9ca985", "ref_doc_id": "83325c20-279a-45b0-87c7-1e9fa8b8f004"}, "a1b6a349-57ec-45a2-985a-8a6c61c2181e": {"doc_hash": "e76b223947f1d2e7f2258b870bbb261f6d23051afa4ba6d433b5ba8e620a19fb", "ref_doc_id": "da1c62ec-2636-4424-9800-b7f0cb1c92ad"}, "e66cb4aa-e780-4769-b248-bd5821fc0fcd": {"doc_hash": "faa309d0fe92f3e8e902befac4eb2544a76ad9384370f345de4836e2d794ab20", "ref_doc_id": "23ceedd7-57e1-42be-8905-7d96b813f318"}, "cc1de9fc-57b3-4593-9c1a-a2a656c25258": {"doc_hash": "36c6ae69164b0895872ba9e49081cc4410e657d57383878edd34f0bc3db0a262", "ref_doc_id": "7f48cc91-9c3e-46f5-85c8-567291df5f20"}, "c5e41230-db5d-4cfc-8bdf-239f58f55839": {"doc_hash": "75e0875a37fa4c0d3d3be8eee61ebd0ea70f88e03e7b69ba40534e183854b6ed", "ref_doc_id": "e871de30-8532-491e-a792-180d7ee77014"}, "9d0c893b-33d8-472a-927f-63490f0a3b02": {"doc_hash": "3be337ea1ed16f86e492ba4e4a815ce36eccc8d32a23493eb744b5532f32e49b", "ref_doc_id": "23d2c467-48f7-4a22-84a0-fe72036924a2"}, "b59aa77e-9613-44f0-b431-f70f52d718d3": {"doc_hash": "1d1f47f418d92523e89731869ed8a1dad95634b3ba503b837a67a383438fe39c", "ref_doc_id": "138865f7-77b0-4e77-a646-e9945b79649b"}, "698946bf-c232-405f-a056-231e6a7941b9": {"doc_hash": "38d9aa8b391fd444c84e0480df1473bf2b9a3f4a4a6edab296111828581f0e2a", "ref_doc_id": "a0c02117-9c30-4611-9a04-2789d85a6782"}, "ff2264ee-dc44-42f5-b3f0-352e0bde6cec": {"doc_hash": "df7877725509f70329e15d66609f0b109717b4824a357138cacc37f63f5f490d", "ref_doc_id": "2ac6849b-d9a1-42e7-8fff-2859fa9c34d1"}, "8c4266d6-8538-488a-a396-305464f8b1ac": {"doc_hash": "93aae3caec4a52ba6ebe7e95e62de982bae5420a35dbef2bd65f3ed7d2adc94a", "ref_doc_id": "275a1c0d-d39d-4fc0-989f-8fc8fd430d9b"}, "ef1064c8-00a1-43e0-a4dc-f08f656ec9ac": {"doc_hash": "bcabc2182bc49c61e37eba4e88cbb1d7acf8d83890c463cb6350f35dc35c4ca0", "ref_doc_id": "a47ec575-ab3c-418b-b63f-5d2a8f738cac"}, "dd33c794-f724-4f91-b027-a0a3d30846ba": {"doc_hash": "ba3d39849afc427d091e6e18103386a4439031ca15b5dd43c7cd380aeebb112f", "ref_doc_id": "78fab72b-a332-4216-9842-4dbf17e3c871"}, "ac950014-551a-4a18-ad18-8517ece31e9b": {"doc_hash": "4e8487c7367c3c3329dee795a8abd0a3e235460a169d31b6b74e2d2d5dd64164", "ref_doc_id": "8fdb09d9-4a84-4d9f-ad21-56bb090c6f0f"}, "28fc359d-c4b7-4381-9d73-ec1739438393": {"doc_hash": "03f903ae91fa2e38e6a937a67f4a150290a7a0a31824e80f57ee214de5f886ba", "ref_doc_id": "de6326c3-8f5d-402a-84f0-1d3b8cd968c8"}, "0e3274c6-18a8-4e9f-970f-d8f249d17e74": {"doc_hash": "d7bd156ef9b89d5ffbaa475442804a1dfaf0309c210fc0da62c8f0365cc48b38", "ref_doc_id": "32d2ff3c-083b-4707-b558-9d7e94cda8c9"}, "5daafa88-9c03-4038-86a9-1fe80786afcc": {"doc_hash": "9e83d051baf3267b21d43c5c45347e9e846390072238c5b1854fbe487a779914", "ref_doc_id": "1393c641-8e24-47ac-a333-28fb99f2fce2"}, "5e6a013b-07f3-4535-acfe-58b2d788f510": {"doc_hash": "d69086ad99b07bafbe1440ed2fdb72cd6d3264315985bdb1c6f04cc19c7ea8c8", "ref_doc_id": "80080954-fc66-4edb-bdfc-35982c5c93cd"}, "9f1b0313-2218-45ad-b5e9-18781765919c": {"doc_hash": "d7d25a2944336762d297677c3a2ce615b1a64abfc7ca60fca5b8dfefcbaf6419", "ref_doc_id": "2b3bdc96-a2de-4efa-9967-a01a58900e50"}, "6e73d11b-b0ca-4575-9d22-5cd1b3743326": {"doc_hash": "11b88d313cb4fe57c5f5ef0c5a11a6a5359c828b1f7170aebf9aabbddf66f3d3", "ref_doc_id": "25925ec5-0707-4f25-874d-11816a34f621"}, "1936b253-6bb0-476d-9767-6fdf5c2c8096": {"doc_hash": "663f93477c68dd2f9b7791496116e7a588618dd211494b69582967fb06de3b34", "ref_doc_id": "d4547b89-f042-4a34-9e7e-9526ea72964f"}, "0909c775-3215-476c-a519-2095af621a55": {"doc_hash": "588fcdb60947348fe7e9bb8e45e99a365f38df0e775a16b0a4072fd84e37cf52", "ref_doc_id": "d488199d-a5a5-4915-8320-ee2e8072addb"}, "5c1e9478-004d-45eb-b533-019abd4fffd3": {"doc_hash": "1e6cb2b0300877df8aa5ded7090366f9bedcf3c3bb9886e5e19cf91f4e78121a", "ref_doc_id": "5f1cb4c2-ecbf-4d79-8994-902ffcce0731"}, "8edded74-e740-4262-a311-93789f1ab6c4": {"doc_hash": "5aa10e7b0fbead8cae03c641076b7fa30f3611626193ed4c3ce5fd7a111c5089", "ref_doc_id": "68d71651-8483-47de-b2df-196156f4ba87"}, "fe0ef0b1-77bd-49c3-8750-f309bbf82e92": {"doc_hash": "eaf56dc52b431b7080eb7cff71b1a92047f34f8e531b7c686814d05e3076aca1", "ref_doc_id": "a2c6720d-624d-437d-b303-a798899684b9"}, "dc8f0491-16f2-4149-8d92-4e4324ddbb4f": {"doc_hash": "b635bb81fe0a606a541ee57e011ccdf659ca6478428a0b15cb6f8b9c269f1659", "ref_doc_id": "a63ff3c3-fa23-4c8a-9b12-0c9b76ff128a"}, "f3e8d359-4f61-4c4d-bc12-3487e43f8b4e": {"doc_hash": "dd71627ef29544446ad19570269460b1a7eec6c91d6935a5632e91e42e9552ab", "ref_doc_id": "b7018b8d-a764-4dcb-b8e2-17c5ee384e9d"}, "c928124f-cda7-46ab-9435-0ceac7997798": {"doc_hash": "ba1bc93b37c0779d747451d96cb8c692e5c83ebb2de6dab1eee1277f4df351b0", "ref_doc_id": "a059e43d-b131-4725-81af-1599493cf769"}, "d4bc3108-9569-45d0-89e7-9fcd314a5a5c": {"doc_hash": "ecf9dad0a22b67c68d00613aaf2392c47fde43ee32f65ca64fbb1c67b81e67c7", "ref_doc_id": "8707fba8-509d-41de-9f7d-f8c1006e27de"}, "e0104e43-de56-472c-9450-b731fa80e4c4": {"doc_hash": "2fcfe85eee704f2e471f96bc9aa9c3de429d5af5210d36eebdcb28f9f035e0b4", "ref_doc_id": "cd22d62b-0d90-40fa-8ab0-26511e5675e8"}, "2aa89f8a-55cf-4430-974d-fe8556c11031": {"doc_hash": "52ab9036e0a0e51b5b6516e23ee003c7815a9bbc6dec7a57494bb760bc52bed7", "ref_doc_id": "b896a6e8-3eb5-4336-ae98-cb78e86b357f"}, "a3a76478-420e-4e7b-b530-e47c9538a1d2": {"doc_hash": "08ce8d9ed558a2eaead177cca82e8bb05140115144fca3ebedfc3f4e4f6bd5fe", "ref_doc_id": "7f5d26a1-0c64-45b0-94d3-0c2e9aed4898"}, "5a1402c5-7458-4e64-8c4e-2540e2a6a8d1": {"doc_hash": "047cf01696def947f98d905771db75af927aec138695687916948a07daf23649", "ref_doc_id": "c8fca6bd-03d3-4bf3-a23a-5a93ef07c027"}, "9551cf04-fec4-4910-a89a-aed5427eb987": {"doc_hash": "204a343085b9f07eefb4b2ae34c983a2bdf80574979548fb41f06c2a557518a0", "ref_doc_id": "46097bfd-96ab-421d-b6a3-de00c4b9694b"}, "0369a904-39f2-457c-a4dd-074cc1eab899": {"doc_hash": "5fea9c6dc2cfacc108ae293d980b632eb7e31da9e7bfd377eaa98c0b0c9c7cf7", "ref_doc_id": "6e4100ab-734f-4c5a-8386-b61029b126c9"}, "1f791435-7faf-46c3-8bc4-9978134fbde9": {"doc_hash": "815d69831aa9310dd69a681f92a749ec09b1e9a3d82224690d3cd4a3d8a1afa9", "ref_doc_id": "8bebe3e5-0529-413b-b243-b3d499a873c5"}, "8f2edc7e-4440-48b6-af9c-9bcd938548a4": {"doc_hash": "d43d23c6ce1622181273ba4ccc758f5d8eab91f748e9fa9b6b546e8ea39f8582", "ref_doc_id": "6a4cfe11-fc27-4b83-bcad-342a38c3f039"}, "5208a8ba-07f2-47d1-9abc-85e1b1c6167b": {"doc_hash": "659eed4ddb3a41133cfb8365f1c01412e6532f751a3b0e698d757501d620c644", "ref_doc_id": "62ea4c80-a0ca-4665-a4d5-c4b0cc2cb7f0"}, "97ce3b47-1d3b-422d-af18-6b2d09342048": {"doc_hash": "02a7d48d1e314d2d24cc061287e2e9a4fd3bf3bbcd8eafdd1f06f8236c49a308", "ref_doc_id": "6080e8ff-e7be-4981-aed6-01c683f169ac"}, "2382fb7c-33d2-4539-ae03-e13f1de8a54a": {"doc_hash": "3589384c0e0abfc1338540f6150710bc35c4e0dededc339fef3f912da60e03cc", "ref_doc_id": "87d7aa3c-80fb-4c2c-8e92-eb6c67428315"}, "29dcfd9a-f700-4f8b-b1ba-261e3b15a12d": {"doc_hash": "25f15807b97bd532758384550bc03421abf254181ab5317c4b9259339becb401", "ref_doc_id": "3c310313-3c33-45ee-ad42-17dff9eae989"}, "9ab19c9b-62df-4c36-8180-8d5092d6a246": {"doc_hash": "a802a37fed1ee307e90be8396b1826434c1105135b5b0a39c4fbcb9e04ae4332", "ref_doc_id": "21e86423-e88a-4b97-b736-b0b0d7ab8efe"}, "b946b8c4-9ff3-470b-a231-cde95a3dfcb5": {"doc_hash": "6ada347a29cc792a49af8a334ca4433e55d4c48c51766ccc36825e17fc7071e5", "ref_doc_id": "bdd4f762-f7b8-4fbb-add2-ffa79a22ca37"}, "8b148c6d-a5cb-4b0c-95b9-f4ad38276193": {"doc_hash": "b1fb0b82584ddbab4903f9fb59ff2e69a531c86898bdbe7aa1b73dcc2d477398", "ref_doc_id": "dfa3cfcf-269f-43a7-a294-dbf998169be5"}, "6eaf47b1-8994-4b8d-8327-94c5f6fcc5a2": {"doc_hash": "69defdce2a5c0e9847c1f099f1af81e0534dbaa94892d97c4c5661a561773031", "ref_doc_id": "508dc100-0972-4dc6-ae44-d57084fced3a"}, "bf8eda26-dd22-4642-be2b-708f66631e52": {"doc_hash": "1da287fd24ddfec814c827606d39b4f7c8e201b2e17f136e108f3666e6998f66", "ref_doc_id": "507849b8-ed25-4346-99f5-7d108fc54753"}, "08643010-bf07-45f6-94ba-f27742e767ea": {"doc_hash": "fe2486e98d50259561a8939afd8f6045bdcebc3809cf38c5ec37b6420d0a0a26", "ref_doc_id": "004efd65-2443-48ea-9d2c-c73983289e0d"}, "382991f7-fb0d-44f1-9c18-2870fefec121": {"doc_hash": "a095c48dbd922ae690c1b8d7ab0cb2cae9417b5e8f80e3f4d19e6d7de8733e16", "ref_doc_id": "f2c25fbb-ed9b-4816-b720-5ee7cf8c2221"}, "e81b8a8b-418c-4703-ac45-f2d7f40766c8": {"doc_hash": "a79e7f083a1f3379fd53dc2f9d15a89ce40e62a6866092b23b1af0d6e79ca404", "ref_doc_id": "086565fa-f127-4e47-8260-022216a8a6c1"}, "1ab588e2-d47b-4882-9da1-d5ac28693eda": {"doc_hash": "cc2b704088cd619993d51463f1c7d01e2a6fa7fd53d7b5f7d966125627f30f34", "ref_doc_id": "114b8ce6-75da-4212-9013-bef3907dd520"}, "34dee817-57e0-46b4-8a11-584a8bef5444": {"doc_hash": "06080d4a5a4288e2c1933b57dd7ea22f6262f21324c50180bd99e6da676f869e", "ref_doc_id": "8c8fcb7f-2b9a-48b0-a7ff-8e843b2f74f5"}, "e6f7f79a-de3f-4fe0-a123-bb76e0ab69db": {"doc_hash": "56ab3f641216409cb104637f513ff96a2c03bf0a02e934c394d04f0405604fea", "ref_doc_id": "633af932-0c41-4c87-8252-32bb7894481d"}, "322a4344-3a7b-4cdf-8ffb-dc679e967ef2": {"doc_hash": "fcb041679fb90d5931b03d11009bbf07b5a20292a48f96234508bc9c959d5535", "ref_doc_id": "dcca2fee-d258-4bcf-abbf-276e9244e1b4"}, "9d15791c-7d16-4f1d-b961-a7f05d0ac272": {"doc_hash": "22fd1db4f4070f6c9338bf10bb13b7e8dab3317caa78456b2db6912863f3db20", "ref_doc_id": "6631ce49-9c9c-45ed-b570-66b6950ec48a"}, "c3945cc4-1d98-4b71-b97f-205d4b56a744": {"doc_hash": "c22fd420604f25904319ab4efe0e01774897718058a27ed3d617143e4d425fa7", "ref_doc_id": "9ac6e846-2e0d-49bd-a299-f608b265b393"}, "9f2bf40c-90c9-45fb-a375-63017cc36302": {"doc_hash": "ce43f0450a9711588f033aaaadebc45ac6b8c9f637b730f9d0f83c117c4381b4", "ref_doc_id": "ad7e60da-c33f-4f92-80e4-0d25dde15446"}, "c39e743b-b20e-4949-b697-5984952ac433": {"doc_hash": "f21fc0540e903293a6e77a8e751bc00629449b65e064b3bd964fb2d9f20b7785", "ref_doc_id": "e1e146aa-baac-4e5e-b32f-eaccc391aad3"}, "fca1d3f2-4034-441b-ad32-bae654b0d2ac": {"doc_hash": "eff0c14240f7ca8543c5d064b21e7a1ff4a13b53c23ca0648f484d442c46fbce", "ref_doc_id": "1499f467-6304-481b-a63a-cfa688140176"}, "75c23303-1371-416a-a3e0-935de045b55f": {"doc_hash": "f5122213749d6e0c2cc96a1b66c1bcd713e67927961a1a33ff7780e31aedb3a0", "ref_doc_id": "ce7887fa-11d6-47ed-8b51-9eac3f4d80df"}, "f4e12164-6f7a-4055-8a7c-e4a9c9f46052": {"doc_hash": "90b3de80cc4a75ac654b33c0bcd5e12daf8af9a2db499843477e8d2020983d50", "ref_doc_id": "758dbe39-d01c-43ff-9823-6cf8e62879f9"}, "15ce4fc7-8c50-47d9-8105-7a9526fddaa5": {"doc_hash": "e3de7779484c8845d4855ae9a85399e94c46ed4c2c4d6ed4c2d9a4b4a1f0afc4", "ref_doc_id": "d50d8d90-7c9a-4f96-9cb6-2302cd20fcf3"}, "56e7ccb7-6298-49bf-aea3-77442de968cd": {"doc_hash": "759c1f4bda7037f51e59160d4032c7ce6a46b11eabaa1a7ef62b5f1aa0d1573b", "ref_doc_id": "0247e755-31c2-449b-85b3-33650727f053"}, "d8ce423b-15f1-4b3a-9fc0-8132db0130b3": {"doc_hash": "1fb9881486a6724d0f3b9eef11102ded42fe42eaf7e9152272eeeb4ad87e3402", "ref_doc_id": "0fbbf768-8dce-44f6-9522-ee8750bac54d"}, "1358ae23-f358-4669-ba8d-e5392cfd733c": {"doc_hash": "48ec33070d1b691b20059dc18967569f7ff68f83e33be117166c5cdc48e16a85", "ref_doc_id": "80da111d-306d-43b4-9811-3bd1f9a93c24"}, "6a8b72ae-8c38-498a-9d1f-706ee147745d": {"doc_hash": "0d68b3691d9cfe29b4829f4b337aca609c12990089e276618213f8e5f5a8cbde", "ref_doc_id": "d6eb2dd0-1c37-4e68-8932-6eaaf36fd94c"}, "a151bbba-d08f-4d98-b064-ffe798529f73": {"doc_hash": "3d737599f04cf1f4f357a55ccb8d823ce089f0cedaf62b07c1f6332fdda441a7", "ref_doc_id": "78ade4ee-520d-4f5c-81e8-0c6f9bd532bd"}, "2e83f2cd-2261-44f3-81db-a879c9df1b8c": {"doc_hash": "4fe69da0f1200232529f6920997243e39587c4eca5fe5cc403cf482af96399ac", "ref_doc_id": "15f1f5c2-f546-416a-ab51-b72076e93bdf"}, "7e8e88a7-1cfc-4cde-92f7-5ff9d027cdef": {"doc_hash": "4847a0dfa3923fd2db5bd44b52a3d3fe389d79d93436aefb76755f4e8a84e09d", "ref_doc_id": "ef49c2e6-b8a7-4354-a499-2cba224dd3c6"}, "ffbbac72-413c-4de9-9d88-ddee9d1c4be3": {"doc_hash": "75d60fa6d97098acf6296f304c0cc55150f4c7d5e5a258eaa13d5e9287bc9fd8", "ref_doc_id": "121f9361-40a1-4d85-9f3e-21dd1e81f272"}, "6bcd7c42-c58a-4c15-b063-b271a24faa3c": {"doc_hash": "cfaf06a3b20fd5356a82a042ae75b76f9331664fb40ee5414b87f87daa390a58", "ref_doc_id": "07d0943b-9d24-460f-a58b-f2d5ff609048"}, "927e27d1-dcff-4052-9766-055fe1e97283": {"doc_hash": "8cd316ce2de078d9148582c825ea1e8648355ce7d5c29bd37023490a5781add9", "ref_doc_id": "df1c1dc0-89aa-421a-93a7-f05576c40e0d"}, "ad8525aa-308f-49c1-9b33-a6d7def983ef": {"doc_hash": "cd13007712490784015ec52134380926d688cac3130e1592bd6914bf080fd291", "ref_doc_id": "de9b9807-c0ef-41b4-a497-862040ccc0a7"}, "c819d81d-d153-4f02-ad38-a22196b46829": {"doc_hash": "c9143fcf7ba22bb390e78020f56c7cad136ad2e5f9fb69785306cbceeaf3ff08", "ref_doc_id": "0276bb85-a36a-40c3-9d81-ae61429ccef6"}, "90fbb569-1fb7-4cd3-b2bb-d172e9bcd9b4": {"doc_hash": "522cff4a43fac222ee0fd066b010782291f66b503d8962c9611a9c58f785e080", "ref_doc_id": "a4635b4b-7196-4b9c-a071-2bb83fc59786"}, "2953ac72-eb20-4d77-b539-e45ffa4dd9ea": {"doc_hash": "091e9d2a14f963ba70904d6fbd5eeb0e94daadd2e64d0e5b1771b59055a98a31", "ref_doc_id": "dadde287-8b1e-4bb8-b813-b0a4f176316b"}, "d6379e70-3ee9-4c0c-b530-8edbe76cfe3f": {"doc_hash": "a2ff1bca71d1c2fefba75551831383757cd06c03fc7e316aa598d9c4f47a48d7", "ref_doc_id": "46840c2c-9db3-48e3-8526-ed50c89481e1"}, "dfd217cc-57d5-4110-8a4c-dfe7c580ad9f": {"doc_hash": "40c6c7b2e250cbce0884b30313d25182735d422f2c5dbf1ae69c3763ab339eee", "ref_doc_id": "1add03c0-848a-4cb8-8bad-3265c8d61752"}, "b6a15f9f-0bbf-4a2c-b50e-4e12228ed010": {"doc_hash": "abf65f546e7f96f06dc59e8751a50ea09c884fc8e1c9d26f07ba0cc290173364", "ref_doc_id": "e21d9c6d-8438-49bd-a5ab-90f5560a2ce7"}, "07a84d7c-7fc1-4a18-a1cc-147c02f5f819": {"doc_hash": "7d103cbe20a57d3adbb526da4f9a9efe4d29c4001a67fb4a7b03dde5de61fd4a", "ref_doc_id": "8ea60a77-e6c6-42bc-b230-596bd0eb64ed"}, "7a51fad4-2cb5-4ce1-80a6-a387fa11e76b": {"doc_hash": "77a005e5e899bc43000fc312baf91acee47e5f02122fdf49bbb9fc5129e6c8dd", "ref_doc_id": "558ad263-ffde-42c6-b7b5-913533920fa2"}, "1edceb96-1176-4f7e-bc71-60294ae22cd4": {"doc_hash": "f770e057fa2014dea042765aa9939b4f6a727e28427fc9f09a12244b637a9f9b", "ref_doc_id": "3557d504-42cb-468f-9d55-834cf519c63a"}, "a3f77112-987d-4ea8-a45d-29c10de4833f": {"doc_hash": "c78c462db5d642d53c4c5c9ef61740c40ea39ec4eb45dc694ff6f5c59aed59ba", "ref_doc_id": "cd67c46f-a9d4-488d-9e00-99038ddd1b57"}, "aa7b5a31-6b96-4bd9-9a72-a33f6c414a96": {"doc_hash": "6697c1882b325dca0c065f2ed79cabf78e86cf02fe7e75c3ba566f68e443cc67", "ref_doc_id": "c8327f63-39fc-4b79-b811-8ca9067e337e"}, "ffa3cb6c-2251-4b0b-a72d-60043472bcba": {"doc_hash": "3d6f9b8d291c9a741f0a5bdfa47e55c776d6587d5c0b2e24391edb4753518c62", "ref_doc_id": "bc8292de-1df3-4da7-becb-8b614abad96a"}, "bcaa6cfd-7c75-4880-890b-f10a2b6b07b0": {"doc_hash": "d7c7a5994a063a1bb50b8c00d67bcf1ddf75ac59fb5ad08a5f07e359ad24077c", "ref_doc_id": "c72bef93-2767-43ae-a693-ae4e47eff9ac"}, "29158ac0-f1ff-49c6-9c60-e41a54a15b3e": {"doc_hash": "81c75c3aff6da8299c096d87c966e7c41d9e58d5a6df557bef98ecbbc11441d4", "ref_doc_id": "78f3dcf2-29bb-4b88-a975-a6429119e755"}, "f2137c9e-41d9-4791-be45-cc75b4a0d843": {"doc_hash": "5019d6b0b761d8e4e578c728e50658a1f0d0682201454b49f40d71dffd8e776a", "ref_doc_id": "0d78ed61-4e05-4750-9e20-c7caad359760"}, "8a51eee4-4faa-4984-8ba5-bd269564d700": {"doc_hash": "a855c87ffe5f16bfb2ce86a04deb8628258917511de433f6c570bc54774e2cff", "ref_doc_id": "e08a4edd-af60-4719-b1d2-e3c070c07a82"}, "354e0415-cf38-41c7-8fc3-ba2ebc3eb896": {"doc_hash": "2724a3610435f7e486dee0f339937b386f3752be844b7b54cd63d46a243323c6", "ref_doc_id": "247d984a-3c79-4e3e-be60-6b7050b69a65"}, "f0e09827-31fb-40cc-ab3d-dc20bd175f01": {"doc_hash": "fbee2ccc541889a0cafb9e49d8d8aeb3d655a77e09bd4b6b67768607c1b4d3e8", "ref_doc_id": "ffeb173c-1a18-4e34-9cf7-ed5081d5c7d5"}, "7ae7478f-1f22-442b-b640-a8a527039da4": {"doc_hash": "5ab6784992831b45307bd0bd7e281c155d8228f0a83ba4f15bf8e39064d24846", "ref_doc_id": "87d61007-2221-4876-a1ac-60dd7acf8240"}, "94895fba-960d-45ea-8b45-2e8e7def4a0a": {"doc_hash": "73c6e20a37c3a86cfb785893fa3d30883dc5e7793f9b91afef846252fe57292f", "ref_doc_id": "4e73fb27-a794-451b-8b84-ab0ff5410d36"}, "a9195cca-1f1f-4cd0-acee-c8c14bd2d101": {"doc_hash": "e5cd126a3090044b8e1c54050407fca4628ab4102350ad4f7df960d1c4e2a63d", "ref_doc_id": "77faf3d9-1103-4f77-9a61-498e5aafa985"}, "bd078d28-ffd8-4672-ae70-958598be15d1": {"doc_hash": "e1fe03af5443ed606a776e8ae9cdc4e09a0cf145198b34d91274c65c4a72f281", "ref_doc_id": "7951d1a5-4df4-4973-b4ea-935c3c12c081"}, "fa3b70d8-8c5b-4185-9f7b-711c67b7ca10": {"doc_hash": "898baae75c00a99235a30dcbdc9822cf665acb36d1c894ffc2308b772dbc1248", "ref_doc_id": "51d7c345-f023-4f57-9f51-b04fc2432cc2"}, "8203a1a4-3767-4635-aaa1-d4a57d5a0f92": {"doc_hash": "74979817b6e4e4b1ab62a249b2e7f440f31c310cf97609aad4927f37e99e747b", "ref_doc_id": "94bb0a44-3fef-4c51-99f4-550737ce40d2"}, "61ee8ba5-d018-431e-9872-ddbf292d7fee": {"doc_hash": "ac092515d4f70edab0dd1ef9c55bcb87d575e49a7fb023ce22f979dbcf4595cf", "ref_doc_id": "a9682377-c0ee-49ef-a23d-4d7e182419ef"}, "787d20d6-7df4-49b1-ad16-fc483d7e54a8": {"doc_hash": "84efc887676bb35164cd0e19a6f31b6715479b19ae21ed29dc25ee70e78f052c", "ref_doc_id": "6abc409f-37cf-4a53-8400-7ff57472ee2f"}, "44e87891-92f3-48ff-8053-3031cd806cef": {"doc_hash": "01c0250d20891821ac858803825b4c0b9856fcfe68d5a9c4fdcb06a8c31176c2", "ref_doc_id": "94ac2ab4-47c6-4d10-8110-0d238cb078cf"}, "f6d91ea9-4812-4c4b-b44b-d8939a797599": {"doc_hash": "cf09c049ca9dda0bdeaf840902a0cfde7f79aaf498e07f51ebba4ee3783c813b", "ref_doc_id": "95a005ad-f0b5-4a3a-a0f1-16c992eb5d74"}, "eea281bb-fa93-40df-aa47-2e5e25749def": {"doc_hash": "ef77519d1fe8f5c16f3fdc9a3a1610cdcac5f8abd0ae497486d30b8b6d59a3da", "ref_doc_id": "a02bcb24-35ff-4e4c-aafd-0c6b9b5957de"}, "d307392c-3912-46bd-b72f-0da258fccee8": {"doc_hash": "f1d78af87a0e18975392e9ff5e92c65484530480f67760ab928e5d68a43a0032", "ref_doc_id": "ab72c98b-4577-4160-9502-097e7e780f15"}, "0401efeb-ca89-42de-959d-8a0ef7fe0424": {"doc_hash": "b9072a06cc43f0eb752a9fe8e9b39f2d3dfb7f4c2abf03a2ac634bf6fa83dfd0", "ref_doc_id": "f7f7af08-1552-482d-b735-e1a3ce67bf28"}, "9513b161-e964-4cb4-82f5-2a0580d998ce": {"doc_hash": "dfc629e66f477b7c794f00e582d417cfd6bb8e369dbc7e9ecdbb66e8222cf41c", "ref_doc_id": "69a32055-d30f-4946-a47f-14a264f19eee"}, "e9cf8cba-9068-4103-a120-29dae73227d5": {"doc_hash": "42759cc2876e960ecafd7e4c5475c258b111caefd38038fb4c13c7796dc47930", "ref_doc_id": "acf7146f-75e4-47fa-acf2-3fe31fd6fe4d"}, "8c6b3641-ecc3-4e6b-bd1c-39d0a9cf6812": {"doc_hash": "bb1abf5fba81a6bf4a3a2b1e4cdcce185c49e5ad59d0349fe51f638f6f39caa2", "ref_doc_id": "5cdb6e55-b772-44b5-9f33-ba9307e9583d"}, "850f9238-d920-4d5c-babb-b9fdf722674d": {"doc_hash": "9b7c0c2b664fbb13e978faa8a8f422b7314a16295158af9a7954a0cdaf1ff0fe", "ref_doc_id": "4725e493-7f03-4188-9bcb-5e3ca2762b24"}, "780cf419-b5ce-4175-b2e6-3aa435bc5d3c": {"doc_hash": "d793db3bdbf8d8e715b2e33055489226e77b457dee3cdca629f0f1c8b46c4c30", "ref_doc_id": "ab2c3c79-d20e-4657-b26d-e36edc75c654"}, "6bfaac1d-955a-4e06-aec4-f69b457ee3aa": {"doc_hash": "f0d12c25732ed5698235ac1a97706c0416dce143804960459ce40a3ce4d55e5e", "ref_doc_id": "e7043aa8-4ada-463f-aea8-364ad491fcac"}, "4ae3188c-374f-4252-9fcb-fd3280a1749e": {"doc_hash": "24893caec51284b9334139afd060cd494afe01762ed6fa16e90c8d89be74e180", "ref_doc_id": "ba4d27fb-10a6-49ef-8b51-6b27c61b80fe"}, "7d7c0d3d-4a72-4566-8d7a-77908c94092e": {"doc_hash": "f8e55b6c88dfeaf980a10b60dbf676055f0346a0ef9afa8ba6afb22218d618fb", "ref_doc_id": "e55f865f-8e11-4f7e-b4db-59f0aa92da85"}, "3d49904c-dd3c-4ecb-abc0-28fa7920627a": {"doc_hash": "68b72d0b7b94670355f29b004f31645e0aac3a70e40f00a937c96f4285e7bf68", "ref_doc_id": "5ede3ff9-e7f4-4745-ad15-3ee087bfbdc1"}, "9e95ffa3-48b7-4d7d-bbad-a587064b7a8f": {"doc_hash": "4f4de71634a68ac1ce61f6f095b946f38016e966fbf3c21d3d5ec3c3b556243b", "ref_doc_id": "5a22b1aa-b859-485d-bdb5-6bc47d2804fa"}, "17bb1153-5581-45f5-9c0d-a3bcf3987a8e": {"doc_hash": "77c3f5614edea36f547606a5d12d5103d18e81863212678bfe42fadc36929e50", "ref_doc_id": "24dab8f4-7064-41ee-80c1-6bd7cc23c3fd"}, "ed4c92b1-2ed6-4356-be3d-7770969f728c": {"doc_hash": "b96f0f1e0b8a0c0a48001c60e736c8e344d6aed59d53ee338b43a1f1c5dde461", "ref_doc_id": "0c73d0f3-876a-4b87-a42e-9c8d1b560bee"}, "068874b1-4336-4741-a970-f55f0c5be626": {"doc_hash": "e0ec4cc3a74e8f4bd7a9d020df1ab9d117d06e085eb4bdf000a0128645e66ab5", "ref_doc_id": "3583205d-5450-4b31-8a49-4c0b5cb65b14"}, "4cd2d5c1-8abe-4989-b475-362d9f7fa550": {"doc_hash": "dd2a63809c1a1ad7a222ef24aaacab3ecce30e52ad48aba9e9aa6199ef63e212", "ref_doc_id": "39b31029-8c1c-4ada-a102-2d7631aa8471"}, "8e905a21-69fe-49da-8dd3-d81a3724dc1c": {"doc_hash": "aeec1b4f9da2a8a266ed4377823f0aa664b3dcf6ebd05b41ecbcb0a52a26057b", "ref_doc_id": "5cb561e4-ec01-4b82-a21b-9dcec146fa1d"}, "d6f9a5cb-6c10-4ba0-b48b-8ba49f7f9b94": {"doc_hash": "ebc8b38bb28ee7a8f9c48fd4538429bbe565c4aa78b5c67e88127b12682da0dc", "ref_doc_id": "07286f3f-8e8b-4733-ae7d-b70ea7f4d0e4"}, "ea0b4c78-3082-480c-af75-9d8e49bb26b0": {"doc_hash": "5c983d4150a73b7cf143d1c07aaa625f123e0727a04caa6feb45586def0d0398", "ref_doc_id": "94a1ea6c-87e6-49d5-ae67-3e19b07ce9fa"}, "78acd7bd-575c-49a9-9f74-73428925ec4a": {"doc_hash": "f3e8a57340f4051d254d5680f4b8b9015f8f506bb35ed653635c0deaed677e66", "ref_doc_id": "2609894b-b9b0-4655-8497-aa10c4708dd8"}, "201e6356-0f8b-4d36-b64d-26d18f295f45": {"doc_hash": "fb479cb1d362be018c31c730212687c9ec38737e7fbce9b0ac31b41b95cdce85", "ref_doc_id": "3b0b1a52-c981-4627-9a14-15d7cadbbcd2"}, "f49d2f07-6985-4185-a032-4d31f7cb6801": {"doc_hash": "b06744f639c2df9219e0673890da560d2f1528326ce90b71ef1957a510993ea2", "ref_doc_id": "60eb08b1-d2ac-4cb7-a94c-d177c8c958c5"}, "abe04782-6de9-457d-8211-0a0a2209e5d6": {"doc_hash": "f8150989de0d5a70a3f7bd0a22f6201bb877a8c36fdfca9ab381e13b028f2e20", "ref_doc_id": "df3c0f07-6a28-4edc-8094-cd7814cbb23c"}, "0b60e6b8-801e-4b79-970b-38d804d7c7ae": {"doc_hash": "d27844384061e827c012de5c58b86022b891e9b8a923f59840942665bb0ff62a", "ref_doc_id": "26f4e3b4-6fa4-4365-9e8b-a0ea729102a3"}, "d034c4fe-4a0e-4a02-a954-e9490577c00c": {"doc_hash": "60571da3db9ceb7953dc1523926c037a4e97ac5d2184c565889571f19026b8eb", "ref_doc_id": "df2a3492-1771-460d-9f63-fa6cf8014eec"}, "9855127c-d5a1-4d20-8905-7293d3ab727b": {"doc_hash": "7a16cf3cc2c3cf61f6fa8029d74dd93d180e2b0f4692bb8ee8a88f154fbbe3ed", "ref_doc_id": "0b452979-6d92-483c-9c4a-e658f7f7c57e"}, "a6dacf3f-50a3-449d-b9db-eb3b69390aea": {"doc_hash": "ee81a4018a4780266cc90facdb023e94c862d8fd92eff3c4aea8dd0531c377e1", "ref_doc_id": "81308c8a-2f9d-435a-8e09-775896c8e395"}, "3cac6de3-595c-4cc6-8b18-56a969b78536": {"doc_hash": "51b13133ea9f64520df2d8ce83ad33e1084e93f39b1e42a8bf7a727cc3e8970a", "ref_doc_id": "1a5972b4-cd29-429f-a8ec-6b2ab6beb073"}, "97193ef7-ac5d-4541-bd90-b235fc1dc844": {"doc_hash": "c10794d9e97cc4f0696ce8778f63501ea5fbeca65e4fa96a11a9087294a458bc", "ref_doc_id": "66e468b7-4c21-40d2-a900-0ee735401d7b"}, "c90eb876-9688-4547-84ae-72b5ceedfa78": {"doc_hash": "32cf77a8997a8fd3b425a9e96173aacc08f1d47567edf2e842e03ef45813faa9", "ref_doc_id": "0e0cb180-f887-4458-bed6-35464a266f7d"}, "f39c49e5-a9e2-42a4-a561-1846d3d5a97b": {"doc_hash": "84a0dc01c27bf5fc495f0f45ac34880e22edbcf7e5c0e99b6e4d9bd50a69dc9e", "ref_doc_id": "6cef2fb0-b427-4e6f-a6e6-14933765b29c"}, "4b9759b5-0d72-46aa-ae7e-60aa904a0a0e": {"doc_hash": "5103f73893757a1774fec31b960c4c2af2974e979c273a42da6ec19568a5ead8", "ref_doc_id": "01cb1b4c-cc47-4f16-bf45-7b5a6447f76f"}, "c73a8c23-3ed7-4084-945b-940d3b56ebfc": {"doc_hash": "586926c7f0998b016d8d858c3ce54235056cf1dc81097bb6b5167ff07356bf72", "ref_doc_id": "3c430dd1-ed89-4dc1-8514-f8865fbbecb4"}, "955fecd9-cc4d-4682-8aa5-6513c8bfcc84": {"doc_hash": "e58228ea1fac30da91d145d2a952351be42527972d4e9f32bd2407d50b516360", "ref_doc_id": "cff80025-df10-49be-9301-6b2836922236"}, "0038f1f2-7755-454e-be67-97aa6fc46bd0": {"doc_hash": "e5bf9bb3c8e4f4fcc6f6933ffae53d2c7187261c1eabb26b8f12749a6048f8a3", "ref_doc_id": "749cd542-5c14-4707-b708-2d5f5ae288ab"}, "e730bf65-1ec8-490e-b04a-ab55149a2c0c": {"doc_hash": "6cc3ea426a05c04151f3871b2a52b40364cab9c4ee5ba789791ffd67083d4d55", "ref_doc_id": "bdde8bcf-c9c4-42a0-936a-d8cc8ec932e8"}, "6515052e-4dc8-49e7-a11d-15dfae7deb7a": {"doc_hash": "5941607df7694b294118d43d3be44ae4c71eee1e67f4a3d8a401add97641cdb5", "ref_doc_id": "336abce8-ec2c-4360-a948-5e01dd0d7783"}, "ec29bb5c-6b44-4086-a389-d20f6ac21da4": {"doc_hash": "dee8decf6f0d7b20bb20210651f643523d1b04ea5ab51fdfbead69aeb9bddd84", "ref_doc_id": "384768ff-e2aa-40ca-912f-5b6416124c3a"}, "4fae2431-af9b-4060-8a32-32cddc5e4291": {"doc_hash": "c532d623ad6afb76f5251804b368d58299560f1ce94655a95b5f1be1ad20eaa2", "ref_doc_id": "776d0b00-5b8a-4b45-b458-ef32f5193812"}, "d1363008-a323-44bf-b2aa-1da950980fcc": {"doc_hash": "b71c6f327b4ca6fe5644334ef25aa932f5d2a1a04b2b321d83b259f29de2fd64", "ref_doc_id": "b4c149af-53d6-4255-9210-7d4d7357e3c2"}, "f727b4fb-6d3b-430b-a0c3-bcb7f59f7046": {"doc_hash": "97f1e5f704be4eee24ae333b87bd74e36a69869f4673f73837dd1b438503b957", "ref_doc_id": "462d23ff-7436-4a2c-ade2-41f55927ca03"}, "f6f2655c-1288-4b4f-9929-3ba335aefab2": {"doc_hash": "d26aba8762b31362a12c8f59e7682f3eb03daf502e0470eb00dea1a60c209c68", "ref_doc_id": "414ecf77-57d4-413a-94ae-750508e5ed94"}, "a38bb385-df45-4fd4-b059-8b0dea2bbb6d": {"doc_hash": "3902ae7a7307a0f51aa204c6fe89dbf4c8f25878bc3fb297bcfd07c98f4bfff0", "ref_doc_id": "4171b3ff-2964-4db9-8628-002c92bce3b9"}, "2f907a19-b6d3-4e7f-9fec-a8d6d7547a9f": {"doc_hash": "f365d5f79f2c1e926fcae2f52efd3b99818b5a8e6f8c085d04766ea088175bd2", "ref_doc_id": "af5f1c45-7c22-4c70-99a6-98d8cb2721bd"}, "9865f2ad-f6a1-467e-8ff7-85b77c5ee8c6": {"doc_hash": "09c68b04858cd3c1f9c6caa730431addf7e46d39090d543e74fc3802f9c32d0b", "ref_doc_id": "2a48de98-0286-414d-a6db-3aee15c99be6"}, "dcd7e421-86ff-4257-b1c6-a572af7a1084": {"doc_hash": "5288d8602834d1ecf55e72bb312248df106ff1d2df950348fb5702ceebc8193b", "ref_doc_id": "3a8df7df-0ae3-4bfd-ac1d-42ba092c7d6b"}, "43ada732-52bc-4fb6-9c15-b2638262c489": {"doc_hash": "53cb4a9ec7e8c1eecf8768103d7c01b7c311e353ac2fe519f9985fd470cff3bc", "ref_doc_id": "ec850558-5fe6-48b8-b194-602252973974"}, "7c254f65-67de-43a8-bf9c-453305b0913c": {"doc_hash": "e8fc83ac2ad82677b11cb4613efdbd2b8ceca4072edb37f97155ea520a2a519f", "ref_doc_id": "24a41545-a3fc-4622-a3bb-c00df3d5db67"}, "0ed4d19c-a44b-46a4-a741-c9fa1b3ee5f4": {"doc_hash": "52372f4d820d92df1d19a5080bb8c4840413760ab34c9724f81d2fe4230270e2", "ref_doc_id": "37d01a7f-8a52-4362-8b82-9c0def403bb2"}, "03a16896-b01b-4385-9277-0490c71ea03f": {"doc_hash": "17198ac5f239d40e4f9d3c038ae68705bd65315d3cc4ef41cee15db7e9830d34", "ref_doc_id": "9ecb09c7-a8ae-4ede-bd71-ba6c1bed02a2"}, "4f89973b-478e-46f3-bc78-4cf742266554": {"doc_hash": "e710b25d5b5454a7cd2dc4a72c339fc1e1f703ea08437b4cede4d039b1168dc6", "ref_doc_id": "5dfdd7d6-b8aa-40f0-9540-53005d5051f8"}, "8f8f06a8-f407-478d-b35a-43fd7aeed25f": {"doc_hash": "9cc44d18ebe796b136889c2e598d2394ae94a23bb8cfada6792a434a0cebfaef", "ref_doc_id": "ca0cbef1-2f62-4bd2-b5cd-e1c8567310c1"}, "e27fe8dd-f326-4ee9-bfd2-4b1ee0dee945": {"doc_hash": "64ec383759adf12b7206cf43527f1caeaf3dc70ce800834fcc9d72cb76f4765f", "ref_doc_id": "ecede01a-446b-4293-b61c-d048af2c319f"}, "2529215b-cf3b-41f9-98a7-e65d906a44ce": {"doc_hash": "6ebb28facbb788e9ceb951419d013f930a221bc53280090e4b288af25012dc90", "ref_doc_id": "f3d745c2-a69c-4c86-b0fa-d7b548f01c3e"}, "81dca8f8-2d17-4589-bd11-e97503a4cc52": {"doc_hash": "b6f591966d7cbe3c8b00bb6e8e05cb1193e69477f83fadc823ee4493f6b8a82b", "ref_doc_id": "60bc563b-5de0-4d8f-9706-3cd073d7e0b2"}, "387d8976-73a1-4622-ae5a-5f2b4ee107a1": {"doc_hash": "872ff7ac39936528c40290eabeadbbead51d8f93392733b686d6eedac1e123b5", "ref_doc_id": "ce8a2086-3000-4a51-bb7b-29520c7f2ba4"}, "55967287-7588-4a47-ba8d-d401fb7b476f": {"doc_hash": "831cef305f57543741bad238d22de900cde4a636ca585bc0bad6d4e7693da81a", "ref_doc_id": "40876388-91ee-4964-a5bf-131db01c4e0f"}, "d4dde60a-ed31-4d33-82b9-9a30a7bb5214": {"doc_hash": "3ca47e7c03c7d67cb188e1ad943fe9dbccdb0a350bd45b9ae09e86b74133711b", "ref_doc_id": "fe42144d-77fe-4521-b31e-f0823544694b"}, "c324b847-384d-467f-961e-c16ae97d54f2": {"doc_hash": "4faddd1708707537999b52f41f823f593de2f6aca877e222bf2ba04cd0052db6", "ref_doc_id": "4f2454e1-59fb-4793-8932-fb2a993618a6"}, "88243c49-1427-4a22-bf7c-249b6432eadd": {"doc_hash": "ae4a7706e20151fbe14c3c37ce8e58497e0f41e83da0c3dbc2fac95d4d995cff", "ref_doc_id": "b0974ac5-8ae1-4b2f-8a9c-69f0b6eac6e6"}, "44cbde19-d1c0-4f53-ab2a-5286ef34e289": {"doc_hash": "f97023581a23d4570bee46d2c57dec570a09aa8df4bf45af45b351cb5e0051e6", "ref_doc_id": "226b529d-4b0b-49fa-a8b2-7064d3b5cbea"}, "0175dfc5-757e-4ae4-9db0-740cf8dc1d90": {"doc_hash": "9243e0544449bc6d5fdd41e528b065a058bd50a22f9d679ebe2b1bf3834741ad", "ref_doc_id": "e6e5ddac-d620-4627-93ec-5337445784c2"}, "98d4c05e-08f3-4328-9da6-8f91d50122b0": {"doc_hash": "7bfcbbc3f5a3ff0ae52f6b499ef2dde4efb2fc34edad96569cb12920243f9922", "ref_doc_id": "232f29bc-c4a0-42ff-96a1-a90352605f5d"}, "006990df-7627-4faf-a24b-62ff39751d36": {"doc_hash": "5e0769f500009d63deb2be747b906a5739e958feb4a3cc3075c819aa429532d5", "ref_doc_id": "b51c56fc-0a71-49e6-a1b7-10a32cebd706"}, "96a84b8f-7a50-4f93-8fdd-43cbffbb3d87": {"doc_hash": "2579680557a62cb562075ad9c14091ea02cad2d9b307912d1b669075ca8fdc42", "ref_doc_id": "98ff0b8f-129c-47e3-b55c-809f905860e4"}, "b2e5479c-9bfe-4b19-9887-942dd000daf1": {"doc_hash": "c7109b8c8c656b83c7d3d6c006c59fe776ae89dd8f9d82c939e0463a117067e7", "ref_doc_id": "b5f65755-5547-45ee-b105-565be28f523f"}, "af3be54d-6663-44ef-8f12-b87bd7945823": {"doc_hash": "3d16620256ca28cec4e4e57c9108ed43a3123502da73589c7d641ddd5823bb9f", "ref_doc_id": "42ea1e25-cf2f-43a3-9337-11dc472a014e"}, "38cda45c-009a-4bdc-a434-ba23aa7503b1": {"doc_hash": "a47cc75861908b7e421874700d0513e30fec6839eca3054d481f70029fd9315a", "ref_doc_id": "18d36f4d-ca74-4901-9067-94bbd0efe45d"}, "4710042e-9a78-447f-b4fa-8f4078a8a1df": {"doc_hash": "7125ae6f7b6764ae917df0a3bb2963371ae9459dc8658dcae8ea0d5d9789dc34", "ref_doc_id": "d6e934d2-8c37-42a4-8778-736efd10fde4"}, "4ceb835b-878a-4611-b0a6-4a6d4c7ab15a": {"doc_hash": "c2ac0e2626fb83f0f2e6e3e015592b09815eaddf8ae4b07b4650e62c17343953", "ref_doc_id": "96dff55e-3917-43d3-b8ab-99863b131ce6"}, "ea866d2d-4a9a-4190-aa49-06b057298ef3": {"doc_hash": "8f8b1115864e7bf4d931f054d9a8d33bbb0136a4ddc680a52829a0f9b6c44415", "ref_doc_id": "257468ea-ae7d-4161-ae66-83ce63718261"}, "e998a342-b8f8-4c30-aa32-3b5859069d7d": {"doc_hash": "899cb8ad8910cdbab3ed79a90b3685b26f8c379ae2850cadab851696d49c7513", "ref_doc_id": "44fe6449-503d-400a-8f3d-3f275a100420"}, "5bb4148a-6227-4ae9-a44b-5ca5fca286c6": {"doc_hash": "0eb23c61c195267a7ec40dc5fdba90797e24287895f7b395a4aaf2070ba931c9", "ref_doc_id": "e2333efd-72b0-4095-8c0e-3b3fbe4692f7"}, "451e9d7f-0538-42cb-97a8-dacd4e1710cc": {"doc_hash": "24c5b15776826280e4e237b9adb078219cb403528fffddd85b3a442b99e83c8a", "ref_doc_id": "f3eabe6d-d169-4594-aef9-7f543d5556cd"}, "5358de7c-6e7b-470c-8c3a-e0faf226bc0b": {"doc_hash": "071abb3639ac7813f0fc9ed3e89a0e7c1286bc762cec4436ffa98193e7fe22eb", "ref_doc_id": "8c102189-e2eb-49dc-8454-45d03575fe84"}, "8f7d053c-a2d5-42fc-bbf2-1582da38ec76": {"doc_hash": "091efd93d5452740028791eaedd350261991ea04076882556319316ea68e8d26", "ref_doc_id": "4bf88be7-80ae-40c3-a395-bda7db450141"}, "7368dc06-7900-430f-bcb9-9b37abff02a3": {"doc_hash": "09ab3bacd48b5c5ff596fe45b275dfb08d93de42f9625a020d659310a76bbb68", "ref_doc_id": "3ff72645-dcc6-4428-9488-3871755a0762"}, "ac01f906-5f8e-4e96-8413-e02cd1b58068": {"doc_hash": "0debbafd1915553754babe49277c26bbbacc73a675bbd91f7a3fc38107d77863", "ref_doc_id": "48a6d3cc-7119-4a71-96db-5735901c03c8"}, "3febb6a9-c76b-4c6c-a4b6-27518a474a1a": {"doc_hash": "71034fc4cb806ddf3234cedbbae0646223d7e0250d18f72d5ce4487d7378d9ba", "ref_doc_id": "4f5d46cb-c9d7-4864-a33c-6727843ac3bc"}, "020e5f41-e689-4c14-a650-2858abd353f2": {"doc_hash": "05958e6e31826b4a14b1a7250feb0f0def7cad7a7543b6931964f5e3b4e40dca", "ref_doc_id": "69063419-5029-4d09-8ddf-9562e50ffc45"}, "5f66589c-7f61-43e4-8248-ee2ff7a82b82": {"doc_hash": "b6dff4f80d5987f44de13be228dc472b2ff68b3b3e4c1152e1ddbca589942514", "ref_doc_id": "6dc4e23e-5da1-48c8-83b1-bd800489482c"}, "4f478de9-e57b-4d8a-af10-fbc9b7a24160": {"doc_hash": "171ae65bbe665b935d9645a4363068e95b16642cd26817e84967df90a80a2bc4", "ref_doc_id": "a2d448fd-f3cc-4816-88fd-5053e26d4105"}, "488f957d-ef56-46a8-b33a-eaa62fa7df08": {"doc_hash": "f42f60b206daab6e142700f9eda787118221e7411c2499523d7e4a299a2cabbc", "ref_doc_id": "12c79bfb-e559-47f6-9f99-2cf62da9e53a"}, "ca485d5c-9cb2-4e0c-ae03-71bc5b759623": {"doc_hash": "7f680019db829cf1c7773ea82e927a2cbb1446a9c13371be7f13b1ab4c9a2f4a", "ref_doc_id": "e126ca03-2a60-4321-b541-e649a37ccd4f"}, "7a657c28-4321-4a88-8e8c-99f05dc847ea": {"doc_hash": "56bd2efa2d7eaf0c984bafccf0c6d81105a8565c3becb0dafa3c8c8917f8cc93", "ref_doc_id": "b0cfcc2b-ec77-4807-a009-1c1173cbab3e"}, "492c8765-cdbe-447d-b7b2-1d8ac4daefe9": {"doc_hash": "d34e537714e8163696682fb185af575ae2ab8c54189ccaa9cff18c46b53c1192", "ref_doc_id": "45009599-a8bc-43fb-9a55-6d5aa5c7c19f"}, "7cfff30f-ab6d-483a-8b4d-8a08d0ac27ea": {"doc_hash": "f5ad1834936ac4747e122e5b426511cb4b59592eea089f051b3c769e5baf6013", "ref_doc_id": "a39e3f8e-443e-44f1-a80b-3aed7b618597"}, "b42059f1-be3d-4cd2-98f0-b2908a83b1a8": {"doc_hash": "38b8c353f6b635ce39afb274829d3e2fc76cf2a18da61e6a5b7dee3bc5c36f88", "ref_doc_id": "e4572bba-8711-43b1-9198-cd474de46866"}, "3ff821f4-6d06-441a-ae6e-132645bffc43": {"doc_hash": "04c25104eef5bbac9194c99864f9c7a59b5cd91960dbb38d11f02c9799ceec7c", "ref_doc_id": "65dfb233-3dcf-4356-a908-41ef6a66f5d0"}, "334a6160-c908-44bd-a54b-2211479f8fde": {"doc_hash": "90acf9d30a8881223e496375d7350e028052c00b74c3786deff45b6a6172729d", "ref_doc_id": "e1164e5b-3b62-4f61-b926-a034caa7dfea"}, "3dbd59c1-579d-41ca-a5c4-fa74c8ef22d7": {"doc_hash": "b41a6d232110177f288f083b0d60b2f6fab2fc8ec5228bd6d0e7136d64f9cebf", "ref_doc_id": "35c0bffb-7b02-40b7-bfad-f8b7d9bea40c"}, "74de8415-af9b-4b8a-8618-8e1d185a71dd": {"doc_hash": "b95e3f17a4bd3f060cd9fcd613bc679cc40799e711b46d26af216ac190d11b6c", "ref_doc_id": "22ffd56f-6035-44b6-9570-e26b64f2ce7b"}, "703883af-8bf9-4060-99dd-5bb356c95309": {"doc_hash": "67eada0fe5b94b3421669e3084ac36a3fccda390328de4fac5a6815cdc752501", "ref_doc_id": "a1d7a51a-d6c8-4a1c-ad13-c1ca3d0f03de"}, "b64ea6cc-5b23-4db3-a747-fa039e24db57": {"doc_hash": "5ef12117dc2b31163b6896068bac0bbef8f4550f4c35252c6a8b71b36dfff619", "ref_doc_id": "fc8d5073-29ee-477a-b1f4-7e30307ba454"}, "a631dafc-b283-451d-959c-3c709095d9b2": {"doc_hash": "2fca61db99a56a79a377e625809de73c2e63fb465cb608294b7ada2b7776a3e6", "ref_doc_id": "a8ef26c0-cde7-48ba-ab31-90be94e7cdd9"}, "ca3f54b9-5472-4cd8-bf7d-8ff8915cebe2": {"doc_hash": "58fcb8927f678e15bf03e9c71328c53ff02729825b56016881cec50527ed2d52", "ref_doc_id": "9b5c4d08-b6e0-4ac2-87e7-29e2923c2a2d"}, "8b705786-0bfd-496f-a02c-23776027cf4c": {"doc_hash": "02ac1ec6a4e6fb79132b63db5645b7c62a69dda6001887469b78def09b15e92f", "ref_doc_id": "e11fd00a-4766-4334-9313-c1f86c914a00"}, "5dad3e21-e2c5-4ddf-b3f2-f78f8f83af57": {"doc_hash": "461755b32edbe221c36c8bb86d969dca9fa2bb8121bc3bc587aae8b2c8b61946", "ref_doc_id": "7862bc3b-0436-4254-912e-5673e6133f39"}, "bda38b47-08e2-4e79-b7cd-f1a595030b7c": {"doc_hash": "88741a892bf7c143adfd1d30e97719191a6faf424b0c6e37c5d162e893dde299", "ref_doc_id": "90e68fd0-c37f-401a-835b-c203f5995f0e"}, "d28555d7-798d-43e7-8d34-6d01a498ca05": {"doc_hash": "a63f3b4349134c97c0b26d0b37a19f2d962339f9e8fcf09f8080da6ad3854742", "ref_doc_id": "21899607-b365-48d9-a6e7-931bda1a421e"}, "002314dd-fc6b-494a-8faa-ada13e991af1": {"doc_hash": "b146119393c744a213d4c8c09da55a4a425d73e8965a7bf7b1bef88c2db1d86d", "ref_doc_id": "cda036b4-0f2a-4fdc-836b-152edc0f19b7"}, "1c9091c8-21ce-46cf-b7f0-2fe48a5a6594": {"doc_hash": "60d14c46dc1dff225542f898f61b5810cd95eb0bd4c54a3f953e60f350329639", "ref_doc_id": "1e830ae7-5d66-4a7a-a47e-997f5ec4b79b"}, "99e42df5-e612-4f52-aae7-91c158cd0ac9": {"doc_hash": "8f26cebb78ec9605fb42a05eea9596526d4edace8cf442582dcccf5b5c07d7f5", "ref_doc_id": "34624f91-2ffa-4889-bdad-8284ef515811"}, "4d63ebd8-77ff-49d7-b25f-9efa93afc02d": {"doc_hash": "b55a2d28b49662aa4785bebea4176c28220ded792fd3806a2f23736e60c1d5ca", "ref_doc_id": "9e697894-019c-4e06-9ff9-0e80c4b9d417"}, "cbebd2eb-4eda-4859-8136-8253dffd49e8": {"doc_hash": "68174e1296d429ebed6130e1d0994716422dc50064357fcc42595d6c26afcf24", "ref_doc_id": "7b75a06d-207d-472e-a794-2d40ee948c06"}, "1cda8364-b707-4155-82f0-e39516bb6b94": {"doc_hash": "4bfd13253e9abc48e5724124df10804c5b00ea9178aee403a861ba9e3fdaf0f2", "ref_doc_id": "3065eb16-5ab7-4da7-a614-33579b5501fe"}, "fc49c44b-f106-48ce-998d-8a863b34dc22": {"doc_hash": "e2b3a66ea2eb342d53f2f94aa3c7a926fd815e91e4598a5d83706489ff4ba2a0", "ref_doc_id": "b6519bd7-7c9e-4148-91d7-af69cf468b3d"}, "71546001-f484-429a-b5e8-912a20b60e0d": {"doc_hash": "07c403cbe0ddb900f7413e4fc00837ab60bd49ac244f2861588e158ce4c2302c", "ref_doc_id": "c5b244f0-5ec1-4f82-9772-fe331a5e41f9"}, "1dd0b841-be46-4692-a6e5-b5b1df298323": {"doc_hash": "0231209d4479089131a022df86a2ab8a91058fadaa9a47a99a667cf99baf42b4", "ref_doc_id": "677d206f-470b-4c7e-9c04-a9c0584bf4bf"}, "7eeb39da-7c98-47cd-af23-4c1018ec8264": {"doc_hash": "76a725d20a102e1c62bdc05d6dc3d332073d90788d477b5d2fefa9204b739e3d", "ref_doc_id": "1e0cabdf-3fdc-473c-b71f-ea6800595025"}, "28bbeee3-7a83-43bc-917a-be874b607714": {"doc_hash": "ab703c86f8ffc12d187f0601516c26f7b8a702ebad85b5121895da966849b2dd", "ref_doc_id": "b1997818-dff9-4017-acf7-faf2bbc1a2d7"}, "9b36f7e8-f78b-4fd7-9b97-3ca7bc28113d": {"doc_hash": "1bcc1a8b95d65c755090a5a3eec59d06e2723b284f93a74a6bc133a76cc8c546", "ref_doc_id": "ee2a612c-1ae1-4b1d-b2c0-593ba514712a"}, "3318a725-4fbd-4ee1-a2be-78a2d99b02e3": {"doc_hash": "e63f4c882ab19bad18efc360fedbcf7cbe11ef502c3843e9d087ea8c3e73c126", "ref_doc_id": "b6831d47-f333-4b52-b989-8fc3ae399f32"}, "da28393a-c79e-498e-b579-5b62592b619f": {"doc_hash": "58fa7d4e5be4d5863bd7b15919c28f3a13e6a9c849211dea608960e24a2f266a", "ref_doc_id": "1531f16e-236c-4df4-975c-cb4a1f276cae"}, "cfda2ff8-f456-4133-b96a-9b4fc955aaf4": {"doc_hash": "ee55b778509ad531de6071d5f6fe1405a5e62badde4080bf053bf956c051b351", "ref_doc_id": "993d37fa-eda9-45fb-94c8-3ee57f9751b6"}, "1a9cc8ee-38cd-4c7a-b9b2-622fda2d189c": {"doc_hash": "4b79920179467f52f4c6414a99af48a3dc606b543506a99ab7e88481ec5d1b53", "ref_doc_id": "2cbb2d3f-68c3-49b4-8d01-f9855a055f46"}, "80e74c01-f6de-40bc-8ffd-c26187bd1212": {"doc_hash": "6ee3196ebfc244ccdd260223377e93c27f20b591a4126f90cc2242bcffd14eaf", "ref_doc_id": "dfc67de1-e93d-4d04-9d1e-0d48266d789e"}, "56f7a74a-ba53-4239-9362-bb28d5865ea3": {"doc_hash": "b9617ea05bd6e981e2a0c47c600225c26518873be80655e5303a5f273431db84", "ref_doc_id": "ee1b9385-b668-4dcd-9855-43babf162488"}, "487223e0-55e5-4a06-9535-a8870f47f6e4": {"doc_hash": "28989e524137fa28afe213859ed56db5da73396dbe014e3d8583fbc1562faaf9", "ref_doc_id": "a21c61ba-76cd-4646-83af-d52ec3cdc4af"}, "0eb95164-f8df-4b01-b127-d006c3241f7e": {"doc_hash": "3444f3a7d730e424ee36f5b9b81848845b6ec13c8686b80e2474eb78faa3fd50", "ref_doc_id": "d0caeda5-7dc1-4f76-a910-0734bd5ca345"}, "e482013e-5db1-48b7-b405-273d5ab147f9": {"doc_hash": "3134b12c09bc34717cbfa08d523e39ce0cc56a0473da428566223c8439b0d0ee", "ref_doc_id": "09a4c596-e330-4b3e-87db-31583e9b1ff3"}, "27757c46-2adb-4959-a3dd-cfd2f3a0eff3": {"doc_hash": "729515d0881f7ac58d95257a30ef531c7f42c242d6255141569e95caa717a41a", "ref_doc_id": "9596f487-e87b-4e2a-ac93-31e50ea1b7c8"}, "a2f6ddf8-0d76-4747-ac09-b83f6d0c107b": {"doc_hash": "254a0b4aaa6a91a88cc2d28676a3964e082b28e766781e24d9f3f73568ea460c", "ref_doc_id": "9be01ad9-3ff4-44be-aef2-dd4c7ce9f8da"}, "1bf3ef12-1591-4b6f-8609-d9cdd7638adc": {"doc_hash": "0b91ebd23e5d566ffb0d98b1ae46ef5c9de1944154741bb2f9634e5b571bcb5b", "ref_doc_id": "15795960-3957-4a62-b842-d68025b9b0f7"}, "30857626-dbc4-478c-b0de-a01b28c47be4": {"doc_hash": "73c167d6ea64010ea35314290624882b6afe01c1bd9f57250366fb082984ce10", "ref_doc_id": "a483d805-ae51-4d4f-851e-f43b7694a986"}, "8a0ce770-30f1-45ac-a23f-e878cc9978a7": {"doc_hash": "6112d289e9499e3440ecd3fa5d54c538209140f65157795c93da8c1aff3821c8", "ref_doc_id": "2f301f63-42ba-48ff-b518-3a4b0331239f"}, "2a4ff576-904c-45eb-a94e-25a711b69f9d": {"doc_hash": "07424611e0c6e04e715b3377627995b940e137d2bd9bf349a8eb549efbc0a780", "ref_doc_id": "a9f2669b-e1f0-4ed1-82ab-fc2ddc3176a3"}, "881b16ed-cefc-4bd6-953f-38434587ab35": {"doc_hash": "f47afe721fb33b63ac0d0bbd6c0e32578a11a131f2423d6ce32048c7e7dcb693", "ref_doc_id": "72071ce9-8943-44ef-b0f4-173473900109"}, "c0fbdc59-6e0b-4569-8c89-ef7957e81792": {"doc_hash": "be2501210cf0fbc4add2b20dc2c55b20f9e53a18ff56f72349ecae60eb2465b9", "ref_doc_id": "c2d0fa78-51a7-4f25-a286-f37e24004221"}, "96fdd029-27d6-4b02-8c5b-90a3e5a6d49e": {"doc_hash": "4554ba4b7cd2d964914925fc7452c30dd3b42413541b516251b7d01fc28ba766", "ref_doc_id": "463ebedf-6f3a-4a66-9c98-9167ba3904c0"}, "6a9c7d86-11b6-42fc-b776-b9ce293a55bc": {"doc_hash": "f409c3bdb7b91689b214f63c5ea40586708e2ff0933e3acf420b5d256d9fafca", "ref_doc_id": "37809a6f-b2f5-45db-b29c-9a55ef6e2489"}, "c9f24c44-b718-43ae-a1d0-f1bb724680f2": {"doc_hash": "e7a5afcf0351c061e0de98d6feefd9b1b5547a2f03febe854089b97123eb123c", "ref_doc_id": "693eaf89-71c1-4f60-95aa-352de08cc3ad"}, "c555d382-0caf-4bfe-915b-222822e41f44": {"doc_hash": "434e57efa6c343c3ad6147fb16815c907d893372519322b7945a4d00c30ab2d0", "ref_doc_id": "a635a522-9234-4c38-91b4-01eedb898e5a"}, "efaab952-db8d-483a-95c7-8c21d919ce22": {"doc_hash": "4604be88ec5203e535bb553afcfe01b42a227e1c3de6d23c2962184c2c02d4a6", "ref_doc_id": "fb0dcbb5-8062-4d93-96e1-513967316679"}, "78ecccb7-7853-44db-a72c-bdfad171f9a7": {"doc_hash": "c3d2efc69222b15820106f74e4b20910a37ce0b6fc511984f65e2104511d4fa1", "ref_doc_id": "daad47a3-2fbe-4a84-8a66-fd8f30d37b22"}, "b9f55d22-dfec-4fe5-860b-e50b4f405698": {"doc_hash": "9a2b8638a7ba7ffd53eb6ad1814cd5cca6d7987114d5525b2cf27b44d3e802bb", "ref_doc_id": "382dc190-350c-471a-bf5e-29f3d21b4183"}, "54276fe0-90bb-4c71-9727-6a0b66d964f5": {"doc_hash": "7ac3217da9c03d9e8d702816666e0170632bca0939ada251612a6a923c97eef3", "ref_doc_id": "b19860d0-a8b2-4fd8-a497-08317d6b458e"}, "a594843e-1ae9-453f-b28b-35307515e532": {"doc_hash": "2a3a08e56f0c3d81b1fe6aa7fd570c9a0cf23e0c092b908857e1257cc25d60cb", "ref_doc_id": "76b417b2-e951-4961-bb01-f9a807cb1fdb"}, "e08f3971-3b5c-4d66-a61e-4e8694313af5": {"doc_hash": "25a9d4ed71ff7a2d5c6d8bf9753714ba66d036a232542bcbb5bedcac2810378b", "ref_doc_id": "4603de5a-4ed7-4aca-bff8-efbad600648b"}, "37f2a501-e4a8-4408-818c-8b45783e333d": {"doc_hash": "fc906645e3f5b54a4bc2d2742ddba5611f9a6f655cdbaf5a39a1b570821a8e37", "ref_doc_id": "460b2792-0635-425e-a325-1cfbaabea87c"}, "f367f092-50a9-4277-885d-ce111fa10f75": {"doc_hash": "233718b6baa9bde1b28b0485de3b395b623e6dc17cc4e6c91e6e083317834fde", "ref_doc_id": "230b0a18-d3d4-4add-ad16-c7d1796f37e1"}, "f1c430d6-b694-42fb-bc25-fc7ce19b9094": {"doc_hash": "790bc96839b5160e1289f7d59a866eb7bc60e03ce6d217abb146fca13a815eed", "ref_doc_id": "41859b7c-0fe0-4414-881e-5e1e5dee2e25"}, "1f079a5c-f225-4f2b-a1e7-0d60ad4d866f": {"doc_hash": "9c1b8f3bda3630f4b86f6088fa6ffe451e0509bbafda40c615920605602560cc", "ref_doc_id": "1c6a9a9d-ffd2-42c1-88cb-6576f7270649"}, "22715473-75d4-4d1b-8f7b-fb1bf3830f48": {"doc_hash": "c98e16a3a1880c00d9a971bd65c092bebba4ff543b57396dd448abb81a529d65", "ref_doc_id": "31c2981a-30ed-4cf1-8620-e284f5c1a9f7"}, "fcb29b46-7831-47e2-a56a-4daa0336ec26": {"doc_hash": "f318707125ad37c20dc4ec9e396f811487a59df8b47f257faff32ac98f5ea229", "ref_doc_id": "c725e63d-eb03-45ef-b8dd-2ac5513d0869"}, "62a8be04-fb96-45de-93c1-be8276e889ac": {"doc_hash": "24b206312102ae5a927b65bb220af138a484ef86622d6db74904c466551f7df0", "ref_doc_id": "d16ab139-677f-446d-bd7d-c91cb4b4ea09"}, "19265670-4059-4ee1-88d9-65deeb407c8e": {"doc_hash": "80f8e3462741c5ebb304be6f1b7d56c13b5df484567d4bb8d945dcad0f3f540e", "ref_doc_id": "cc4733cf-c374-4ab9-ac86-2c2d349f460b"}, "fae6e2a5-e636-4989-9a4f-f5e11563f325": {"doc_hash": "13dca6a8be47fe675822876fb2e023aa8af80ba59d1c73f3d596c9c72f012778", "ref_doc_id": "3215ecd1-ac16-4bdc-b6ab-67c0522f8f39"}, "aae2a2e3-fec3-4e1f-b490-ba46e5160abe": {"doc_hash": "ac1a73c518e7b33955a258c805558af1c08c2c00716734dda4f641c7e482d761", "ref_doc_id": "d141ff33-267c-419e-be58-effb86936228"}, "6c6bf142-58e3-4cd0-85c7-42a0ac4358e6": {"doc_hash": "e910b4fff59e67e2e3a796c642992fd95b59fbd989680caf2e245dc11a8e02f8", "ref_doc_id": "5efcbdbe-63d7-474c-933a-f574e37660ee"}, "0518bd10-110d-4fff-8c52-805f5ea01252": {"doc_hash": "2048706dd58fb34513489356aedb54f13141a88ffdd637996adff6ea3ac713a8", "ref_doc_id": "4ed5e69b-0198-4c78-8bf1-9259f274f6e9"}, "5673735d-95d3-4166-a509-f118055eb917": {"doc_hash": "d969aa76be6087a64982bd18ad7600dbc14e21ed155c46e668638450d68779fd", "ref_doc_id": "8fc317ad-54a4-4fb2-81de-b2c218683806"}, "3ba2197a-e29a-4d18-a103-dbcecaf8c455": {"doc_hash": "707bd56329e3d2109e03552c25c93059272e4671d7ccdcf7cdb0d5653576f133", "ref_doc_id": "a0f7551e-0226-47d3-8902-27475db55773"}, "8f95cfe2-7bb8-4540-80f2-ef20818bfcf9": {"doc_hash": "552547722e9f210f34973ef266f8021aeffd4a2f1cf39d93aaf4f15544b9d1f0", "ref_doc_id": "816dfe9f-d71a-404f-acb2-2e62cc31c9fc"}, "b3c9a1dc-ac0f-4bcc-85fe-d762b488cc3d": {"doc_hash": "4e9e2f1531811041586166453c82b2118a35985f4bf11219a40bfdb63810e219", "ref_doc_id": "47c5846a-8764-4cea-8c73-fe7222394144"}, "5e0654b1-7304-4898-945d-b4f359a0aadc": {"doc_hash": "dea1e9547148de7c0e1796c73959ec16daf58f58ee4a945096250f65d7019c22", "ref_doc_id": "1c075cc5-b177-466d-9fa4-08b5459bde7d"}, "d176515d-5618-4171-a7eb-fa4c019ba968": {"doc_hash": "39d0e6072a5840b04818278205b101491407157253ca2899ef2c4475fd0cc3ef", "ref_doc_id": "543d46f6-df78-4208-a7e2-19eac4abe0a1"}, "7d8534db-dc8c-4e21-b99d-9227f8b41b38": {"doc_hash": "34b86c5e69640547f444e70f1392a72b60abf92b4607add0a6c1b570531120f9", "ref_doc_id": "c5f27eb3-1472-4f01-b1b7-a9f2c59a6e14"}, "2af7ceca-3bf3-4ed4-b501-80c0b08aee25": {"doc_hash": "5e06f2bea334f13bdc681fcb1494a1773e2bc90a17aed4a6750c6ebfd641abe6", "ref_doc_id": "63f6f599-08d0-41f1-aa0b-7853d37680de"}, "225deadd-845e-475b-b26f-64101ab30e28": {"doc_hash": "65a42f87b43a785273d73eb999ac542885078291ca640544ce03f8f5c8a35172", "ref_doc_id": "0f2f3811-f208-48a3-a8bd-ee2235511082"}, "f3afb49e-5381-4446-ae5d-d514e63015b3": {"doc_hash": "7513ad48164857dea3bc0c7aa7b06dec4df6c0c64b1b1505596029a5b93229fb", "ref_doc_id": "f903908a-bc35-4bec-abc6-893a7361d491"}, "82cc373f-7ec2-477d-aefb-736e26e2c7b3": {"doc_hash": "ff7bd90c0f762daceaf87cb8223874574359d5c0cdcaad1f0787f6ea7962adf9", "ref_doc_id": "0559c94e-060e-4999-951e-d90b6b4ec9a2"}, "c5604f4d-a6e1-476c-a478-cba1fe857d95": {"doc_hash": "56301e58c4bdef5e4b09a97579037f315a15e77497ef5018f3d0083974f1601c", "ref_doc_id": "a9a5525c-0cd9-44d3-b2f4-91409f2af742"}, "ffc7d5ec-e5a8-4808-b499-5a6f8e9b4bfd": {"doc_hash": "4b5fe6eedd897892484041daee1936e8f54d2cc882bc525f5edd7164a9248cec", "ref_doc_id": "1e2056f2-499e-45b5-8779-8eabe6734ecf"}, "5fbbe4c8-77da-449e-8ca6-2ec2cebbf472": {"doc_hash": "0ccd6d52858c8a618685abf33f85fd916cc8d46fc329804d59a6555e194c0e22", "ref_doc_id": "e878de0e-a3d9-4d63-a971-4cd1b5803615"}, "2e43c1b1-154a-47dd-ac7e-f2639b14bee8": {"doc_hash": "b6946abf763e295c9ccbf3a3face7db0e721b87eb472c67465f0bad3a1b315fc", "ref_doc_id": "81669650-a9ba-4971-abe1-0ccebe3dd724"}, "18af92ce-f91e-4fa7-9588-caad85a9c511": {"doc_hash": "fb3f37474e54277604d81346b81a37a8973e24f2f151db04256ab5587c0f76c6", "ref_doc_id": "377c898d-7e9f-4bf1-826e-85fda05e57a2"}, "bda4f18b-a7df-42a5-8f91-3e8a58055249": {"doc_hash": "07f4a356ea24973c87a632e12fa1be1bdf7f33f52a90647fe3e5210ad4d6e76b", "ref_doc_id": "c55afdb3-1a01-4b96-b04c-f20047f90e8c"}, "f0b15c18-fba5-427e-b526-d96bcc8e830e": {"doc_hash": "e610a450bced5ccf55cfa563d45c03153591190ff0f8a60e372781d8696d6cb9", "ref_doc_id": "ba6f5e33-35c8-496a-b13a-1cb45e6e9d26"}, "61e05fd5-4415-4e25-bcb5-fcede87483f6": {"doc_hash": "c626386253694e4f2bfffe88c64946218d4ea3eadb59d5e440555a9ee0cbb1dc", "ref_doc_id": "d5ff17a3-c856-4373-a805-fe3005eb7a71"}, "5452d07a-d1b4-4975-a7b8-8dcb99b1c843": {"doc_hash": "a0d2080bd6862146fa4aa4dd40f4e91602910680af587ce334ab5bb58edc3660", "ref_doc_id": "dcff5e19-8243-48c8-8fdb-a69f22bce720"}, "974615f5-007a-4a88-8f0f-ccaa7e5ddc5b": {"doc_hash": "b2cd5dc7ded7a87dd1930dc5331642aeacea49d4cd94f580e3569cdc64fdd240", "ref_doc_id": "cba15e6b-ac48-4d01-92bd-11198429ce24"}, "42cebb9f-6bb7-46ca-b9de-e8b76fc88686": {"doc_hash": "f21d8c187db5eb4a9f197b7c5c1ce491c9af849054e387452041dceb2b0ee513", "ref_doc_id": "47ed7d38-b865-4b68-b694-6fef2ad83a7f"}, "c861fb02-29ed-4342-b10a-fecb03df7c32": {"doc_hash": "83dc4d63e73d9c034e327d81bbfe9e4df87bbef4fe72129bf40bb797f6e1343f", "ref_doc_id": "063b52cb-0999-4696-a03e-954fc0cc234a"}, "5a7ff84d-f018-42f6-ba40-4c35572a5f39": {"doc_hash": "772126c0c4d37784f501ca5f336760c67a898047ad1927f112746886ad414a2a", "ref_doc_id": "cbaa77d4-c12e-49f0-98ed-265aa167838e"}, "b30e144f-2952-4298-93c7-ed980670eb36": {"doc_hash": "b92be0f701a1e1675897753d56e72e01cc823b7fcc56f10e7efd3192e02f99c1", "ref_doc_id": "cb151eb1-aa1a-41c0-b412-c0412a1a4ed9"}, "8b152745-7bfe-4763-9578-0f269bc292fe": {"doc_hash": "2b1f1968d15e170078941ce4ab021c79e8de776b75f024dbecaa726c2a2db52c", "ref_doc_id": "79b48b04-8ebd-4436-8714-a18e48155ba4"}, "38fd24f9-55f8-4eda-a85e-bf3017577b42": {"doc_hash": "05eded15faf496181767681bcf7b9521c2278631478e9e7fef70123b0da17338", "ref_doc_id": "9d4d3440-2785-4647-9312-c96b2ef9036a"}, "4cea0fdd-a19c-4ff5-9d1a-aee8f847968d": {"doc_hash": "39589dbc9af8d1512520083d9b4f238facb7d0e31008f6c1f5eae918c54be9b2", "ref_doc_id": "9b9c3b6d-cfaa-40d0-8560-a57ba65fc468"}, "63a8a489-8aba-4af8-a6e8-726df0cc8e66": {"doc_hash": "14a396ac44f3a661cb3ff421b2cb6ddab4a3ca36235d7ec548e6aad477faae8b", "ref_doc_id": "a54a31d8-ad0e-43a0-ad86-2d27768cb95c"}, "e9f6e980-d6c0-4c03-9bd8-a5ab037702e4": {"doc_hash": "a8511e002fb339de4d6bb649ef8f4cd6fd96f308064b87a2db2e7477a1a7d548", "ref_doc_id": "31298161-4dc4-450a-9497-ba577031a9f0"}, "f3a6e4e9-66f3-4a01-9d11-85c7b2883922": {"doc_hash": "8be8631b8e65d438728e2e236792edc05b167808e9843de4fbc9acf209d521fc", "ref_doc_id": "be33ca8e-f443-4cff-8917-48d588d3090b"}, "bf506543-6cdb-43f2-b736-0218e509d707": {"doc_hash": "b57004d802ccb317d618e58091784c137d7121863397bd8c47cfb8ba7ed3847f", "ref_doc_id": "ebc0fad6-6550-44d4-b789-a9231f27064c"}, "449b48b7-a228-4736-8d23-d3aba6abaf5d": {"doc_hash": "7fb39d89759a4d00f24c75f04295e3fa7a8c9f15211aa6cb7f6dcbb1b8968551", "ref_doc_id": "7084a685-83d8-4166-aa96-392f356434a5"}, "259c8441-f1c3-4684-84bb-3b0a4a69db07": {"doc_hash": "f71067d04689e486c8716735cbbc82da6b6695a8c0a2cb4b18a1c22a206c43c7", "ref_doc_id": "f1bcfd1c-0e47-46b8-a3f2-c8e297c38e95"}, "970a332d-aa27-4f81-a75f-7a923e2514cc": {"doc_hash": "f3843f85deb3bd1cb4a7667cb9d23befa35b483fa0d94764317afe6a87810bb7", "ref_doc_id": "57fb5e34-7f4e-492a-ba50-00850d2825ed"}, "31642533-dc57-4b59-a4d9-4c453ddff48f": {"doc_hash": "53703e258dd7c538f431c8deea1c85dd527c02512140d85830d7956885631342", "ref_doc_id": "fa9bea77-18b4-4d86-885e-66739e3ab9f8"}, "9ae50e80-72eb-4fd0-8908-9b8a9652c5f4": {"doc_hash": "e3aa1d1141f91417755d9b0692de3886c89409faa637bb98998c54ecf5413791", "ref_doc_id": "f1afef2e-28ea-4a5c-bf4d-34fa7874eed8"}, "c4007f61-fe21-4224-a719-377f57f96ca0": {"doc_hash": "df70882a2347d8f11bf441fc4dd2ada43d47c372dae19d6d014bd4427b4a6568", "ref_doc_id": "95e7d944-bb77-4e58-a666-6474b8bcf00b"}, "339a7d48-f745-4580-824a-3af9545ef028": {"doc_hash": "e0fcfa6da8dad008fae0d43ee6fa14df29491fc8e1369cda3b31268389c0bd4e", "ref_doc_id": "2f63ee3e-f938-4ea3-bf53-8d3b11cde4a6"}, "2cf83360-c4d3-48da-8429-3714b050dcfa": {"doc_hash": "1d076b715623a820c73ec3710f639caa3345c3e4052cf14dfd838f4fc3206569", "ref_doc_id": "ecefb3dc-9971-446d-ac1b-859dc79a46c8"}, "7bb82104-ad72-4dd1-93cd-402d3754fde8": {"doc_hash": "0a12e0421867097d0b219327bb9fa7dbcd3f8cdadf47b7f6b875d533e167c268", "ref_doc_id": "3ed2688a-a340-48f7-b8e0-290364f4523e"}, "d51871a8-6afd-481f-91a9-376f60cf94fc": {"doc_hash": "4e285f1dafc2603df70cddfaf16cd0f68033e77a617bc94723ae19b9887b4102", "ref_doc_id": "038bf8e0-7cef-4b5c-9eb8-27e6892cd040"}, "7ab6a887-19e9-4bba-ba4f-555b8530cce8": {"doc_hash": "dfd618d377db11a335a16ae62a360cac3017d9183b5564e6cc8e96cac746135b", "ref_doc_id": "a59ea249-c96c-4e51-a549-78207b5a38bf"}, "0b9a3017-6fdc-46ad-a3fa-a66975f3fbc2": {"doc_hash": "575664585e0d6c45ba9095381d5b580cb5e79b60143a803281f4608b83e11bf7", "ref_doc_id": "66c60223-5c98-4811-8c80-751e492bee12"}, "edf4db94-a109-43bd-9197-622efcbf2954": {"doc_hash": "a8d5e0e0703dc9360115fb4c21d1b87b9208e5ecf7b1db6cfaf5e46a4d1c5d55", "ref_doc_id": "5fbaf4a9-bb83-4705-b764-7fa18079d8cb"}, "b652e2a0-225b-4105-affc-3405a5ceda4d": {"doc_hash": "51024e9ba7c9d09bb7adf8becbad52a055eedbc5df232bb38f00f5f6ad0b223f", "ref_doc_id": "70af5338-1745-4bca-aa86-7844d2eec1d4"}, "2e9f3c74-6543-4ea6-a98c-66fde8ca147e": {"doc_hash": "4add8b21deae4e4a6c4819989800a2128244e2dacd4e49f20e97d8b7ef8a4e36", "ref_doc_id": "7c3ead24-69b6-4d90-8d03-758c13653368"}, "ef1df2ab-a61a-42ee-9a3a-6fa244902196": {"doc_hash": "0fcba8ed48f0ae12d2bcb5633b70fa8518f805c19c7637cb4c16071ce8f98484", "ref_doc_id": "5e2cbb88-6965-4df3-8963-b213aa51d63c"}, "a8cd47ee-eb41-401b-8bb1-b388b31b6204": {"doc_hash": "7baec82d760bfb84d3164ea2275601d29865aaf6b140ee4eb20f06379c727e69", "ref_doc_id": "9505e518-cc79-4165-8303-86dd9d256127"}, "b989716e-ed9a-4cd0-91a1-b8feab4c4d48": {"doc_hash": "d6f09ce442626bc9f3ae8afcfe78c432842048a55d2841db5bda6707d95e9038", "ref_doc_id": "92e4c537-733c-4e23-adca-4c8103d9d2e4"}, "e0637e71-58db-4ab2-b31a-c2896a334e8b": {"doc_hash": "d9a0d252a6de62eea346dc72938cd4e9003031fd9de0cfc73c34dd9659dc2462", "ref_doc_id": "c50d516c-91dd-42be-b02f-5891c960b1be"}, "61eab87a-bbba-4713-a9b7-10dd4ce722f1": {"doc_hash": "8990a534f265746de82af5c077bea21b1edf41841e85dc3db0e3e81c318d2cef", "ref_doc_id": "cfb83702-5ed4-4e1a-a30b-70165a53212d"}, "ba555a6d-062d-477e-8774-463328a5d449": {"doc_hash": "a1d55b0b9cd18ffa5757ee5f483aa3eb2a2651614b6f06e715252f80b0401eb4", "ref_doc_id": "4bfc9a7e-5144-47c7-9fc0-e3fe8c05c137"}, "e4e68299-2544-414e-a336-cde553ffea37": {"doc_hash": "7dfec5b3863bff86dcda62a5ec91abba8423f24d2dfb1a3c0698c8cac0a2bbbd", "ref_doc_id": "8f1e0af0-532f-410f-a28c-1954f6c7e031"}, "0e5b7bb7-e9fa-4643-8944-b646baf33dcd": {"doc_hash": "632d9259386e117f704a65245b474bd809255e8f1d38491ffa6ab7cdf5210fde", "ref_doc_id": "7407440f-62eb-48b3-9d34-8a6ba12532cb"}, "c18aab26-a58f-4b28-b1cd-ce6f44b10ee6": {"doc_hash": "a10e5bf581bb2499cbe5e1361be778ca285e50c419d01b4ae25841652130921f", "ref_doc_id": "c6c39b15-a458-4fe8-8a59-d3b7b79641ef"}, "e7fadaa2-1098-4632-be64-1ed38a44ff18": {"doc_hash": "46b0e8ba0e4c3181c4e048c4f1e7fc5f77ed5c523b13b2fce01c329a4772ef1f", "ref_doc_id": "1745d44f-99d0-4d3e-b055-92b27e5ecb7d"}, "8cb2ac7b-4fab-4994-b543-9fb80e3fc16c": {"doc_hash": "ee953b73c944db50b24d8fe367bdc2e6b4c4772ca14074f14ed7ffa018bee1ae", "ref_doc_id": "7c8017f2-b028-4e02-83de-fd7ad7e10925"}, "2989b029-076c-4d3d-920a-78cc08f4c2b7": {"doc_hash": "11cca91ae4c075448850fb69292ff42b5e2068c91c3b7fb51ed7a1aea5faa82b", "ref_doc_id": "5db5bced-031e-4adc-bc4d-17634d2ccec5"}, "65881e5f-a03c-4ae2-9e39-f1bd6430fe9f": {"doc_hash": "25bbec73623aaa76845b70cfad0de5b5cee4c166dc5239cccd8d19c05c4bbbb6", "ref_doc_id": "4bfdd0b3-18b8-405d-84fb-ccfc5f48490b"}, "e2da1f4f-b365-4b3d-bf0f-94085b7d8767": {"doc_hash": "0d478f8d29da3042898dbf60d4287f9e65857da2ce1c087c5b00025dcc5b38aa", "ref_doc_id": "5e0f0676-70ca-4f35-bf2a-7471428972f1"}, "b2e98b18-e002-4330-aca8-85decb6f077f": {"doc_hash": "3c74330254a1d820985dabcb527216cb2d9e6523c4f47ce04d5917341809fdab", "ref_doc_id": "02c3045e-942e-4fed-9d9a-205bf3708177"}, "e726f119-fc84-4a3e-ba05-9356c690e380": {"doc_hash": "d563f56ae41068e65ff5a42fb37ba46fe1e86631c807ebfd85a4e44d401a0b2b", "ref_doc_id": "ac22a433-f284-4c89-8527-9c97f81dcabe"}, "66ad97a3-e34b-4a06-bbde-238dbe33c11c": {"doc_hash": "53074d04ecf18eeb4662efae4ffe72c442d37dac57b44bf82f98678164232617", "ref_doc_id": "776c361f-2d56-4134-92d6-721b1a74b7bb"}, "01e86f14-1724-4843-a94c-f9a43cc9ae80": {"doc_hash": "d0c7357468198ab11970db85c4a13a79a90ce9b3602145e6ae68ac627638d499", "ref_doc_id": "bcc9205d-6149-40b2-b74e-ef50462d9f59"}, "a0f064ca-c352-405c-9383-98183dd38259": {"doc_hash": "d744c3fbfd6a92f12e5db5a4c192f524f7e98f4b65c1c840e53668c1fae286ea", "ref_doc_id": "0565530d-301c-45ac-aaa0-44b1d8cdb36a"}, "e7943ad1-c579-410f-b708-90ac4b982722": {"doc_hash": "e2f6492fca845a26822431a54ca9eeac7976a6cd00d7b8f1f2958af0ee5bea3c", "ref_doc_id": "90473aca-452d-468f-92dd-bb27d3d4191b"}, "07e8fd14-7ba1-458a-a807-83894f081c06": {"doc_hash": "c076e491d9e7d8b5d8672a47a151c15f0d424b84e1f489bb7e2d5058b73f98f0", "ref_doc_id": "4d91befa-f6ff-4a94-8f35-8d9d70194f8e"}, "cfc5e652-a898-4df8-9021-d17b21bf39fa": {"doc_hash": "0ed87e30e093f7d2db735b4da9021827a4c8369e5960956c2498de553b03e4ca", "ref_doc_id": "40811b3b-4b90-44cd-8288-a0e58a632068"}, "1beb2649-3411-480f-b14d-faf250b75df1": {"doc_hash": "0899c451d3e4fdb6d228191ca30e5031437f8577d6b2d02bec9b06ab1720031c", "ref_doc_id": "f18533ec-40f7-4f2e-bb74-f837928f1582"}, "faeaf271-1f84-416c-874e-72cfe9d8a296": {"doc_hash": "897139a0abad3b9528e3bc871eaa59090e8d9820346267cc9b51c143dcfcfa30", "ref_doc_id": "93bf7c7a-d3c9-4d3f-89dc-36e0225a6131"}, "f4eee52f-55e1-41cb-8e3f-a664c9fa9b86": {"doc_hash": "3c701b228971c8737843f7d44b09f8625730c9837d02d8d24ba725765a1f6d1b", "ref_doc_id": "da28e9b1-4c67-4b7d-a3b7-02c716f15884"}, "40a3aa91-c52a-4960-b069-43f68ad04b9e": {"doc_hash": "fc6bf8509971c46cff29c30fa69704247e3cc185f4ce2c4d5d50a22a92cf7ebd", "ref_doc_id": "ae4a396c-fd92-497c-b2ce-50ceba4cd2ca"}, "4909a2d9-84a2-45d3-a887-acba255a5c34": {"doc_hash": "9eeea49d9e91dfa2c58dbb8f63776eb66d391aa676460bab96f464b64b0fbd03", "ref_doc_id": "f0175172-52d1-4e1f-b9ce-3653697804d2"}, "8cd09970-fb68-48cf-ab76-b3e6adbe9f0d": {"doc_hash": "3d72f9dafcfce14970e113c9f3d1a3813a852e7078d89aaf3a8482f635957440", "ref_doc_id": "6fc42ca3-9179-403d-adc1-34d1a2cac95d"}, "ebee5cca-c5a3-43e4-99ac-63a889a9bdd7": {"doc_hash": "60a4cc61d1a860402afd1e11ca7b47a00a347ab9357761624ae5cbf64c739961", "ref_doc_id": "a28ba738-07a6-4228-a914-c5333d4b10d1"}, "29c2bbb5-c96e-4856-aeae-2b3df7b557b8": {"doc_hash": "442804c8ed22224524abadee7e197aced090ee64815dbde449601fff4241613d", "ref_doc_id": "a465c11b-032f-4d8a-84e6-475f5e026c12"}, "3b1a94cf-f216-4965-9590-5ad7855752ca": {"doc_hash": "98d2207458764b3143163eef478c03aeda5790cbc6ad761802694514cb4a6ee9", "ref_doc_id": "66bfe2ad-b7c3-4a94-b565-31f95ccda9ae"}, "91bf2d06-bad1-4f73-b81f-9dd024642cb0": {"doc_hash": "f9ad5753de66af7171a87f3839b769e5c6ab4a01a6ac2614fe929e56366777ed", "ref_doc_id": "4f410207-d907-4f28-b2b3-10f9973edbae"}, "85a3bdf8-8eca-4217-adad-fd8b5246d572": {"doc_hash": "772d3bc56acc1f54e293cbebfaddb84002f6b02c0b0bb30a714a8a64b54ca0fb", "ref_doc_id": "970fdd93-4f95-465e-b78f-23f9a42f749f"}, "c906778d-79fe-4013-ad07-5e1cba35663d": {"doc_hash": "2f5b5ee36a9b76eda21b4e1a1305d4e633c43ce0b06922327d0cabcdd0b9f7b9", "ref_doc_id": "e373ec7a-cf77-4dbe-8ac0-87e1def9cb7e"}, "0e5d033b-e77c-46eb-8259-31c939356e34": {"doc_hash": "de1ad28a33d541a01f4c0ab797f622e3edbf023ce08b52e2240a64745cd0373f", "ref_doc_id": "7463f9c0-325e-47b9-a5de-fc6dd92946bd"}, "94b380e6-4e5b-407b-ad79-b0349e20b077": {"doc_hash": "af552d9e792e4f16f2c2507ec6d7a729395a9547322ef9d23227ed80058c99a8", "ref_doc_id": "0c863ddf-b040-489b-907e-1b3cabea62e7"}, "aacd5263-fd60-4e6b-b43d-533c753928af": {"doc_hash": "ed3c809c92ec0b5437d67743bbe39961f8d39e5967abbcb83b33a77b236b5994", "ref_doc_id": "134da570-79fa-4e90-8ac6-1fc22abbd5bb"}, "aca4d2be-d4a3-4450-8641-6bc7353ce19a": {"doc_hash": "36c9530a07b8c0f04eb24c245a4405cacad3552ec6acf60ba14e14dde1643297", "ref_doc_id": "5daeb425-4a9f-4bd8-9174-758c37177f13"}, "2b0d3255-0492-41f9-8ecf-7691a3294b87": {"doc_hash": "356b0f60650ce90192222fe8dabc845fdb056fa785099269e7ac1fcfc8aceb23", "ref_doc_id": "47277464-fb86-42b1-a160-a0cf8235ec95"}, "8321c303-5b62-4904-891e-8c8c1deffedd": {"doc_hash": "17d816d449d5de47b76ee1a49469af36676f8e8da4cde83b731602d5d541f6f0", "ref_doc_id": "9fef27f8-1a57-4fa2-bd44-289942713981"}, "c6a41617-96ed-4094-ad7e-5d3a6e9aa71a": {"doc_hash": "3db2cf027c722413b3200f2964d6858cf1a5b85566fbc5a0914bc92fcece5af5", "ref_doc_id": "95cf5097-407a-4607-96d5-e471e34174fb"}, "4c2aaba9-6fe7-4ead-9fd8-ace3849c66ba": {"doc_hash": "157bbb6080c315366196f1a4da4bdc4196146f6a83016e288dd29afcf309ce14", "ref_doc_id": "fb4b34d3-279e-4b6a-916e-e2c1ae1676c9"}, "1581619a-81ea-4812-9521-8c2cc3bd3a73": {"doc_hash": "6bc151ca046ad8ccafd16855f09b6b46255f715f8cb856a7688e516a351b8979", "ref_doc_id": "a61514eb-9daf-49b6-90fb-58e4585e5e36"}, "3343a8b4-0b58-4781-a514-278fdee4890a": {"doc_hash": "915138058ae45c5744b2a84f257a09ffd3206bc3a7a9685acbcd152d0dc1cb4c", "ref_doc_id": "75f9b52e-83bb-4c03-a327-a65faf58304b"}, "c8057314-74ba-4c0c-8007-8412e5aaef37": {"doc_hash": "7bd07f1086ecf855592d70eb751e695882d8fa0610712eeb7e1c2e441f76dae6", "ref_doc_id": "4335e411-a543-41c2-bf42-364a8c482cf8"}, "9ad23b6a-90ed-485f-b1d9-a9c0a1857919": {"doc_hash": "fc64e9ed99b30d56c13d796bcef96b7a2e7dd27d19649fe87713c2f05bc6b099", "ref_doc_id": "d815c595-b5d1-4918-94da-e8f92bf2d95b"}, "01cf9e2a-9851-4eb6-bc8c-21ad39d03540": {"doc_hash": "68ac1b36385193eed3f8bb9f999a78ebce82e2fb79ff8b5949993a9319a600c6", "ref_doc_id": "31ba72e0-0cb9-45fb-bdf8-37d3661d7afe"}, "128330ab-6690-4d66-a373-a8d07ff72d5e": {"doc_hash": "c052ba1f16504a41f35822ee942fed2c232233710406bd62188b26ffb3f69e96", "ref_doc_id": "9e1c853b-10c6-4a43-892a-404777e6f766"}, "edaf5f55-2173-4996-9c3f-63554ea61be5": {"doc_hash": "d44497bcda5f16d86836ca65959df35bdd9692b8babd4287cc1ffd93dca7c92c", "ref_doc_id": "6654c66c-1993-47ff-9a43-d03f063dd893"}, "7aa8349e-2408-4801-a065-aa726eac7eb1": {"doc_hash": "180a6426cdad69fc04af4ed92fb40efb3ea6ffb99616ca1ee6e3674ce0170e7c", "ref_doc_id": "85d680ec-46d5-4908-bee2-5b642800c54a"}, "59bacfc6-e309-4f69-b0bc-339d51a689c7": {"doc_hash": "a4e50d66415fd12403d7817d796efd6fbd0369ca80c2e90c261402f94fa33250", "ref_doc_id": "01591232-3e55-487b-819e-5433b570998f"}, "1b532328-bf14-4e7b-a869-c88f54e20daa": {"doc_hash": "954f5e179191ede242cc6fc3fd5a97e982bd6c939806918f275ec4923a18afd6", "ref_doc_id": "7c461718-0a2c-4d28-a6c2-54cddbbe36fa"}, "1eb7c451-a607-427b-bc2c-235b4364d433": {"doc_hash": "7055025b7e69fa2703a7c9a024886571b141e41f54f30815848119b35970aaf9", "ref_doc_id": "a6176669-729e-43df-9c4d-3e9938a9d8b2"}, "a2ebfc14-7106-4532-9788-60e121b83c4c": {"doc_hash": "d6587ca452c15ee5e10e60aa96435645dfc9114cda7141f58715264c3d14528a", "ref_doc_id": "0766d2d3-fc00-416f-bd84-d51be4430048"}, "1c956516-bf64-49e7-98ea-20ab4dd87258": {"doc_hash": "b326b768afc66a6cf9ebc571bd4eb8e3afecb93225c6ae338033458bc2507c38", "ref_doc_id": "66cd6f43-e0e2-4e31-91a3-6af0685ad24e"}, "5ccac1c4-d6f1-4c65-9d4a-bc837cd8a778": {"doc_hash": "a92e54fbdccb9e5369216707c5376e21d1924ff1757c58f5964457db35fcc1f0", "ref_doc_id": "66cd6f43-e0e2-4e31-91a3-6af0685ad24e"}, "52ef6ef9-8905-4547-a1e1-30e04b8a36d1": {"doc_hash": "512a5810cd2cd149af0070379cd7bf701ec506a22aa0faf5fa50af5a9cdf531a", "ref_doc_id": "febd6f07-4102-4322-a244-85c462a8074e"}, "06735e6a-5bf2-4f45-b83e-a374fdff67ca": {"doc_hash": "ff4cc29c72602e99cf77e9724e786266f27d3cd0cba1eadc8975dfa991cab904", "ref_doc_id": "febd6f07-4102-4322-a244-85c462a8074e"}}, "docstore/data": {"d309e2b0-159c-4762-811e-5dc5f466c4a4": {"__data__": {"text": "H0028_ANOC_MAPD_HMOPOS_015000_2023_M H0028015000ANOC23\nANOC050Humana Gold Plus\nSNP-DE H0028-015 (HMO-POS D-SNP)\nMissouri\nSelect Counties in Missouri2023\nAnnual Notice of Changes", "doc_id": "d309e2b0-159c-4762-811e-5dc5f466c4a4", "embedding": null, "doc_hash": "fab5f5dcde0394deeb7797887bce5e1e9c0efb2be054a6389104ee9a6f11251b", "extra_info": {"page_label": "1", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 177, "_node_type": "1"}, "relationships": {"1": "4536c7a5-f8a1-49c6-a684-2bc5c5c8b362"}}, "__type__": "1"}, "7b470071-5400-423e-bb72-46aafe894580": {"__data__": {"text": "* 2021 Humana Inc. Annual Report 2/17/2022 We believe the simplest way to help you feel your best is to do what\u2019s right by you. That  \nmeans going above and beyond what you may expect. We call this human care, and it\u2019s one  \nof the reasons millions* of people have chosen Humana for their Medicare Advantage plan.\nWe hope you would like to keep your current Humana plan. If so, you don\u2019t need to do  \nanything; it will automatically renew on January 1, 2023.\nPlan for the 2023 Medicare Annual Election Period\nSee how your plan is different. Review this Annual Notice of Changes (ANOC)  \ndocument for changes to your medical coverage, prescription drug coverage,  \nin-network pharmacies, and costs like premium, copays, deductibles and coinsurance.\nThis booklet doesn\u2019t include all your benefits. The ANOC shows plan changes, but it  \nisn\u2019t a full list of your plan benefits.  Starting October 15, see your 2023 Evidence of  \nCoverage (EOC) at Humana.com/PlanDocuments for a complete listing. See the back  \ncover for more instructions. \nKeep your current Humana member ID card. Humana does not issue new ID cards  \neach plan year for members who stay on their current Humana Medicare plan. You will  \nonly receive a new ID card if the card\u2019s information changes or you select a different  \nplan for 2023.\nStarting on January 1, 2023, your Humana Gold Plus SNP-DE H0028-015 (HMO-POS  \nD-SNP) will be simpler because your drug coverage will be the same at all  \nin-network retail pharmacies. This means that you\u2019ll have the same cost-share no  \nmatter where you fill your prescriptions as long as the retail pharmacy is  \nin-network. Thank you for being a Humana member", "doc_id": "7b470071-5400-423e-bb72-46aafe894580", "embedding": null, "doc_hash": "de4c7fd47df9a7151c93ba1c4f157ff77ac3e444ce449dee97413d708caf238a", "extra_info": {"page_label": "2", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1667, "_node_type": "1"}, "relationships": {"1": "b8e0fd88-9c5c-4bee-8d5f-34c7cfddf61b"}}, "__type__": "1"}, "5bf2afcc-9668-499c-a8c4-3425fb05394b": {"__data__": {"text": "OMB Approval 0938-1051 (Expires: February 29, 2024)Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) offered by CHA HMO, Inc., a Humana company.\nAnnual Notice of Changes for 2023\nYou are currently enrolled as a member of Humana Gold Plus SNP-DE H0028-015 (HMO D-SNP). Next year, there  \nwill be changes to the plan's costs and benefits. Please see page 6 for a Summary of Important Costs, including  \nPremium.\nThis document tells about the changes to your plan. To get more information about costs, benefits, or rules please  \nreview the Evidence of Coverage, which is located on our website at Humana.com/PlanDocuments. You may also  \ncall Customer Care to ask us to mail you an Evidence of Coverage.\nWhat to do now \n1. ASK: Which changes apply to you\nCheck the changes to our benefits and costs to see if they affect you. \n\u2022Review the changes to Medical care costs (doctor, hospital).\n\u2022Review the changes to our drug coverage, including authorization requirements and costs.\n\u2022Think about how much you will spend on premiums, deductibles, and cost sharing.\nCheck the changes in the 2023 Drug Guide to make sure the drugs you currently take are still covered.\nCheck to see if your primary care doctors, specialists, hospitals and other providers, including pharmacies will  \nbe in our network next year.\nThink about whether you are happy with our plan.\n2. COMPARE: Learn about other plan choices\nCheck coverage and costs of plans in your area. Use the Medicare Plan Finder at \nwww.medicare.gov/plan-compare website or review the list in the back of your Medicare & You 2023 handbook.\nOnce you narrow your choice to a preferred plan, confirm your costs and coverage on the plan\u2019s website.\n3. CHOOSE: Decide whether you want to change your plan\n\u2022If you don't join another plan by December 7, 2022, you will stay in Humana Gold Plus SNP-DE H0028-015  \n(HMO-POS D-SNP).\n\u2022To change to a different plan, you can switch plans between October 15 and December 7. Your new  \ncoverage will start on January 1, 2023. This will end your enrollment with Humana Gold Plus SNP-DE  \nH0028-015 (HMO-POS D-SNP).\n\u2022Look in section 3.2 to learn more about your choices.\n\u2022If you recently moved into, currently live in, or just moved out of an institution (like a skilled nursing facility or  \nlong-term care hospital), you can switch plans or switch to Original Medicare (either with or without a  \nseparate Medicare prescription drug plan) at any time.\nAdditional Resources\n\u2022This document is available for free in Spanish. ", "doc_id": "5bf2afcc-9668-499c-a8c4-3425fb05394b", "embedding": null, "doc_hash": "0d7146c4ec75c1d31b8bd3c55675705aedd85c434febe8aeeb958f9b15768f8e", "extra_info": {"page_label": "3", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 2501, "_node_type": "1"}, "relationships": {"1": "dcb8d134-6b29-4205-9f66-2571af10521a"}}, "__type__": "1"}, "4e4d811d-b2e0-43ad-8e12-5f28d42c3a10": {"__data__": {"text": "\u2022Please contact our Customer Care number at 1-800-457-4708 for additional information. (TTY users should  \ncall 711.) Hours are 8 a.m. to 8 p.m. seven days a week from October 1 - March 31 and 8 a.m. to 8 p.m.  \nMonday-Friday from April 1 - September 30. \n\u2022This information is available in different formats, including braille, large print, and audio. Please call Customer  \nCare at the number listed above if you need plan information in another format.\n\u2022Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient  \nProtection and Affordable Care Act's (ACA) individual shared responsibility requirement. Please visit the  \nInternal Revenue Service (IRS) website at www.irs.gov/Affordable-Care-Act/Individuals-and-Families for  \nmore information.\nAbout Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP)\n\u2022Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) is a Coordinated Care plan with a Medicare contract  \nand a contract with the Missouri Medicaid program. Enrollment in this Humana plan depends on contract  \nrenewal. The plan also has a written agreement with the Missouri Medicaid program to coordinate your  \nMedicaid benefits.\n\u2022When this document says \"we,\" \"us,\" or \"our,\" it means CHA HMO, Inc., a Humana company. When it says  \n\"plan\" or \"our plan,\" it means Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP).\nH0028_ANOC_MAPD_HMOPOS_015000_2023_M", "doc_id": "4e4d811d-b2e0-43ad-8e12-5f28d42c3a10", "embedding": null, "doc_hash": "3e5a3136b76227151a439aa0d3074edcfbc14d904542602f38d94391c1fe6232", "extra_info": {"page_label": "4", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1395, "_node_type": "1"}, "relationships": {"1": "44e6b813-b597-4855-8c73-abd185bdc9ab"}}, "__type__": "1"}, "6f5993d5-50dc-4fad-a6d3-6b599a2d3ae1": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 5\nAnnual Notice of Changes for 2023 \nTable of Contents\nSummary of Important Costs for 2023............................................................................6\nSECTION 1 We Are Changing the Plan's Name.............................................................10\nSECTION 2 Changes to Benefits and Costs for Next Year...............................................10\nSection 2.1 -Changes to the Monthly Premium................................................................10\nSection 2.2 -Changes to Your Maximum Out-of-Pocket Amount..........................................10\nSection 2.3 -Changes to the Provider and Pharmacy Networks............................................11\nSection 2.4 -Changes to Benefits and Costs for Medical Services..........................................11\nSection 2.5 -Changes to Part D Prescription Drug Coverage.................................................20\nSECTION 3 Deciding Which Plan to Choose.................................................................22\nSection 3.1 -If you want to stay in Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP)......22\nSection 3.2 -If you want to change plans.......................................................................22\nSECTION 4 Changing Plans.......................................................................................23\nSECTION 5 Programs That Offer Free Counseling about Medicare and Medicaid...............24\nSECTION 6 Programs That Help Pay for Prescription Drugs............................................24\nSECTION 7 Questions?.............................................................................................25\nSection 7.1 -Getting Help from Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP)..........25\nSection 7.2 -Getting Help from Medicare........................................................................25\nSection 7.3 -Getting Help from Medicaid........................................................................26\nExhibit A.\nLists the names, addresses, phone numbers, and other contact information for a  \nvariety of helpful resources in your state.State Agency Contact Information............................................................27", "doc_id": "6f5993d5-50dc-4fad-a6d3-6b599a2d3ae1", "embedding": null, "doc_hash": "f5c41f14108cb3f3968235476b9e80b401250eb7394c618bc51280f94c73d943", "extra_info": {"page_label": "5", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 2282, "_node_type": "1"}, "relationships": {"1": "090f6cbd-7594-4c59-ab80-cdfa9103caf3"}}, "__type__": "1"}, "aa3ef838-0ecc-4ef0-858a-0978e528c581": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 6For PageNumber2\nSummary of Important Costs for 2023\nThe table below compares the 2022 costs and 2023 costs for Humana Gold Plus SNP-DE H0028-015 (HMO-POS \nD-SNP) in several important areas. Please note this is only a summary of costs. \nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\nMonthly plan premium*\n* Your premium may be  \nhigher or lower than this  \namount. See Section 2.1 for  \ndetails.$0 or up to $21.10 $0 or up to $36.30\nDeductible $0 Not Applicable $0 Not Applicable\nMaximum out-of-pocket  \namount\nThis is the most you will pay  \nout-of-pocket for your  \ncovered Part A and Part B  \nservices. (See Section 2.2 for  \ndetails.)$3,450\nYou are not  \nresponsible for  \npaying any  \nout-of-pocket costs  \ntoward the  \nmaximum  \nout-of-pocket  \namount for covered  \nPart A and Part B  \nservices.Not Applicable \nYou are not  \nresponsible for  \npaying any  \nout-of-pocket costs  \ntoward the  \nmaximum  \nout-of-pocket  \namount for covered  \nPart A and Part B  \nservices.From network  \nproviders: $8,300\nYou are not  \nresponsible for  \npaying any  \nout-of-pocket costs  \ntoward the  \nmaximum  \nout-of-pocket  \namount for covered  \nPart A and Part B  \nservices.From network and  \nout-of-network  \nproviders  \ncombined: Not  \nApplicable\nYou are not  \nresponsible for  \npaying any  \nout-of-pocket costs  \ntoward the  \nmaximum  \nout-of-pocket  \namount for covered  \nPart A and Part B  \nservices. \nDoctor office visits Primary care visits:\n$0 copayment per  \nvisitNot Applicable Primary care visits:\n$0 copayment per  \nvisitNot Applicable\nSpecialist visits:\n$0 copayment per  \nvisitNot Applicable Specialist visits:\n$0 copayment per  \nvisitNot Applicable", "doc_id": "aa3ef838-0ecc-4ef0-858a-0978e528c581", "embedding": null, "doc_hash": "ec18919b143c2d95b466e45e61b4d8b9afbc624e2fd20babb89c59d3419cc7a7", "extra_info": {"page_label": "6", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1780, "_node_type": "1"}, "relationships": {"1": "4828d225-5d1f-4e35-b4fd-717e3351c219"}}, "__type__": "1"}, "9127f353-b2b0-4728-a732-0de7296c043e": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 7\nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\nInpatient hospital stays $0 copayment per  \nstay $0 copayment per  \nstay\nNot Applicable$0 copayment per  \nstay $0 copayment per  \nstay\nNot Applicable\nPart D prescription drug  \ncoverage  \n \n(See Section 2.5 for details.)$0 Rx Copay Benefit is not available. $0 Rx Copay Benefit applies, if you  \nqualify for \u201cExtra Help\u201d. You will pay the  \nfollowing:\nDeductible: $0\nCopayment during the Initial Coverage  \nStage:\nFor retail and mail-order pharmacy  \ncost-sharing:\n\u2022Drug Tier 1: $0\n\u2022Drug Tier 2: $0\n\u2022Drug Tier 3: $0\n\u2022Drug Tier 4: $0\n\u2022Drug Tier 5: $0\nCost shares apply to 30 and 90-day  \nsupply. Drug Tier 5 is limited to a 30-day  \nsupply.\n$0 Rx Copay Benefit does not apply, if  \nyou do not qualify for \u201cExtra Help\u201d. You  \nwill pay the following:", "doc_id": "9127f353-b2b0-4728-a732-0de7296c043e", "embedding": null, "doc_hash": "f180f1e8922c2641423ac268a3a59fd38981a6487ba6894409c2a063da0597f7", "extra_info": {"page_label": "7", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 924, "_node_type": "1"}, "relationships": {"1": "7078060a-ea3a-4282-9c23-db78c9d21dff"}}, "__type__": "1"}, "54a534e1-3c1c-466c-90da-a09a3870ebd9": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 8\nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\n  \n Deductible: $300\nCopayment/Coinsurance during the  \nInitial Coverage Stage:\nFor a 30-day supply from a retail  \npharmacy with preferred  \ncost-sharing: \n\u2022Drug Tier 1: $0\n\u2022Drug Tier 2: $9\n\u2022Drug Tier 3: $47\n\u2022Drug Tier 4: $100\n\u2022Drug Tier 5: 28%Deductible: $505\nFor a 30-day supply from a retail  \npharmacy with preferred  \ncost-sharing: \n\u2022Not applicable, see 30-day supply  \nfrom a retail pharmacy with  \nstandard cost-sharing below. \nFor a 30-day supply from a retail  \npharmacy with standard  \ncost-sharing:\n\u2022Drug Tier 1: $0\n\u2022Drug Tier 2: $20\n\u2022Drug Tier 3: $47\n\u2022Drug Tier 4: $100\n\u2022Drug Tier 5: 28%For a 30-day supply from a retail  \npharmacy with standard  \ncost-sharing:\n\u2022All Drug Tiers: 25%\nFor a 90-day supply from a \nmail-order pharmacy with  \npreferred cost-sharing: \n\u2022Drug Tier 1: $0\n\u2022Drug Tier 2: $0\n\u2022Drug Tier 3: $131\n\u2022Drug Tier 4: $290\n\u2022Drug Tier 5: Not availableFor a 90-day supply from a \nmail-order pharmacy with  \npreferred cost-sharing: \nNot applicable", "doc_id": "54a534e1-3c1c-466c-90da-a09a3870ebd9", "embedding": null, "doc_hash": "0be49e3dfc8397ae20b444c53f849c294b1ab2c54b054a0440ac6d0effb3aeab", "extra_info": {"page_label": "8", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1146, "_node_type": "1"}, "relationships": {"1": "1484d1dd-5f29-4f11-927c-a575f7810445"}}, "__type__": "1"}, "c3b5ee34-c8dc-465c-b9df-b4711eaa07fb": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 9\nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\nFor a 90-day supply from a \nmail-order pharmacy with  \nstandard cost-sharing: \n\u2022Drug Tier 1: $0\n\u2022Drug Tier 2: $60\n\u2022Drug Tier 3: $141\n\u2022Drug Tier 4: $300\n\u2022Drug Tier 5: Not availableFor a 90-day supply from a \nmail-order pharmacy with  \nstandard cost-sharing: \n\u2022All Drug Tiers: 25%", "doc_id": "c3b5ee34-c8dc-465c-b9df-b4711eaa07fb", "embedding": null, "doc_hash": "930bca57faca3cf2628c570024734022bd9136724b6d2b950c61774dcf4af960", "extra_info": {"page_label": "9", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 455, "_node_type": "1"}, "relationships": {"1": "1c2ffb2b-2ff1-4786-8c1e-6a2206ee767b"}}, "__type__": "1"}, "7f8a6a0b-f398-400d-83c1-7f638c5ea1ed": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 10\nSECTION 1 We Are Changing the Plan's Name\nOn January 1, 2023, our plan name will change from Humana Gold Plus SNP-DE H0028-015 (HMO D-SNP) to \nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP).\nYou will receive a new ID card in the mail with the new Humana plan name prior to your effective date. Any plan \ndocuments you receive after January 1, 2023 will use the new plan name.\nSECTION 2 Changes to Benefits and Costs for Next Year\nSection 2.1 - Changes to the Monthly Premium\nCost 2022 (this year) 2023 (next year)\nMonthly premium\n(You must also continue to pay your \nMedicare Part B premium unless it is \npaid for you by MO HealthNet \n(Medicaid).)$0 or up to $21.10  $0 or up to $36.30  \nSection 2.2 - Changes to Your Maximum Out-of-Pocket Amount\nMedicare requires all health plans to limit how much you pay \"out-of-pocket\" for the year. This limit is called the \n\"maximum out-of-pocket amount.\" Once you reach this amount, you generally pay nothing for covered Part A and \nPart B services for the rest of the year.\nCost 2022 (this year) 2023 (next year)\nN/A In-Network Out-of-Network In-Network Out-of-Network\nMaximum out-of-pocket  \namount\nYour costs for covered medical  \nservices (such as copays) count  \ntoward your maximum  \nout-of-pocket amount. Your plan  \npremium and your costs for  \nprescription drugs do not count  \ntoward your maximum  \nout-of-pocket amount.$3,450 Not Applicable $8,300\nOnce you have  \npaid $8,300 \nout-of-pocket for  \ncovered Part A and  \nPart B services, you  \nwill pay nothing  \nfor your covered  \nPart A and Part B  \nservices for the  \nrest of the  \ncalendar year.Not Applicable", "doc_id": "7f8a6a0b-f398-400d-83c1-7f638c5ea1ed", "embedding": null, "doc_hash": "e81217dd37c5d9e743190c3eb4f9d5447886850aca7c0f6ca5f79eb069657b16", "extra_info": {"page_label": "10", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1702, "_node_type": "1"}, "relationships": {"1": "37543027-c634-4a4f-91cc-dfdaff6de13a"}}, "__type__": "1"}, "9bb4d2df-62b3-4dda-b8e3-4eac95e186d6": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 11\nSection 2.3 - Changes to the Provider and Pharmacy Networks\nUpdated directories are located on our website at Humana.com/PlanDocuments. You may also call Customer Care \nfor updated provider and/or pharmacy information or to ask us to mail you a directory.\nThere are changes to our network of providers for next year. Please review the 2023 Provider Directory to see if \nyour providers (primary care provider, specialists, hospitals, etc.) are in our network.\nThere are changes to our network of pharmacies for next year. Please review the 2023 Provider Directory to see \nwhich pharmacies are in our network.\nIt is important that you know that we may make changes to the hospitals, doctors, and specialists (providers), and \npharmacies that are part of your plan during the year. If a mid-year change in our providers affects you, please \ncontact Customer Care so we may assist. \nSection 2.4 - Changes to Benefits and Costs for Medical Services\nPlease note that the Annual Notice of Changes tells you about changes to your Medicare benefits and costs.\nWe are making changes to costs and benefits for certain medical services next year. The information below \ndescribes these changes.\nServices received at Rural Health Clinics, Federally Qualified Health Clinics, and Critical Access Hospitals may be \nsubject to the Primary Care Physician or Specialist copay or coinsurance, as applicable, for 2023.\nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\nDeductible exclusions Services not \ncovered by Original \nMedicare, Part A \nservices (IP, Skilled \nNursing and Home \nHealth), Medicare \ncovered Preventive \nservices, \nAmbulance and \nEmergency Room \nservices, Urgently \nNeeded Services at \nUrgent Care \nCenters, Diabetic \nMonitoring Supplies \nand Part B Drugs \nfrom a Network \nRetail Pharmacy, \nand COVID-19 Tests \nand Treatment do \nnot apply to the Not Applicable Services not \ncovered by Original \nMedicare, Part A \nservices (IP, Skilled \nNursing and Home \nHealth), Medicare \nCovered Preventive \nservices, \nAmbulance and \nEmergency Room \nservices, Urgently \nNeeded Services at \nUrgent Care \nCenters, Diabetic \nMonitoring \nSupplies, \nChemotherapy \nDrugs and \nAdministration, and \nMedicare Part B \nCovered Drugs do \nnot apply to the Not Applicable", "doc_id": "9bb4d2df-62b3-4dda-b8e3-4eac95e186d6", "embedding": null, "doc_hash": "49d7a88a2652517f6ddc29bbb75bab2bdbc33ff171a725c0e0c9703c6675c26c", "extra_info": {"page_label": "11", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 2371, "_node_type": "1"}, "relationships": {"1": "f7ba0b1a-e60e-4015-b8de-4b4ff07d3b44"}}, "__type__": "1"}, "0e7c5f44-aeb1-423b-b605-3fc02cf668e9": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 12\nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\nin-network Part B \ndeductible.in-network Part B \ndeductible.\n$0 Rx Copay Benefit Not Covered Not Covered $0 copayment for \nall Medicare \ncovered Part D \nprescription drugs, \non all tiers, through \nall stages.\nTo qualify, \nmembers must be \neligible for \"Extra \nHelp\".\nFor more details \nabout covered \ndrugs see the Drug \nGuide.\nFor additional \ndetails about this \nbenefit, see \nChanges to Part D \nPrescription Drug \nCoverage within this \ndocument.Not Covered\nCOVID-19 testing and \ntreatment\n\u2022COVID-19 testing $0 copayment\nIf you are eligible \nfor Medicare \ncost-sharing \nassistance under \nMedicaid, you pay a \n$0 copayment \namount.Not Applicable Cost-share may \napply, coverage is \nthe same as similar \ndiagnostic testingNot Applicable\n\u2022COVID-19 treatment $0 copayment\nIf you are eligible \nfor Medicare \ncost-sharing \nassistance under \nMedicaid, you pay a \n$0 copayment \namount.Not Applicable Cost-share may \napply, coverage is \nthe same as similar \ntreatmentsNot Applicable", "doc_id": "0e7c5f44-aeb1-423b-b605-3fc02cf668e9", "embedding": null, "doc_hash": "618b8a90c26868a5d13701e4a43600775d135ff5d7d81ec16e0d9a379171d492", "extra_info": {"page_label": "12", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1151, "_node_type": "1"}, "relationships": {"1": "16f976f9-6952-4ce8-b03b-fcb350f08f01"}}, "__type__": "1"}, "81a30b8e-c842-4830-8055-cb1d206eb2f1": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 13\nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\n\u2022Meals with confirmed \nCOVID-19 diagnosisCovered Not Covered Not Covered Not Covered\nDental services\n\u2022Supplemental dental \nbenefits:DEN345\n$0 copayment for \nscaling and root \nplaning (deep \ncleaning) up to 1 \nper quadrant every \n3 years.\n$0 copayment for \ncomprehensive oral \nevaluation or \nperiodontal exam, \nocclusal \nadjustment, scaling \nfor moderate \ninflammation up to \n1 every 3 years.\n$0 copayment for \ncomplete dentures, \ncrown \nrecementation, \npanoramic film or \ndiagnostic x-rays, \npartial dentures up \nto 1 every 5 years.\n$0 copayment for \ncrown up to 1 per \ntooth per lifetime.\n$0 copayment for \nbitewing x-rays, \nintraoral x-rays up \nto 1 set(s) per year.\n$0 copayment for \nadjustments to \ndentures, denture \nrebase, denture \nreline, denture \nrepair, emergency \ndiagnostic exam, \ntissue conditioning \nup to 1 per year.\n$0 copayment for \nemergency \ntreatment for pain, \nfluoride treatment, \nperiodic oral exam, Not Covered DEN144\n$0 copayment for \nscaling and root \nplaning (deep \ncleaning) up to 1 \nper quadrant every \n3 years.\n$0 copayment for \ncomprehensive oral \nevaluation or \nperiodontal exam, \nocclusal \nadjustment, scaling \nfor moderate \ninflammation up to \n1 every 3 years.\n$0 copayment for \nbridges, complete \ndentures, crown \nrecementation, \ndenture \nrecementation, \npanoramic film or \ndiagnostic x-rays, \npartial dentures up \nto 1 every 5 years.\n$0 copayment for \ncrown, root canal, \nroot canal \nretreatment up to 1 \nper tooth per \nlifetime.\n$0 copayment for \nbitewing x-rays, \nintraoral x-rays up \nto 1 set(s) per year.\n$0 copayment for \nadjustments to \ndentures, denture \nrebase, denture \nreline, denture \nrepair, emergency \ndiagnostic exam, \ntissue conditioning \nup to 1 per year.DEN144\n$0 copayment for \nscaling and root \nplaning (deep \ncleaning) up to 1 \nper quadrant every \n3 years.\n$0 copayment for \ncomprehensive oral \nevaluation or \nperiodontal exam, \nocclusal \nadjustment, scaling \nfor moderate \ninflammation up to \n1 every 3 years.\n$0 copayment for \nbridges, complete \ndentures, crown \nrecementation, \ndenture \nrecementation, \npanoramic film or \ndiagnostic x-rays, \npartial dentures up \nto 1 every 5 years.\n$0 copayment for \ncrown, root canal, \nroot canal \nretreatment up to 1 \nper tooth per \nlifetime.\n$0 copayment for \nbitewing x-rays, \nintraoral x-rays up \nto 1 set(s) per year.\n$0 copayment for \nadjustments to \ndentures, denture \nrebase, denture \nreline, denture \nrepair, emergency \ndiagnostic exam, \ntissue conditioning \nup to 1 per year.", "doc_id": "81a30b8e-c842-4830-8055-cb1d206eb2f1", "embedding": null, "doc_hash": "9ab750afdf4297843fc9ffa65017845fa06b868b080a5f8ac74932326628128d", "extra_info": {"page_label": "13", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 2657, "_node_type": "1"}, "relationships": {"1": "5dd7398c-23f1-4e80-92e9-da81baaa2f7f"}}, "__type__": "1"}, "638c9691-c4ca-4365-a7de-942ffb3c8c1b": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 14\nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\nprophylaxis \n(cleaning) up to 2 \nper year.\n$0 copayment for \nperiodontal \nmaintenance up to \n4 per year.\n$0 copayment for \namalgam and/or \ncomposite filling, \nnecessary \nanesthesia with \ncovered service, \nsimple or surgical \nextraction up to \nunlimited per year.\n$3,000 maximum \nbenefit coverage \namount per year for \npreventive and \ncomprehensive \nbenefits.$0 copayment for \nemergency \ntreatment for pain, \nfluoride treatment, \noral surgery, \nperiodic oral exam, \nprophylaxis \n(cleaning) up to 2 \nper year.\n$0 copayment for \nperiodontal \nmaintenance up to \n4 per year.\n$0 copayment for \namalgam and/or \ncomposite filling, \nnecessary \nanesthesia with \ncovered service, \nsimple or surgical \nextraction up to \nunlimited per year.\n$5,000 combined \nmaximum benefit \ncoverage amount \nper year for \npreventive and \ncomprehensive \nbenefits.$0 copayment for \nemergency \ntreatment for pain, \nfluoride treatment, \noral surgery, \nperiodic oral exam, \nprophylaxis \n(cleaning) up to 2 \nper year.\n$0 copayment for \nperiodontal \nmaintenance up to \n4 per year.\n$0 copayment for \namalgam and/or \ncomposite filling, \nnecessary \nanesthesia with \ncovered service, \nsimple or surgical \nextraction up to \nunlimited per year.\n$5,000 combined \nmaximum benefit \ncoverage amount \nper year for \npreventive and \ncomprehensive \nbenefits.\nBenefits received \nout-of-network are \nsubject to any \nin-network benefit \nmaximums, \nlimitations, and/or \nexclusions.\nHealthy Foods Card $75 allowance \namount per month \nfor Healthy Foods \nCard for members \nto spend at \nparticipating \nretailers toward the \npurchase of \napproved healthy \nfoods.Not Covered See \"Healthy \nOptions \nAllowance\" section \nin this chart for \nmore information.Not Covered", "doc_id": "638c9691-c4ca-4365-a7de-942ffb3c8c1b", "embedding": null, "doc_hash": "b68803a320a49ed5e6ad6dd9fbec0a305f570af15f6293ade15e6689aa4be490", "extra_info": {"page_label": "14", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1884, "_node_type": "1"}, "relationships": {"1": "2fad2dca-54a6-4c85-b947-124bf62f5a6d"}}, "__type__": "1"}, "2d88d7ca-4e2a-432a-9583-e8fd6c76fabf": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 15\nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\nHMO travel benefit Not Covered Not Covered Members can \nreceive in-network \nbenefits when \nservices are \nreceived from a \nparticipating HMO \nNational Network \nprovider during \ntheir travels to \nother states and \nPuerto Rico.Not Covered\nHospital services in the \nhome:  Facility referredNot Covered Not Covered Provides an acute \nlevel of care in the \nhome with a 30 day \nmodel of care from \nan emergency \ndepartment \nreferral.\nMember must have \nemergency \ndepartment visit \nwithin the 30 day \nepisode of care.\nCare begins after \nyou're evaluated, \ndetermined to be \neligible, and your \nprovider refers you.Not Covered\nHumana Healthy Options \nAllowanceNot Covered Not Covered $175 automatically \nloaded on a prepaid \ncard every month \nto use toward the \npurchase of food, \nover-the-counter \n(OTC) products, and \nhome supplies from \na national network \nof retailers.\nThe card may also \nbe used to pay for \nnon-medical \ntransportation, \ngeneral supports for \nliving (such as rent \nassistance, \ninternet, and Not Covered", "doc_id": "2d88d7ca-4e2a-432a-9583-e8fd6c76fabf", "embedding": null, "doc_hash": "c23260cfb460a168adc9bb4f6c268b43086d46a19ca3135ccb3183612aeaf3a3", "extra_info": {"page_label": "15", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1194, "_node_type": "1"}, "relationships": {"1": "24880012-18f6-456d-af2b-076a33f5067c"}}, "__type__": "1"}, "5944387b-7d5c-43c7-8959-a83970997ecb": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 16\nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\nutilities), social \nneeds, aging \nsupport and \nassistive devices, \npest control, and \npet care and \nsupplies.\nUnused funds will \nroll over to the next \nmonth and expire \nat the end of the \nplan year.\nSee \"Humana \nSpending Account \nCard\" section in this \nchart for more \ninformation.\nOver-the-counter (OTC) \nAllowance$75 maximum \nbenefit coverage \namount per month \nfor \nover-the-counter \n(OTC) prepaid card \nto purchase eligible \nOTC health and \nwellness products \nat participating \nretailers.\nUnused amount \nexpires at the end \nof the month.Not Covered See \"Healthy \nOptions \nAllowance\" section \nin this chart for \nmore information.Not Covered\nPersonal Home Care (PHC) Covered Not Covered Not Covered Not Covered\nPost-discharge personal \nhome careNot Covered Not Covered $0 copayment for a \nminimum of 4 \nhours per day, up to \na maximum of 44 \nhours per year for \ncertain in-home \nsupport services \nfollowing a \ndischarge from a \nskilled nursing \nfacility or from an Not Covered", "doc_id": "5944387b-7d5c-43c7-8959-a83970997ecb", "embedding": null, "doc_hash": "a4448682bed82c05fde02d9121a100e28f3fb8145bf522e669854e38714d68e0", "extra_info": {"page_label": "16", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1157, "_node_type": "1"}, "relationships": {"1": "63719f8c-6ce3-4d45-b06a-14e0f1334343"}}, "__type__": "1"}, "9dbfdb02-df96-4cad-a69d-3cedcbdb99df": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 17\nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\ninpatient \nhospitalization.\nQualified aides can \noffer assistance \nperforming \nactivities of daily \nliving (ADLs) and \nInstrumental \nActivities of Daily \nliving (IADLs) within \nthe home.\nActivities of daily \nliving are activities \nrelated to personal \ncare.\nThey include \nbathing or \nshowering, \ndressing, getting in \nand out of bed or a \nchair, walking, \nusing the toilet, and \neating.\nInstrumental \nActivities of Daily \nLiving are activities \nrelated to \nindependent living.\nThey include \npreparing meals, \nshopping on behalf \nof the member for \ngroceries or \npersonal items, \nperforming light \nhousework, \nlaundry, dishes, \nand/or using a \ntelephone.\nA member must be \nreceiving assistance \nwith a minimum of \none ADL to receive \nassistance with any \nIADL.\nServices must be \ninitiated within 30 \ndays of discharge ", "doc_id": "9dbfdb02-df96-4cad-a69d-3cedcbdb99df", "embedding": null, "doc_hash": "115b3cb7957719d77aa2c62f63d67aae220251943c0c8951b3e4f711d0232bbf", "extra_info": {"page_label": "17", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 995, "_node_type": "1"}, "relationships": {"1": "d68c272e-e910-4430-bd9d-5a33c35064fe"}}, "__type__": "1"}, "f7fe4a39-6a00-414f-b7f6-826a11a87b72": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 18\nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\nevent and utilized \nwithin 60 days of \ndischarge for each \nqualifying event up \nto the maximum \nannual allowance.\nSpecial Supplemental \nBenefits for the Chronically \nIll\n\u2022Humana Flexible Care \nAssistanceHumana Flexible \nCare Assistance is \navailable to \nchronically ill \nmembers who are \nparticipating with \ncare management \nservices and meet \nprogram criteria.\nEligible members \nmay receive \nmedical expenses \nassistance, \nprimarily health \nrelated, and \nnon-primarily \nhealth related \nadditional benefits \nto address specific \nneeds based on the \nindividual's unique \nsituations.\nBenefits are limited \nup to $500 per year \nand must be \ncoordinated and \nauthorized by a \ncare manager.\nMembers may \ncontact their care \nmanager with \nquestions.\nThere is no \ncoinsurance, \ncopayment, or \ndeductible to \nparticipate.Not Covered Humana Flexible \nCare Assistance is \navailable to \nchronically ill \nmembers who are \nparticipating with \ncare management \nservices and meet \nprogram criteria.\nEligible members \nmay receive \nmedical expenses \nassistance, \nprimarily health \nrelated, and \nnon-primarily \nhealth related \nadditional benefits \nto address specific \nneeds based on the \nindividual's unique \nsituations.\nBenefits are limited \nup to $1,000 per \nyear and must be \ncoordinated and \nauthorized by a \ncare manager.\nMembers may \ncontact their care \nmanager with \nquestions.\nThere is no \ncoinsurance, \ncopayment, or \ndeductible to \nparticipate.Not Covered", "doc_id": "f7fe4a39-6a00-414f-b7f6-826a11a87b72", "embedding": null, "doc_hash": "5e1660402d89589e0d4bcc62a2ad33469c2c933bd820fcf439f256882812eefb", "extra_info": {"page_label": "18", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1626, "_node_type": "1"}, "relationships": {"1": "1a41dd19-ac4c-4f83-bd47-daf1a2d21ef6"}}, "__type__": "1"}, "a7fe926c-482d-4374-a1ef-8f171e038f8e": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 19\nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\nTransportation $0 copayment for \nplan approved \nlocation up to 48 \none-way trip(s) per \nyear.\nThis benefit is not to \nexceed 25 miles per \ntrip.Not Covered $0 copayment for \nplan approved \nlocation up to 60 \none-way trip(s) per \nyear.\nThis benefit is not to \nexceed 75 miles per \ntrip.Not Covered\nVision care\n\u2022Routine vision services: VIS733\n$0 copayment for \nroutine exam up to \n1 per year.\n$300 maximum \nbenefit coverage \namount per year for \ncontact lenses or \neyeglasses-lenses \nand frames, fitting \nfor \neyeglasses-lenses \nand frames.\nEyeglass lens \noptions may be \navailable with the \nmaximum benefit \ncoverage amount \nup to 1 pair per \nyear.\nMaximum benefit \ncoverage amount is \nlimited to one time \nuse per year.Not Covered VIS701\n$0 copayment for \nroutine exam up to \n1 per year.\n$400 maximum \nbenefit coverage \namount per year for \ncontact lenses or \neyeglasses-lenses \nand frames, fitting \nfor \neyeglasses-lenses \nand frames.\nEyeglass lens \noptions may be \navailable with the \nmaximum benefit \ncoverage amount \nup to 1 pair per \nyear.\nMaximum benefit \ncoverage amount is \nlimited to one time \nuse per year.Not Covered\nAdditional Drug Coverage\nFor select Erectile  \nDysfunction drugs, you pay:Covered Not Applicable Not Covered Not Applicable\nAdditional Drug Coverage\nFor select Anti-Obesity drugs,  \nyou pay:Covered Not Applicable Not Covered Not Applicable", "doc_id": "a7fe926c-482d-4374-a1ef-8f171e038f8e", "embedding": null, "doc_hash": "11c97f1681b34519bf215a6b6f78c4f54bbde9bf22b573b0c815a183ce64b462", "extra_info": {"page_label": "19", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1546, "_node_type": "1"}, "relationships": {"1": "e6f86a9a-b581-495f-8243-5ea667154734"}}, "__type__": "1"}, "74dea28b-9c0a-4217-8cc4-67cb46b92759": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 20\nCost 2022 (this year) 2023 (next year)\nIn-Network Out-of-Network In-Network Out-of-Network\nHumana Spending Account  \nCard\nAllowance(s) listed will be  \nloaded onto a single prepaid  \ncard. Allowance amounts  \ncannot be combined.  \nAllowance(s) shown are  \naccessed by using this card.\nPlease keep this card even  \nafter the allowance is spent as  \nfuture allowances will be  \nloaded to this card.Not Available Not Available Your card-based  \nallowance(s)  \ninclude:\n\u2022Humana Healthy  \nOptions  \nAllowance Not Available\nSection 2.5 - Changes to Part D Prescription Drug Coverage\nChanges to Our Drug Guide\nOur list of covered drugs is called a Formulary or \"Drug Guide.\" A copy of our Drug Guide is provided electronically. \nThe Drug Guide includes many - but not all - of the drugs that we will cover next year. If you don\u2019t see your drug on \nthis list, it might still be covered. You can get the complete Drug Guide by calling Customer Care (see the back \ncover) or visiting our website (Humana.com/PlanDocuments).\nWe made changes to our Drug Guide, including changes to the drugs we cover and changes to the restrictions that \napply to our coverage for certain drugs. Review the Drug Guide to make sure your drugs will be covered next \nyear and to see if there will be any restrictions.\nMost of the changes in the Drug Guide are new for the beginning of each year. However, during the year, we might \nmake other changes that are allowed by Medicare rules. For instance, we can immediately remove drugs \nconsidered unsafe by the FDA or withdrawn from the market by a product manufacturer. We update our online \nDrug Guide to provide the most up to date list of drugs.\nIf you are affected by a change in drug coverage at the beginning of the year or during the year, please review \nChapter 9 of your Evidence of Coverage and talk to your doctor to find out your options, such as asking for a \ntemporary supply, applying for an exception and/or working to find a new drug. You can also contact Customer \nCare for more information.\nChanges to Prescription Drug Costs\nNote: If you are in a program that helps pay for your drugs (\"Extra Help\"), the information about costs for Part D \nprescription drugs does not apply to you.\nThere are four \"drug payment stages.\"\nThe information below shows the changes to the first two stages \u2013 the Yearly Deductible Stage and the Initial \nCoverage Stage. (Most members do not reach the other two stages \u2013 the Coverage Gap Stage or the Catastrophic \nCoverage Stage.)", "doc_id": "74dea28b-9c0a-4217-8cc4-67cb46b92759", "embedding": null, "doc_hash": "1bf770896ba11a6f0486766430f6b11a63238f9fdaf4c480b6dcde651911b3a3", "extra_info": {"page_label": "20", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 2583, "_node_type": "1"}, "relationships": {"1": "2ae52e95-7e2b-44bf-97fd-e28f183ecf1d"}}, "__type__": "1"}, "1b5c4a5e-7d87-4769-a332-2899afb908dd": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 21\nChanges to the Deductible Stage\nStage 2022 (this year) 2023 (next year)\nStage 1: Yearly Deductible Stage\nDuring this stage, you pay the full \ncost of your drugs until you have \nreached the yearly deductible.The deductible is $300.\nDuring this stage, you pay $0 \ncost-sharing for drugs on Tier 1, $9 \ncost-sharing for drugs on Tier 2 and \nthe full cost of drugs on Tier 3, Tier 4, \nand Tier 5 until you have reached the \nyearly deductible.\nYour deductible amount is either $0 \nor $99, depending on the level of \n\"Extra Help\" you receive.If you qualify for \"Extra Help\", for all \nMedicare Part D covered prescription \ndrugs on your formulary for all tiers\nThe deductible is $0.\nDuring this stage, you pay $0 \ncost-sharing for drugs on Tier 1, Tier \n2, Tier 3, Tier 4, and Tier 5. \nIf you do not qualify for \"Extra Help\"\nThe deductible is $505.\nChanges to Your Cost Sharing in the Initial Coverage Stage \nStage 2022 (this year) 2023 (next year)\nStage 2: Initial Coverage Stage\nOnce you pay the yearly deductible, \nyou move to the Initial Coverage \nStage. During this stage, the plan \npays its share of the cost of your \ndrugs and you pay your share of \nthe cost.\nThe cost in these rows are for a \none-month (up to a 30-day) supply \nwhen you fill your prescription at a \nnetwork pharmacy. For information \nabout the costs for a long-term \nsupply or for mail-order \nprescriptions, look in Chapter 6, \nSection 5 of your Evidence of \nCoverage.Your cost for a one-month (up to a \n30-day) supply at a retail network \npharmacy:If you qualify for \"Extra Help\", you \nwill pay $0 for all Medicare Part D \ncovered prescription drugs on your \nformulary for all tiers.\nIf you do not qualify for \"Extra Help\", \nyour cost for a one-month (up to a \n30-day) supply filled at a network \npharmacy is below:\nFor 2022 you paid \"a $0 copayment\" \nfor drugs on the Preferred Generic \ntier. For 2023 you will pay \"25% \ncoinsurance\u201d for drugs on this tier.Preferred Generic:\nStandard cost sharing: You pay $0 per \nprescription.\nPreferred cost sharing: You pay $0 per \nprescription.Preferred Generic:\nRetail (Standard) cost sharing: You pay \n25% per prescription.\nFor 2022 you paid \"a $20 \ncopayment\" for drugs on the Generic \ntier. For 2023 you will pay \"25% \ncoinsurance\" for drugs on this tier.Generic:\nStandard cost sharing: You pay $20 \nper prescription.\nPreferred cost sharing: You pay $9 per \nprescription.Generic:\nRetail (Standard) cost sharing: You pay \n25% per prescription.\nFor 2022 you paid \"a $47 \ncopayment\" for drugs on the \nPreferred Brand tier. For 2023 you Preferred Brand:\nStandard cost sharing: You pay $47 \nper prescription.Preferred Brand:\nRetail (Standard) cost sharing: You pay \n25% per prescription.", "doc_id": "1b5c4a5e-7d87-4769-a332-2899afb908dd", "embedding": null, "doc_hash": "f2ef8618bf66db944bcc1395a6afb3298444bd371f439c4983b9bb15733aa393", "extra_info": {"page_label": "21", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 2781, "_node_type": "1"}, "relationships": {"1": "b1065af6-39c3-4a18-9bdb-7c6c134d20d9"}}, "__type__": "1"}, "aedecc0e-3e40-4d09-bb60-e571a0263a24": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 22\nStage 2022 (this year) 2023 (next year)\nwill pay \"25% coinsurance\u201d for drugs \non this tier.Preferred cost sharing: You pay $47 \nper prescription.\nFor 2022 you paid \"a $100 \ncopayment\" for drugs on the \nNon-Preferred Drug tier. For 2023 \nyou will pay \"25% coinsurance\" for \ndrugs on this tier.Non-Preferred Drug:\nStandard cost sharing: You pay $100 \nper prescription.\nPreferred cost sharing: You pay $100 \nper prescription.Non-Preferred Drug:\nRetail (Standard) cost sharing: You pay \n25% per prescription.\nSpecialty Tier:\nStandard cost sharing: You pay 28% \nper prescription.\nPreferred cost sharing: You pay 28% \nper prescription.Specialty Tier:\nRetail (Standard) cost sharing: You pay \n25% per prescription.\nOnce your total drug costs have \nreached $4,430 , you will move to \nthe next stage (the Coverage Gap \nStage).Once your total drug costs have \nreached $4,660 , you will move to \nthe next stage (the Coverage Gap \nStage).\nImportant Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you, \neven if you haven\u2019t paid your deductible. Call Customer Care for more information.\nImportant Message About What You Pay for Insulin - You won\u2019t pay more than $35 for a one-month (up to \n30-day) supply of each Part D insulin product covered by our plan, no matter what cost-sharing tier it\u2019s on, even if \nyou haven\u2019t paid your deductible. Please see your Prescription Drug Guide to find all Part D insulins covered by your \nplan. To get more information about costs, benefits, or rules please review the Evidence of Coverage, which is \nlocated on our website at Humana.com/PlanDocuments.\nChanges to your VBID Part D Benefit\nYou will pay nothing for all Medicare Part D prescription drugs on all tiers through all stages. To qualify, members \nmust be eligible for \"Extra Help\".\nSECTION 3 Deciding Which Plan to Choose\nSection 3.1 - If you want to stay in Humana Gold Plus SNP-DE H0028-015 (HMO-POS  \nD-SNP)\nTo stay in our plan, you don't need to do anything. If you do not sign up for a different plan or change to Original \nMedicare by December 7, you will automatically be enrolled in our Humana Gold Plus SNP-DE H0028-015 \n(HMO-POS D-SNP).\nSection 3.2 - If you want to change plans\nWe hope to keep you as a member next year but if you want to change plans for 2023 follow these steps:\nStep 1: Learn about and compare your choices", "doc_id": "aedecc0e-3e40-4d09-bb60-e571a0263a24", "embedding": null, "doc_hash": "21eef70a776b00022a417c4aa2e0087a94454b340d5d96f6536c80c997bfd06d", "extra_info": {"page_label": "22", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 2453, "_node_type": "1"}, "relationships": {"1": "eb66606e-d697-4ccc-ad77-d8228b4bb745"}}, "__type__": "1"}, "a10a9382-80b9-4e23-95bb-f87e667dc552": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 23\n\u2022You can join a different Medicare health plan,\n\u2022-- OR-- You can change to Original Medicare. If you change to Original Medicare, you will need to decide \nwhether to join a Medicare drug plan.\nTo learn more about Original Medicare and the different types of Medicare plans, use the Medicare Plan Finder \n(www.medicare.gov/plan-compare), read the Medicare & You 2023 handbook, call your State Health Insurance \nAssistance Program (see Section 5), or call Medicare (see Section 7.2).\nStep 2: Change your coverage\n\u2022To change to a different Medicare health plan, enroll in the new plan. You will automatically be disenrolled \nfrom Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP).\n\u2022To change to Original Medicare with a prescription drug plan, enroll in the new drug plan. You will \nautomatically be disenrolled from Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP).\n\u2022To change to Original Medicare without a prescription drug plan, you must either:\n\u2013Send us a written request to disenroll or visit our website to disenroll online. Contact Customer Care if you \nneed more information on how to do so.\n\u2013\u2013 or \u2013 Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask \nto be disenrolled. TTY users should call 1-877-486-2048.\nIf you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may \nenroll you in a drug plan unless you have opted out of automatic enrollment.\nSECTION 4 Changing Plans\nIf you want to change to a different plan or Original Medicare for next year, you can do it from October 15 until \nDecember 7. The change will take effect on January 1, 2023. \nAre there other times of the year to make a change?\nIn certain situations, changes are also allowed at other times of the year. Examples include people with Medicaid, \nthose who get \u201cExtra Help\u201d paying for their drugs, those who have or are leaving employer coverage, and those \nwho move out of the service area.\nIf you enrolled in a Medicare Advantage plan for January 1, 2023, and don\u2019t like your plan choice, you can switch to \nanother Medicare health plan (either with or without Medicare prescription drug coverage) or switch to Original \nMedicare (either with or without Medicare prescription drug coverage) between January 1 and March 31, 2023.\nIf you recently moved into, currently live in, or just moved out of an institution (like a skilled nursing facility or \nlong-term care hospital), you can change your Medicare coverage at any time. You can change to any other \nMedicare health plan (either with or without Medicare prescription drug coverage) or switch to Original Medicare \n(either with or without a separate Medicare prescription drug plan) at any time.", "doc_id": "a10a9382-80b9-4e23-95bb-f87e667dc552", "embedding": null, "doc_hash": "886c219efb630abb78a783a005af3363761ef649c5743e1e3e3f55dffff61dad", "extra_info": {"page_label": "23", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 2809, "_node_type": "1"}, "relationships": {"1": "ddde86fc-815b-4682-8fad-1f5189243770"}}, "__type__": "1"}, "86e02bec-5f67-451f-8bf1-c551a48c700c": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 24\nSECTION 5 Programs That Offer Free Counseling about Medicare and  \nMedicaid\nThe State Health Insurance Assistance Program (SHIP) is an independent government program with trained \ncounselors in every state.\nIt is a state program that gets money from the Federal government to give free local health insurance counseling \nto people with Medicare. State Health Insurance Assistance Program (SHIP) counselors can help you with your \nMedicare questions or problems. They can help you understand your Medicare plan choices and answer questions \nabout switching plans. You can call your State Health Insurance Assistance Program at the number listed in \n\"Exhibit A\" in the back of this document.\nFor questions about your MO HealthNet (Medicaid) benefits, contact MO HealthNet (Medicaid). Ask how joining \nanother plan or returning to Original Medicare affects how you get your MO HealthNet (Medicaid) coverage. You \ncan call MO HealthNet (Medicaid) at the number listed in \"Exhibit A\" in the back of this document.\nSECTION 6 Programs That Help Pay for Prescription Drugs\nYou may qualify for help paying for prescription drugs. Below we list different kinds of help:\n\u2022\"Extra Help\" from Medicare. Because you have MO HealthNet (Medicaid), you are already enrolled in \u2018Extra \nHelp,\u2019 also called the Low Income Subsidy. \"Extra Help\" pays some of your prescription drug premiums, \nannual deductibles and coinsurance. Because you qualify, you do not have a coverage gap or late enrollment \npenalty. If you have questions about \"Extra Help\", call:\n\u20131-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a \nweek;\n\u2013The Social Security Office at 1-800-772-1213 between 8 am and 7 pm, Monday through Friday for a \nrepresentative. Automated messages are available 24 hours a day. TTY users should call, \n1-800-325-0778; or\n\u2013Your State Medicaid Office (applications).\n\u2022Help from your state's pharmaceutical assistance program. Many states have State Pharmaceutical \nAssistance Programs (SPAPs) that help people pay for prescription drugs based on their financial need, age, or \nmedical condition. To learn more about the program, check with your State Health Insurance Assistance \nProgram.\n\u2022Prescription Cost-sharing Assistance for Persons with HIV/AIDS. The AIDS Drug Assistance Program \n(ADAP) helps ensure that ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV \nmedications. Individuals must meet certain criteria; including proof of State residence and HIV status, low \nincome as defined by the State, and uninsured/under-insured status. Medicare Part D prescription drugs that \nare also covered by ADAP qualify for prescription cost-sharing assistance through the ADAP program. For \ninformation on eligibility criteria, covered drugs, or how to enroll in the program, please call the ADAP \nprogram (the name and phone numbers for this organization are in \"Exhibit A\" in the back of this document).", "doc_id": "86e02bec-5f67-451f-8bf1-c551a48c700c", "embedding": null, "doc_hash": "b7da13266762448b8da32de4bbd8b6619fde4977712fe3022ea3c162dd466553", "extra_info": {"page_label": "24", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 3037, "_node_type": "1"}, "relationships": {"1": "477640e2-4f9b-4613-962b-409368857896"}}, "__type__": "1"}, "5f7c8912-8806-4f1f-9f0a-b5723b6eec7c": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 25\nSECTION 7 Questions?\nSection 7.1 - Getting Help from Humana Gold Plus SNP-DE H0028-015 (HMO-POS  \nD-SNP)\nQuestions? We're here to help. Please call Customer Care at 1-800-457-4708. (TTY only, call 711.) We are available \nfor phone calls from 8 a.m. to 8 p.m., seven days a week from Oct. 1 \u2013 Mar. 31 and 8 a.m. to 8 p.m. Monday-Friday \nfrom Apr. 1 - Sept. 30. Calls to these numbers are free.\nRead your 2023 Evidence of Coverage (it has details about next year's benefits and costs)\nThis Annual Notice of Changes gives you a summary of changes in your benefits and costs for 2023. For details, look \nin the 2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP). The Evidence of \nCoverage is the legal, detailed description of your plan benefits. It explains your rights and the rules you need to \nfollow to get covered services and prescription drugs. A copy of the Evidence of Coverage is located on our website \nat Humana.com/PlanDocuments. You may also call Customer Care to ask us to mail you an Evidence of Coverage.\nVisit our Website\nYou can also visit our website at Humana.com/PlanDocuments. As a reminder, our website has the most \nup-to-date information about our provider network (Provider Directory) and our list of covered drugs \n(Formulary/Drug Guide).\nSection 7.2 - Getting Help from Medicare\nTo get information directly from Medicare:\nCall 1-800-MEDICARE (1-800-633-4227)\nYou can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call \n1-877-486-2048.\nVisit the Medicare Website\nVisit the Medicare website (www.medicare.gov). It has information about cost, coverage, and quality Star Ratings \nto help you compare Medicare health plans in your area. To view the information about plans, go to \nwww.medicare.gov/plan-compare.\nRead Medicare & You 2023\nRead the Medicare & You 2023 handbook. Every fall, this booklet is mailed to people with Medicare. It has a \nsummary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about \nMedicare. If you don't have a copy of this document, you can get it at the Medicare website \n(https://www.medicare.gov/Pubs/pdf/10050-medicare-and-you.pdf) or by calling 1-800-MEDICARE \n(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.", "doc_id": "5f7c8912-8806-4f1f-9f0a-b5723b6eec7c", "embedding": null, "doc_hash": "84777ec9c1751827021fcc3556c7772911e2cc2c616c8e835f4f3f3ff3e7e03e", "extra_info": {"page_label": "25", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 2407, "_node_type": "1"}, "relationships": {"1": "59d84232-09ab-4b2e-8973-665b464d8278"}}, "__type__": "1"}, "e603d02d-ae0e-4b9c-a562-c688baef6385": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Annual Notice of Changes for 2023 26\nSection 7.3 - Getting Help from Medicaid\nTo get information from Medicaid, you can call MO HealthNet (Medicaid) at the numbers listed in \"Exhibit A\" in the \nback of this document.", "doc_id": "e603d02d-ae0e-4b9c-a562-c688baef6385", "embedding": null, "doc_hash": "7c290a8cd0470d157d70a5486ffb294d716341a70b028f612b8de0e9f4635fd1", "extra_info": {"page_label": "26", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 266, "_node_type": "1"}, "relationships": {"1": "4a42ac7a-14b5-4066-849f-68b1bd25395d"}}, "__type__": "1"}, "9494501e-3430-4719-844e-2da439a99205": {"__data__": {"text": "2023 Annual Notice of Changes for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 27\nExhibit A - State Agency Contact InformationEOC075\nExhibit A- State Agency Contact Information\nThis section provides the contact information for the state agencies referenced in this Annual Notice of Changes. If  \nyou have trouble locating the information you seek, please contact Customer Care at the phone number on the  \nback cover of this booklet.\nMissouri\nSHIP Name and Contact Information CLAIM\n1105 Lakeview Avenue\nColumbia, MO 65201\n1-800-390-3330 (toll free)\n1-573-817-8300 (local)\nhttp://www.missouriclaim.org\nQuality Improvement Organization Livanta BFCC-QIO Program\n10820 Guilford Road\nSuite 202\nAnnapolis Junction, MD 20701\n1-888-755-5580\n1-888-985-9295 (TTY)\n1-833-868-4061 (Fax)\nhttps://livantaqio.com/\nState Medicaid Office MO HealthNet (Medicaid)\n615 Howerton Court\nP.O. Box 6500\nJefferson City, MO 65102-6500\n1-855-373-4636 (toll free)\n1-573-751-3425 (local)\n1-800-735-2966 (TTY)\nhttp://www.dss.mo.gov/mhd/\nState Pharmacy Assistance Program(s) Missouri RX Plan\nPO Box 6500\nJefferson City, MO 65102\n1-800-375-1406 (toll free)\nwww.morx.mo.gov/\nAIDS Drug Assistance Program Missouri AIDS Drug Assistance Program\nBureau of HIV, STD, and Hepatitis, Missouri Department of Health & \nSenior Services\nPO Box 570\nJefferson City, MO 65102\n1-573-751-6439\n1-573-751-6447 (fax)\nhttp://health.mo.gov/living/healthcondiseases/communicable/hivai\nds/casemgmt.php\nn/a", "doc_id": "9494501e-3430-4719-844e-2da439a99205", "embedding": null, "doc_hash": "0357bbd151e33d1af7f2ab68471c2526f61dfdbbd4fb5aa1eaa18ea5e85a66c9", "extra_info": {"page_label": "27", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1454, "_node_type": "1"}, "relationships": {"1": "1b061e34-9fa7-4aa7-8fce-b16fb7f0617e"}}, "__type__": "1"}, "9c77689a-846d-4edf-a0bc-3de6ca2e40fb": {"__data__": {"text": "Notice of Privacy Practices\nFor your personal health information\nTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW \nYOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.\nThe privacy of your personal and health information is important. You don't need to do anything unless you \nhave a request or complaint.\nWe may change our privacy practices and the terms of this notice at any time, as allowed by law. Including \ninformation we created or received before we made the changes. When we make a significant change in our \nprivacy practices, we will change this notice and send the notice to our health plan subscribers.\nWhat is personal and health information?\nPersonal and health information includes both medical information and personal information, like your name, \naddress, telephone number, or Social Security number. The term \u201cinformation\u201d in this notice includes any personal \nand health information. This includes information created or received by a healthcare provider or health plan. The \ninformation relates to your physical or mental health or condition, providing healthcare to you, or the payment for \nsuch healthcare.\nHow do we protect your information?\nWe have a responsibility to protect the privacy of your information in all formats including electronic, written and \noral information. We have safeguards in place to protect your information in various ways including:\n\u2022Limiting who may see your information \n\u2022Limiting how we use or disclose your information\n\u2022Informing you of our legal duties about your information\n\u2022Training our employees about our privacy program and procedures\nHow do we use and disclose your information?\nWe use and disclose your information:\n\u2022To you or someone who has the legal right to act on your behalf\n\u2022To the Secretary of the Department of Health and Human Services\nWe have the right to use and disclose your information:\n\u2022To a doctor, a hospital, or other healthcare provider so you can receive medical care.\n\u2022For payment activities, including claims payment for covered services provided to you by healthcare providers \nand for health plan premium payments.\n\u2022For healthcare operation activities. Including processing your enrollment, responding to your inquiries, \ncoordinating your care, improving quality, and determining premiums.\n\u2022For performing underwriting activities. However, we will not use any results of genetic testing or ask questions \nregarding family history.\n\u2022To your plan sponsor to permit them to perform, plan administration functions such as eligibility, enrollment \nand disenrollment activities. We may share summary level health information about you with your plan sponsor \nin certain situations. For example, to allow your plan sponsor to obtain bids from other health plans. Your \ndetailed health information will not be shared with your plan sponsor. We will ask your permission or your plan \nsponsor has to certify they agree to maintain the privacy of your information.\n\u2022To contact you with information about health-related benefits and services, appointment reminders, or \ntreatment alternatives that may be of interest to you. If you have opted out as described below, we will not \ncontact you.\n\u2022To your family and friends if you are unavailable to communicate, such as in an emergency. To your family and \nfriends or any other person you identify. This applies if the information is directly relevant to their involvement \nwith your health care or payment for that care. For example, if a family member or a caregiver calls us with prior \nknowledge of a claim, we may confirm if the claim has been received and paid.", "doc_id": "9c77689a-846d-4edf-a0bc-3de6ca2e40fb", "embedding": null, "doc_hash": "eabc4808f26295aa6bcc3943acbdb79105bbb56de9ee574a178c4db09f9e1887", "extra_info": {"page_label": "28", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 3651, "_node_type": "1"}, "relationships": {"1": "b327e644-bfa6-4c8d-8917-1952346384a5"}}, "__type__": "1"}, "9960b106-e385-4f4f-af51-12442ac44635": {"__data__": {"text": "\u2022To provide payment information to the subscriber for Internal Revenue Service substantiation.\n\u2022To public health agencies, if we believe that there is a serious health or safety threat.\n\u2022To appropriate authorities when there are issues about abuse, neglect, or domestic violence.\n\u2022In response to a court or administrative order, subpoena, discovery request, or other lawful process.\n\u2022For law enforcement purposes, to military authorities, and as otherwise required by law.\n\u2022To help with disaster relief efforts.\n\u2022For compliance programs and health oversight activities.\n\u2022To fulfill our obligations under any workers\u2019 compensation law or contract.\n\u2022To avert a serious and imminent threat to your health or safety or the health or safety of others.\n\u2022For research purposes in limited circumstances.\n\u2022For procurement, banking, or transplantation of organs, eyes, or tissue.\n\u2022To a coroner, medical examiner, or funeral director.\nWill we use your information for purposes not described in this notice?\nWe will not use or disclose your information for any reason that is not described in this notice, without your written \npermission. You may cancel your permission at any time by notifying us in writing.\nThe following uses and disclosures will require your written permission:\n\u2022Most uses and disclosures of psychotherapy notes\n\u2022Marketing purposes\n\u2022Sale of personal and health information\nWhat do we do with your information when you are no longer a member?\nYour information may continue to be used for purposes described in this notice. This includes when you do not \nobtain coverage through us. After the required legal retention period, we destroy the information following strict \nprocedures to maintain the confidentiality.\nWhat are my rights concerning my information?\nWe are committed to responding to your rights request in a timely manner\n\u2022Access - You have the right to review and obtain a copy of your information that may be used to make decisions \nabout you. You also may receive a summary of this health information. If you request copies, we may charge \nyou a fee for the labor for copying, supplies for creating the copy (paper or electronic) and postage.\n\u2022Adverse Underwriting Decision - If we decline your application for insurance, you have the right to be provided a \nreason for the denial.\n\u2022Alternate Communications - To avoid a life- threatening situation, you have the right to receive your information \nin a different manner or at a different place. We will accommodate your request if it is reasonable.\n\u2022Amendment - You have the right to request correction of any of this personal information through amendment \nor deletion. Within 30 business days of receipt of your written request, we will notify you of our amendment or \ndeletion of the information in dispute, or of our refusal to make such correction after further investigation. In the \nevent that we refuse to amend or delete the information in dispute, you have the right to submit to us a written \nstatement of the reasons for your disagreement with our assessment of the information in dispute and what \nyou consider to be the correct information. We shall make such a statement accessible to any and all parties \nreviewing the information in dispute.*\n\u2022Disclosure - You have the right to receive a listing of instances in which we or our business associates have \ndisclosed your information.  This does not apply to treatment, payment, health plan operations, and certain \nother activities. We maintain this information and make it available to you for six years. If you request this list \nmore than once in a 12-month period, we may charge you a reasonable, cost-based fee.\n\u2022Notice - You have the right to request and receive a written copy of this notice any time.\n\u2022Restriction - You have the right to ask to limit how your information is used or disclosed. We are not required to \nagree to the limit, but if we do, we will abide by our agreement. You also have the right to agree to or terminate \na previously submitted limitation.\nWhat types of communications can I opt out of that are made to me?\n\u2022Appointment reminders\n\u2022Treatment alternatives or other health-related", "doc_id": "9960b106-e385-4f4f-af51-12442ac44635", "embedding": null, "doc_hash": "15a5bef8aa5dd5d2cee20df9fadc9e3f5ca5f00bf89c525aa6fafd3575d8d5c8", "extra_info": {"page_label": "29", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 4153, "_node_type": "1"}, "relationships": {"1": "3b80bc31-f6d5-45ee-8d44-54714a155751", "3": "d75c3b67-8eab-4785-be62-69533a8cf716"}}, "__type__": "1"}, "d75c3b67-8eab-4785-be62-69533a8cf716": {"__data__": {"text": "to me?\n\u2022Appointment reminders\n\u2022Treatment alternatives or other health-related benefits or services", "doc_id": "d75c3b67-8eab-4785-be62-69533a8cf716", "embedding": null, "doc_hash": "77f82384e3788d33b004978d2d8383351e1d52d78cfad66a1c2f3c492a67a8cc", "extra_info": {"page_label": "29", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 4076, "end": 4174, "_node_type": "1"}, "relationships": {"1": "3b80bc31-f6d5-45ee-8d44-54714a155751", "2": "9960b106-e385-4f4f-af51-12442ac44635"}}, "__type__": "1"}, "5e3f4c80-e66c-4242-91e1-e55f0777e9bb": {"__data__": {"text": "\u2022Fundraising activities\nHow do I exercise my rights or obtain a copy of this notice?\nAll of your privacy rights can be exercised by obtaining the applicable forms. You may obtain any of the forms by:\n\u2022Contacting us at 1-866-861-2762\n\u2022Accessing our Website at Humana.com and going to the Privacy Practices link\n\u2022Send completed request form to:\nHumana Inc.\nPrivacy Office 003/10911\n101 E. Main Street\nLouisville, KY 40202\n* This right applies only to our Massachusetts residents in accordance with state regulations.\nIf I believe that my privacy has been violated, what should I do?\nIf you believe that your privacy has been violated you may file a complaint with us by calling us at \n1-866-861-2762 any time.\nYou may also submit a written complaint to the U.S. Department of Health and Human Services, Office for Civil \nRights (OCR). We will give you the appropriate OCR regional address on request. You can also e-mail your complaint \nto OCRComplaint@hhs.gov. If you elect to file a complaint, your benefits will not be affected and we will not punish \nor retaliate against you in any way.\nWe support your right to protect the privacy of your personal and health information. \nWe follow all federal and state laws, rules, and regulations addressing the protection of personal and health \ninformation. In situations when federal and state laws, rules, and regulations conflict, we follow the law, rule, or \nregulation which provides greater protection.\nWe are required by law to abide by the terms of this notice currently in effect.\nWhat will happen if my information is used or disclosed inappropriately?\nWe are required by law to provide individuals with notice of our legal duties and privacy practices regarding \npersonal and health information. If a breach of unsecured personal and health information occurs, we will notify \nyou in a timely manner.\nThe following affiliates and subsidiaries also adhere to our privacy program and procedures:\nArcadian Health Plan, Inc.\nCarePlus Health Plans, Inc.\nCariten Health Plan, Inc.\nCHA HMO, Inc.\nCompBenefits Company\nCompBenefits Dental, Inc.\nCompBenefits Insurance Company\nDentiCare, Inc.\nEmphesys Insurance Company\nHumanaDental Insurance Company\nHumana Benefit Plan of Illinois, Inc.\nHumana Benefit Plan of South Carolina, Inc. \nHumana Benefit Plan of Texas, Inc.\nHumana Employers Health Plan of Georgia, Inc.\nHumana Health Benefit Plan of Louisiana, Inc.\nHumana Health Company of New York, Inc.\nHumana Health Insurance Company of Florida, Inc.", "doc_id": "5e3f4c80-e66c-4242-91e1-e55f0777e9bb", "embedding": null, "doc_hash": "fe8f29a60a91a37e33b888d1b8db4746caec3695e6f2e6956e464f33e9ddc96e", "extra_info": {"page_label": "30", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 2493, "_node_type": "1"}, "relationships": {"1": "c863b8d5-e3fd-4a57-9c4e-0ed9cc10fae5"}}, "__type__": "1"}, "e1462f50-d16f-4dfa-b286-72062460870c": {"__data__": {"text": "Humana Health Plan of California, Inc.\nHumana Health Plan of Ohio, Inc.\nHumana Health Plan of Texas, Inc.\nHumana Health Plan, Inc.\nHumana Health Plans of Puerto Rico, Inc.\nHumana Insurance Company\nHumana Insurance Company of Kentucky\nHumana Insurance Company of New York\nHumana Insurance of Puerto Rico, Inc.\nHumana Medical Plan, Inc.\nHumana Medical Plan of Michigan, Inc.\nHumana Medical Plan of Pennsylvania, Inc.\nHumana Medical Plan of Utah, Inc.\nHumana Regional Health Plan, Inc.\nHumana Wisconsin Health Organization Insurance Corporation\nGo365 by Humana for Healthy Horizons\nManaged Care Indemnity, Inc.\nThe Dental Concern, Inc. \nEffective 9/2013", "doc_id": "e1462f50-d16f-4dfa-b286-72062460870c", "embedding": null, "doc_hash": "5b64196d8001f62f7e48383ac7e2a85c29db5f2f9e65373a9e2e5f467e5950f7", "extra_info": {"page_label": "31", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 650, "_node_type": "1"}, "relationships": {"1": "01db5cee-01e4-435b-ba79-11ad2dcc85a1"}}, "__type__": "1"}, "53354811-2f7e-4efa-bf1b-b38c21f6d882": {"__data__": {"text": "EOC075\nImportant\nAt Humana, it is important you are treated fairly.\nHumana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color,  \nnational origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity,  \nmarital status, religion or language. Discrimination is against the law. Humana and its subsidiaries  \ncomply with applicable federal civil rights laws. If you believe that you have been discriminated  \nagainst by Humana or its subsidiaries, there are ways to get help.\n\u2022You may file a complaint, also known as a grievance:  \nDiscrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.  \nIf you need help filing a grievance, call 1-877-320-1235 or if you use a TTY, call 711.\n\u2022You can also file a civil rights complaint with the U.S. Department of Health and Human  \nServices, Office for Civil Rights electronically through their Complaint Portal, available at \nhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at U.S. Department of Health and Human  \nServices, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, \n1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at \nhttps://www.hhs.gov/ocr/office/file/index.html.\n\u2022California residents: You may also call California Department of Insurance toll-free hotline  \nnumber: 1-800-927-HELP (4357), to file a grievance.\nAuxiliary aids and services, free of charge, are available to you.  \n1-877-320-1235 (TTY: 711)\nHumana provides free auxiliary aids and services, such as qualified sign language interpreters,  \nvideo remote interpretation, and written information in other formats to people with disabilities  \nwhen such auxiliary aids and services are necessary to ensure an equal opportunity to participate.\nGCHJV5REN_2020", "doc_id": "53354811-2f7e-4efa-bf1b-b38c21f6d882", "embedding": null, "doc_hash": "26a83c85efa443756be73aea96c289e330cc5eefdb6304566cb75ac1b787bf68", "extra_info": {"page_label": "32", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1800, "_node_type": "1"}, "relationships": {"1": "bc5bdfd5-1f27-4c78-8c43-05609d3dd81c"}}, "__type__": "1"}, "11f9c439-458b-4c05-bab9-d5b7bb85ff07": {"__data__": {"text": "The information you need  \nis just a click away\nThese member documents give you more information about your plan  \ncoverage: \n\u2022Evidence of Coverage: Details about your overall plan, including  \nbenefits and costs\n\u2022Drug List: List of drugs covered in your plan \n\u2022Provider Directory: List of providers in your plan\u2019s network \nYou can view these 2023 plan documents starting October 15, 2022 at \nHumana.com/PlanDocuments. Here, you can see the most up-to-date  \ninformation about your plan. It\u2019s easy to search, so you can find what  \nyou are looking for quickly.\nWe\u2019re here for you. If you need help using these online tools, please call  \nthe number on the back of your Humana member ID card for support.\nTo get paper copies of these documents by mail, make your request  \nonline at the website above, or call 800-457-4708 (TTY: 711), 24 hours  \na day, seven days a week. Please have your Humana member ID card  \nready when you call. When asked why you\u2019ve called, say \u201cEvidence of  \nCoverage,\u201d \u201cDrug List,\u201d and/or \u201cProvider Directory.\u201d Please allow up to  \ntwo weeks to receive the documents by mail.", "doc_id": "11f9c439-458b-4c05-bab9-d5b7bb85ff07", "embedding": null, "doc_hash": "dde897dc5ef74d33c986e5d559cea62c52121920061186b02686a3bb0d629282", "extra_info": {"page_label": "35", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 1099, "_node_type": "1"}, "relationships": {"1": "e3c1a094-d8a2-47cf-b4bf-cfa98da8ef0e"}}, "__type__": "1"}, "52f3c867-069f-43ff-9e8d-28427e4b4ac0": {"__data__": {"text": "H0028015000ANOC23 \nH0028_ANOC_MAPD_HMOPOS_015000_2023_M H0028015000ANOC23Humana Inc.\nPO Box 14168 \nLexington, KY 40512-4168\nLook inside\nHere\u2019s a summary of your Humana Gold  \nPlus SNP-DE H0028-015 (HMO-POS D-SNP)  \nthat takes effect on January 1, 2023.\n1-800-457-4708 (TTY: 711)Important information about changes to your  \nMedicare Advantage and prescription drug plan \nHumana.com", "doc_id": "52f3c867-069f-43ff-9e8d-28427e4b4ac0", "embedding": null, "doc_hash": "5891e79129a300d5773a3dc3cc65028f81ded462a4b99cf7f02233696aad6148", "extra_info": {"page_label": "36", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}, "node_info": {"start": 0, "end": 381, "_node_type": "1"}, "relationships": {"1": "e4ae379f-9d63-413b-8afa-afc20b5d0840"}}, "__type__": "1"}, "f50ec48a-2bd6-493d-afad-aa8d488b4e1e": {"__data__": {"text": "Find\nmy\ndetails\nbelow\nN a m e :\nD u c\nA g e :\n2 5\nH e a l t h :\nG o o d\nP r e s c r i p t i o n\n:\nc e l e c o x i b\n1 0 0\nm g\nC h r o n i c\nc o n d i t i o n :\nC o l d\nI n s u r a n c e\np l a n :\nH u m a n a\nG o l d\nP l u s\nS N P - D E\nH 0 0 2 8 - 0 1 5\n( H M O - P O S\nD - S N P )\nF a v o r i t e\ns p o r t\nt e a m :\nA I\nG i a n t s\nB a n k\na c c o u n t :\nH D F C\nB a n k\nb a l a n c e :\n$ 5 0 , 0 0 , 0 0 0\nF i n a n c i a l\ng o a l :\nT o\nb u i l d\nA I\nc o m p a n y\nH o s p i t a l\n:\nM e r c y\nH o s p i t a l\nW a s h i n g t o n\nP h a r m a c y\n:\nW A L G R E E N S\nD o s a g e\n:\nT a k e\n2\nt a b l e t s\nd a i l y\ni n\nt h e\nm o r n i n g\na f t e r\nf o o d\na n d\no n e\ni n\nt h e\ne v e n i n g .\nD o c t o r\n:\nD r . J a c k s o n ,\nD r . J a c o b", "doc_id": "f50ec48a-2bd6-493d-afad-aa8d488b4e1e", "embedding": null, "doc_hash": "d3b12621a74676641591280dc80537bf3e467e139f3cb9fb667cb1c96f7b6f91", "extra_info": {"page_label": "1", "file_name": "DucDetails.pdf"}, "node_info": {"start": 0, "end": 749, "_node_type": "1"}, "relationships": {"1": "0902737a-cecc-43dc-a42c-f1170e797f3e"}}, "__type__": "1"}, "5a064a9e-3536-496a-a879-dcedb35b0f66": {"__data__": {"text": "Find\nmy\ndetails\nbelow\nN a m e :\nG i r i s h\nA g e :\n3 0\nH e a l t h :\nG o o d\nP r e s c r i p t i o n\n:\ni b u p r o f e n\n4 0 0\nm g\nC h r o n i c\nc o n d i t i o n :\nC o u g h\nI n s u r a n c e\np l a n :\nH u m a n a\nG o l d\nP l u s\nS N P - D E\nH 0 0 2 8 - 0 1 5\n( H M O - P O S\nD - S N P )\nF a v o r i t e\ns p o r t\nt e a m :\nN e w\nY o r k\nG i a n t s\nB a n k\na c c o u n t :\nC h a s e\nB a n k\nb a l a n c e :\n$ 5 0 , 0 0 0\nF i n a n c i a l\ng o a l :\nT o\nb u y\na\nh o u s e\nb y\nt h e\ne n d\no f\nt h e\ny e a r\nH o s p i t a l\n:\nC i t y\nc l i n i c\nH o s p i t a l\nP h a r m a c y\n:\nF a m i l y\nC a r e\nD o s a g e\n:\nT a k e\n1\nt a b l e t\nd a i l y\ni n\nt h e\nm o r n i n g\na f t e r\nf o o d .\nD o c t o r\n:\nD r .\nS r i v a s t a v a ,\nD r .\nA n i l", "doc_id": "5a064a9e-3536-496a-a879-dcedb35b0f66", "embedding": null, "doc_hash": "9d900b42b177e2b4a05e0aaa237ebd55da0a7a85a1ef5c1bf22060c9c9c5da85", "extra_info": {"page_label": "1", "file_name": "GirishDetails.pdf"}, "node_info": {"start": 0, "end": 745, "_node_type": "1"}, "relationships": {"1": "1dd89492-3c6b-45cf-bf4c-0f0846bd5e6a"}}, "__type__": "1"}, "2abb7291-582b-482a-9690-d68abd48619e": {"__data__": {"text": "IMPORTANT INFORMATION: IMPORTANT INFORMATION: \n2023 Medicare Star Ratings 2023 Medicare Star Ratings\nHumana - H0028\nFor 2023, Humana - H0028 received the For 2023, Humana - H0028 received the following Star Ratings from Medicare: following Star Ratings from Medicare: \nOverall Star Rating: Overall Star Rating:\nHealth Services Rating: Health Services Rating:\nDrug Services Rating: Drug Services Rating:\nEvery year, Medicare evaluates plans based on a 5-star rating system. Every year, Medicare evaluates plans based on a 5-star rating system.\nThe number of stars show how The number of stars show how \nwell a plan performs. well a plan performs.\nEXCELLENT\nABOVE AVERAGE\nAVERAGE\nBELOW AVERAGE\nPOORWhy Star Ratings Are Important Why Star Ratings Are Important\nMedicare rates plans on their health and drug services.\nThis lets you easily compare plans based on quality and\nperformance. \n  Star Ratings are based on factors that include:\nFeedback from members about the plan\u2019s service and care\nThe number of members who left or stayed with the plan\nThe number of complaints Medicare got about the plan\nData from doctors and hospitals that work with the plan\nMore stars mean a better plan \u2013 for example, members may\nget better care and better, faster customer service.\nGet More Information on Star Ratings Online Get More Information on Star Ratings Online \nCompare Star Ratings for this and other plans online at medicare.gov/plan-compare medicare.gov/plan-compare.\nQuestions about this plan? Questions about this plan? \nContact Humana 7 days a week from 8:00 a.m. to 8:00 p.m. local time at 800-833-2364 (toll-free) or 711 (TTY), from\nOctober 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday from 8:00\na.m. to 8:00 p.m. local time. Current members please call 800-457-4708 (toll-free) or 711 (TTY).\n1/1H0028_PRDEN23_M", "doc_id": "2abb7291-582b-482a-9690-d68abd48619e", "embedding": null, "doc_hash": "36d2228d3a1dbe90d6b9ef67989b6edd6aa962f1119d608e68889f297e5c1140", "extra_info": {"page_label": "1", "file_name": "Humana Gold Plus (HMO) - CMS Plan Rating.pdf"}, "node_info": {"start": 0, "end": 1858, "_node_type": "1"}, "relationships": {"1": "453afa2a-95c5-464a-ab4c-71d860b2f67e"}}, "__type__": "1"}, "3d82f039-4ee2-452d-b6a7-d5561e2854cc": {"__data__": {"text": "  GHHLNNXEN 0522Important _____________________________________________________________________\nAt Humana, it is important you are treated fairly. \nHumana Inc. and its subsidiaries do not discriminate or exclude people because of their race, \ncolor, national origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, \nethnicity, marital status, religion, or language. Discrimination is against the law. Humana and \nits subsidiaries comply with applicable federal civil rights laws. If you believe that you have \nbeen discriminated against by Humana or its subsidiaries, there are ways to get help. \n\u2022   You may file a complaint, also known as a grievance:  \nDiscrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618 \nIf you need help filing a grievance, call 1-877-320-1235 or if you use a TTY, call 711.\n\u2022   You can also file a civil rights complaint with the U.S. Department of Health and Human \nServices, Office for Civil Rights electronically through their Complaint Portal, available at \nhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at U.S. Department of Health and Human \nServices, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, \n1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at  \nhttps://www.hhs.gov/ocr/office/file/index.html.\n\u2022   California residents: You may also call the California Department of Insurance toll-free \nhotline number: 1-800-927-HELP (4357), to file a grievance.\nAuxiliary aids and services, free of charge, are available to you.  \n1-877-320-1235 (TTY: 711)\nHumana provides free auxiliary aids and services, such as qualified sign language  \ninterpreters, video remote interpretation, and written information in other formats  \nto people with disabilities when such auxiliary aids and services are necessary to  \nensure an equal opportunity to participate. \nH0028_PRDEN23_M", "doc_id": "3d82f039-4ee2-452d-b6a7-d5561e2854cc", "embedding": null, "doc_hash": "5d47ffc4474dd8e46e260b57a39958f7d18afa61f8b7d1323fab0eb094781ae8", "extra_info": {"page_label": "2", "file_name": "Humana Gold Plus (HMO) - CMS Plan Rating.pdf"}, "node_info": {"start": 0, "end": 1891, "_node_type": "1"}, "relationships": {"1": "5dbde026-bebb-42ed-b237-366ab5b3815d"}}, "__type__": "1"}, "65d6c4c8-708b-4cee-a3e1-79b9d88e6a46": {"__data__": {"text": "  GHHLNNXEN 0522Multi-Language Insert \nMulti-language Interpreter Services\nEnglish: We have free interpreter services to answer any questions you may have \nabout our health or drug plan. To get an interpreter, just call us at 1-877-320-1235 \n(TTY: 711). Someone who speaks English can help you. This is a free service.\nSpanish: Tenemos servicios de int\u00e9rprete sin costo alguno para responder \ncualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. \nPara hablar con un int\u00e9rprete, por favor llame al 1-877-320-1235 (TTY: 711). Alguien \nque\u00a0hable espa\u00f1ol le podr\u00e1 ayudar. Este es un servicio gratuito.\nChinese Mandarin:\u202f \u6211\u4eec\u63d0\u4f9b\u514d\u8d39\u7684\u7ffb\u8bd1\u670d\u52a1\uff0c\u5e2e\u52a9\u60a8\u89e3\u7b54\u5173\u4e8e\u5065\u5eb7\u6216\u836f\u7269\u4fdd\u9669\u7684\u4efb\u4f55\u7591\u95ee\u3002\u5982\u679c\n\u60a8\u9700\u8981\u6b64\u7ffb\u8bd1\u670d\u52a1\uff0c\u8bf7\u81f4\u7535  1-877-320-1235 (TTY: 711) \u3002\u6211\u4eec\u7684\u4e2d\u6587\u5de5\u4f5c\u4eba\u5458\u5f88\u4e50\u610f\u5e2e\u52a9\u60a8\u3002\u8fd9\u662f\n\u4e00\u9879\u514d\u8d39\u670d\u52a1\u3002\nChinese Cantonese: \u202f\u60a8\u5c0d\u6211\u5011\u7684\u5065\u5eb7\u6216\u85e5\u7269\u4fdd\u96aa\u53ef\u80fd\u5b58\u6709\u7591\u554f \uff0c\u70ba\u6b64\u6211\u5011\u63d0\u4f9b\u514d\u8cbb\u7684\u7ffb\u8b6f\u670d\u52d9 \u3002  \n\u5982\u9700\u7ffb\u8b6f\u670d\u52d9 \uff0c\u8acb\u81f4\u96fb  1-877-320-1235 (TTY: 711) \u3002\u6211\u5011\u8b1b\u4e2d\u6587\u7684\u4eba\u54e1\u5c07\u6a02\u610f\u70ba\u60a8\u63d0\u4f9b\u5e6b\u52a9 \u3002\u9019\u662f\n\u4e00\u9805 \u514d \u8cbb \u670d \u52d9\u3002\nTagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot \nang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan \no panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa \n1-877-320-1235 (TTY: 711). Maaari kayong tulungan ng isang nakakapagsalita \nng\u00a0Tagalog. Ito ay libreng serbisyo.\nFrench: Nous proposons des services gratuits d\u2019interpr\u00e9tation pour r\u00e9pondre \u00e0 \ntoutes vos questions relatives \u00e0 notre r\u00e9gime de sant\u00e9 ou d\u2019assurance-m\u00e9dicaments. \nPour acc\u00e9der au service d\u2019interpr\u00e9tation, il vous suffit de nous appeler au \n1-877-320-1235 (TTY: 711). Un interlocuteur parlant Fran\u00e7ais pourra vous aider. \nCe\u00a0service est gratuit.\nVietnamese: Ch\u00fang t\u00f4i c\u00f3 d\u1ecbch v\u1ee5 th\u00f4ng d\u1ecbch mi\u1ec5n ph\u00ed \u0111\u1ec3 tr\u1ea3 l\u1eddi c\u00e1c c\u00e2u h\u1ecfi v\u1ec1 \nch\u01b0\u01a1ng s\u1ee9c kh\u1ecfe v\u00e0 ch\u01b0\u01a1ng tr\u00ecnh thu\u1ed1c men. N\u1ebfu qu\u00ed v\u1ecb c\u1ea7n th\u00f4ng d\u1ecbch vi\u00ean xin \ng\u1ecdi\u00a01-877-320-1235 (TTY: 711) s\u1ebd c\u00f3", "doc_id": "65d6c4c8-708b-4cee-a3e1-79b9d88e6a46", "embedding": null, "doc_hash": "7d338aebe13204edc74d75a43d9405342f5ade386410e5c050fd1d14c5620db4", "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus (HMO) - CMS Plan Rating.pdf"}, "node_info": {"start": 0, "end": 1751, "_node_type": "1"}, "relationships": {"1": "4bc1f1b7-8730-4a4f-8e64-705677c17aad", "3": "96ae10a3-3e55-434a-a9fc-29bf3994780f"}}, "__type__": "1"}, "96ae10a3-3e55-434a-a9fc-29bf3994780f": {"__data__": {"text": "(TTY: 711) s\u1ebd c\u00f3 nh\u00e2n vi\u00ean n\u00f3i ti\u1ebfng Vi\u1ec7t gi\u00fap \u0111\u1ee1 qu\u00ed v\u1ecb. \u0110\u00e2y l\u00e0 \nd\u1ecbch v\u1ee5 mi\u1ec5n ph\u00ed.\nGerman: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu \nunserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie \nunter 1-877-320-1235 (TTY: 711). Man wird Ihnen dort auf Deutsch weiterhelfen. \nDieser Service ist kostenlos.\nKorean:  \ub2f9\uc0ac\ub294 \uc758\ub8cc \ubcf4\ud5d8 \ub610\ub294 \uc57d\ud488 \ubcf4\ud5d8\uc5d0 \uad00\ud55c \uc9c8\ubb38\uc5d0 \ub2f5\ud574 \ub4dc\ub9ac\uace0\uc790 \ubb34\ub8cc \ud1b5\uc5ed \uc11c\ube44\uc2a4\ub97c \uc81c\uacf5\ud558\uace0 \n\uc788\uc2b5\ub2c8\ub2e4. \ud1b5\uc5ed \uc11c\ube44\uc2a4\ub97c \uc774\uc6a9\ud558\ub824\uba74 \uc804\ud654  1-877-320-1235 (TTY: 711) \ubc88\uc73c\ub85c \ubb38\uc758\ud574 \uc8fc\uc2ed\uc2dc\uc624 . \n\ud55c\uad6d\uc5b4\ub97c \ud558\ub294 \ub2f4\ub2f9\uc790\uac00 \ub3c4\uc640 \ub4dc\ub9b4 \uac83\uc785\ub2c8\ub2e4. \uc774 \uc11c\ube44\uc2a4\ub294 \ubb34\ub8cc\ub85c \uc6b4\uc601\ub429\ub2c8\ub2e4.  \nH0028_PRDEN23_M", "doc_id": "96ae10a3-3e55-434a-a9fc-29bf3994780f", "embedding": null, "doc_hash": "13af101350976e28264f1c5556279062adcebba7c817b9244558cf634c1dcf70", "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus (HMO) - CMS Plan Rating.pdf"}, "node_info": {"start": 1735, "end": 2267, "_node_type": "1"}, "relationships": {"1": "4bc1f1b7-8730-4a4f-8e64-705677c17aad", "2": "65d6c4c8-708b-4cee-a3e1-79b9d88e6a46"}}, "__type__": "1"}, "e056ae5f-1b79-4e74-8fda-d124bf45f28d": {"__data__": {"text": "  GHHLNNXEN 0522Russian:  \u0415\u0441\u043b\u0438 \u0443 \u0432\u0430\u0441 \u0432\u043e\u0437\u043d\u0438\u043a\u043d\u0443\u0442 \u0432\u043e\u043f\u0440\u043e\u0441\u044b \u043e\u0442\u043d\u043e\u0441\u0438\u0442\u0435\u043b\u044c\u043d\u043e \u0441\u0442\u0440\u0430\u0445\u043e\u0432\u043e\u0433\u043e \u0438\u043b\u0438 \n\u043c\u0435\u0434\u0438\u043a\u0430\u043c\u0435\u043d\u0442\u043d\u043e\u0433\u043e \u043f\u043b\u0430\u043d\u0430, \u0432\u044b \u043c\u043e\u0436\u0435\u0442\u0435 \u0432\u043e\u0441\u043f\u043e\u043b\u044c\u0437\u043e\u0432\u0430\u0442\u044c\u0441\u044f \u043d\u0430\u0448\u0438\u043c\u0438 \u0431\u0435\u0441\u043f\u043b\u0430\u0442\u043d\u044b\u043c\u0438 \n\u0443\u0441\u043b\u0443\u0433\u0430\u043c\u0438 \u043f\u0435\u0440\u0435\u0432\u043e\u0434\u0447\u0438\u043a\u043e\u0432. \u0427\u0442\u043e\u0431\u044b \u0432\u043e\u0441\u043f\u043e\u043b\u044c\u0437\u043e\u0432\u0430\u0442\u044c\u0441\u044f \u0443\u0441\u043b\u0443\u0433\u0430\u043c\u0438 \u043f\u0435\u0440\u0435\u0432\u043e\u0434\u0447\u0438\u043a\u0430, \n\u043f\u043e\u0437\u0432\u043e\u043d\u0438\u0442\u0435 \u043d\u0430\u043c \u043f\u043e \u0442\u0435\u043b\u0435\u0444\u043e\u043d\u0443 1-877-320-1235 (TTY: 711). \u0412\u0430\u043c \u043e\u043a\u0430\u0436\u0435\u0442 \u043f\u043e\u043c\u043e\u0449\u044c \n\u0441\u043e\u0442\u0440\u0443\u0434\u043d\u0438\u043a, \u043a\u043e\u0442\u043e\u0440\u044b\u0439 \u0433\u043e\u0432\u043e\u0440\u0438\u0442 \u043f\u043e-p\u0443\u0441\u0441\u043a\u0438. \u0414\u0430\u043d\u043d\u0430\u044f\u00a0\u0443\u0441\u043b\u0443\u0433\u0430 \u0431\u0435\u0441\u043f\u043b\u0430\u0442\u043d\u0430\u044f.\n\u0625\u0646\u0646\u0627 \u0646\u0642\u062f\u0645 \u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0645\u062a\u0631\u062c\u0645 \u0627\u0644\u0641\u0648\u0631\u064a \u0627\u0644\u0645\u062c\u0627\u0646\u064a\u0629 \u0644\u0644\u0625\u062c\u0627\u0628\u0629 \u0639\u0646 \u0623\u064a \u0623\u0633\u0626\u0644\u0629 \u062a\u062a\u0639\u0644\u0642 \u0628\u0627\u0644\u0635\u062d\u0629  Arabic\n\u0623\u0648 \u062c\u062f\u0648\u0644 \u0627\u0644\u0623\u062f\u0648\u064a\u0629 \u0644\u062f\u064a\u0646\u0627. \u0644\u0644\u062d\u0635\u0648\u0644 \u0639\u0644\u0649 \u0645\u062a\u0631\u062c\u0645 \u0641\u0648\u0631\u064a\u060c \u0644\u064a\u0633 \u0639\u0644\u064a\u0643 \u0633\u0648\u0649 \u0627\u0644\u0627\u062a\u0635\u0627\u0644 \u0628\u0646\u0627\n\u0633\u064a\u0642\u0648\u0645 \u0634\u062e\u0635 \u0645\u0627 \u064a\u062a\u062d\u062f\u062b \u0627\u0644\u0639\u0631\u0628\u064a\u0629 \u0628\u0645\u0633\u0627\u0639\u062f\u062a\u0643. \u0647\u0630\u0647 1-877-320-1235 (TTY: 711)  \u0639\u0644\u0649\n\u062e\u062f\u0645\u0629 \u0645\u062c\u0627\u0646\u064a\u0629.\nHindi:  \u0939\u092e\u093e\u0930\u0947 \u0938\u094d\u093e \u0938\u094d\u0925\u094d\u092f \u0925\u094d\u092f \u093e \u0926\u094d\u093e \u0915\u0940 \u0925\u094d\u092f \u094b\u091c\u0928\u093e \u0915 \u0947  \u092c\u093e\u0930\u0947 \u092e\u0947\u0902 \u0906\u092a\u0915 \u0947  \u0915\u0915 \u0938\u0940 \u092d\u0940 \u092a\u094d\u0930\u0936\u094d\u0928 \u0915 \u0947  \u091c\u094d \u093e\u092c \u0926\u0947\u0928\u0947 \u0915 \u0947  \u0932\u093f\u090f \u0939\u092e\u093e\u0930\u0947 \u092a\u093e\u0938 \u092e\u0941\u092b\u094d\u0924 \n\u0926\u0941\u092d\u093e\u0915\u093f\u0925\u094d\u092f\u093e \u0938\u0947\u094d\u093e\u090f\u0901 \u0909\u092a\u093f \u092c\u094d\u0927 \u0939\u0948\u0902. \u090f\u0915 \u0926\u0941\u092d\u093e\u0915 \u093f\u0925\u094d\u092f\u093e \u092a\u094d\u0930\u093e\u092a\u094d\u0924 \u0915\u0930\u0928\u0947 \u0915 \u0947  \u0932\u093f\u090f, \u092c\u0938 \u0939\u092e\u0947\u0902 1-877-320-1235 (TTY: 711) \u092a\u0930 \n\u092b\u094b\u0928 \u0915\u0930\u0947\u0902. \u0915\u094b\u0908 \u0935\u094d\u092f\u0932 \u0924\u093f \u091c\u094b \u0915\u0939\u0928 \u0926\u0926\u0940 \u092c\u094b\u093f\u094d\u0924\u093e \u0939\u0948 \u0906\u092a\u0915\u0940 \u092e\u0926\u0926 \u0915\u0930 \u0938\u0915\u094d\u0924 \u093e \u0939\u0948. \u0925\u094d\u092f \u0939 \u090f\u0915 \u092e\u0941\u092b\u094d\u0924 \u0938\u0947\u094d \u093e \u0939\u0948.", "doc_id": "e056ae5f-1b79-4e74-8fda-d124bf45f28d", "embedding": null, "doc_hash": "1539d814c35d66817701a67734c09e5cee2da2da33cec9c597bb604d0f1e63d3", "extra_info": {"page_label": "4", "file_name": "Humana Gold Plus (HMO) - CMS Plan Rating.pdf"}, "node_info": {"start": 0, "end": 915, "_node_type": "1"}, "relationships": {"1": "86c64624-4863-40cf-a897-99aada3d293e", "3": "1787b3bf-8484-42f5-9e3c-123532075e09"}}, "__type__": "1"}, "1787b3bf-8484-42f5-9e3c-123532075e09": {"__data__": {"text": "\nItalian:  \u00c8 disponibile un servizio di interpretariato gratuito per rispondere a \neventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, \ncontattare il numero 1-877-320-1235 (TTY: 711). Un nostro incaricato che parla \nItalianovi fornir\u00e0 l\u2019assistenza necessaria. \u00c8\u00a0un servizio gratuito.\nPortugues:  Dispomos de servi\u00e7os de interpreta\u00e7\u00e3o gratuitos para responder \na\u00a0qualquer quest\u00e3o que tenha acerca do nosso plano de sa\u00fade ou de medica\u00e7\u00e3o. \nPara obter um int\u00e9rprete, contacte-nos atrav\u00e9s do n\u00famero 1-877-320-1235 \n(TTY:\u00a0711). Ir\u00e1 encontrar algu\u00e9m que fale\u00a0o idioma Portugu\u00eas para o ajudar. \nEste\u00a0servi\u00e7o \u00e9\u00a0gratuito.\nFrench Creole: Nou genyen s\u00e8vis ent\u00e8pr\u00e8t gratis pou reponn tout kesyon ou ta \ngenyen kons\u00e8nan plan medikal oswa dw\u00f2g nou an. Pou jwenn yon ent\u00e8pr\u00e8t, jis rele \nnou nan 1-877-320-1235 (TTY: 711). Yon moun ki pale Krey\u00f2l kapab ede w. Sa a se \nyon s\u00e8vis ki gratis.\nPolish:  Umo\u017cliwiamy bezp\u0142atne skorzystanie z us\u0142ug t\u0142umacza ustnego, kt\u00f3ry \npomo\u017ce w\u00a0uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania \nlek\u00f3w. Aby skorzysta\u0107 z pomocy t\u0142umacza znaj\u0105cego j\u0119zyk polski, nale\u017cy zadzwoni\u0107 \npod numer 1-877-320-1235 (TTY: 711). Ta\u00a0us\u0142uga jest bezp\u0142atna.\nJapanese  :\u00a0\u5f53\u793e\u306e\u5065\u5eb7\u5065\u5eb7\u4fdd\u967a\u3068\u85ac\u54c1\u51e6\u65b9\u85ac\u30d7\u30e9\u30f3\u306b\u95a2\u3059\u308b\u3054\u8cea\u554f\u306b\u304a\u7b54\u3048\u3059\u308b\u305f\u3081\u306b\u200c\u3001\u7121\u6599\u306e\u901a\u8a33\n\u30b5\u200c\u30fc\u30d3\u30b9\u304c\u3042\u308a\u307e\u3059\u3054\u3056\u3044\u307e\u3059\u200c\u3002\u901a\u8a33\u3092\u3054\u7528\u547d\u306b\u306a\u308b\u306b\u306f\u200c\u3001 1-877-320-1235 (TTY : 711 )\u306b\u304a\u96fb\u8a71\u304f\u3060\n\u3055\u3044\u200c\u3002\u65e5\u672c\u8a9e\u3092\u8a71\u3059\u4eba\u8005\u304c\u652f\u63f4\u3044\u305f\u3057\u307e\u3059\u200c\u3002\u3053\u308c\u306f\u7121\u6599\u306e\u30b5\u200c\u30fc\u30d3\u30b9\u3067\u3059\u200c\u3002\nH0028_PRDEN23_M", "doc_id": "1787b3bf-8484-42f5-9e3c-123532075e09", "embedding": null, "doc_hash": "a8374a568f0db37729a55aec5b4adc96937d25852d63f9403f84b692b7faa143", "extra_info": {"page_label": "4", "file_name": "Humana Gold Plus (HMO) - CMS Plan Rating.pdf"}, "node_info": {"start": 916, "end": 2285, "_node_type": "1"}, "relationships": {"1": "86c64624-4863-40cf-a897-99aada3d293e", "2": "e056ae5f-1b79-4e74-8fda-d124bf45f28d"}}, "__type__": "1"}, "d7f2211e-3ab3-4cdb-bcaa-0834dc35de19": {"__data__": {"text": "H0028_EOC_MAPD_HMO_014000_2023_C H0028014000EOC23EOC082\nYour 2023 \nEvidence of Coverage", "doc_id": "d7f2211e-3ab3-4cdb-bcaa-0834dc35de19", "embedding": null, "doc_hash": "434a7b52cb35bac8daa08cf7708cf2fbf257992924697947338acef2e8617a5a", "extra_info": {"page_label": "1", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 87, "_node_type": "1"}, "relationships": {"1": "ead21676-478c-4016-8130-55d7a1b30667"}}, "__type__": "1"}, "6f7923d3-d1f3-4acc-9ff5-c8fd6a3b0aa6": {"__data__": {"text": "Thanks for being a Humana Gold Plus H0028-014 (HMO) member. We value your  \nmembership, and we're dedicated to helping you be the best you want to be. \nThis Evidence of Coverage contains important information about your plan. This book is a very  \ndetailed document with the full, legal description of your benefits and costs. You should keep  \nthis document for reference throughout the plan year.\nHumana cares about your well-being\nWe look forward to being your partner in health for many years to come. If you have any  \nquestions, we're here to help.", "doc_id": "6f7923d3-d1f3-4acc-9ff5-c8fd6a3b0aa6", "embedding": null, "doc_hash": "c3c8b0e8a7f421f1aa51703966725aa3e8b4706e5630d67f68be96a2cf631708", "extra_info": {"page_label": "2", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 554, "_node_type": "1"}, "relationships": {"1": "07bf2223-6f67-4480-9464-061c9446a7ba"}}, "__type__": "1"}, "72900278-f191-49f6-abfd-117594e73859": {"__data__": {"text": "H0028_EOC_MAPD_HMO_014000_2023_C H0028014000EOC232023\nHumana Gold Plus\nH0028-014 (HMO)\nSt. Louis\nSt. Louis Metro areaEvidence of Coverage", "doc_id": "72900278-f191-49f6-abfd-117594e73859", "embedding": null, "doc_hash": "a758e4b060a423375fc6cd8912cb29dcbb2a3d181adbd8c9c9571d32200f3cf9", "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 137, "_node_type": "1"}, "relationships": {"1": "3e310d24-ca9b-406d-afa6-ca08e60a881f"}}, "__type__": "1"}, "b28491b4-a24c-4960-a6f8-3a607e4bf97e": {"__data__": {"text": "OMB Approval 0938-1051 (Expires: February 29, 2024)January 1 - December 31, 2023\nEvidence of Coverage:\nYour Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Humana Gold \nPlus H0028-014 (HMO)\nThis document gives you the details about your Medicare health care and prescription drug coverage from January \n1 - December 31, 2023. This is an important legal document. Please keep it in a safe place.\nFor questions about this document, please contact Customer Care at 1-800-457-4708 for additional \ninformation. (TTY users should call 711). Hours are from 8 a.m. to 8 p.m. seven days a week from Oct. 1 - \nMar. 31 and 8 a.m. to 8 p.m. Monday-Friday from Apr. 1 - Sept. 30.\nThis plan, Humana Gold Plus H0028-014 (HMO), is offered by CHA HMO, Inc., a Humana company. (When this \nEvidence of Coverage says \"we,\" \"us,\" or \"our,\" it means CHA HMO, Inc., a Humana company. When it says \"plan\" or \n\"our plan,\" it means Humana Gold Plus H0028-014 (HMO).)\nThis document is available for free in Spanish.\nThis information is available in a different format, including Braille, large print, and audio. Please call Customer Care \nat the number listed above if you need plan information in another format.\nBenefits, premiums, deductibles, and/or copayments/coinsurance may change on January 1, 2024.\nThe formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when \nnecessary. We will notify affected enrollees about changes at least 30 days in advance.\nThis document explains your benefits and rights. Use this document to understand about: \n\u2022Your plan premium and cost sharing; \n\u2022Your medical and prescription drug benefits; \n\u2022How to file a complaint if you are not satisfied with a service or treatment; \n\u2022How to contact us if you need further assistance; and,\n\u2022Other protections required by Medicare law. \nH0028_EOC_MAPD_HMO_014000_2023_C", "doc_id": "b28491b4-a24c-4960-a6f8-3a607e4bf97e", "embedding": null, "doc_hash": "b471e3b8094946ba29c0e1f5be471b5e24200e875ffc555b5c2157b74871d3dd", "extra_info": {"page_label": "5", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1904, "_node_type": "1"}, "relationships": {"1": "a7edf12c-ddf8-4bd2-9d1e-74fe6714b246"}}, "__type__": "1"}, "9ff278e1-9fa8-4fdf-9cb0-681c4435c7c2": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 6\nTable of Contents\n2023 Evidence of Coverage\nTable of Contents\nChapter 1.Getting started as a member.....................................................................9\nSECTION 1 Introduction..........................................................................................10\nSECTION 2 What makes you eligible to be a plan member?..............................................11\nSECTION 3 Important membership materials you will receive..........................................11\nSECTION 4 Your monthly costs for Humana Gold Plus H0028-014 (HMO)............................13\nSECTION 5 More information about your monthly premium.............................................15\nSECTION 6 Keeping your plan membership record up to date...........................................18\nSECTION 7 How other insurance works with our plan......................................................19\nChapter 2.Important phone numbers and resources..................................................21\nSECTION 1 Humana Gold Plus H0028-014 (HMO) contacts (how to contact us, including how \nto reach Customer Care ) ..........................................................................22\nSECTION 2 Medicare (how to get help and information directly from the Federal Medicare \nprogram)...............................................................................................25\nSECTION 3 State Health Insurance Assistance Program (free help, information, and \nanswers to your questions about Medicare)...................................................26\nSECTION 4 Quality Improvement Organization.............................................................27\nSECTION 5 Social Security ........................................................................................27\nSECTION 6 Medicaid...............................................................................................28\nSECTION 7 Information about programs to help people pay for their prescription drugs..........29\nSECTION 8 How to contact the Railroad Retirement Board ..............................................31\nSECTION 9 Do you have \"group insurance\" or other health insurance from an employer? .......32\nChapter 3.Using the plan for your medical services....................................................33\nSECTION 1 Things to know about getting your medical care as a member of our plan............34\nSECTION 2 Use providers in the plan's network to get your medical care.............................35\nSECTION 3 How to get services when you have an emergency or urgent need for care or \nduring a disaster.....................................................................................38\nSECTION 4 What if you are billed directly for the full cost of your services?...........................40\nSECTION 5 How are your medical services covered when you are in a \"clinical research \nstudy\"?.................................................................................................41\nSECTION 6 Rules for getting care in a \"religious non-medical health care institution\".............42\nSECTION 7 Rules for ownership of durable medical equipment.........................................43\nChapter 4.Medical Benefits Chart (what is covered and what you pay)..........................45\nSECTION 1 Understanding your out-of-pocket costs for covered services............................46\nSECTION 2 Use the Medical Benefits Chart to find out what is covered and how much you \nwill pay.................................................................................................47\nSECTION 3 What services are not covered by the plan?...................................................84\nChapter 5.Using the plan\u2019s coverage for Part D prescription drugs...............................90\nSECTION 1 Introduction..........................................................................................91\nSECTION 2 Fill your prescription at a network pharmacy or through the plan's mail-order\n service .................................................................................................91", "doc_id": "9ff278e1-9fa8-4fdf-9cb0-681c4435c7c2", "embedding": null, "doc_hash": "8cc68ba328895de6b2ac51f191381347b1f5f755daeafd657c429316d201ede3", "extra_info": {"page_label": "6", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 4156, "_node_type": "1"}, "relationships": {"1": "1cd7ed3d-28fc-486b-a305-fe41714edd67"}}, "__type__": "1"}, "0ade37bd-3aaa-4a62-93ae-bd818203bd28": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 7\nTable of Contents\nSECTION 3 Your drugs need to be in the plan's \"Drug Guide\"............................................95\nSECTION 4 There are restrictions on coverage for some drugs...........................................97\nSECTION 5 What if one of your drugs is not covered in the way you'd like it to be covered?......98\nSECTION 6 What if your coverage changes for one of your drugs?....................................101\nSECTION 7 What types of drugs are not covered by the plan?..........................................103\nSECTION 8 Filling a prescription...............................................................................104\nSECTION 9 Part D drug coverage in special situations....................................................104\nSECTION 10Programs on drug safety and managing medications....................................106\nChapter 6.What you pay for your Part D prescription drugs.......................................108\nSECTION 1 Introduction.........................................................................................109\nSECTION 2 What you pay for a drug depends on which \u201cdrug payment stage\u201d you are in \nwhen you get the drug............................................................................111\nSECTION 3 We send you reports that explain payments for your drugs and which payment \nstage you are in.....................................................................................111\nSECTION 4 There is no deductible for \nHumana Gold Plus H0028-014 (HMO).........................................................113\nSECTION 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and \nyou pay your share................................................................................113\nSECTION 6 Costs in the Coverage Gap Stage...............................................................117\nSECTION 7 During the Catastrophic Coverage Stage, the plan pays most of the cost for your \ndrugs..................................................................................................120\nSECTION 8 Additional benefits information................................................................120\nSECTION 9 Part D Vaccines. What you pay for depends on how and where you get them......120\nChapter 7.Asking us to pay our share of a bill you have received for covered medical \nservices or drugs..................................................................................123\nSECTION 1 Situations in which you should ask us to pay our share of the cost of your covered \nservices or drugs....................................................................................124\nSECTION 2 How to ask us to pay you back or to pay a bill you have received.......................126\nSECTION 3 We will consider your request for payment and say yes or no...........................126\nChapter 8.Your rights and responsibilities..............................................................127\nSECTION 1 Our plan must honor your rights and cultural sensitivities as a member of \nthe plan...............................................................................................128\nSECTION 2 You have some responsibilities as a member of the plan.................................137\nChapter 9.What to do if you have a problem or complaint (coverage decisions, \nappeals, complaints)............................................................................139\nSECTION 1 Introduction.........................................................................................140\nSECTION 2 Where to get more information and personalized assistance...........................140\nSECTION 3 To deal with your problem, which process should you use?..............................141\nSECTION 4 A guide to the basics of coverage decisions and appeals ................................141\nSECTION 5 Your medical care: How to ask for a coverage decision or make an appeal of a \ncoverage decision..................................................................................143\nSECTION 6 Your Part D prescription drugs: How to ask for a coverage decision or make \nan appeal ............................................................................................150\nSECTION 7 How to ask us to cover a longer inpatient hospital stay if you think the doctor is \ndischarging you too soon........................................................................158", "doc_id": "0ade37bd-3aaa-4a62-93ae-bd818203bd28", "embedding": null, "doc_hash": "efc21db147df4182cf3ff6d57e1bc5f3d63e8da8fc531cfc05a17c6b7cc8fee6", "extra_info": {"page_label": "7", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 4501, "_node_type": "1"}, "relationships": {"1": "9a45a111-0d63-4a6d-a051-ef74ab85bd94"}}, "__type__": "1"}, "11f88103-34d2-44ab-ac8b-7e9e1738f9f2": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 8\nTable of Contents\nSECTION 8 How to ask us to keep covering certain medical services if you think your \ncoverage is ending too soon.....................................................................163\nSECTION 9 Taking your appeal to Level 3 and beyond...................................................169\nSECTION 10How to make a complaint about quality of care, waiting times, customer service, \nor other concerns..................................................................................171\nChapter 10.Ending your membership in the plan.......................................................175\nSECTION 1 Introduction to ending your membership in our plan .....................................176\nSECTION 2 When can you end your membership in our plan?.........................................176\nSECTION 3 How do you end your membership in our plan? ............................................179\nSECTION 4 Until your membership ends, you must keep getting your medical services and \nDrugs through our plan ..........................................................................179\nSECTION 5 Humana Gold Plus H0028-014 (HMO)  must end your membership \nin the plan in certain situations.................................................................180\nChapter 11.Legal notices.......................................................................................182\nSECTION 1 Notice about governing law .....................................................................183\nSECTION 2 Notice about nondiscrimination................................................................183\nSECTION 3 Notice about Medicare Secondary Payer subrogation rights.............................183\nSECTION 4 Additional Notice about Subrogation (Recovery from a Third Party) ...................183\nSECTION 5 Notice of coordination of benefits..............................................................184\nChapter 12.Definitions of important words...............................................................187\nExhibit A. State Agency Contact Information..........................................................197\nLists the names, addresses, phone numbers, and other contact information for a  \nvariety of helpful resources in your state.", "doc_id": "11f88103-34d2-44ab-ac8b-7e9e1738f9f2", "embedding": null, "doc_hash": "789b81edfcfe2bc7da238f62499152350165c6c6d582bd79190815c8acad8a46", "extra_info": {"page_label": "8", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2313, "_node_type": "1"}, "relationships": {"1": "5727633c-2a70-4b63-850e-f9a827e549c2"}}, "__type__": "1"}, "6a7619ee-346c-4a47-931a-cf535877e28f": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 9\nChapter 1 Getting started as a memberEOC082\nCHAPTER 1:\nGetting started as a member", "doc_id": "6a7619ee-346c-4a47-931a-cf535877e28f", "embedding": null, "doc_hash": "16121edf64f19ef3667148581c0e1eeb1cefb56054de5cb2650f2f7fba09672f", "extra_info": {"page_label": "9", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 147, "_node_type": "1"}, "relationships": {"1": "3301a21a-1eac-4e82-a4f8-d1a7799151ac"}}, "__type__": "1"}, "7d176641-205b-4e70-95e0-11dabb434b0b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 10\nChapter 1 Getting started as a member\nSECTION 1 Introduction\nSection 1.1 You are enrolled in Humana Gold Plus H0028-014 (HMO), which is a  \nMedicare HMO  \nYou are covered by Medicare, and you have chosen to get your Medicare health care and your prescription drug \ncoverage through our plan, Humana Gold Plus H0028-014 (HMO). We are required to cover all Part A and Part B \nservices. However, cost sharing and provider access in this plan differ from Original Medicare.\nHumana Gold Plus H0028-014 (HMO) is a Medicare Advantage HMO Plan (HMO stands for Health Maintenance \nOrganization) approved by Medicare and run by a private company. \nCoverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient Protection \nand Affordable Care Act\u2019s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue \nService (IRS) website at: www.irs.gov/Affordable-Care-Act/Individuals-and-Families for more information.\nSection 1.2 What is the Evidence of Coverage document about?\nThis Evidence of Coverage document tells you how to get your medical care and prescription drugs. It explains your \nrights and responsibilities, what is covered, what you pay as a member of the plan, and how to file a complaint if \nyou are not satisfied with a decision or treatment.\nThe words \"coverage\" and \"covered services\" refer to the medical care and services and the prescription drugs \navailable to you as a member of Humana Gold Plus H0028-014 (HMO).\nIt's important for you to learn what the plan's rules are and what services are available to you. We encourage you \nto set aside some time to look through this Evidence of Coverage document.\nIf you are confused or concerned, or just have a question, please contact Customer Care.\nSection 1.3 Legal information about the Evidence of Coverage\nThis Evidence of Coverage is part of our contract with you about how Humana Gold Plus H0028-014 (HMO) covers \nyour care. Other parts of this contract include your enrollment form, the Prescription Drug Guide (Formulary), and \nany notices you receive from us about changes to your coverage or conditions that affect your coverage. These \nnotices are sometimes called \"riders\" or \"amendments.\"\nThe contract is in effect for months in which you are enrolled in Humana Gold Plus H0028-014 (HMO) between \nJanuary 1, 2023 and December 31, 2023.\nEach calendar year, Medicare allows us to make changes to the plans that we offer. This means we can change the \ncosts and benefits of Humana Gold Plus H0028-014 (HMO) after December 31, 2023. We can also choose to stop \noffering the plan in your service area, after December 31, 2023.\nMedicare (the Centers for Medicare & Medicaid Services) must approve Humana Gold Plus H0028-014 (HMO) each \nyear. You can continue each year to get Medicare coverage as a member of our plan as long as we choose to \ncontinue to offer the plan and Medicare renews its approval of the plan.", "doc_id": "7d176641-205b-4e70-95e0-11dabb434b0b", "embedding": null, "doc_hash": "0e5e9085bf9d24122e8cd541ead21adce63ce28bf2f36cc93d31e8f3e1f39d6c", "extra_info": {"page_label": "10", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3006, "_node_type": "1"}, "relationships": {"1": "8577f61f-7da5-4b39-aa64-93207290cb2f"}}, "__type__": "1"}, "ec2b1ff7-edf0-45f2-9a4f-5e5b05ec5821": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 11\nChapter 1 Getting started as a member\nSECTION 2 What makes you eligible to be a plan member?\nSection 2.1 Your eligibility requirements\nYou are eligible for membership in our plan as long as:\n\u2022You have both Medicare Part A and Medicare Part B\n\u2022-- and -- you live in our geographic service area (Section 2.2 below describes our service area). Incarcerated \nindividuals are not considered living in the geographic service area even if they are physically located in it.\n\u2022-- and -- you are a United States citizen or are lawfully present in the United States\nSection 2.2 Here is the plan service area for Humana Gold Plus H0028-014 (HMO)\nHumana Gold Plus H0028-014 (HMO) is available only to individuals who live in our plan service area. To remain a \nmember of our plan, you must continue to reside in the plan service area. The service area is described below.\nOur service area includes the following county/counties in Illinois and Missouri: Bond, Calhoun, Clinton, Jersey, \nMacoupin, Madison, St. Clair Counties, IL; Audrain, Boone, Callaway, Crawford, Franklin, Iron, Jefferson, Lincoln, \nMadison, Perry, Pike, St. Charles, St. Francois, St. Louis, St. Louis City, Warren, Washington Counties, MO.\nIf you plan to move out of the service area, you cannot remain a member of this plan. Please contact Customer \nCare to see if we have a plan in your new area. When you move, you will have a Special Enrollment Period that will \nallow you to switch to Original Medicare or enroll in a Medicare health or drug plan that is available in your new \nlocation.\nIt is also important that you call Social Security if you move or change your mailing address. You can find phone \nnumbers and contact information for Social Security in Chapter 2, Section 5.\nSection 2.3 U.S. Citizen or Lawful Presence\nA member of a Medicare health plan must be a U.S. citizen or lawfully present in the United States. Medicare (the \nCenters for Medicare & Medicaid Services) will notify Humana Gold Plus H0028-014 (HMO) if you are not eligible to \nremain a member on this basis. Humana Gold Plus H0028-014 (HMO) must disenroll you if you do not meet this \nrequirement.\nSECTION 3 Important membership materials you will receive\nSection 3.1 Your plan membership card\nWhile you are a member of our plan, you must use your membership card whenever you get services covered by \nthis plan and for prescription drugs you get at network pharmacies. You should also show the provider your \nMedicaid card, if applicable. Here\u2019s a sample membership card to show you what yours will look like:", "doc_id": "ec2b1ff7-edf0-45f2-9a4f-5e5b05ec5821", "embedding": null, "doc_hash": "86bd7cfa7f3e64974c37e19d846199b6f3d9a8cf8b8943ed7268fc72fa4296d7", "extra_info": {"page_label": "11", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2617, "_node_type": "1"}, "relationships": {"1": "7d021290-03b8-4928-ae52-30e37ea681e1"}}, "__type__": "1"}, "842b0cef-7ec7-439c-a04b-fbbbae3da790": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 12\nChapter 1 Getting started as a member\nDo NOT use your red, white, and blue Medicare card for covered medical services while you are a member of this \nplan. If you use your Medicare card instead of your Humana Gold Plus H0028-014 (HMO) membership card, you \nmay have to pay the full cost of medical services yourself. Keep your Medicare card in a safe place. You may be \nasked to show it if you need hospital services, hospice services, or participate in Medicare approved clinical \nresearch studies also called clinical trials.\nIf your plan membership card is damaged, lost, or stolen, call Customer Care right away and we will send you a \nnew card.\nSection 3.2 Provider Directory\nThe Provider Directory lists our network providers, durable medical equipment suppliers, and pharmacies.\nNetwork providers are the doctors and other health care professionals, medical groups, durable medical \nequipment suppliers, hospitals, and other health care facilities that have an agreement with us to accept our \npayment and any plan cost-sharing as payment in full.\nYou must use network providers to get your medical care and services. If you go elsewhere without proper \nauthorization you will have to pay in full. The only exceptions are emergencies, urgently needed services when the \nnetwork is not available (that is, in situations when it is unreasonable or not possible to obtain services in-network), \nout-of-area dialysis services, and cases in which Humana Gold Plus H0028-014 (HMO) authorizes use of \nout-of-network providers.\nThe Provider Directory lists our network pharmacies. Network pharmacies are all of the pharmacies that have \nagreed to fill covered prescriptions for our plan members. See Chapter 5, Section 2.5 for information on when you \ncan use pharmacies that are not in the plan\u2019s network. You can use the Provider Directory to find the network \npharmacy you want to use.\nThe Provider Directory will also tell you which of the pharmacies in our network have preferred cost sharing, which \nmay be lower than the standard cost-sharing offered by other network pharmacies for some drugs. \nIf you don\u2019t have the Provider Directory, you can get a copy from Customer Care. You can also find this information \non our website at Humana.com/PlanDocuments. Both Customer Care and the website can give you the most \nup-to-date information about changes in our network providers and pharmacies.", "doc_id": "842b0cef-7ec7-439c-a04b-fbbbae3da790", "embedding": null, "doc_hash": "5ee458dbe40450ec316a6a10997fa46ef9d02076aa0dbb6db8717c4f7a805c26", "extra_info": {"page_label": "12", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2464, "_node_type": "1"}, "relationships": {"1": "04296aab-2a9d-4182-80b0-9d6fd5485bfa"}}, "__type__": "1"}, "7609548b-f30b-41e5-afcc-8b6b8e2aedcd": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 13\nChapter 1 Getting started as a member\nSection 3.3 The plan's Prescription Drug Guide (Formulary)\nThe plan has a Prescription Drug Guide (Formulary). We call it the \"Drug Guide\" for short. It tells which Part D \nprescription drugs are covered under the Part D benefit included in Humana Gold Plus H0028-014 (HMO). The drugs \non this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet \nrequirements set by Medicare. Medicare has approved the Humana Gold Plus H0028-014 (HMO) Drug Guide.\nThe Drug Guide also tells you if there are any rules that restrict coverage for your drugs.\nWe will provide you a copy of the Drug Guide. The Drug Guide we provide you includes information for the covered \ndrugs that are most commonly used by our members. However, we cover additional drugs that are not included in \nthe provided Drug Guide. If one of your drugs is not listed in the Drug Guide, you should visit our website or contact \nCustomer Care to find out if we cover it. To get the most complete and current information about which drugs are \ncovered, you can visit the plan's website (Humana.com/PlanDocuments) or call Customer Care.\nSECTION 4 Your monthly costs for Humana Gold Plus H0028-014 (HMO)\nYour costs may include the following:\n\u2022Plan Premium (Section 4.1)\n\u2022Monthly Medicare Part B Premium (Section 4.2)\n\u2022Part D Late Enrollment Penalty (Section 4.3)\n\u2022Income Related Monthly Adjusted Amount (Section 4.4)\nMedicare Part B and Part D premiums differ for people with different incomes. If you have questions about these  \npremiums review your copy of Medicare & You 2023 handbook, the section called \"2023 Medicare Costs.\" If you  \nneed a copy, you can download it from the Medicare website (www.medicare.gov). Or you can order a printed copy  \nby phone at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.\nSection 4.1 Plan Premium\nYou do not pay a separate monthly plan premium for Humana Gold Plus H0028-014 (HMO).\nSection 4.2 Monthly Medicare Part B Premium\nMany members are required to pay other Medicare premiums\nYou must continue paying your Medicare premiums to remain a member of the plan. This includes your \npremium for Part B. It may also include a premium for Part A which affects members who aren\u2019t eligible for \npremium free Part A.\nSection 4.3 Part D Late Enrollment Penalty\nSome members are required to pay a Part D late enrollment penalty. The Part D late enrollment penalty is an \nadditional premium that must be paid for Part D coverage if at any time after your initial enrollment period is over, \nthere is a period of 63 days or more in a row when you did not have Part D or other creditable prescription drug \ncoverage. \"Creditable prescription drug coverage\" is coverage that meets Medicare\u2019s minimum standards since it is ", "doc_id": "7609548b-f30b-41e5-afcc-8b6b8e2aedcd", "embedding": null, "doc_hash": "30611f2dab6c26d3ba5e6d99e7796c168173030e8d0614ae7635dde424033b2c", "extra_info": {"page_label": "13", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2906, "_node_type": "1"}, "relationships": {"1": "13f8f39f-0fd5-4540-9645-4f5c7e4dca54"}}, "__type__": "1"}, "9b06b38a-6cbe-465f-9e35-a4db146f5a89": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 14\nChapter 1 Getting started as a member\nexpected to pay, on average, at least as much as Medicare\u2019s standard prescription drug coverage. The cost of the \nlate enrollment penalty depends on how long you went without Part D or other creditable prescription drug \ncoverage. You will have to pay this penalty for as long as you have Part D coverage.\nWhen you first enroll in Humana Gold Plus H0028-014 (HMO), we let you know the amount of the penalty. If you do \nnot pay your Part D late enrollment penalty, you could lose your prescription drug benefits.\nYou will not have to pay it if:\n\u2022You receive \"Extra Help\" from Medicare to pay for your prescription drugs.\n\u2022You have gone less than 63 days in a row without creditable coverage.\n\u2022You have had creditable drug coverage through another source such as a former employer, union, TRICARE, \nor Department of Veterans Affairs. Your insurer or your human resources department will tell you each year if \nyour drug coverage is creditable coverage. This information may be sent to you in a letter or included in a \nnewsletter from the plan. Keep this information, because you may need it if you join a Medicare drug plan \nlater.\n\u2013Note: Any notice must state that you had \u201ccreditable\u201d prescription drug coverage that is expected to pay \nas much as Medicare\u2019s standard prescription drug plan pays.\n\u2013Note: The following are not creditable prescription drug coverage: prescription drug discount cards, free \nclinics, and drug discount websites.\nMedicare determines the amount of the penalty. Here is how it works:\n\u2022If you went 63 days or more without Part D or other creditable prescription drug coverage after you were first \neligible to enroll in Part D, the plan will count the number of full months that you did not have coverage. The \npenalty is 1% for every month that you did not have creditable coverage. For example, if you go 14 months \nwithout coverage, the penalty will be 14%.\n\u2022Then Medicare determines the amount of the average monthly premium for Medicare drug plans in the \nnation from the previous year. For 2023, this average premium amount is $32.74.\n\u2022To calculate your monthly penalty, you multiply the penalty percentage and the average monthly premium \nand then round it to the nearest 10 cents. In the example here it would be 14% times $32.74, which equals \n$4.58. This rounds to $4.60. This amount would be added to the monthly premium for someone with a Part \nD late enrollment penalty.\nThere are three important things to note about this monthly Part D late enrollment penalty:\n\u2022First, the penalty may change each year, because the average monthly premium can change each year.\n\u2022Second, you will continue to pay a penalty every month for as long as you are enrolled in a plan that has \nMedicare Part D drug benefits, even if you change plans.\n\u2022Third, if you are under 65 and currently receiving Medicare benefits, the Part D late enrollment penalty will \nreset when you turn 65. After age 65, your Part D late enrollment penalty will be based only on the months \nthat you don\u2019t have coverage after your initial enrollment period for aging into Medicare.\nIf you disagree about your Part D late enrollment penalty, you or your representative can ask for a review. \nGenerally, you must request this review within 60 days from the date on the first letter you receive stating you \nhave to pay a late enrollment penalty. However, if you were paying a penalty before joining our plan, you may not \nhave another chance to request a review of that late enrollment penalty.\nImportant: Do not stop paying your Part D late enrollment penalty while you\u2019re waiting for a review of the decision \nabout your late enrollment penalty. If you do, you could be disenrolled for failure to pay your premiums.", "doc_id": "9b06b38a-6cbe-465f-9e35-a4db146f5a89", "embedding": null, "doc_hash": "337ee5f0d3d7b40b2511861ae7c24dba9978fb5eb935fd8f20579ae370133a54", "extra_info": {"page_label": "14", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3816, "_node_type": "1"}, "relationships": {"1": "752f075f-b7f3-446d-83b1-9aa5b36e58a3"}}, "__type__": "1"}, "898b42c3-5d28-4e96-90b9-e5b5aeecb592": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 15\nChapter 1 Getting started as a member\nSection 4.4 Income Related Monthly Adjustment Amount\nSome members may be required to pay an extra charge, known as the Part D Income Related Monthly Adjustment \nAmount, also known as IRMAA. The extra charge is figured out using your modified adjusted gross income as \nreported on your IRS tax return from 2 years ago. If this amount is above a certain amount, you\u2019ll pay the standard \npremium amount and the additional IRMAA. For more information on the extra amount you may have to pay \nbased on your income, visit \nhttps://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug\n-plans.\nIf you have to pay an extra amount, Social Security, not your Medicare plan, will send you a letter telling you what \nthat extra amount will be. The extra amount will be withheld from your Social Security, Railroad Retirement Board, \nor Office of Personnel Management benefit check, no matter how you usually pay your plan premium, unless your \nmonthly benefit isn\u2019t enough to cover the extra amount owed. If your benefit check isn\u2019t enough to cover the extra \namount, you will get a bill from Medicare. You must pay the extra amount to the government. It cannot be \npaid with your monthly plan premium. If you do not pay the extra amount you will be disenrolled from the \nplan and lose prescription drug coverage.\nIf you disagree about paying an extra amount because of your income, you can ask Social Security to review the \ndecision. To find out more about how to do this, contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778).\nIn some situations, your plan premium could be more than the amount listed above in Section 4.1. These \nsituations are described below. \n\u2022Some members are required to pay a Part D late enrollment penalty because they did not join a Medicare drug \nplan when they first became eligible or because they had a continuous period of 63 days or more when they \ndidn\u2019t have \"creditable\" prescription drug coverage. (\"Creditable\" means the drug coverage is expected to pay, \non average, at least as much as Medicare\u2019s standard prescription drug coverage.) For these members, the Part D \nlate enrollment penalty is added to the plan\u2019s monthly premium. Their premium amount will be the monthly \nplan premium plus the amount of their Part D late enrollment penalty. \n\u2013If you are required to pay the Part D late enrollment penalty, the cost of the late enrollment penalty \ndepends on how long you went without Part D or other creditable prescription drug coverage. Chapter 1, \nSection 5 explains the Part D late enrollment penalty.\n\u2013If you have a Part D late enrollment penalty and do not pay it, you could be disenrolled from the plan. \nSome members may be required to pay an extra charge, known as the Part D Income Related Monthly Adjustment \nAmount, also known as IRMAA, because, 2 years ago, they had a modified adjusted gross income, above a certain \namount, on their IRS tax return. Members subject to an IRMAA will have to pay the standard premium amount and \nthis extra charge, which will be added to their premium. Chapter 1, Section 6 explains the IRMAA in further detail.\nSECTION 5 More information about your monthly premium\nSection 5.1If you pay a Part D late enrollment penalty, there are several ways you  \ncan pay your penalty \nIf you pay a Part D late enrollment penalty, there are four ways you can pay the penalty.", "doc_id": "898b42c3-5d28-4e96-90b9-e5b5aeecb592", "embedding": null, "doc_hash": "3565a28cea842bccab56074582ff676c375bde3ce56cc3a7c61814cb291318ea", "extra_info": {"page_label": "15", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3494, "_node_type": "1"}, "relationships": {"1": "1b057de8-418b-45c3-945b-de77c1d90051"}}, "__type__": "1"}, "e8353196-347b-418d-992d-8746e5a407ed": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 16\nChapter 1 Getting started as a member\nYou were asked to choose one when you enrolled, but you can change your method of payment at any time. The \nfour options described below are:\n\u2022Pay by check\n\u2022Set up automatic payments from your bank account or credit card\n\u2022Set up automatic payments from your Railroad Retirement Board check\n\u2022Set up automatic payments from your Social Security check\nIf you'd like to change your payment option, call Customer Care at 1-800-457-4708, TTY 711. If you're selecting \nany of the options for automatic payments, you can also go to Humana.com/pay and sign in with your username \nand password. (If it's the first time you're signing in, click on Register for MyHumana and follow the instructions on \nthe screen.)\nIf you decide to change the way you pay your Part D late enrollment penalty, it can take up to three months for \nyour new payment method to take effect. While we are processing your request for a new payment method, you \nare responsible for making sure that your Part D late enrollment penalty is paid on time.\nOption 1: Paying by check\nYou can pay by check using the Humana coupon book that we\u2019ll give you. If you choose this option, your Part D late \nenrollment penalty will always be due on the first day of the month.\nMake sure you follow these steps so there are no delays in processing your payments:\n\u2022Make your check out to Humana. You can also use a money order if you don't have a checking account.\n\u2022Always include the coupon along with your payment and send it to the address on the coupon.\n\u2022Write your Humana account number on your check. You can find your account number on the top left corner \nof your coupon.\n\u2022If the payment is for multiple members or accounts, write all account numbers on your check, as well as the \npayment amount intended for each.\n\u2022If someone else makes a payment for you, be sure your name and Humana account number are written on \nthe check.\nIf you want to pay more than one month's Part D late enrollment penalty, just send in all the coupons you want to \npay at one time and make your check out for the total amount.\nRemember\u2014don't make out or send checks to the Centers for Medicare & Medicaid Services or to the US \nDepartment of Health and Human Services because that would cause a delay and your Part D late enrollment \npenalty might be late.\nIf you need to replace your coupon book, call Customer Care at 1-800-457-4708, TTY 711.\nOption 2: You can set up automatic payments from your checking or savings account, or through your credit \ncard or debit card\nYou can have your monthly Part D late enrollment penalty automatically withdrawn from your checking or savings \naccount, or automatically charged to your credit card or debit card. You can contact Customer Care for more ", "doc_id": "e8353196-347b-418d-992d-8746e5a407ed", "embedding": null, "doc_hash": "d815da0113137b0529890a06ae06e6e9a03421e0cff14e036d480ba587b424fd", "extra_info": {"page_label": "16", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2829, "_node_type": "1"}, "relationships": {"1": "5e3b5a88-532c-4bf3-a6de-2e3ba09049a4"}}, "__type__": "1"}, "23e195e2-4f0f-492e-9a5f-f8bd0294ab20": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 17\nChapter 1 Getting started as a member\ninformation on how to pay your late enrollment penalty this way or you can visit Humana.com/pay and sign into \nMyHumana to set up your automatic payments from your bank account or credit card.\nIf you choose this option, we'll withdraw the Part D late enrollment penalty from your bank account, or charge it to \nyour card, between the 2nd -7th of each month.\nOption 3: You can have the Part D late enrollment penalty taken out of your monthly Railroad Retirement \nBoard check\nYou can have the Part D late enrollment penalty taken out of your monthly Railroad Retirement Board check. You \ncan contact Customer Care for more information on how to pay your late enrollment penalty this way or you can \nvisit Humana.com/pay and sign into MyHumana to set up your RRB payment option. We will be happy to help you \nset this up.\nOption 4: Having your Part D late enrollment penalty taken out of your monthly Social Security check\nYou can have the Part D late enrollment penalty taken out of your monthly Social Security check. Contact \nCustomer Care for more information on how to pay your penalty this way. We will be happy to help you set this up.\nChanging the way you pay your premium. If you decide to change the way you pay your premium, it can take up \nto three months for your new payment method to take effect. While we are processing your request for a new \npayment method, you are responsible for making sure that your plan premium is paid on time. To change your \npayment method, if applicable, please contact Customer Care. If you\u2019re selecting any of the options for automatic \npayments, you can also go to Humana.com/pay and sign in with your username and password. (If it's the first \ntime you're signing in, click on Register for MyHumana and follow the instructions on the screen.)\nWhat to do if you are having trouble paying your Part D late enrollment penalty\nYour Part D late enrollment penalty is due in our office by the first day of the month. If we have not received your \npenalty payment by the 15th of the month, we will send you a notice of your account balance and advise your \naccount may continue with further collection activity. If you are required to pay a Part D late enrollment penalty, \nyou must pay the penalty to keep your prescription drug coverage.\nIf you are having trouble paying your Part D late enrollment penalty on time, please contact Customer Care to see if \nwe can direct you to programs that will help with your penalty.\nIf we end your membership because you did not pay your Part D late enrollment penalty, you will have health \ncoverage under Original Medicare.\nIf we end your membership with the plan because you did not pay your Part D late enrollment penalty, then you \nmay not be able to receive Part D coverage until the following year if you enroll in a new plan during the annual \nenrollment period. During the annual Medicare open enrollment period, you may either join a stand-alone \nprescription drug plan or a health plan that also provides drug coverage. (If you go without \"creditable\" drug \ncoverage for more than 63 days, you may have to pay a Part D late enrollment penalty for as long as you have Part \nD coverage.)\nAt the time we end your membership, you may still owe us for the penalty you have not paid. We have the right to \npursue collection of the penalty amount you owe. In the future, if you want to enroll again in our plan (or another \nplan that we offer), you will need to pay the amount you owe before you can enroll.\nIf you think we have wrongfully ended your membership, you can make a complaint (also called a grievance); see \nChapter 9 for how to file a complaint. If you had an emergency circumstance that was out of your control and it \ncaused you to not be able to pay your Part D late enrollment penalty within our grace period, you can ask us to ", "doc_id": "23e195e2-4f0f-492e-9a5f-f8bd0294ab20", "embedding": null, "doc_hash": "1200997680bb4ee086bf36980fd62469cfd4b141208b6b229b773c051f7de23d", "extra_info": {"page_label": "17", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3931, "_node_type": "1"}, "relationships": {"1": "d4f7dce2-6393-4313-bc0c-2cdfebe762cc"}}, "__type__": "1"}, "925343d8-a08d-47f7-8440-e30cf09cc867": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 18\nChapter 1 Getting started as a member\nreconsider this decision by calling 1-800-457-4708 between 8 a.m. and 8 p.m. TTY users should call 711. You must \nmake your request no later than 60 days after the date your membership ends.\nSection 5.2 Can we change your monthly plan premium during the year?\nNo. We are not allowed to begin charging a monthly plan premium during the year. If the monthly plan premium \nchanges for next year we will tell you in September and the change will take effect on January 1.\nHowever, in some cases, you may need to start paying or may be able to stop paying a late enrollment penalty. \n(The late enrollment penalty may apply if you had a continuous period of 63 days or more when you didn\u2019t have \n\"creditable\" prescription drug coverage.) This could happen if you become eligible for the \u201cExtra Help\u201d program or if \nyou lose your eligibility for the \"Extra Help\" program during the year:\n\u2022If you currently pay the Part D late enrollment penalty and become eligible for \"Extra Help\" during the year, \nyou would be able to stop paying your penalty. \n\u2022If you lose your low income subsidy (\"Extra Help\"), you may be subject to the late enrollment penalty if you \ngo 63 days or more in a row without Part D or other creditable prescription drug coverage.\nYou can find out more about the \u201cExtra Help\u201d program in Chapter 2, Section 7.\nSECTION 6 Keeping your plan membership record up to date\nYour membership record has information from your enrollment form, including your address and telephone \nnumber. It shows your specific plan coverage including your Primary Care Provider.\nThe doctors, hospitals, pharmacists, and other providers in the plan's network need to have correct information \nabout you. These network providers use your membership record to know what services and drugs are \ncovered and the cost-sharing amounts for you. Because of this, it is very important that you help us keep your \ninformation up to date.\nLet us know about these changes:\n\u2022Changes to your name, your address, or your phone number\n\u2022Changes in any other health insurance coverage you have (such as from your employer, your spouse's \nemployer, workers' compensation, or Medicaid)\n\u2022If you have any liability claims, such as claims from an automobile accident\n\u2022If you have been admitted to a nursing home\n\u2022If you receive care in an out-of-area or out-of-network hospital or emergency room\n\u2022If your designated responsible party (such as a caregiver) changes\n\u2022If you are participating in a clinical research study (Note: You are not required to tell your plan about the clinical \nresearch studies, you intend to participate in, but we encourage you to do so)\nIf any of this information changes, please let us know by calling Customer Care.", "doc_id": "925343d8-a08d-47f7-8440-e30cf09cc867", "embedding": null, "doc_hash": "a2c138d79b6a274fa97e2c2574e6c3ffb6fe764330fa92309cd7dd2f02b091a6", "extra_info": {"page_label": "18", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2810, "_node_type": "1"}, "relationships": {"1": "cccd72e1-8f73-41d2-b15e-b5ec34e88f6e"}}, "__type__": "1"}, "518dce73-3313-4479-aaaa-5bb55ef71efc": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 19\nChapter 1 Getting started as a member\nIt is also important to contact Social Security if you move or change your mailing address. You can find phone \nnumbers and contact information for Social Security in Chapter 2, Section 5.\nSECTION 7 How other insurance works with our plan\nOther insurance\nMedicare requires that we collect information from you about any other medical or drug insurance coverage that \nyou have. That\u2019s because we must coordinate any other coverage you have with your benefits under our plan. This \nis called Coordination of Benefits.\nOnce each year, we will send you a letter that lists any other medical or drug insurance coverage that we know \nabout. Please read over this information carefully. If it is correct, you don\u2019t need to do anything. If the information \nis incorrect, or if you have other coverage that is not listed, please call Customer Care. You may need to give your \nplan member ID number to your other insurers (once you have confirmed their identity) so your bills are paid \ncorrectly and on time.\nWhen you have other insurance (like employer group health coverage), there are rules set by Medicare that decide \nwhether our plan or your other insurance pays first. The insurance that pays first is called the \"primary payer\" and \npays up to the limits of its coverage. The one that pays second, called the \"secondary payer,\" only pays if there are \ncosts left uncovered by the primary coverage. The secondary payer may not pay all of the uncovered costs. If you \nhave other insurance, tell your doctor, hospital, and pharmacy.\nThese rules apply for employer or union group health plan coverage:\n\u2022If you have retiree coverage, Medicare pays first.\n\u2022If your group health plan coverage is based on your or a family member's current employment, who pays \nfirst depends on your age, the number of people employed by your employer, and whether you have \nMedicare based on age, disability, or End-Stage Renal Disease (ESRD):\n\u2013If you're under 65 and disabled and you or your family member is still working, your group health plan \npays first if the employer has 100 or more employees or at least one employer in a multiple employer plan \nthat has more than 100 employees.\n\u2013If you're over 65 and you or your spouse is still working, your group health plan pays first if the employer \nhas 20 or more employees or at least one employer in a multiple employer plan that has more than 20 \nemployees.\n\u2022If you have Medicare because of ESRD, your group health plan will pay first for the first 30 months after you \nbecome eligible for Medicare.\nThese types of coverage usually pay first for services related to each type:\n\u2022No-fault insurance (including automobile insurance)\n\u2022Liability (including automobile insurance)\n\u2022Black lung benefits\n\u2022Workers' compensation", "doc_id": "518dce73-3313-4479-aaaa-5bb55ef71efc", "embedding": null, "doc_hash": "0d93731ef1455b79d850a1b44d987b8551f81c9da345a7d262f1b26657ec8039", "extra_info": {"page_label": "19", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2852, "_node_type": "1"}, "relationships": {"1": "e187c352-dbdc-4526-8a11-acb8819f1e88"}}, "__type__": "1"}, "835d7195-762f-4f3c-8014-83d4520db493": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 20\nChapter 1 Getting started as a member\nMedicaid and TRICARE never pay first for Medicare-covered services. They only pay after Medicare, employer group \nhealth plans, and/or Medigap have paid.", "doc_id": "835d7195-762f-4f3c-8014-83d4520db493", "embedding": null, "doc_hash": "e66d5561573a6f0585fe2b053ff29f1b3e32ee6eea7dcd2baa18e656ed28fc53", "extra_info": {"page_label": "20", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 257, "_node_type": "1"}, "relationships": {"1": "f2316407-e14b-4c19-be75-42bc7b59b074"}}, "__type__": "1"}, "ddc948bb-5fc7-4fbd-9aa2-895943dd2f07": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 21\nChapter 2 Important phone numbers and resourcesEOC082\nCHAPTER 2:\nImportant phone numbers \nand resources", "doc_id": "ddc948bb-5fc7-4fbd-9aa2-895943dd2f07", "embedding": null, "doc_hash": "6efba0bb12b748cf087531d5119c596c0a5051a03f1ef65751cf275e8f04853e", "extra_info": {"page_label": "21", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 169, "_node_type": "1"}, "relationships": {"1": "2777322f-b9ce-46e2-b8d4-c17b971e1b72"}}, "__type__": "1"}, "ed87ddb3-110c-4ea5-984e-98d31f33b6d3": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 22\nChapter 2 Important phone numbers and resources\nSECTION 1 Humana Gold Plus H0028-014 (HMO) contacts\n(how to contact us, including how to reach Customer Care)\nHow to contact our plan's Customer Care\nFor assistance with claims, billing, or member card questions, please call or write to Humana Gold Plus H0028-014 \n(HMO) Customer Care. We will be happy to help you.\nMethod Customer Care \u2013 Contact Information\nCALL 1-800-457-4708 \nCalls to this number are free. You can call us seven days a week, from 8 a.m. to 8 p.m.  \nHowever, please note that our automated phone system may answer your call during  \nweekends and holidays from April 1 to September 30. \nCustomer Care also has free language interpreter services available for non-English speakers.\nTTY 711 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free. Hours of operation are the same as above.\nFAX 1-877-837-7741\nWRITE Humana\nP.O. Box 14168\nLexington, KY 40512-4168\nWEBSITE Humana.com/customer-support\nLive chat available through Humana.com, Monday through Friday, 8 a.m. to 8 p.m., Eastern  \nStandard Time.\nHow to contact us when you are asking for a coverage decision or appeal about your medical care\nA coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for \nyour medical services or Part D prescription drugs. An appeal is a formal way of asking us to review and change a \ncoverage decision we have made. For more information on asking for coverage decisions or appeals about your \nmedical care or Part D prescription drugs, see Chapter 9 (What to do if you have a problem or complaint (coverage \ndecisions, appeals, complaints)).\nMethod Coverage Decisions For Medical Care \u2013 Contact Information\nCALL 1-800-457-4708, for fast (expedited) coverage decisions, call 1-866-737-5113 \nCalls to this number are free. You can call us seven days a week, from 8 a.m. to 8 p.m.  \nHowever, please note that our automated phone system may answer your call during  \nweekends and holidays from April 1 to September 30.", "doc_id": "ed87ddb3-110c-4ea5-984e-98d31f33b6d3", "embedding": null, "doc_hash": "17225b402bb733f0dbf9ae55151a8cf7789f675f65a2c74f727f36a1be15969e", "extra_info": {"page_label": "22", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2186, "_node_type": "1"}, "relationships": {"1": "85466ec0-cd68-485a-ac5a-e4faa41257bd"}}, "__type__": "1"}, "000b7117-126c-403a-abed-aa13b0a0d299": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 23\nChapter 2 Important phone numbers and resources\nMethod Coverage Decisions For Medical Care \u2013 Contact Information\nTTY 711 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free. Hours of operation are the same as above.\nFAX 1-888-200-7440 for expedited coverage decisions only\nWRITE Humana \nP.O. Box 14168 \nLexington, KY 40512-4168\nWEBSITE Humana.com/medicare-support/member-guidelines/exceptions-and-appeals\nLive chat available through Humana.com, Monday through Friday, 8 a.m. to 8 p.m., Eastern  \nStandard Time.\nMethod Coverage Decisions for Part D Prescription Drugs - Contact Information\nCALL 1-800-555-2546\nCalls to this number are free. You can call us seven days a week, from 8 a.m. to 8 p.m.  \nHowever, please note that our automated phone system may answer your call during  \nweekends and holidays from April 1 to September 30. \nTTY 711 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free. Hours of operation are the same as above.\nFAX 1-877-486-2621 for coverage determinations only.\nWRITE Humana Clinical Pharmacy Review \nAttn: Medicare Part D Coverage Determinations \nP.O. Box 33008 \nLouisville, KY  40232\nWEBSITE Humana.com/member/member-rights/pharmacy-authorizations \nLive chat available through Humana.com, Monday through Friday, 8 a.m. to 8 p.m., Eastern  \nStandard Time. \nMethod Appeals For Medical Care or Part D prescription drugs \u2013 Contact Information\nCALL 1-800-457-4708  \nCalls to this number are free. You can call us seven days a week, from 8 a.m. to 8 p.m. For  \nexpedited appeals please call 1-800-867-6601.", "doc_id": "000b7117-126c-403a-abed-aa13b0a0d299", "embedding": null, "doc_hash": "5d581896dbaaaa0ad95c0a53ded3be44dd5e6a1fe174af3aad3ef11c15b64fd8", "extra_info": {"page_label": "23", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1801, "_node_type": "1"}, "relationships": {"1": "6a785e8e-6fcb-4f83-93e9-663da5167de6"}}, "__type__": "1"}, "8264139e-4817-4af1-8158-2d444714022d": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 24\nChapter 2 Important phone numbers and resources\nMethod Appeals For Medical Care or Part D prescription drugs \u2013 Contact Information\nTTY 711 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free. Hours of operation are the same as above.\nFAX 1-888-556-2128\nWRITE Humana Grievances and Appeals Dept.\nP.O. Box 14165\nLexington, KY 40512-4165\nWEBSITE Humana.com/denial\nLive chat available through Humana.com, Monday through Friday, 8 a.m. to 8 p.m., Eastern  \nStandard Time.\nHow to contact us when you are making a complaint about your medical care\nYou can make a complaint about us or one of our network providers or pharmacies, including a complaint about \nthe quality of your care. This type of complaint does not involve coverage or payment disputes. For more \ninformation on making a complaint about your medical care, see Chapter 9 (What to do if you have a problem or \ncomplaint (coverage decisions, appeals, complaints)).\nMethod Complaints About Medical Care \u2013 Contact Information\nCALL 1-800-457-4708  \nCalls to this number are free. You can call us seven days a week, from 8 a.m. to 8 p.m. For  \nexpedited grievances please call 1-800-867-6601.\nTTY 711 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free. Hours of operation are the same as above.\nFAX 1-888-556-2128\nWRITE Humana Grievances and Appeals Dept. \nP.O. Box 14165 \nLexington, KY 40512-4165\nMEDICARE  \nWEBSITEYou can submit a complaint about Humana Gold Plus H0028-014 (HMO) directly to Medicare.  \nTo submit an online complaint to Medicare, go to \nwww.medicare.gov/MedicareComplaintForm/home.aspx.", "doc_id": "8264139e-4817-4af1-8158-2d444714022d", "embedding": null, "doc_hash": "38605c6a58ce835d35a6cc472fb720b693cfc4c06646d4af3036ea9a8601f648", "extra_info": {"page_label": "24", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1829, "_node_type": "1"}, "relationships": {"1": "5f614161-3f67-43c0-84fd-d1814299e861"}}, "__type__": "1"}, "81e0b601-5751-4cf3-b905-845d4661f46d": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 25\nChapter 2 Important phone numbers and resources\nWhere to send a request asking us to pay for our share of the cost for medical care or a drug you have \nreceived\nIf you have received a bill or paid for services (such as a provider bill) that you think we should pay for, you may \nneed to ask us for reimbursement or to pay the provider bill. See Chapter 7 (Asking us to pay our share of a bill you \nhave received for covered medical services or drugs).\nPlease note: If you send us a payment request and we deny any part of your request, you can appeal our decision. \nSee Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) for more \ninformation.\nMethod Payment Requests \u2013 Contact Information\nCALL 1-800-457-4708  \nCalls to this number are free. You can call us seven days a week, from 8 a.m. to 8 p.m.  \nHowever, please note that our automated phone system may answer your call during  \nweekends and holidays from April 1 to September 30.\nTTY 711 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free. Hours of operation are the same as above.\nWRITE Humana \nP.O. Box 14168 \nLexington, KY 40512-4168\nWEBSITE Humana.com\nLive chat available through Humana.com, Monday through Friday, 8 a.m. to 8 p.m., Eastern  \nStandard Time.\nSECTION 2 Medicare\n(how to get help and information directly from the Federal Medicare program)\nMedicare is the Federal health insurance program for people 65 years of age or older, some people under age 65 \nwith disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney \ntransplant).\nThe Federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services (sometimes called \n\"CMS\"). This agency contracts with Medicare Advantage organizations including us.\nMethod Medicare \u2013 Contact Information\nCALL 1-800-MEDICARE, or 1-800-633-4227 \nCalls to this number are free. \n24 hours a day, 7 days a week.", "doc_id": "81e0b601-5751-4cf3-b905-845d4661f46d", "embedding": null, "doc_hash": "fd9ce39f8fa1c03d23c07a453ba606162dc4bbdf6d9d1583b00c60dcd8290342", "extra_info": {"page_label": "25", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2105, "_node_type": "1"}, "relationships": {"1": "cb003932-8052-4708-a030-7392202b9adf"}}, "__type__": "1"}, "072c7972-46a3-46c6-8d7c-926dfb698e7b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 26\nChapter 2 Important phone numbers and resources\nMethod Medicare \u2013 Contact Information\nTTY 1-877-486-2048 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free.\nWEBSITE www.medicare.gov\nThis is the official government website for Medicare. It gives you up-to-date information about \nMedicare and current Medicare issues. It also has information about hospitals, nursing homes, \nphysicians, home health agencies, and dialysis facilities. It includes documents you can print \ndirectly from your computer. You can also find Medicare contacts in your state.\nThe Medicare website also has detailed information about your Medicare eligibility and \nenrollment options with the following tools:\n\u2022Medicare Eligibility Tool: Provides Medicare eligibility status information.\n\u2022Medicare Plan Finder: Provides personalized information about available Medicare \nprescription drug plans, Medicare health plans, and Medigap (Medicare Supplement \nInsurance) policies in your area. These tools provide an estimate of what your \nout-of-pocket costs might be in different Medicare plans.\nYou can also use the website to tell Medicare about any complaints you have about Humana \nGold Plus H0028-014 (HMO):\n\u2022Tell Medicare about your complaint: You can submit a complaint about Humana Gold \nPlus H0028-014 (HMO) directly to Medicare. To submit a complaint to Medicare, go to \nwww.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your \ncomplaints seriously and will use this information to help improve the quality of the \nMedicare program.\nIf you don't have a computer, your local library or senior center may be able to help you visit \nthis website using its computer. Or you can call Medicare and tell them what information you \nare looking for. They will find the information on the website and review the information with \nyou. (You can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a \nweek. TTY users should call 1-877-486-2048.)\nSECTION 3 State Health Insurance Assistance Program\n(free help, information, and answers to your questions about Medicare)\nThe State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every \nstate. Contact information for your State Health Insurance Assistance Program (SHIP) can be found in \u201cExhibit A\u201d in \nthe back of this document.", "doc_id": "072c7972-46a3-46c6-8d7c-926dfb698e7b", "embedding": null, "doc_hash": "88f3c0e579b3b764398c276801e1e22df9b79350596e51c007e9315eccff9927", "extra_info": {"page_label": "26", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2493, "_node_type": "1"}, "relationships": {"1": "04edc4bb-4ad9-4bd4-a7dd-93add88a3521"}}, "__type__": "1"}, "0a0e1fa2-4b1d-4741-9dd7-11aacc076305": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 27\nChapter 2 Important phone numbers and resources\nThe State Health Insurance Assistance Program (SHIP) is an independent (not connected with any insurance \ncompany or health plan) state program that gets money from the Federal government to give free local health \ninsurance counseling to people with Medicare. \nState Health Insurance Assistance Program (SHIP) counselors can help you understand your Medicare rights, help \nyou make complaints about your medical care or treatment, and help you straighten out problems with your \nMedicare bills. State Health Insurance Assistance Program (SHIP) counselors can also help you with Medicare \nquestions or problems and help you understand your Medicare plan choices and answer questions about switching \nplans.\n METHOD TO ACCESS SHIP and OTHER RESOURCES:\n\u2022Visit www.medicare.gov \n\u2022Click on \"Talk to Someone\" in the middle of the homepage\n\u2022You now have the following options\n\u2013Option #1: You can have a live chat with a 1-800-MEDICARE representative \n\u2013Option #2: You can select your STATE from the dropdown menu and click GO. This will take you to a page \nwith phone numbers and resources specific to your state.\nSECTION 4 Quality Improvement Organization\nThere is a designated Quality Improvement Organization for serving Medicare beneficiaries in each state. Contact \ninformation for your state Quality Improvement Organization (QIO) can be found in \"Exhibit A\" in the back of this \ndocument.\nThe Quality Improvement Organization (QIO) has a group of doctors and other health care professionals who are \npaid by Medicare to check on and help improve the quality of care for people with Medicare. The Quality \nImprovement Organization (QIO) is an independent organization. It is not connected with our plan.\nYou should contact your Quality Improvement Organization (QIO) in any of these situations:\n\u2022You have a complaint about the quality of care you have received.\n\u2022You think coverage for your hospital stay is ending too soon.\n\u2022You think coverage for your home health care, skilled nursing facility care, or Comprehensive Outpatient \nRehabilitation Facility (CORF) services are ending too soon.\nSECTION 5 Social Security\nSocial Security is responsible for determining eligibility and handling enrollment for Medicare. U.S. citizens and \nlawful permanent residents who are 65 or older, or who have a disability or End-Stage Renal Disease and meet \ncertain conditions, are eligible for Medicare. If you are already getting Social Security checks, enrollment into \nMedicare is automatic. If you are not getting Social Security checks, you have to enroll in Medicare. To apply for \nMedicare, you can call Social Security or visit your local Social Security office.\nSocial Security is also responsible for determining who has to pay an extra amount for their Part D drug coverage \nbecause they have a higher income. If you got a letter from Social Security telling you that you have to pay the ", "doc_id": "0a0e1fa2-4b1d-4741-9dd7-11aacc076305", "embedding": null, "doc_hash": "ea5cd98335b6b7a4229dc8429cc6c409d68f54b76ae3f963a4268852decbee81", "extra_info": {"page_label": "27", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3000, "_node_type": "1"}, "relationships": {"1": "b564ceac-4cef-4a26-9c80-a23be11dc10b"}}, "__type__": "1"}, "13f557cd-d4d4-4908-ad7c-82603d0bc21b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 28\nChapter 2 Important phone numbers and resources\nextra amount and have questions about the amount or if your income went down because of a life-changing \nevent, you can call Social Security to ask for reconsideration.\nIf you move or change your mailing address, it is important that you contact Social Security to let them know.\nMethod Social Security \u2013 Contact Information\nCALL 1-800-772-1213 \nCalls to this number are free. \nAvailable 8:00 am to 7:00 pm, Monday through Friday. \nYou can use Social Security's automated telephone services to get recorded information and  \nconduct some business 24 hours a day.\nTTY 1-800-325-0778 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free. \nAvailable 8:00 am to 7:00 pm, Monday through Friday.\nWEBSITE www.ssa.gov\nSECTION 6 Medicaid\nMedicaid is a joint Federal and state government program that helps with medical costs for certain people with \nlimited incomes and resources. Some people with Medicare are also eligible for Medicaid.\nThe programs offered through Medicaid help people with Medicare pay their Medicare costs, such as their Medicare \npremiums. These \u201cMedicare Savings Programs\u201d include:\n\u2022Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost \nsharing (like deductibles, coinsurance, and copayments). (Some people with QMB are also eligible for full \nMedicaid benefits (QMB+).)\n\u2022Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums. (Some people with SLMB \nare also eligible for full Medicaid benefits (SLMB+).)\n\u2022Qualifying Individual (QI): Helps pay Part B premiums.\n\u2022Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums.\nTo find out more about Medicaid and its programs, contact your state Medicaid office. Contact information for your \nstate Medicaid Office can be found in \"Exhibit A\" in the back of this document.", "doc_id": "13f557cd-d4d4-4908-ad7c-82603d0bc21b", "embedding": null, "doc_hash": "2c5f5a430eaa9592473329c7b0e698a8e1e9c1fd3df8af0c4446930db98e57b1", "extra_info": {"page_label": "28", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2033, "_node_type": "1"}, "relationships": {"1": "32cc05f1-2a71-4f76-a2dd-21b48a0f732f"}}, "__type__": "1"}, "b8d5a8bf-ed1a-4499-9d67-f2c0c0da3889": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 29\nChapter 2 Important phone numbers and resources\nSECTION 7 Information about programs to help people pay for their  \nprescription drugs\nThe Medicare.gov website \n(https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/costs-in-the-coverage-gap\n/5-ways-to-get-help-with-prescription-costs) provides information on how to lower your prescription drug costs. \nFor people with limited incomes, there are also other programs to assist, described below.\nMedicare's \"Extra Help\" Program\nMedicare provides \"Extra Help\" to pay prescription drug costs for people who have limited income and resources. \nResources include your savings and stocks, but not your home or car. If you qualify, you get help paying for any \nMedicare drug plan's monthly premium, yearly deductible, and prescription copayments. This \"Extra Help\" also \ncounts toward your out-of-pocket costs.\nIf you automatically qualify for \u201cExtra Help\u201d Medicare will mail you a letter. You will not have to apply. If you do not \nautomatically qualify you may be able to get \u201cExtra Help\u201d to pay for your prescription drug premiums and costs. To \nsee if you qualify for getting \u201cExtra Help,\u201d call:\n\u20221-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day,7 days a week;\n\u2022The Social Security Office at 1-800-772-1213, between 8 am to 7 pm, Monday through Friday. TTY users \nshould call 1-800-325-0778 (applications); or\n\u2022Your State Medicaid Office (applications). (See Section 6 of this chapter for contact information.)\nIf you believe you have qualified for \"Extra Help\" and you believe that you are paying an incorrect cost-sharing \namount when you get your prescription at a pharmacy, our plan has a process for you to either request assistance \nin obtaining evidence of your proper copayment level, or, if you already have the evidence, to provide this evidence \nto us.\n\u2022If you already have a document that proves you have qualified for \"Extra Help,\" you can also show it the next \ntime you go to a pharmacy to have a prescription filled. You can use any one of the following documents to \nprovide evidence to us, or to show as proof at the pharmacy.\nProof that you already have \"Extra Help\" status\n\u2022A copy of your Medicaid card showing your name and the date you became eligible for \"Extra Help.\" The date \nhas to be in the month of July or later of last year.\n\u2022A letter from the Social Security Administration showing your \"Extra Help\" status. This letter could be called \nImportant Information, Award Letter, Notice of Change, or Notice of Action.\n\u2022A letter from the Social Security Administration showing that you receive Supplemental Security Income. If \nthat\u2019s the case, you also qualify for \"Extra Help.\"\nProof that you have active Medicaid status\n\u2022A copy of any state document or any printout from the state system showing your active Medicaid status. \nThe active date shown has to be in the month of July or later of last year.", "doc_id": "b8d5a8bf-ed1a-4499-9d67-f2c0c0da3889", "embedding": null, "doc_hash": "b0107c77faa0885d95f048cc3d11cb36eaa3d31d1f3522fce988f15d2e817df6", "extra_info": {"page_label": "29", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3006, "_node_type": "1"}, "relationships": {"1": "f2589de3-8eaf-4cb4-aa97-0364ffa07d21"}}, "__type__": "1"}, "16f515ca-0dd5-4dca-85ab-7e7e85e0977d": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 30\nChapter 2 Important phone numbers and resources\nProof of a Medicaid payment for a stay at a medical facility\nYour stay at the medical facility must be at least one full month long, and must be in the month of July or later of \nlast year.\n\u2022A billing statement from the facility showing the Medicaid payment\n\u2022A copy of any state document or any printout from the state system showing the Medicaid payment for you\nIf you first show one of the documents listed above as proof at the pharmacy, please also send us a copy. Mail the \ndocument to:\nHumana\nP.O. Box 14168\nLexington, KY 40512-4168\n\u2022When we receive the evidence showing your copayment level, we will update our system so that you can pay \nthe correct copayment when you get your next prescription at the pharmacy. If you overpay your \ncopayment, we will reimburse you. Either we will forward a check to you in the amount of your overpayment, \nor we will offset future copayments. If the pharmacy hasn't collected a copayment from you and is carrying \nyour copayment as a debt owed by you, we may make the payment directly to the pharmacy. If a state paid \non your behalf, we may make the payment directly to the state. Please contact Customer Care if you have \nquestions (phone numbers are printed on the back cover of this booklet). \nWhat if you have coverage from a State Pharmaceutical Assistance Program (SPAP)?\nMany states and the U.S. Virgin Islands offer help paying for prescriptions, drug plan premiums and/or other drug \ncosts. If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program that provides \ncoverage for Part D drugs (other than \"Extra Help\"), you still get the 70% discount on covered brand name drugs. \nAlso, the plan pays 5% of the costs of brand drugs in the coverage gap. The 70% discount and the 5% paid by the \nplan are both applied to the price of the drug before any SPAP or other coverage.\nWhat if you have coverage from an AIDS Drug Assistance Program (ADAP)?\nWhat is the AIDS Drug Assistance Program (ADAP)?\nThe AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access to \nlife-saving HIV medications. Medicare Part D prescription drugs that are also on the ADAP formulary qualify for \nprescription cost-sharing assistance through the ADAP operating in your State. \nNote: To be eligible for the ADAP operating in your State, individuals must meet certain criteria, including proof of \nState residence and HIV status, low income as defined by the State, and uninsured/under-insured status. If you \nchange plans, please notify your local ADAP enrollment worker so you can continue to receive assistance. For \ninformation on eligibility criteria, covered drugs, or how to enroll in the program, please call the ADAP operating in \nyour State. Contact information for your AIDS Drug Assistance Program (ADAP) can be found in \u201cExhibit A\u201d in the \nback of this document.\nState Pharmaceutical Assistance Programs\nMany states have State Pharmaceutical Assistance Programs that help some people pay for prescription drugs \nbased on financial need, age, medical condition, or disabilities. Each state has different rules to provide drug \ncoverage to its members.", "doc_id": "16f515ca-0dd5-4dca-85ab-7e7e85e0977d", "embedding": null, "doc_hash": "e4ae3a1b7fbf10702da421d50fbc23398f5000f6b37cf77e1dbf1625407b26f8", "extra_info": {"page_label": "30", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3283, "_node_type": "1"}, "relationships": {"1": "cce6f646-7384-487c-b324-309fc6affb77"}}, "__type__": "1"}, "f90568da-45a5-413e-9db0-5c55f1f40766": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 31\nChapter 2 Important phone numbers and resources\nContact information for your State Pharmaceutical Assistance Program (SPAP) can be found in \"Exhibit A\" in the \nback of this document.\nHumana Gold Plus H0028-014 (HMO) offers additional gap coverage for Select Insulins as part of the Insulin \nSavings Program. During the Coverage Gap stage, your out-of-pocket costs for Select Insulins will be $35 for a \none-month (up to a 30-day) supply. Please go to Chapter 6, Section 6 for more information about your coverage \nduring the Coverage Gap stage. Note: This cost-sharing only applies to beneficiaries who do not qualify for a \nprogram that helps pay for your drugs (\u201cExtra Help\u201d). To find out which drugs are Select Insulins, review the most \nrecent Drug Guide we provided electronically. You can identify Select Insulins by the \u201cISP\u201d indicator in the Drug \nGuide. If you have questions about the Drug Guide, you can also call Customer Care (Phone numbers for Customer \nCare are printed on the back cover of this booklet).\nYour plan also provides enhanced insulin coverage which means you will pay no more than $35 for a one-month \n(up to 30-day) supply for all Part D insulins covered by our plan, including select insulins, no matter what \ncost-sharing tier it's on. The enhanced insulin coverage is available, even if you receive \"Extra Help\". \nSECTION 8 How to contact the Railroad Retirement Board\nThe Railroad Retirement Board is an independent Federal agency that administers comprehensive benefit \nprograms for the nation\u2019s railroad workers and their families. If you receive your Medicare through the Railroad \nRetirement Board, it is important that you let them know if you move or change your mailing address. If you have \nquestions regarding your benefits from the Railroad Retirement Board, contact the agency. \nMethod Railroad Retirement Board \u2013 Contact Information\nCALL 1-877-772-5772 \nCalls to this number are free. \nIf you press \"0,\" you may speak with an RRB representative from 9:00 am to 3:30 pm, Monday,  \nTuesday, Thursday, and Friday, and from 9:00 am to 12:00 pm on Wednesday. \nIf you press \"1\", you may access the automated RRB HelpLine and recorded information 24  \nhours a day, including weekends and holidays.\nTTY 1-312-751-4701 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are not free.\nWEBSITE rrb.gov/", "doc_id": "f90568da-45a5-413e-9db0-5c55f1f40766", "embedding": null, "doc_hash": "31d47c6439d5780406b551dc02f64a8d3ad8deb44b33c0bc04db653f7b5aabe0", "extra_info": {"page_label": "31", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2496, "_node_type": "1"}, "relationships": {"1": "b6bad8bd-bdbb-4ad6-a3b0-4b2f6c32cc30"}}, "__type__": "1"}, "f7af7fa3-0968-46bf-8e5d-bd93caa02d5b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 32\nChapter 2 Important phone numbers and resources\nSECTION 9 Do you have \"group insurance\" or other health insurance from  \nan employer?\nIf you (or your spouse) get benefits from your (or your spouse's) employer or retiree group as part of this plan, you \nmay call the employer/union benefits administrator or Customer Care if you have any questions. You can ask about \nyour (or your spouse's) employer or retiree health benefits, premiums, or the enrollment period. (Phone numbers \nfor Customer Care are printed on the back cover of this document.) You may also call 1-800-MEDICARE \n(1-800-633-4227; TTY: 1-877-486-2048) with questions related to your Medicare coverage under this plan.\nIf you have other prescription drug coverage through your (or your spouse's) employer or retiree group, please \ncontact that group's benefits administrator. The benefits administrator can help you determine how your \ncurrent prescription drug coverage will work with our plan.", "doc_id": "f7af7fa3-0968-46bf-8e5d-bd93caa02d5b", "embedding": null, "doc_hash": "bdca984fe8949826514bbdd4e41c420058ae7439b35efa56e6acf7ba77085e3b", "extra_info": {"page_label": "32", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1027, "_node_type": "1"}, "relationships": {"1": "3554f076-0cf7-4007-872e-53ad1157c837"}}, "__type__": "1"}, "65bb1aaa-83fb-48b3-8e44-0302c2011fe3": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 33\nChapter 3 Using the plan for your medical servicesEOC082\nCHAPTER 3:\nUsing the plan  \nfor your medical services", "doc_id": "65bb1aaa-83fb-48b3-8e44-0302c2011fe3", "embedding": null, "doc_hash": "f70f318e896696cc1fcdd9138b270763db293eef378f81560fc08a0260f76d74", "extra_info": {"page_label": "33", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 176, "_node_type": "1"}, "relationships": {"1": "1ab8f553-673b-4e15-a1b3-9ce906842891"}}, "__type__": "1"}, "99d5bb5b-f7c2-4f9f-874e-53ec082be9b2": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 34\nChapter 3 Using the plan for your medical services\nSECTION 1 Things to know about getting your medical care as a member of  \nour plan\nThis chapter explains what you need to know about using the plan to get your medical care covered. It gives \ndefinitions of terms and explains the rules you will need to follow to get the medical treatments, services, \nequipment, prescription drugs, and other medical care that are covered by the plan.\nFor the details on what medical care is covered by our plan and how much you pay when you get this care, use the \nbenefits chart in the next chapter, Chapter 4 (Medical Benefits Chart, what is covered and what you pay).\nSection 1.1 What are \"network providers\" and \"covered services\"?\n\u2022\"Providers\" are doctors and other health care professionals licensed by the state to provide medical services \nand care. The term \"providers\" also includes hospitals and other health care facilities.\n\u2022\"Network providers\" are the doctors and other health care professionals, medical groups, hospitals, and \nother health care facilities that have an agreement with us to accept our payment and your cost-sharing \namount as payment in full. We have arranged for these providers to deliver covered services to members in \nour plan. The providers in our network bill us directly for care they give you. When you see a network provider, \nyou pay only your share of the cost for their services.\n\u2022\"Covered services\" include all the medical care, health care services, supplies, equipment, and Prescription \nDrugs that are covered by our plan. Your covered services for medical care are listed in the benefits chart in \nChapter 4. Your covered services for prescription drugs are discussed in Chapter 5.\nSection 1.2 Basic rules for getting your medical care covered by the plan\nAs a Medicare health plan, Humana Gold Plus H0028-014 (HMO) must cover all services covered by Original \nMedicare and must follow Original Medicare's coverage rules.\nHumana Gold Plus H0028-014 (HMO) will generally cover your medical care as long as:\n\u2022The care you receive is included in the plan's Medical Benefits Chart (this chart is in Chapter 4 of this \ndocument).\n\u2022The care you receive is considered medically necessary. \"Medically necessary\" means that the services, \nsupplies, equipment, or drugs are needed for the prevention, diagnosis, or treatment of your medical \ncondition and meet accepted standards of medical practice.\n\u2022You have a network primary care provider (a PCP) who is providing and overseeing your care. As a \nmember of our plan, you must choose a network PCP (for more information about this, see Section 2.1 in this \nchapter).\n\u2013Your network PCP will coordinate the care you receive from other providers in the plan's network, such as \nspecialists, hospitals, skilled nursing facilities, or home health care agencies. However, referrals are not \nrequired to receive covered services from in-network providers. For more information about this, see \nSection 2.3 of this chapter.", "doc_id": "99d5bb5b-f7c2-4f9f-874e-53ec082be9b2", "embedding": null, "doc_hash": "cf26626764b9b8226650736298292e090252e360b516bd0c31e26c0cd6cc3217", "extra_info": {"page_label": "34", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3059, "_node_type": "1"}, "relationships": {"1": "d987d3a4-06d7-4953-9805-66d59b44e91c"}}, "__type__": "1"}, "1cf03328-e574-43a5-a3cc-ece84c14fa1e": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 35\nChapter 3 Using the plan for your medical services\n\u2022You must receive your care from a network provider (for more information about this, see Section 2 in this \nchapter). In most cases, care you receive from an out-of-network provider (a provider who is not part of our \nplan's network) will not be covered. This means that you will have to pay the provider in full for the services \nfurnished. Here are three exceptions:\n\u2013The plan covers emergency care or urgently needed services that you get from an out-of-network \nprovider. For more information about this, and to see what emergency or urgently needed services means, \nsee Section 3 in this chapter.\n\u2013If you need medical care that Medicare requires our plan to cover but there are no specialists in our \nnetwork that provide this care, you can get this care from an out-of-network provider at the same cost \nsharing you normally pay in-network. You must obtain authorization from the plan prior to seeking care \nfrom an out-of-network provider. In this situation, you will pay the same as you would pay if you got the \ncare from a network provider. For information about getting approval to see an out-of-network doctor, see \nSection 2.4 in this chapter.\n\u2013The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are \ntemporarily outside the plan's service area or when your provider for this service is temporarily unavailable \nor inaccessible. The cost sharing you pay the plan for dialysis can never exceed the cost sharing in Original \nMedicare. If you are outside the plan\u2019s service area and obtain the dialysis from a provider that is outside \nthe plan\u2019s network, your cost sharing cannot exceed the cost sharing you pay in-network. However, if your \nusual in-network provider for dialysis is temporarily unavailable and you choose to obtain services inside \nthe service area from a provider outside the plan\u2019s network the cost sharing for the dialysis may be higher.\nSECTION 2 Use providers in the plan's network to get your medical care\nSection 2.1 You must choose a Primary Care Provider (PCP) to provide and oversee  \nyour medical care\nWhat is a \"PCP\" and what does the PCP do for you?\nA \"PCP\" is your Primary Care Provider. When you become a member of the plan, you must choose a network doctor \nto be your PCP. Your PCP is a provider who meets state license requirements and is trained to give you basic medical \ncare.\nHaving a PCP is an important step in managing your overall well-being. As the doctor who gets to know your \nmedical history best, your PCP can provide you with routine healthcare and ongoing preventive care to keep you as \nhealthy as possible. If you need to see specialists or get other services such as:\n\u2022X-Rays\n\u2022Lab Tests\n\u2022Physical Therapy\n\u2022Care from specialists\n\u2022Hospital admissions \n\u2022Follow-up care\nYour PCP can help make sure all your care is coordinated, by checking with other network providers about your \ncare.", "doc_id": "1cf03328-e574-43a5-a3cc-ece84c14fa1e", "embedding": null, "doc_hash": "ec459fc2f3aa97db8c7d35e24d74aafaf72233f6049a96b93e61fdd69f86d740", "extra_info": {"page_label": "35", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3019, "_node_type": "1"}, "relationships": {"1": "7bf72344-40b0-469b-b6ee-81ad3c35aa5a"}}, "__type__": "1"}, "890049a7-f634-4c57-84d6-09709e3d5823": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 36\nChapter 3 Using the plan for your medical services\nYour plan requires you to have a PCP, but you don\u2019t need a referral from your PCP to see other network doctors or \nreceive the covered services listed in Chapter 3, Section 2.2 below. In some cases, your PCP will need to ask for prior \nauthorization (prior approval). Chapter 4 has more information on which services require prior authorization. \nJust call your PCP to make an appointment when you need one. To help your PCP understand your medical history \nand oversee all your care, you may want to have your previous doctors send your past medical records to your new \nPCP.\nHow do you get care from your PCP?\nYou will usually see your PCP first for most of your routine health care needs; however, there are a few types of \ncovered services you may get on your own, without first contacting your PCP. See Chapter 3, Section 2.2 for more \ninformation.\nIf it is after normal business hours and you have a need for routine care, please call your PCP back during normal \nbusiness hours. If you have an emergency or have an urgent need for care after normal business hours, see \nSections 3.1 or 3.2 in this chapter. \nHow do you choose your PCP?\nWhen you enrolled, you received a Provider Directory with a list of many PCPs in your area. If you need help finding \nor choosing one, call Customer Care or you can always see the most up-to-date list online at \nHumana.com/findadoctor.\nTo choose a PCP that's a good fit for you, call them to ask how long it usually takes to get an appointment and be \nsure the office hours are convenient for you. If there are particular network hospitals that you think you might \nwant to use, you should also ask if the PCP uses them.\nWhen you receive your Humana member ID card, the name and phone number of your PCP will be printed on it, so \nyou always have it handy. \nChanging your PCP\nYou may change your PCP for any reason, at any time. Also, it's possible that your PCP might leave our plan's \nnetwork of providers and you would have to find a new PCP. \nTo change your PCP call Customer Care. We'll make sure your new PCP is accepting new patients and then send you \nan updated member ID card. The change usually goes into effect on the first day of the month after you call.\nBe sure to tell Customer Care if you're currently seeing specialists or any other providers that required a referral \nfrom your old PCP. We'll make sure you can continue with any services that had already been approved.\nSection 2.2 What kinds of medical care can you get without a referral from your PCP?\nYou can get the services listed below without getting approval in advance from your PCP.\n\u2022Routine women's health care, which includes breast exams, screening mammograms (x-rays of the breast), \nPap tests, and pelvic exams as long as you get them from a network provider.\n\u2022Flu shots, COVID-19 vaccinations, Hepatitis B vaccinations, and pneumonia vaccinations as long as you get \nthem from a network provider.", "doc_id": "890049a7-f634-4c57-84d6-09709e3d5823", "embedding": null, "doc_hash": "3a78eed90f68da9e9cb5c9216bef574dd7580c2ef5631cf6d14a13cccbfd51b9", "extra_info": {"page_label": "36", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3042, "_node_type": "1"}, "relationships": {"1": "c14d73e6-7c07-489d-a20c-b75f6cdb00c3"}}, "__type__": "1"}, "2c0c93e2-99a9-488f-a364-be8a10159c85": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 37\nChapter 3 Using the plan for your medical services\n\u2022Emergency services from network providers or from out-of-network providers\n\u2022Urgently needed services are covered services that are not emergency services, provided when the network \nproviders are temporarily unavailable or inaccessible or when the enrollee is out of the service area. For \nexample, you need immediate care during the weekend. Services must be immediately needed and \nmedically necessary.\n\u2022Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside \nthe plan's service area. (If possible, please call Customer Care before you leave the service area so we can \nhelp arrange for you to have maintenance dialysis while you are away.)\n\u2022All covered preventive services from network providers. These services are indicated in the Chapter 4 Medical \nBenefits Chart with an .  \n\u2022Any other covered services from network providers\n\u2022Supplemental Benefits covered by the plan. These services are indicated in the Chapter 4 Medical Benefits \nChart with an asterisk (*)\nSection 2.3 How to get care from specialists and other network providers\nA specialist is a doctor who provides health care services for a specific disease or part of the body. There are many \nkinds of specialists. Here are a few examples:\n\u2022Oncologists care for patients with cancer.\n\u2022Cardiologists care for patients with heart conditions.\n\u2022Orthopedists care for patients with certain bone, joint, or muscle conditions.\nReferrals\nYou do not need a referral for covered services. \nFor some types of services, your PCP may need to get approval in advance from our plan (this is called getting \"prior \nauthorization\"). See Chapter 4, Section 2.1 for information about which services require prior authorization.\nWhat if a specialist or another network provider leaves our plan?\nWe may make changes to the hospitals, doctors, and specialists (providers) that are part of your plan during the \nyear. If your doctor or specialist leaves your plan you have certain rights and protections that are summarized \nbelow:\n\u2022Even though our network of providers may change during the year, Medicare requires that we furnish you \nwith uninterrupted access to qualified doctors and specialists.\n\u2022We will make a good faith effort to provide you with at least 30 days' notice that your provider is leaving our \nplan so that you have time to select a new provider.\n\u2022We will assist you in selecting a new qualified provider to continue managing your health care needs.", "doc_id": "2c0c93e2-99a9-488f-a364-be8a10159c85", "embedding": null, "doc_hash": "5d823a597f391c2e17f3ca3da3a8beb681b432e68d6c8769e0d36429b28ecbe1", "extra_info": {"page_label": "37", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2590, "_node_type": "1"}, "relationships": {"1": "f336b233-6662-4dd3-9adb-17a39907b54f"}}, "__type__": "1"}, "8a64f27d-be93-40f9-a922-11f1879a4d9d": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 38\nChapter 3 Using the plan for your medical services\n\u2022If you are undergoing medical treatment, you have the right to request, and we will work with you to ensure \nthat the medically necessary treatment you are receiving is not interrupted.\n\u2022If our network does not have a qualified specialist for a plan-covered service, we must cover that service at \nin-network cost sharing when the service is received from an out-of-network specialist. Prior authorization is \nrequired for service to be covered.\n\u2022If you find out your doctor or specialist is leaving your plan, please contact us so we can assist you in finding a \nnew provider to manage your care.\n\u2022If you believe we have not furnished you with a qualified provider to replace your previous provider or that \nyour care is not being appropriately managed, you have the right to file a quality of care complaint to the \nQIO, a quality of care grievance to the plan, or both. Please see Chapter 9.\nContact Customer Care at 1-800-457-4708, TTY 711 for assistance with selecting a new qualified provider to \ncontinue managing your health care needs.\nSection 2.4 How to get care from out-of-network providers\nYour network PCP or plan must give you approval in advance before you can use providers not in the plan's \nnetwork. This is called giving you a \"referral.\" For more information about this and situations when you can see an \nout-of-network provider without a referral (such as an emergency), see Sections 2.2 and 2.3 of this chapter. If you \ndon't have a referral (approval in advance) before you get services from an out-of-network provider, you may have \nto pay for these services yourself.\nFor some types of services, your doctor may need to get approval in advance from our plan (this is called getting \n\"prior authorization\"). See Chapter 4, Section 2.1 for more information about which services require prior \nauthorization.\nIt is best to ask an out-of-network provider to bill the plan first. But, if you have already paid for the covered \nservices, we will reimburse you for our share of the cost for covered services. Or if an out-of-network provider sends \nyou a bill that you think we should pay, you can send it to us for payment. See Chapter 7 (Asking us to pay our share \nof a bill you have received for covered medical services or drugs) for information about what to do if you receive a bill \nor if you need to ask for reimbursement.\nNote: Members are entitled to receive services from out-of-network providers for emergency or urgently needed  \nservices. In addition, plans must cover dialysis services for ESRD members who have traveled outside the plans  \nservice area and are not able to access contracted ESRD providers.\nSECTION 3 How to get services when you have an emergency or urgent  \nneed for care or during a disaster\nSection 3.1 Getting care if you have a medical emergency\nWhat is a \"medical emergency\" and what should you do if you have one?\nA \"medical emergency\" is when you, or any other prudent layperson with an average knowledge of health and \nmedicine, believe that you have medical symptoms that require immediate medical attention to prevent your loss \nof life (and, if you are a pregnant woman, loss of an unborn child), loss of a limb or function of a limb, or loss of or ", "doc_id": "8a64f27d-be93-40f9-a922-11f1879a4d9d", "embedding": null, "doc_hash": "06a385cad239267f8f2fde7bb58543185f026be383c0411ce2a13faa60d2ad4c", "extra_info": {"page_label": "38", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3333, "_node_type": "1"}, "relationships": {"1": "82429d40-80fd-4194-bfee-b641afe43cdf"}}, "__type__": "1"}, "2a7f6739-0a1e-471e-b6e8-e0b3b4b69f23": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 39\nChapter 3 Using the plan for your medical services\nserious impairment to a bodily function. The medical symptoms may be an illness, injury, severe pain, or a medical \ncondition that is quickly getting worse.\nIf you have a medical emergency:\n\u2022Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for \nan ambulance if you need it. You do not need to get approval or a referral first from your PCP. You do not need \nto use a network doctor. You may get covered emergency medical care whenever you need it, anywhere in \nthe United States or its territories, and from any provider with an appropriate state license even if they are not \npart of our network.\n\u2022As soon as possible, make sure that our plan has been told about your emergency. We need to follow up \non your emergency care. You or someone else should call to tell us about your emergency care, usually \nwithin 48 hours. Call Customer Care using the phone number printed on the back cover of this booklet.\nWhat is covered if you have a medical emergency?\nOur plan covers ambulance services in situations where getting to the emergency room in any other way could \nendanger your health. We also cover medical services during the emergency.\nThe doctors who are giving you emergency care will decide when your condition is stable and the medical \nemergency is over.\nAfter the emergency is over you are entitled to follow-up care to be sure your condition continues to be stable. Your \ndoctors will continue to treat you until your doctors contact us and make plans for additional care. Your follow-up \ncare will be covered by our plan.\nIf your emergency care is provided by out-of-network providers, we will try to arrange for network providers to take \nover your care as soon as your medical condition and the circumstances allow.\nWhat if it wasn't a medical emergency?\nSometimes it can be hard to know if you have a medical emergency. For example, you might go in for emergency \ncare \u2013 thinking that your health is in serious danger \u2013 and the doctor may say that it wasn't a medical emergency \nafter all. If it turns out that it was not an emergency, as long as you reasonably thought your health was in serious \ndanger, we will cover your care.\nHowever, after the doctor has said that it was not an emergency, we will cover additional care only if you get the \nadditional care in one of these two ways:\n\u2022You go to a network provider to get the additional care.\n\u2022\u2013 or \u2013 The additional care you get is considered \"urgently needed services\" and you follow the rules for \ngetting this urgent care (for more information about this, see Section 3.2 below).\nSection 3.2 Getting care when you have an urgent need for services\nWhat are \"urgently needed services\"?\nAn urgently needed service is a non-emergency situation requiring immediate medical care but given your \ncircumstances, it is not possible or not reasonable to obtain these services from a network provider. The plan must \ncover urgently needed services provided out of network. Some examples of urgently needed services are i) a severe ", "doc_id": "2a7f6739-0a1e-471e-b6e8-e0b3b4b69f23", "embedding": null, "doc_hash": "c7e2a4ebe79133e934325bde718289d6f22622e431fa52f2d4bda1671ec0a06c", "extra_info": {"page_label": "39", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3165, "_node_type": "1"}, "relationships": {"1": "ef6a1017-7adc-4f8f-82fa-3b8a87431952"}}, "__type__": "1"}, "884aabff-0470-4f2c-a48d-725bd776eee9": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 40\nChapter 3 Using the plan for your medical services\nsore throat that occurs over the weekend or ii) an unforeseen flare-up of a known condition when you are \ntemporarily outside the service area.\nThe plan's Provider Directory will tell you which facilities in your area are in-network. This information can also be \nfound online at Humana.com/findadoctor. For any other questions regarding urgently needed services, please \ncontact Customer Care.\nOur plan covers worldwide emergency and urgent care services outside of the United States under the following \ncircumstances. If you have an emergency or an urgent need for care outside of the U.S. and its territories, you will \nbe responsible to pay for those services upfront and request appropriate reimbursement from us. We will \nreimburse you, for covered out-of-network emergency and urgent care services outside of the U.S. and its \nterritories, at rates no greater than the rates at which Original Medicare would pay for such services had the \nservices been performed in the United States in the locality where you reside. The amount we pay you, if any, will \nbe reduced by any applicable cost-sharing. Because we will reimburse at rates no greater than the rates at which \nOriginal Medicare would reimburse, and because foreign providers might charge more for services than the rates at \nwhich Original Medicare would pay, the total of our reimbursement plus the applicable cost-sharing may be less \nthan the amounts you pay the foreign provider. This is a supplemental benefit not generally covered by Medicare. \nYou must submit proof of payment to Humana for reimbursement. See Chapter 4 (Medical Benefits Chart, what is \ncovered and what you pay) for more information. If you have already paid for the covered services, we will \nreimburse you for our share of the cost for covered services. You can send the bill with medical records to us for \npayment consideration. See Chapter 7 (Asking us to pay our share of a bill you have received for covered medical \nservices or drugs) for information about what to do if you receive a bill or if you need to ask for reimbursement.\nSection 3.3 Getting care during a disaster\nIf the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States \ndeclares a state of disaster or emergency in your geographic area, you are still entitled to care from your plan.\nPlease visit the following website: Humana.com/alert for information on how to obtain needed care during a \ndisaster.\nIf you cannot use a network provider during a disaster, your plan will allow you to obtain care from out-of-network \nproviders at in-network cost-sharing. If you cannot use a network pharmacy during a disaster, you may be able to \nfill your prescription drugs at an out-of-network pharmacy. Please see Chapter 5, Section 2.5 for more information.\nSECTION 4 What if you are billed directly for the full cost of your services?\nSection 4.1 You can ask us to pay our share of the cost of covered services\nIf you have paid more than your plan cost-sharing for covered services, or if you have received a bill for the full cost \nof covered medical services, go to Chapter 7 (Asking us to pay our share of a bill you have received for covered medical \nservices or drugs) for information about what to do.", "doc_id": "884aabff-0470-4f2c-a48d-725bd776eee9", "embedding": null, "doc_hash": "d58fc92584fd45455af9d4d03c8e93386b20eab76679eef0491835e5d31fdb92", "extra_info": {"page_label": "40", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3389, "_node_type": "1"}, "relationships": {"1": "13d1e588-85e5-4d85-a5fb-c9e94b74d89c"}}, "__type__": "1"}, "5837d3dc-1bf6-40ed-abce-b23d102a9aca": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 41\nChapter 3 Using the plan for your medical services\nSection 4.2 If services are not covered by our plan, you must pay the full cost\nHumana Gold Plus H0028-014 (HMO) covers all medically necessary services as listed in the Medical Benefits Chart \nin Chapter 4 of this document. If you receive services not covered by our plan or services obtained out-of-network \nand were not authorized, you are responsible for paying the full cost of services.\nFor covered services that have a benefit limitation, you also pay the full cost of any services you get after you have \nused up your benefit for that type of covered service. Paying for costs once a benefit limit has been reached will not \ncount toward your out-of-pocket maximum. You can call Customer Care when you want to know how much of \nyour benefit limit you have already used.\nSECTION 5 How are your medical services covered when you are in a  \n\"clinical research study\"?\nSection 5.1 What is a \"clinical research study\"?\nA clinical research study (also called a \"clinical trial\") is a way that doctors and scientists test new types of medical \ncare, like how well a new cancer drug works. Certain clinical research studies are approved by Medicare. Clinical \nresearch studies approved by Medicare typically request volunteers to participate in the study.\nOnce Medicare approves the study, and you express interest, someone who works on the study will contact you to \nexplain more about the study and see if you meet the requirements set by the scientists who are running the \nstudy. You can participate in the study as long as you meet the requirements for the study, and you have a full \nunderstanding and acceptance of what is involved if you participate in the study.\nIf you participate in a Medicare-approved study, Original Medicare pays most of the costs for the covered services \nyou receive as part of the study. If you tell us that you are in a qualified clinical trial, then you are only responsible \nfor the in-network cost sharing for the services in that trial. If you paid more, for example, if you already paid the \nOriginal Medicare cost-sharing amount, we will reimburse the difference between what you paid and the \nin-network cost sharing. However, you will need to provide documentation to show us how much you paid. When \nyou are in a clinical research study, you may stay enrolled in our plan and continue to get the rest of your care (the \ncare that is not related to the study) through our plan.\nIf you want to participate in any Medicare-approved clinical research study, you do not need to tell us or to get \napproval from us or your PCP. The providers that deliver your care as part of the clinical research study do not need \nto be part of our plan's network of providers.\nAlthough you do not need to get our plan's permission to be in a clinical research study, we encourage you to \nnotify us in advance when you choose to participate in Medicare-qualified clinical trials. \nIf you participate in a study that Medicare or our plan has not approved, you will be responsible for paying all costs for \nyour participation in the study.\nSection 5.2 When you participate in a clinical research study, who pays for what?\nOnce you join a Medicare-approved clinical research study, Original Medicare covers the routine items and services \nyou receive as part of the study, including:", "doc_id": "5837d3dc-1bf6-40ed-abce-b23d102a9aca", "embedding": null, "doc_hash": "1d9d19f6370c092273fc1a723720dffe511799ef894ab888a9bfa7645af0d870", "extra_info": {"page_label": "41", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3421, "_node_type": "1"}, "relationships": {"1": "9ef26203-762a-4b72-8726-f5367480317d"}}, "__type__": "1"}, "171c3ced-5bcf-41bd-8367-fe16e37d118f": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 42\nChapter 3 Using the plan for your medical services\n\u2022Room and board for a hospital stay that Medicare would pay for even if you weren't in a study.\n\u2022An operation or other medical procedure if it is part of the research study.\n\u2022Treatment of side effects and complications of the new care.\nAfter Medicare has paid its share of the cost for these services, our plan will pay the difference between the cost \nsharing in Original Medicare and your in-network cost sharing as a member of our plan. This means you will pay the \nsame amount for the services you receive as part of the study as you would if you received these services from our \nplan. However, you are required to submit documentation showing how much cost sharing you paid. Please see \nChapter 7 for more information for submitting requests for payments.\nHere's an example of how the cost-sharing works: Let's say that you have a lab test that costs $100 as part of the \nresearch study. Let's also say that your share of the costs for this test is $20 under Original Medicare, but the \ntest would be $10 under our plan's benefits. In this case, Original Medicare would pay $80 for the test, and you \nwould pay the $20 copay required under Original Medicare. You would then notify your plan that you received a \nqualified clinical trial service and submit documentation such as a provider bill to the plan. The plan would then \ndirectly pay you $10. Therefore, your net payment is $10, the same amount you would pay under our plan\u2019s \nbenefits. Please note that in order to receive payment from your plan, you must submit documentation to your \nplan such a provider bill.\nWhen you are part of a clinical research study, neither Medicare nor our plan will pay for any of the following:\n\u2022Generally, Medicare will not pay for the new item or service that the study is testing unless Medicare would \ncover the item or service even if you were not in a study.\n\u2022Items or services provided only to collect data, and not used in your direct health care. For example, Medicare \nwould not pay for monthly CT scans done as part of the study if your medical condition would normally \nrequire only one CT scan.\nDo you want to know more?\nYou can get more information about joining a clinical research study by visiting the Medicare website to read or \ndownload the publication \"Medicare and Clinical Research Studies.\" (The publication is available at: \nwww.medicare.gov/Pubs/pdf/02226-Medicare-and-Clinical-Research-Studies.pdf.) You can also call \n1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.\nSECTION 6 Rules for getting care covered in a \"religious non-medical  \nhealth care institution\"\nSection 6.1 What is a religious non-medical health care institution?\nA religious non-medical health care institution is a facility that provides care for a condition that would ordinarily \nbe treated in a hospital or skilled nursing facility. If getting care in a hospital or a skilled nursing facility is against a \nmember's religious beliefs, we will instead provide coverage for care in a religious non-medical health care \ninstitution. This benefit is provided only for Part A inpatient services (non-medical health care services).", "doc_id": "171c3ced-5bcf-41bd-8367-fe16e37d118f", "embedding": null, "doc_hash": "eae79ac0bb54e6aa6c51f3ee0dade41d8c7dcca19651e1f2ae49892719e4c199", "extra_info": {"page_label": "42", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3291, "_node_type": "1"}, "relationships": {"1": "10c41412-5362-413a-ac6d-784a2258db5b"}}, "__type__": "1"}, "210f3d60-6df3-42fe-b51a-d948e60dfecf": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 43\nChapter 3 Using the plan for your medical services\nSection 6.2 Receiving Care from a Religious Non-Medical Health Care Institution\nTo get care from a religious non-medical health care institution, you must sign a legal document that says you are \nconscientiously opposed to getting medical treatment that is \"non-excepted.\"\n\u2022\"Non-excepted\" medical care or treatment is any medical care or treatment that is voluntary and not required \nby any federal, state, or local law.\n\u2022\"Excepted\" medical treatment is medical care or treatment that you get that is not voluntary or is required \nunder federal, state, or local law.\nTo be covered by our plan, the care you get from a religious non-medical health care institution must meet the \nfollowing conditions:\n\u2022The facility providing the care must be certified by Medicare.\n\u2022Our plan's coverage of services you receive is limited to non-religious aspects of care.\n\u2022If you get services from this institution that are provided to you in a facility, the following conditions apply:\n\u2013You must have a medical condition that would allow you to receive covered services for inpatient hospital \ncare or skilled nursing facility care.\n\u2013\u2013 and \u2013 you must get approval in advance from our plan before you are admitted to the facility, or your \nstay will not be covered.\nMedicare Inpatient Hospital coverage limits apply (please refer to the Medicare Benefits Chart in Chapter 4).\nSECTION 7 Rules for ownership of durable medical equipment\nSection 7.1 Will you own the durable medical equipment after making a certain  \nnumber of payments under our plan?\nDurable medical equipment (DME) includes items such as oxygen equipment and supplies, wheelchairs, walkers, \npowered mattress systems, crutches, diabetic supplies, speech generating devices, IV infusion pumps, nebulizers, \nand hospital beds ordered by a provider for use in the home. The member always owns certain items, such as \nprosthetics. In this section, we discuss other types of DME that you must rent.\nIn Original Medicare, people who rent certain types of DME own the equipment after paying copayments for the \nitem for 13 months. As a member of Humana Gold Plus H0028-014 (HMO), however, you usually will not acquire \nownership of rented DME items no matter how many copayments you make for the item while a member of our \nplan, even if you made up to 12 consecutive payments for the DME item under Original Medicare before you joined \nour plan. Under certain limited circumstances we will transfer ownership of the DME item to you. Call Customer \nCare.\nWhat happens to payments you made for durable medical equipment if you switch to Original Medicare?", "doc_id": "210f3d60-6df3-42fe-b51a-d948e60dfecf", "embedding": null, "doc_hash": "6667ae549b19f636f4669e788a8e5a9566c8ac589b74f17c3c24f0b34d2d5f7a", "extra_info": {"page_label": "43", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2714, "_node_type": "1"}, "relationships": {"1": "8acec875-a1d0-4812-87c9-12141bdcde8c"}}, "__type__": "1"}, "67c5a110-26ed-43ac-8964-667debcb272c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 44\nChapter 3 Using the plan for your medical services\nIf you did not acquire ownership of the DME item while in our plan, you will have to make 13 new consecutive \npayments after you switch to Original Medicare in order to own the item. The payments made while enrolled in \nyour plan do not count.\nExample 1: You made 12 or fewer consecutive payments for the item in Original Medicare and then joined our plan. \nThe payments you made in Original Medicare do not count. You will have to make 13 payments to our plan before \nowning the item.\nExample 2: You made 12 or fewer consecutive payments for the item in Original Medicare and then joined our plan. \nYou were in our plan but did not obtain ownership while in our plan. You then go back to Original Medicare. You will \nhave to make 13 consecutive new payments to own the item once you join Original Medicare again. All previous \npayments (whether to our plan or to Original Medicare) do not count. \nSection 7.2 Rules for oxygen equipment, supplies, and maintenance\nWhat oxygen benefits are you entitled to?\nIf you qualify for Medicare oxygen equipment coverage Humana Gold Plus H0028-014 (HMO) will cover: \n\u2022Rental of oxygen equipment\n\u2022Delivery of oxygen and oxygen contents\n\u2022Tubing and related oxygen accessories for the delivery of oxygen and oxygen contents\n\u2022Maintenance and repairs of oxygen equipment\nIf you leave Humana Gold Plus H0028-014 (HMO) or no longer medically require oxygen equipment, then the \noxygen equipment must be returned. \nWhat happens if you leave your plan and return to Original Medicare?\nOriginal Medicare requires an oxygen supplier to provide you services for five years. During the first 36 months you \nrent the equipment. The remaining 24 months the supplier provides the equipment and maintenance (you are still \nresponsible for the copayment for oxygen). After five years you may choose to stay with the same company or go \nto another company. At this point, the five-year cycle begins again, even if you remain with the same company, \nrequiring you to pay copayments for the first 36 months. If you join or leave our plan, the five-year cycle starts \nover.", "doc_id": "67c5a110-26ed-43ac-8964-667debcb272c", "embedding": null, "doc_hash": "218886456a5d583d5e20ef410a22795ad37736981ab188904db4dd0e3e7cfc2c", "extra_info": {"page_label": "44", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2207, "_node_type": "1"}, "relationships": {"1": "a306a787-2b16-4671-b764-4821848409fe"}}, "__type__": "1"}, "e25e6f70-00fd-4f99-878f-2adb5797e7f7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 45\nChapter 4. Medical Benefits Chart (what is covered and what you pay)EOC082\nCHAPTER 4:\nMedical Benefits Chart\n(what is covered and \nwhat you pay)", "doc_id": "e25e6f70-00fd-4f99-878f-2adb5797e7f7", "embedding": null, "doc_hash": "17ca4fb17edb7a6befdec8f6bd4cba6dfdaec1955be63c50bf6b538b34c4920e", "extra_info": {"page_label": "45", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 210, "_node_type": "1"}, "relationships": {"1": "95582803-7714-4dfc-a935-817b5ddb574f"}}, "__type__": "1"}, "ada70517-d3a1-42ff-9533-c94cc25f5dc0": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 46\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nSECTION 1 Understanding your out-of-pocket costs for covered services\nThis chapter provides a Medical Benefits Chart that lists your covered services and shows how much you will pay \nfor each covered service as a member of Humana Gold Plus H0028-014 (HMO). Later in this chapter, you can find \ninformation about medical services that are not covered. It also explains limits on certain services. Also, see \nexclusions and limitations pertaining to certain supplemental benefits in the chart in this chapter.\nSection 1.1 Types of out-of-pocket costs you may pay for your covered services\nTo understand the payment information we give you in this chapter, you need to know about the types of \nout-of-pocket costs you may pay for your covered services.\n\u2022A \"copayment\" is the fixed amount you pay each time you receive certain medical services. You pay a \ncopayment at the time you get the medical service. (The Medical Benefits Chart in Section 2 tells you more \nabout your copayments.)\n\u2022\"Coinsurance\" is the percentage you pay of the total cost of certain medical services. You pay a coinsurance at \nthe time you get the medical service. (The Medical Benefits Chart in Section 2 tells you more about your \ncoinsurance.)\nMost people who qualify for Medicaid or for the Qualified Medicare Beneficiary (QMB) program should never pay \ndeductibles, copayments or coinsurance. Be sure to show your proof of Medicaid or QMB eligibility to your provider, \nif applicable.\nSection 1.2 What is the most you will pay for Medicare Part A and Part B covered  \nmedical services?\nBecause you are enrolled in a Medicare Advantage Plan, there is a limit on the total amount you have to pay \nout-of-pocket each year for in-network medical services that are covered under Medicare Part A and Part B. This \nlimit is called the maximum out-of-pocket amount (MOOP) for medical services. For calendar year 2023 this \namount is $2,900.\nThe amounts you pay for copayments and coinsurance for in-network covered services count toward this \nmaximum out-of-pocket amount. The amount you pay for your Part D prescription drugs does not count toward \nyour out-of-pocket maximum. In addition, amounts you pay for some services do not count toward your \nmaximum out-of-pocket amount. These services are marked with an asterisk in the Medical Benefits Chart. The \namounts you pay for any late enrollment penalty and your Part D prescription drugs do not count toward your \nmaximum out-of-pocket amount. If you reach the maximum out-of-pocket amount of $2,900, you will not have \nto pay any out-of-pocket costs for the rest of the year for in-network covered Part A and Part B services. However, \nyou must continue to pay the Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or \nanother third party).\nSection 1.3 Our plan does not allow providers to \"balance bill\" you\nAs a member of Humana Gold Plus H0028-014 (HMO), an important protection for you is that you only have to pay \nyour cost-sharing amount when you get services covered by our plan. Providers may not add additional, separate ", "doc_id": "ada70517-d3a1-42ff-9533-c94cc25f5dc0", "embedding": null, "doc_hash": "56d46265eb543fc606c42331a69a6effbe4ede1ea5ed7faacbdeb9c59ce8095b", "extra_info": {"page_label": "46", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3220, "_node_type": "1"}, "relationships": {"1": "83d42ba2-d396-45ff-97a2-1a713a34b7a2"}}, "__type__": "1"}, "23fd8d25-1218-4ea1-9031-8e866813b324": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 47\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\ncharges, called \"balance billing.\" This protection applies even if we pay the provider less than the provider charges \nfor a service and even if there is a dispute and we don't pay certain provider charges.\nHere is how this protection works.\n\u2022If your cost sharing is a copayment (a set amount of dollars, for example, $15.00), then you pay only that \namount for any covered services from a network provider.\n\u2022If your cost sharing is a coinsurance (a percentage of the total charges), then you never pay more than that \npercentage. However, your cost depends on which type of provider you see:\n\u2013If you receive the covered services from a network provider, you pay the coinsurance percentage multiplied \nby the plan's reimbursement rate (as determined in the contract between the provider and the plan).\n\u2013If you receive the covered services from an out-of-network provider who participates with Medicare, you pay \nthe coinsurance percentage multiplied by the Medicare payment rate for participating providers. \n(Remember, the plan covers services from out-of-network providers only in certain situations, such as when \nyou get a referral or for emergencies or urgently needed services.)\n\u2013If you receive the covered services from an out-of-network provider who does not participate with Medicare, \nyou pay the coinsurance percentage multiplied by the Medicare payment rate for non-participating \nproviders. (Remember, the plan covers services from out-of-network providers only in certain situations, such \nas when you get a referral or for emergencies or urgently needed services.)\n\u2022If you believe a provider has \"balance billed\" you, call Customer Care.\nSECTION 2 Use the Medical Benefits Chart to find out what is covered and  \nhow much you will pay\nSection 2.1 Your medical benefits and costs as a member of the plan\nThe Medical Benefits Chart on the following pages lists the services Humana Gold Plus H0028-014 (HMO) covers \nand what you pay out-of-pocket for each service. Part D prescription drug coverage is in Chapter 5. The services \nlisted in the Medical Benefits Chart are covered only when the following coverage requirements are met:\n\u2022Your Medicare covered services must be provided according to the coverage guidelines established by Medicare.\n\u2022Your services (including medical care, services, supplies, equipment, and Part B prescription drugs) must be \nmedically necessary. \"Medically necessary\" means that the services, supplies, or drugs are needed for the \nprevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical \npractice.\n\u2022You receive your care from a network provider. In most cases, care you receive from an out-of-network provider \nwill not be covered, unless it is emergent or urgent care or unless your plan or a network provider has given you \na referral. This means that you will have to pay the provider in full for the services furnished.\n\u2022You have a primary care provider (a PCP) who is providing and overseeing your care. In most situations, your PCP \nmust give you approval in advance before you can see other providers in the plan's network. This is called giving \nyou a \"referral.\" However, referrals are not required for in-network services.\n\u2022Some of the services listed in the Medical Benefits Chart are covered only if your doctor or other network provider \ngets approval in advance (sometimes called \"prior authorization\") from us. Covered services that need approval ", "doc_id": "23fd8d25-1218-4ea1-9031-8e866813b324", "embedding": null, "doc_hash": "5e398082628ad2928f03079fb5266106a8fc8621d6d6051d5d79171497864ce4", "extra_info": {"page_label": "47", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3586, "_node_type": "1"}, "relationships": {"1": "8ffd8653-1c20-45b5-a9d6-2444054ff836"}}, "__type__": "1"}, "ad48ecd1-f18c-4d01-95db-b4c60873d1f7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 48\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nin advance are marked in the Medical Benefits Chart by a footnote. In addition, the following services not listed \nin the Benefits Chart require prior authorization:\n\u2013The preauthorization list can be found here: www.humana.com/PAL\nOther important things to know about our coverage:\n\u2022Like all Medicare health plans, we cover everything that Original Medicare covers. For some of these benefits, \nyou pay more in our plan than you would in Original Medicare. For others, you pay less. (If you want to know \nmore about the coverage and costs of Original Medicare, look in your Medicare & You 2023 handbook. View it \nonline at www.medicare.gov or ask for a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 \ndays a week. TTY users should call 1-877-486-2048.)\n\u2022For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no \ncost to you. However, if you also are treated or monitored for an existing medical condition during the visit when \nyou receive the preventive service, plan cost-sharing will apply for the care received for the existing medical \ncondition.\n\u2022If Medicare adds coverage for any new services during 2023, either Medicare or our plan will cover those \nservices.\nImportant Benefit Information for Enrollees with Certain Chronic Conditions: \n\u2022If you are diagnosed by a plan provider with any of the following chronic condition(s) identified below and meet \ncertain medical criteria, you may be eligible for targeted supplemental benefits and/or reduced cost sharing:\n\u2013Chronic Obstructive Pulmonary Disease\n\u2013In order to qualify, members must participate in the COPD Inhaler Support Program.\n\u2022For further detail, please go to the \"Help with Certain Chronic Conditions\" row in the Medical Benefits Chart \nbelow.\nImportant Benefit Information for Enrollees with Certain Chronic Conditions: \n\u2022If you are diagnosed by a plan provider with any of the following chronic condition(s) identified below and meet \ncertain medical criteria, you may be eligible for targeted supplemental benefits and/or reduced cost sharing:\n\u2013Atrial Fibrillation (A-Fib)\n\u2013Deep Vein Thrombosis (DVT)\n\u2013Pulmonary Embolism (PE)\n\u2013In order to qualify, members must participate in the DOAC Savings Program.\n\u2022For further detail, please go to the \"Help with Certain Chronic Conditions\" row in the Medical Benefits Chart \nbelow.\nImportant Benefit Information for all Enrollees Participating in Wellness and Health Care Planning (WHP) Services\n\u2022You are eligible for the following WHP services, including advance care planning (ACP) services:\n\u2013Documenting what\u2019s important to you is essential to getting the care you want when you are too ill to speak \nfor yourself.", "doc_id": "ad48ecd1-f18c-4d01-95db-b4c60873d1f7", "embedding": null, "doc_hash": "5112ac9502787cf6b99ad872bc68055df280e48dc46d36bd1524075b8c6eb9c0", "extra_info": {"page_label": "48", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2840, "_node_type": "1"}, "relationships": {"1": "f0533645-d4d0-4a93-a302-190251cd23a2"}}, "__type__": "1"}, "ec586ece-4aed-4be5-be92-145c68956464": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 49\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\n\u2013As a Humana member, you have access to an online advance care planning resource called, MyDirectives\u00ae. \nThis resource helps you to create an advance directive where you can combine the elements of a:\n>Living will\n>Medical power of attorney\n>Do not attempt resuscitation form\n>Organ donation form\n\u2022You can create your own digital care plan on MyDirectives\u00ae and even include video and audio files. If you \nalready have these documents prepared you can store and share them here. MyDirectives\u00ae is available to you \nand your designated medical providers 24 hours a day, seven days a week. You can add new information at any \ntime as your health status or wishes change.\n\u2022To get started, visit Humana.com and log into MyHumana. Go to the MyHealth tab and select MyDirectives\u00ae in \nthe \"Health support for you\" section.\n\u2022Additionally, if you meet certain health conditions now or your health status changes in the future, Humana will \nreach out to you. A clinician or social worker will provide support to ensure you have an advance directive in \nplace and you are able to share it with your family and doctors. Participation in any programs that include \nWellness and Healthcare Planning or Advance Care Planning are voluntary and you are free to decline the \nservices at any time.\nImportant Benefit Information for Enrollees with Chronic Conditions \n\u2022If you are diagnosed with the following chronic condition(s) identified below and meet certain criteria, you may \nbe eligible for special supplemental benefits for the chronically ill.\n\u2013Members diagnosed with Chronic Obstructive Pulmonary Disease (COPD), Diabetes, or Congestive Heart \nFailure (CHF), participating with care management services, and who have had an inpatient hospital or skilled \nnursing facility stay within the last 30 days are eligible to receive meal delivery through the Worry Free\u2122 \nMeals program.\n\u2013Members diagnosed with one or more of the following conditions, and who are eligible to participate with \ncare management services may receive additional benefits through Humana Flexible Care Assistance.\n>Chronic alcohol and other drug dependence\n>Certain autoimmune disorders\n>Cancer, excluding pre-cancer conditions or in-situ status\n>Certain cardiovascular disorders \n>Congestive heart failure\n>Dementia\n>Diabetes mellitus\n>End-stage liver disease\n>End-stage renal disease (ESRD) requiring dialysis\n>Certain severe hematologic (blood) disorders \n>HIV/AIDS\n>Certain chronic lung disorders \n>Certain chronic and disabling mental health conditions\n>Certain neurologic disorders \n>Stroke", "doc_id": "ec586ece-4aed-4be5-be92-145c68956464", "embedding": null, "doc_hash": "52ebfe5250eb7bd8e9f08090668e298191d07936656a68f81acee82e29f69262", "extra_info": {"page_label": "49", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2690, "_node_type": "1"}, "relationships": {"1": "ef8895c9-e158-4328-8bb0-2808888628e9"}}, "__type__": "1"}, "1d0953af-8efa-4a68-8a8f-9043546bbc9c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 50\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\n\u2022Please go to the \"Special Supplemental Benefits for the Chronically Ill\" row in the below Medical Benefits Chart \nfor further detail.\n\u2022Please contact us to find out exactly which benefits you may be eligible for.\n You will see this apple next to the preventive services in the benefits chart.\n* You will see this asterisk next to the supplemental benefits in the Medical Benefits Chart.\nMedical Benefits Chart  \nServices that are covered for you What you must pay when you get  \nthese services\n Abdominal aortic aneurysm screening\nA one-time screening ultrasound for people at risk. The plan only covers \nthis screening if you have certain risk factors and if you get a referral for it \nfrom your physician, physician assistant, nurse practitioner, or clinical \nnurse specialist.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for \nmembers eligible for this preventive \nscreening.\nAcupuncture for chronic low back pain\nCovered services include:\nUp to 20 visits per year for Medicare beneficiaries under the following \ncircumstances:\nFor the purpose of this benefit, chronic low back pain is defined as:\n\u2022Lasting 12 weeks or longer;\n\u2022Nonspecific, in that it has no identifiable systemic cause (i.e., not \nassociated with metastatic, inflammatory, infectious, disease, etc.);\n\u2022Not associated with surgery; and\n\u2022Not associated with pregnancy.\nYour plan allows services to be received by a provider licensed to perform \nacupuncture or by providers meeting the Original Medicare provider \nrequirements.\nPrior authorization requirements may apply.In-Network:\nMedicare Covered Acupuncture \nServices\n$25 copayment\n\u2013Specialist's Office\nAllergy shots and serum\nYou are covered for allergy shots and serum when medically necessary.In-Network:\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\nAmbulance services\n\u2022Covered ambulance services include fixed wing, rotary wing, and \nground ambulance services, to the nearest appropriate facility that can \nprovide care only if they are furnished to a member whose medical \ncondition is such that other means of transportation could endanger \nthe person's health or if authorized by the plan.In-Network:\nEmergency Ambulance\n$290 copayment per date of \nservice regardless of the number of \ntrips\n\u2013Ground Ambulance\n\u2013Air Ambulance", "doc_id": "1d0953af-8efa-4a68-8a8f-9043546bbc9c", "embedding": null, "doc_hash": "3f5b9963ec0bb57ec75c0b3c727c54bf8a8bf5b69e365a0d533d5394c93337eb", "extra_info": {"page_label": "50", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2409, "_node_type": "1"}, "relationships": {"1": "a738b865-19f4-40ae-8ecd-17704b1880a0"}}, "__type__": "1"}, "0fffa81d-2126-40d7-a32a-66055ae15991": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 51\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\n\u2022Non-emergency transportation by ambulance is appropriate if it is \ndocumented that the member's condition is such that other means of \ntransportation could endanger the person's health and that \ntransportation by ambulance is medically required.\nPrior authorization requirements may apply.Non-Emergency Ambulance\n$290 copayment per date of \nservice regardless of the number of \ntrips\n\u2013Ground Ambulance\n\u2013Air Ambulance\n Annual wellness visit\nIf you've had Part B for longer than 12 months, you can get an annual \nwellness visit to develop or update a personalized prevention plan based \non your current health and risk factors. This is covered once every 12 \nmonths.\nNote: Your first annual wellness visit can't take place within 12 months of \nyour \"Welcome to Medicare\" preventive visit. However, you don't need to \nhave had a \"Welcome to Medicare\" visit to be covered for annual wellness \nvisits after you've had Part B for 12 months.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \nannual wellness visit.\n Bone mass measurement\nFor qualified individuals (generally, this means people at risk of losing bone \nmass or at risk of osteoporosis), the following services are covered every 24 \nmonths or more frequently if medically necessary: procedures to identify \nbone mass, detect bone loss, or determine bone quality, including a \nphysician's interpretation of the results.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for \nMedicare-covered bone mass \nmeasurement.\n Breast cancer screening (mammograms)\nCovered services include:\n\u2022One baseline mammogram between the ages of 35 and 39\n\u2022One screening mammogram every 12 months for women aged 40 and \nolder\n\u2022Clinical breast exams once every 24 monthsIn-Network:\nThere is no coinsurance, \ncopayment, or deductible for \ncovered screening mammograms.\nCardiac rehabilitation services\nComprehensive programs of cardiac rehabilitation services that include \nexercise, education, and counseling are covered for members who meet \ncertain conditions with a doctor\u2019s order. The plan also covers intensive \ncardiac rehabilitation programs that are typically more rigorous or more \nintense than cardiac rehabilitation programs.\nPrior authorization requirements may applyIn-Network:\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n Cardiovascular disease risk reduction visit (therapy for \ncardiovascular disease) \nWe cover one visit per year with your primary care doctor to help lower \nyour risk for cardiovascular disease. During this visit, your doctor may \ndiscuss aspirin use (if appropriate), check your blood pressure, and give you In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \nintensive behavioral therapy \ncardiovascular disease preventive \nbenefit.", "doc_id": "0fffa81d-2126-40d7-a32a-66055ae15991", "embedding": null, "doc_hash": "d72a095e0787d461c9d2f224862b346cd5bd5cdf66d25b44fb6ae16e1628a7eb", "extra_info": {"page_label": "51", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2983, "_node_type": "1"}, "relationships": {"1": "74b9126a-4fcc-4a57-88ca-2afc34d8526d"}}, "__type__": "1"}, "c8f5991d-ca30-4f36-8e4d-9491f3c015c7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 52\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\ntips to make sure you're eating healthy.\n Cardiovascular disease testing\nBlood tests for the detection of cardiovascular disease (or abnormalities \nassociated with an elevated risk of cardiovascular disease) once every 5 \nyears (60 months).In-Network:\nThere is no coinsurance, \ncopayment, or deductible for \ncardiovascular disease testing that \nis covered once every 5 years.\n Cervical and vaginal cancer screening\nCovered services include:\n\u2022For all women: Pap tests and pelvic exams are covered once every 24 \nmonths\n\u2022If you are at high risk of cervical or vaginal cancer or you are of \nchildbearing age and have had an abnormal Pap test within the past 3 \nyears: one Pap test every 12 monthsIn-Network:\nThere is no coinsurance, \ncopayment, or deductible for \nMedicare-covered preventive Pap \nand pelvic exams.\nChiropractic services\nCovered services include:\n\u2022We cover only manual manipulation of the spine to correct subluxation\n\u2022Other services performed by a chiropractor are not covered \nPrior authorization requirements may apply.In-Network:\nMedicare Covered Chiropractic \nServices\n$20 copayment\n\u2013Specialist's Office\n Colorectal cancer screening\nFor people 50 and older, the following are covered:\n\u2022Flexible sigmoidoscopy (or screening barium enema as an alternative) \nevery 48 months\nOne of the following every 12 months:\n\u2022Guaiac-based fecal occult blood test (gFOBT)\n\u2022Fecal immunochemical test (FIT)\nDNA based colorectal screening every 3 years\nFor people at high risk of colorectal cancer, we cover:\n\u2022Screening colonoscopy (or screening barium enema as an alternative) \nevery 24 months\nFor people not at high risk of colorectal cancer, we cover:\n\u2022Screening colonoscopy every 10 years (120 months), but not within 48 \nmonths of a screening sigmoidoscopyIn-Network:\nThere is no coinsurance, \ncopayment, or deductible for a \nMedicare-covered colorectal cancer \nscreening exam.\nDental services\nIn general, preventive dental services (such as cleaning, routine dental \nexams, and dental x-rays) are not covered by Original Medicare. We cover:\n\u2022Medically necessary dental services, as covered by Original Medicare\nPrior authorization requirements may apply.In-Network:\nMedicare Covered Dental Services\n$25 copayment\n\u2013Specialist's Office\nSupplemental dental benefits\n*You are covered for supplemental ", "doc_id": "c8f5991d-ca30-4f36-8e4d-9491f3c015c7", "embedding": null, "doc_hash": "79b9ee090c647c70ae358dd701fc2ebb52c7aad4b16c8e0a320c45ef8c6fa9ec", "extra_info": {"page_label": "52", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2519, "_node_type": "1"}, "relationships": {"1": "cbdccf59-e8d9-424b-8ca6-f7a16e015737"}}, "__type__": "1"}, "d8619a5d-3bbe-4475-8baa-727716389c54": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 53\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\ndental benefits. See the \nsupplemental dental benefit \ndescription at the end of this chart \nfor details.\n Depression screening\nWe cover one screening for depression per year. The screening must be \ndone in a primary care setting that can provide follow-up treatment and/or \nreferrals.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for an \nannual depression screening visit.\n Diabetes screening\nWe cover this screening (includes fasting glucose tests) if you have any of \nthe following risk factors: high blood pressure (hypertension), history of \nabnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a \nhistory of high blood sugar (glucose). Tests may also be covered if you \nmeet other requirements, like being overweight and having a family \nhistory of diabetes.\nBased on the results of these tests, you may be eligible for up to two \ndiabetes screenings every 12 months.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \nMedicare-covered diabetes \nscreening tests.\n Diabetes self-management training, diabetic services and supplies\nFor all people who have diabetes (insulin and non-insulin users). Covered \nservices include:\n\u2022Supplies to monitor your blood glucose: Blood glucose monitor, blood \nglucose test strips, lancet devices and lancets, and glucose-control \nsolutions for checking the accuracy of test strips and monitors.\n\u2013These are the only covered brands of blood glucose monitors and \ntest strips: ACCU-CHEK\u00ae manufactured by Roche, or Trividia products \nsometimes packaged under your pharmacy\u2019s name.\n\u2013Humana covers any blood glucose monitors and test strips specified \nwithin the preferred brand list above. In general, alternate \nnon-preferred brand products are not covered unless your doctor \nprovides adequate information that the use of an alternate brand is \nmedically necessary in your specific situation. If you are new to \nHumana and are using a brand of blood glucose monitor and test \nstrips that are not on the preferred brand list, you may contact us \nwithin the first 90 days of enrollment into the plan to request a \ntemporary supply of the alternate non-preferred brand. During this \ntime, you should talk with your doctor to decide whether any of the \npreferred product brands listed above are medically appropriate for \nyou. Non-preferred brand products will not be covered following the \ninitial 90 days of coverage without an approved prior authorization \nfor a coverage exception.\n\u2022For people with diabetes who have severe diabetic foot disease: One \npair per calendar year of therapeutic custom-molded shoes (including In-Network:\nDiabetes self-management training\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\n\u2013Outpatient Hospital\nDiabetic Monitoring Supplies\n$0 copayment\n\u2013Preferred Diabetic Supplier\n20% coinsurance\n\u2013Diabetic Supplier\n10% coinsurance\n\u2013Network Retail Pharmacy\nDiabetic Shoes and Inserts\n$0 copayment\n\u2013Durable Medical Equipment \nProvider\n\u2013Prosthetics Provider", "doc_id": "d8619a5d-3bbe-4475-8baa-727716389c54", "embedding": null, "doc_hash": "d8d3b2c6ce38782b5118871e9861507c01af41a3cea3f87d44d1118e484a4670", "extra_info": {"page_label": "53", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3192, "_node_type": "1"}, "relationships": {"1": "d1cdb3d5-03f1-41f6-ad61-3bb8d2200581"}}, "__type__": "1"}, "9ea4855d-88a4-41d5-b917-23f3228c7140": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 54\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\ninserts provided with such shoes) and two additional pairs of inserts, or \none pair of depth shoes and three pairs of inserts (not including the \nnon-customized removable inserts provided with such shoes). Coverage \nincludes fitting.\n\u2022Diabetes self-management training is covered under certain conditions\n\u2022For Continuous Glucose Monitors, see Durable medical equipment (DME) \nand related supplies.\nThe  (preventive service) only applies to Diabetes self-management \ntraining.\nPrior authorization requirements may apply.\nDurable medical equipment (DME) and related supplies\n(For a definition of \"durable medical equipment,\" see Chapter 12 as well as \nChapter 3, Section 7 of this document.)\nCovered items include, but are not limited to: wheelchairs, crutches, \npowered mattress systems, diabetic supplies, hospital beds ordered by a \nprovider for use in the home, IV infusion pumps, speech generating \ndevices, oxygen equipment, nebulizers, continuous glucose monitors**, \nand walkers.\nWe cover all medically necessary DME covered by Original Medicare. If our \nsupplier in your area does not carry a particular brand or manufacturer, \nyou may ask them if they can special order it for you. The most recent list \nof suppliers is available on our website Humana.com/findadoctor.\nAlso covers Part B insulin used through an insulin pump.\nPrior authorization requirements may apply.\n**Continuous glucose monitors available only through durable medical \nequipment provider.In-Network:\nDurable Medical Equipment\n20% coinsurance\n\u2013Durable Medical Equipment \nProvider\nEffective July 1, 2023, cost sharing \nfor covered Part B Insulin furnished \nthrough a covered item of durable \nmedical equipment will be no more \nthan $35 for a one-month (up to \n30-day) supply. \n EKG screening\nThe screening EKG, when done as a referral from the \"Welcome to \nMedicare\" preventative visit, is only covered once during a beneficiary\u2019s \nlifetime.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for an \nEKG screening visit.\nEmergency care\nEmergency care refers to services that are:\n\u2022Furnished by a provider qualified to furnish emergency services, and\n\u2022Needed to evaluate or stabilize an emergency medical condition\nA medical emergency is when you, or any other prudent layperson with an \naverage knowledge of health and medicine, believe that you have medical \nsymptoms that require immediate medical attention to prevent loss of life In-Network:\nEmergency Services\n$125 copayment\n\u2013Emergency Room\nProvider and Professional Services\n$0 copayment\n\u2013Emergency Room", "doc_id": "9ea4855d-88a4-41d5-b917-23f3228c7140", "embedding": null, "doc_hash": "0e3e366d6a1e3b5298416dcb986b0a7f3517e3c14d5b96fdb36cd2fc6ad4d660", "extra_info": {"page_label": "54", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2765, "_node_type": "1"}, "relationships": {"1": "885b3087-a36d-442c-9748-d0dc6c9d6dfa"}}, "__type__": "1"}, "ff559108-9ae7-44a9-8f1f-f56a73a6f845": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 55\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\n(and, if you are a pregnant woman, loss of an unborn child), loss of a limb, \nor loss of function of a limb. The medical symptoms may be an illness, \ninjury, severe pain, or a medical condition that is quickly getting worse.\nCost-sharing for necessary emergency services furnished out-of-network is \nthe same as for such services furnished in-network.\nYou are covered for emergency care world-wide. If you have an \nemergency outside of the U.S. and its territories, you will be responsible to \npay for the services rendered upfront. You must submit to Humana for \nreimbursement. For more information please see Chapter 7. We may not \nreimburse you for all out of pocket expenses. This is because our \ncontracted rates may be lower than provider rates outside of the U.S. and \nits territories. You are responsible for any costs exceeding our contracted \nrates as well as any applicable member cost-share.You do not pay the emergency \nroom visit cost share if you are \nadmitted to the same hospital \nwithin 24 hours for the same \ncondition.\nIf you receive emergency care at an \nout-of-network hospital and need \ninpatient care after your \nemergency condition is stabilized, \nyou must return to a network \nhospital in order for your care to \ncontinue to be covered OR you \nmust have your inpatient care at \nthe out-of-network hospital \nauthorized by the plan and your \ncost is the cost-sharing you would \npay at a network hospital.\nIf you move into an observation or \ninpatient status, your emergency \ncare copay will be waived and you \nwill pay your observation or \ninpatient copay.  For further \ninformation, see the Outpatient \nObservation or Inpatient Hospital \nCare section of this chart. \n* Health education\nThe Oasis Everywhere benefit offers adult learning and healthy lifestyle \ncourses both virtually and in-person. All programs are live, interactive and \nencourage member participation. Learning classes include\nHistory, Music, Travel, Culture, Art, Science, Technology, Exercise and more. \nMembers will have an $80 allowance per year, with no copayment, toward \ncourses available in the Oasis catalog. Numerous no-cost healthy living \ncourses are available and an additional 3,500+ fee-based classes offered \nnationwide. Members are responsible for costs above and beyond the \nallowance value.$0 copayment\nHearing services\nDiagnostic hearing and balance evaluations performed by your provider to \ndetermine if you need medical treatment are covered as outpatient care \nwhen furnished by a physician, audiologist, or other qualified provider.\nPrior authorization requirements may apply.In-Network:\nMedicare Covered Hearing Services\n$25 copayment\n\u2013Specialist's Office\nSupplemental hearing benefits\n*You are covered for supplemental \nhearing benefits. See the \nsupplemental hearing benefit ", "doc_id": "ff559108-9ae7-44a9-8f1f-f56a73a6f845", "embedding": null, "doc_hash": "0eccc70245efbb57ade2b55748e92dda40d6341e54511deed1dcded16bd4327c", "extra_info": {"page_label": "55", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3013, "_node_type": "1"}, "relationships": {"1": "61671732-245a-4392-b420-0ba6ad322ff3"}}, "__type__": "1"}, "3ea709c6-8702-45d5-8628-edf4341bb8a7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 56\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\ndescription at the end of this chart \nfor details.\nHelp with certain chronic conditions\nCOPD Inhaler Support Program\nThis plan offers members with chronic obstructive pulmonary disease \n(COPD), who are prescribed a controller inhaler and enroll in the COPD \nInhaler Support Program, reduced cost sharing for certain controller \ninhalers. You must complete enrollment to receive the reduced cost \nshares, which apply through the Deductible (if applicable to your plan), \nInitial Coverage, and Coverage Gap Stages.\nOnly controller inhalers used to treat COPD on our preferred brand tier are \nincluded.\nCertain members, meeting additional program criteria, may also receive a \nspacer device at $0 cost share when obtained from any retail or mail order \npharmacy.\nDOAC Savings Program\nThis plan offers members with Atrial Fibrillation (A-Fib), Deep Vein \nThrombosis (DVT), and Pulmonary Embolism (PE) who are prescribed a \ndirect oral anticoagulant (DOAC) and enroll in the DOAC Savings program, \nreduced cost sharing for certain DOACs. You must complete the \nconsultation to receive the reduced cost shares, which apply through the \nDeductible (if applicable to your plan), Initial Coverage, and Coverage Gap \nStages.\nOnly direct oral anticoagulants used for A-Fib, DVT and PE on our preferred \nbrand tier are included.COPD Inhaler Support Program\nIn-Network:\n$0 copayment for 1-month supply \nand 3-month supply\n\u2013CenterWell Pharmacy\u2122 \n(retail and mail order)\n$10 copayment for 1-month supply\n\u2013Retail Pharmacy\n\u2013Mail Order Pharmacy\nDOAC Savings Program\nIn-Network:\n$0 copayment for 1-month supply \nand 3-month supply\n\u2013CenterWell Pharmacy\u2122 \n(retail and mail order) \n$10 copayment for 1-month \nsupply\n\u2013Retail Pharmacy\n\u2013Mail Order Pharmacy\n$30 copayment for 3-month supply\n\u2013Retail Pharmacy\n\u2013Mail Order Pharmacy\n HIV screening\nFor people who ask for an HIV screening test or who are at increased risk \nfor HIV infection, we cover:\n\u2022One screening exam every 12 months\nFor women who are pregnant, we cover:\n\u2022Up to three screening exams during a pregnancyIn-Network:\nThere is no coinsurance, \ncopayment, or deductible for \nmembers eligible for \nMedicare-covered preventive HIV \nscreening.\nHome health agency care\nPrior to receiving home health services, a doctor must certify that you need \nhome health services and will order home health services to be provided by \na home health agency. You must be homebound, which means leaving \nhome is a major effort.\nCovered services include, but are not limited to:\n\u2022Part-time or intermittent skilled nursing and home health aide services \n(To be covered under the home health care benefit, your skilled nursing In-Network:\nHome Health Care\n$0 copayment\n\u2013Member's Home\nDurable Medical Equipment\n20% coinsurance\n\u2013Durable Medical Equipment \nProvider", "doc_id": "3ea709c6-8702-45d5-8628-edf4341bb8a7", "embedding": null, "doc_hash": "2fac6a04c8d1143a00b87dcd89477049777bba9610a5de0e9e7db7692ecbd31b", "extra_info": {"page_label": "56", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2993, "_node_type": "1"}, "relationships": {"1": "9775e379-01ee-4811-afca-34f66c2ce5cf"}}, "__type__": "1"}, "f120f79a-a0c3-4f8b-8ed0-180a56f83c44": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 57\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\nand home health aide services combined must total fewer than 8 hours \nper day and 35 hours per week)\n\u2022Physical therapy, occupational therapy, and speech therapy\n\u2022Medical and social services\n\u2022Medical equipment and supplies\nPrior authorization requirements may apply. \nHome infusion therapy\nHome infusion therapy involves the intravenous or subcutaneous \nadministration of drugs or biologicals to an individual at home. The \ncomponents needed to perform home infusion include the drug (for \nexample, antivirals, immune globulin), equipment (for example, a pump), \nand supplies (for example, tubing and catheters).\nCovered services include, but are not limited to:\n\u2022Professional services, including nursing services, furnished in \naccordance with the plan of care\n\u2022Patient training and education not otherwise covered under the durable \nmedical equipment benefit\n\u2022Remote monitoring\n\u2022Monitoring services for the provision of home infusion therapy and \nhome infusion drugs furnished by a qualified home infusion therapy \nsupplierIn-Network:\nMedical Supplies\n20% coinsurance\n\u2013Medical Supply Provider\nMedicare Part B Covered Drugs\n20% coinsurance\n\u2013PCP's Office\n\u2013Specialist's Office\n\u2013Pharmacy\nProvider and Professional Services\n$0 copayment\n\u2013PCP's Office\nHospice care\nYou are eligible for the hospice benefit when your doctor and the hospice \nmedical director have given you a terminal prognosis certifying that you're \nterminally ill and have 6 months or less to live if your illness runs its normal \ncourse. You may receive care from any Medicare-certified hospice \nprogram. Your plan is obligated to help you find Medicare-certified hospice \nprograms in the plan\u2019s service area, including those the MA organization \nowns, controls, or has a financial interest in. Your hospice doctor can be a \nnetwork provider or an out-of-network provider.\nCovered services include:\n\u2022Drugs for symptom control and pain relief \n\u2022Short-term respite care \n\u2022Home care\nFor hospice services and for services that are covered by Medicare Part A or \nB and are related to your terminal prognosis: Original Medicare (rather than \nour plan) will pay your hospice provider for your hospice services related to \nyour terminal prognosis. While you are in the hospice program, your \nhospice provider will bill Original Medicare for the services that Original \nMedicare pays for. You will be billed Original Medicare cost sharing.\nFor services that are covered by Medicare Part A or B and are not related to When you enroll in a \nMedicare-certified hospice \nprogram, your hospice services and \nyour Part A and Part B services \nrelated to your terminal prognosis \nare paid for by Original Medicare, \nnot Humana Gold Plus H0028-014 \n(HMO). Hospice consultations are \nincluded as part of Inpatient \nhospital care. Provider cost sharing \nmay apply for outpatient \nconsultations.", "doc_id": "f120f79a-a0c3-4f8b-8ed0-180a56f83c44", "embedding": null, "doc_hash": "a2e55d01b32a60b89f5b54b2c228c5a52ab22ac6b6a5c8e394a401fd8f6d62c4", "extra_info": {"page_label": "57", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3055, "_node_type": "1"}, "relationships": {"1": "dacf3b98-0f27-48b1-8f36-c5876bc493aa"}}, "__type__": "1"}, "336b7d6e-2727-4270-9311-65f938627af3": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 58\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\nyour terminal prognosis: If you need non-emergency, non-urgently \nneeded services that are covered under Medicare Part A or B and that are \nnot related to your terminal prognosis, your cost for these services \ndepends on whether you use a provider in our plan's network and follow \nplan rules (such as if there is a requirement to obtain prior authorization).\n\u2022If you obtain the covered services from a network provider and follow \nplan rules for obtaining service, you only pay the plan cost-sharing \namount for in-network services.\n\u2022If you obtain covered services from an out-of-network provider, you pay \nthe cost-sharing under Fee-for-Service Medicare (Original Medicare).\nFor services that are covered by Humana Gold Plus H0028-014 (HMO) but \nare not covered by Medicare Part A or B: Humana Gold Plus H0028-014 \n(HMO) will continue to cover plan-covered services that are not covered \nunder Part A or B whether or not they are related to your terminal \nprognosis. You pay your plan cost-sharing amount for these services.\nFor drugs that may be covered by the plan's Part D benefit: If these drugs \nare unrelated to your terminal hospice condition you pay cost sharing. If \nthey are related to your terminal hospice condition then you pay Original \nMedicare cost sharing. Drugs are never covered by both hospice and our \nplan at the same time. For more information, please see Chapter 5, Section \n9.4 (What if you're in Medicare-certified hospice).\nNote: If you need non-hospice care (care that is not related to your \nterminal prognosis), you should contact us to arrange the services. \n* Humana Flex Allowance\nMembers receive $500 annual allowance on a prepaid card which can be \nused towards out of pocket costs, including copays, for the plan\u2019s dental, \nvision and/or hearing supplemental benefits, allowing members to extend \ntheir coverage.\nThis benefit provides flexibility so members choose how to spend the \nallowance towards the plan's covered vision, dental and/or hearing \nservices.                                                                                                                                                                          \nFor a list of covered services refer to the Dental, Vision, and Hearing \nsupplemental benefit sections at the end of this chart.  Services must be \nprovided where the primary business is Dental Care, Vision Services, or \nHearing Services and provider must accept Visa\u00ae.                                                                                                                                    \n\u2022Unused amount expires at the end of the plan year. \n\u2022Cosmetic procedures and teeth whitening are not covered under this \nbenefit.\n\u2022Please retain receipts from services as Humana reserves the right to \naudit dental,", "doc_id": "336b7d6e-2727-4270-9311-65f938627af3", "embedding": null, "doc_hash": "59a87ecbf82e8ec19393d00f8084d214abec34aea51945faaa01371a8a419b81", "extra_info": {"page_label": "58", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3003, "_node_type": "1"}, "relationships": {"1": "c4bbe220-e335-42fd-8d45-3babaf36e6d7", "3": "87820f8d-32cc-4c8a-b0c3-887a40b52943"}}, "__type__": "1"}, "87820f8d-32cc-4c8a-b0c3-887a40b52943": {"__data__": {"text": "receipts from services as Humana reserves the right to \naudit dental, vision, and hearing purchases made with the prepaid \ncard.$0 copayment", "doc_id": "87820f8d-32cc-4c8a-b0c3-887a40b52943", "embedding": null, "doc_hash": "484058896e61ee077883750c0896776b166d7ed9fe284e030858e3c06eb5fa8d", "extra_info": {"page_label": "58", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 2934, "end": 3074, "_node_type": "1"}, "relationships": {"1": "c4bbe220-e335-42fd-8d45-3babaf36e6d7", "2": "336b7d6e-2727-4270-9311-65f938627af3"}}, "__type__": "1"}, "009e0002-e57e-4029-a725-45b6d512eacb": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 59\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\nSee Humana Spending Account Card section in this chart for more \ninformation.\n* Humana Spending Account Card \n\u2022Because you are enrolled in Humana Gold Plus H0028-014 (HMO) , you \nhave card allowance benefits available for your use. Your allowance \nbenefit(s): \n\u2013* Humana Flex Allowance\n\u2013* OTC Allowance\nThese benefits are designed to help members meet their unique needs, \nand will be loaded onto a single Humana Spending Account Card that you \ncan use at specific locations and network retailers as determined by the \nplan. Allowance amounts cannot be combined with other benefit \nallowances. Limitations and restrictions may apply. Please note, this is not \na Medicaid benefit. Full details on each allowance benefit can be found in \nthis Chapter 4 Medical Benefits Chart.\nPlease activate your card as soon as you receive it in the mail. Funds will be \nadded to your card beginning January 2023. All funds expire as stated in \nthe benefit, at the end of the plan year, or when you leave the plan. \nAdditionally, Humana is not responsible for any lost or stolen cards. Please \nsee the back of your card for more information.$0 copayment\n* Humana Well Dine\u00ae meal program\nAfter your inpatient stay in either the hospital or a nursing facility, you are \neligible to receive 2 meals per day for 7 days at no extra cost to you. 14 \nnutritious meals will be delivered to your home. Meal program limited to 4 \ntimes per calendar year.  Meals have to be requested within 30 days of \ndischarge from inpatient stay.\nFor additional information, please contact the Customer Service number \non the back of your Humana Member ID card.In-Network:\nThere is no coinsurance, \ncopayment, or deductible to \nparticipate.\n Immunizations\nCovered Medicare Part B services include:\n\u2022Pneumonia vaccine\n\u2022Flu shots, once each flu season in the fall and winter, with additional flu \nshots if medically necessary\n\u2022Hepatitis B vaccine if you are at high or intermediate risk of getting \nHepatitis B\n\u2022COVID-19 vaccine\n\u2022Other vaccines if you are at risk and they meet Medicare Part B coverage \nrulesIn-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \npneumonia, influenza, Hepatitis B, \nand COVID-19 vaccines.", "doc_id": "009e0002-e57e-4029-a725-45b6d512eacb", "embedding": null, "doc_hash": "3669ef4629cf6a45123a7fa31899fafa0c81e3c50d3108e230825bb9be2d2e77", "extra_info": {"page_label": "59", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2414, "_node_type": "1"}, "relationships": {"1": "fe2c398a-a70a-480e-a9ba-5c310d24d1d3"}}, "__type__": "1"}, "dbd48933-4c27-4c91-bace-3562cb0abf7a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 60\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\nWe also cover some vaccines under our Part D prescription drug benefit. \nYou can find these vaccines listed in the plan\u2019s Drug Guide (Formulary).\nInpatient hospital care\nIncludes inpatient acute, inpatient rehabilitation, long-term care hospitals \nand other types of inpatient hospital services. Inpatient hospital care starts \nthe day you are formally admitted to the hospital with a doctor's order. The \nday before you are discharged is your last inpatient day.\nCovered services include but are not limited to:\n\u2022Semi-private room (or a private room if medically necessary)\n\u2022Meals including special diets\n\u2022Regular nursing services\n\u2022Costs of special care units (such as intensive care or coronary care units)\n\u2022Drugs and medications\n\u2022Lab tests\n\u2022X-rays and other radiology services\n\u2022Necessary surgical and medical supplies\n\u2022Use of appliances, such as wheelchairs\n\u2022Operating and recovery room costs\n\u2022Physical, occupational, and speech language therapy\n\u2022Inpatient substance abuse services\n\u2022Under certain conditions, the following types of transplants are covered: \ncorneal, kidney, kidney-pancreatic, heart, liver, lung, heart/lung, bone \nmarrow, stem cell, and intestinal/multivisceral. If you need a transplant, \nwe will arrange to have your case reviewed by a Medicare-approved \ntransplant center that will decide whether you are a candidate for a \ntransplant. Transplant providers may be local or outside of the service \narea. If our in-network transplant services are outside the community \npattern of care, you may choose to go locally as long as the local \ntransplant providers are willing to accept the Original Medicare rate. If \nHumana Gold Plus H0028-014 (HMO) provides transplant services at a \nlocation outside the pattern of care for transplants in your community \nand you choose to obtain transplants at this distant location, we will \narrange or pay for appropriate lodging and transportation costs for you \nand a companion.\n\u2013If you are in need of a solid organ or bone marrow/stem cell \ntransplant, please contact our Transplant Department at \n1-866-421-5663, TTY 711 for important information about your \ntransplant care.\n\u2022Blood - including storage and administration. Coverage of whole blood \nand packed red cells begins with the first pint of blood that you need.\n\u2022Physician services\nNote: To be an inpatient, your provider must write an order to admit you \nformally as an inpatient of the hospital. Even if you stay in the hospital Your inpatient cost share will begin \non day one each time you are \nadmitted or transferred to a specific \nfacility type, including Inpatient \nRehabilitation facilities, Long Term \nAcute Care (LTAC) facilities, \nInpatient Acute Care facilities, and \nInpatient Psychiatric facilities.\nIn-Network:\nInpatient Care\nInpatient Hospital\n\u2013$245 copayment per day, \ndays 1 to 8\n\u2013$0 copayment per day, days \n9 to 90\nProvider and Professional Services\n$0 copayment\n\u2013Inpatient Hospital\nIf you get authorized inpatient care \nat an out-of-network hospital after \nyour emergency condition is \nstabilized, your cost is the \ncost-sharing you would pay at a \nnetwork hospital.\nYou are covered for an unlimited \nnumber of medically necessary \ninpatient hospital days.", "doc_id": "dbd48933-4c27-4c91-bace-3562cb0abf7a", "embedding": null, "doc_hash": "cbc30336b1178002dd9ac6f0428c81f70270e9d38c18ad0e45d2eaecddd232cc", "extra_info": {"page_label": "60", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3413, "_node_type": "1"}, "relationships": {"1": "0c348d79-8048-43a4-afe6-1923171d4c80"}}, "__type__": "1"}, "8d4ab7c9-516d-4a13-88dd-4ee847b5a1b7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 61\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\novernight, you might still be considered an \"outpatient.\" If you are not sure \nif you are an inpatient or an outpatient, you should ask the hospital staff.\nYou can also find more information in a Medicare fact sheet called \"Are You \na Hospital Inpatient or Outpatient? If You Have Medicare \u2013 Ask!\" This fact \nsheet is available on the Web at \nhttps://www.medicare.gov/sites/default/files/2021-10/11435-Inpatient-o\nr-Outpatient.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY \nusers call 1-877-486-2048. You can call these numbers for free, 24 hours a \nday, 7 days a week.\nPrior authorization is required for inpatient hospital care.\nPrior authorization is required for transplant services.\nInpatient services in a psychiatric hospital\nCovered services include mental health care services that require a \nhospital stay.\n\u2022190-day lifetime limit for inpatient services in a psychiatric hospital\n\u2013The 190-day limit does not apply to Inpatient Mental Health services \nprovided in a psychiatric unit of a general hospital\n\u2022The benefit days used under the Original Medicare program will count \ntoward the 190-day lifetime reserve days when enrolling in a Medicare \nAdvantage plan\nPrior authorization is required for inpatient mental health care.Your inpatient cost share will begin \non day one each time you are \nadmitted or transferred to a specific \nfacility type, including Inpatient \nRehabilitation facilities, Long Term \nAcute Care (LTAC) facilities, \nInpatient Acute Care facilities, and \nInpatient Psychiatric facilities.\nIn-Network:\nInpatient Mental Health Care\nInpatient Hospital\n\u2013$245 copayment per day, \ndays 1 to 8\n\u2013$0 copayment per day, days \n9 to 90\nInpatient Psychiatric Facility\n\u2013$245 copayment per day, \ndays 1 to 8\n\u2013$0 copayment per day, days \n9 to 90\nProvider and Professional Services\n$0 copayment\n\u2013Inpatient Hospital\n\u2013Inpatient Psychiatric Facility\nInpatient stay: Covered services received in a hospital or SNF during a \nnon-covered inpatient stay\nIf you have exhausted your inpatient benefits or if the inpatient stay is not \nreasonable and necessary, we will not cover your inpatient stay. However, \nin some cases, we will cover certain services you receive while you are in When your inpatient stay is not \ncovered, you will pay the cost of the \nservices received as described \nthroughout this benefit chart.", "doc_id": "8d4ab7c9-516d-4a13-88dd-4ee847b5a1b7", "embedding": null, "doc_hash": "9069cf48d34449924a9a1170e6da99f5ed419f83ef53e9c017402f9bf9218b24", "extra_info": {"page_label": "61", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2550, "_node_type": "1"}, "relationships": {"1": "bf1e24a4-fa67-4d33-b1f8-86f8cf06c7db"}}, "__type__": "1"}, "7566accb-13b5-4f67-ad12-d34dc83d8690": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 62\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\nthe hospital or the skilled nursing facility (SNF). Covered services include, \nbut are not limited to:\n\u2022Physician services\n\u2022Diagnostic tests (like lab tests)\n\u2022X-ray, radium, and isotope therapy including technician materials and \nservices\n\u2022Surgical dressings\n\u2022Splints, casts and other devices used to reduce fractures and \ndislocations\n\u2022Prosthetics and orthotics devices (other than dental) that replace all or \npart of an internal body organ (including contiguous tissue), or all or \npart of the function of a permanently inoperative or malfunctioning \ninternal body organ, including replacement or repairs of such devices\n\u2022Leg, arm, back, and neck braces; trusses; and artificial legs, arms, and \neyes including adjustments, repairs, and replacements required \nbecause of breakage, wear, loss, or a change in the patient's physical \ncondition\n\u2022Physical therapy, speech therapy, and occupational therapy\n Medical nutrition therapy\nThis benefit is for people with diabetes, renal (kidney) disease (but not on \ndialysis), or after a kidney transplant when ordered by your doctor.\nWe cover 3 hours of one-on-one counseling services during your first year \nthat you receive medical nutrition therapy services under Medicare (this \nincludes our plan, any other Medicare Advantage Plan, or Original \nMedicare), and 2 hours each year after that. If your condition, treatment, \nor diagnosis changes, you may be able to receive more hours of treatment \nwith a physician's order. A physician must prescribe these services and \nrenew their order yearly if your treatment is needed into the next calendar \nyear.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for \nmembers eligible for \nMedicare-covered medical nutrition \ntherapy services.\n Medicare Diabetes Prevention Program (MDPP)\nMDPP services will be covered for eligible Medicare beneficiaries under all \nMedicare health plans.\nMDPP is a structured health behavior change intervention that provides \npractical training in long-term dietary change, increased physical activity, \nand problem-solving strategies for overcoming challenges to sustaining \nweight loss and a healthy lifestyle.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \nMDPP benefit.\nMedicare Part B prescription drugs\nThese drugs are covered under Part B of Original Medicare. Members of our \nplan receive coverage for these drugs through our plan. Covered drugs \ninclude:In-Network:\nMedicare Part B Covered Drugs\n20% coinsurance\n\u2013PCP's Office\n\u2013Specialist's Office\n\u2013Pharmacy", "doc_id": "7566accb-13b5-4f67-ad12-d34dc83d8690", "embedding": null, "doc_hash": "6892a508f6cdcb8d1fda331814ef998225cd8fd88e256002aaeb65fcc7c00aeb", "extra_info": {"page_label": "62", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2741, "_node_type": "1"}, "relationships": {"1": "30ec26a6-82c1-4566-bcdf-1452c417d567"}}, "__type__": "1"}, "c6157a54-a39c-46cd-868e-0cdedf70d707": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 63\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\n\u2022Drugs that usually aren't self-administered by the patient and are \ninjected or infused while you are getting physician, hospital outpatient, \nor ambulatory surgical center services\n\u2022Drugs you take using durable medical equipment (such as nebulizers) \nthat were authorized by the plan\n\u2022Clotting factors you give yourself by injection if you have hemophilia\n\u2022Immunosuppressive Drugs, if you were enrolled in Medicare Part A at \nthe time of the organ transplant\n\u2022Injectable osteoporosis drugs, if you are homebound, have a bone \nfracture that a doctor certifies was related to post-menopausal \nosteoporosis, and cannot self-administer the drug\n\u2022Antigens\n\u2022Certain oral anti-cancer drugs and anti-nausea drugs\n\u2022Certain drugs for home dialysis, including heparin, the antidote for \nheparin when medically necessary, topical anesthetics, and \nerythropoiesis-stimulating agents (such as Epogen\u00ae, Procrit\u00ae, Epoetin \nAlfa, Aranesp\u00ae, or Darbepoetin Alfa)\n\u2022Intravenous Immune Globulin for the home treatment of primary \nimmune deficiency diseases\nThere is no additional cost for the administration of Part B drugs\nThe following link will take you to a list of Part B Drugs that may be subject \nto Step Therapy: Humana.com/PAL \nWe also cover some vaccines under our Part B and Part D prescription drug \nbenefit.\nChapter 5 explains the Part D prescription drug benefit, including the rules \nyou must follow to have prescriptions covered. What you pay for your Part \nD prescription drugs through our plan is explained in Chapter 6.\nPrior authorization may be required for in-network Part B drugs. You may \nalso have to try a different drug first before we will agree to cover the drug \nyou are requesting. This is called \"step therapy.\" Contact the plan for \ndetails.Chemotherapy Drugs\n20% coinsurance\n\u2013Specialist's Office\n\u2013Outpatient Hospital\nEffective April 1, 2023, some \nrebatable Part B drugs may be \nsubject to a lower coinsurance. \n Obesity screening and therapy to promote sustained weight loss\nIf you have a body mass index of 30 or more, we cover intensive \ncounseling to help you lose weight. This counseling is covered if you get it \nin a primary care setting, where it can be coordinated with your \ncomprehensive prevention plan. Talk to your primary care doctor or \npractitioner to find out more.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for \npreventive obesity screening and \ntherapy.\nOpioid treatment program services\nMembers of our plan with opioid use disorder (OUD) can receive coverage \nof services to treat OUD through an Opioid Treatment Program (OTP) which \nincludes the following services:In-Network:\n$40 copayment\n\u2013Specialist's Office\n$35 copayment", "doc_id": "c6157a54-a39c-46cd-868e-0cdedf70d707", "embedding": null, "doc_hash": "89d96546f1f1cd1e81e70ab6625ef427f9525c6385c707d2eb61205783cc0ac9", "extra_info": {"page_label": "63", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2898, "_node_type": "1"}, "relationships": {"1": "9fcb5435-78c7-46ac-bdcb-690fec057055"}}, "__type__": "1"}, "db933f85-1138-4661-818c-8d795b12d1cc": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 64\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\n\u2022U.S. Food and Drug Administration (FDA)-approved opioid agonist and \nantagonist medication-assisted treatment (MAT) medications.\n\u2022Dispensing and administration of MAT medications (if applicable)\n\u2022Substance use counseling \n\u2022Individual and group therapy \n\u2022Toxicology testing\n\u2022Intake activities\n\u2022Periodic assessments\nPrior authorization requirements may apply.\u2013Outpatient Hospital\n\u2013Partial Hospitalization\nOutpatient diagnostic tests and therapeutic services and supplies\nCovered services include, but are not limited to:\n\u2022X-rays\n\u2022Radiation (radium and isotope) therapy including technician materials \nand supplies\n\u2022Surgical supplies, such as dressings\n\u2022Splints, casts and other devices used to reduce fractures and \ndislocations\n\u2022Laboratory tests\n\u2022Blood \u2013 including storage and administration. Coverage of whole blood \nand packed red cells begins with the first pint of blood that you need.\n\u2022Other outpatient diagnostic tests\nPrior authorization requirements may apply.In-Network:\nProvider and Professional Services\n$0 copayment\n\u2013PCP's Office\n$25 copayment\n\u2013Specialist's Office\nDiagnostic Procedures and Tests\n$0 copayment\n\u2013PCP's Office\n$25 copayment\n\u2013Specialist's Office\n$30 copayment\n\u2013Urgent Care Center\n$35 copayment\n\u2013Outpatient Hospital\nAdvanced Imaging Services\n$180 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Freestanding Radiological \nFacility\nBasic Radiological Services\n$0 copayment\n\u2013PCP's Office\n$25 copayment\n\u2013Specialist's Office\n$30 copayment", "doc_id": "db933f85-1138-4661-818c-8d795b12d1cc", "embedding": null, "doc_hash": "4d3e98bc87bdb366ae15f2007c005703e182b8541f33643b245b659e197c95d4", "extra_info": {"page_label": "64", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1694, "_node_type": "1"}, "relationships": {"1": "f017f507-17d9-4e64-ac1e-3056163f7b08"}}, "__type__": "1"}, "3e3c1613-f69e-4958-84e5-39656662cb81": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 65\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\n\u2013Urgent Care Center\n$35 copayment\n\u2013Outpatient Hospital\n\u2013Freestanding Radiological \nFacility\nDiagnostic Mammography\n$25 copayment\n\u2013Specialist's Office\n$0 copayment\n\u2013Outpatient Hospital\n\u2013Freestanding Radiological \nFacility\nRadiation Therapy\n$25 copayment\n\u2013Specialist's Office\n$35 copayment\n\u2013Outpatient Hospital\n\u2013Freestanding Radiological \nFacility\nNuclear Medicine Services\n$245 copayment\n\u2013Outpatient Hospital\n\u2013Freestanding Radiological \nFacility\nFacility Based Sleep Study\n$25 copayment\n\u2013Specialist's Office\n$35 copayment\n\u2013Outpatient Hospital\nHome Based Sleep Study\n$0 copayment\n\u2013Member's Home\nMedical Supplies\n20% coinsurance\n\u2013Medical Supply Provider\nDiagnostic Colonoscopy", "doc_id": "3e3c1613-f69e-4958-84e5-39656662cb81", "embedding": null, "doc_hash": "97411b8108986c82872d1c7a7941d16ec7cf5af914f4efa0f2e3c8949413c05b", "extra_info": {"page_label": "65", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 890, "_node_type": "1"}, "relationships": {"1": "eefc82cc-e904-4d89-a023-bca35633a97d"}}, "__type__": "1"}, "58687f56-e150-4871-80ad-949c9fec49ab": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 66\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\n$0 copayment\n\u2013Ambulatory Surgical Center\n\u2013Outpatient Hospital\nLab Services\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Freestanding Laboratory\n$30 copayment\n\u2013Urgent Care Center\nOutpatient hospital observation\nObservation services are hospital outpatient services given to determine if \nyou need to be admitted as an inpatient or can be discharged. \nFor outpatient hospital observation services to be covered, they must meet \nthe Medicare criteria and be considered reasonable and necessary. \nObservation services are covered only when provided by the order of a \nphysician or another individual authorized by state licensure law and \nhospital staff bylaws to admit patients to the hospital or order outpatient \ntests.\nNote: Unless the provider has written an order to admit you as an inpatient \nto the hospital, you are an outpatient and pay the cost-sharing amounts \nfor outpatient hospital services. Even if you stay in the hospital overnight, \nyou might still be considered an \"outpatient.\" If you are not sure if you are \nan outpatient, you should ask the hospital staff.\nYou can also find more information in a Medicare fact sheet called \"Are You \na Hospital Inpatient or Outpatient? If You Have Medicare - Ask!\" This fact \nsheet is available on the Web at \nhttps://www.medicare.gov/sites/default/files/2021-10/11435-Inpatient-o\nr-Outpatient.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY \nusers call 1-877-486-2048. You can call these numbers for free, 24 hours a \nday, 7 days a week.\nPrior authorization requirements may apply.In-Network:\n$195 copayment\n\u2013Outpatient Hospital\nOutpatient hospital services\nWe cover medically-necessary services you get in the outpatient \ndepartment of a hospital for diagnosis or treatment of an illness or injury.\nCovered services include, but are not limited to:\n\u2022Services in an emergency department or outpatient clinic, such as \nobservation services or outpatient surgeryIn-Network:\nDiagnostic Procedures and Tests\n$35 copayment\n\u2013Outpatient Hospital\nAdvanced Imaging Services\n$180 copayment", "doc_id": "58687f56-e150-4871-80ad-949c9fec49ab", "embedding": null, "doc_hash": "a07189e94d89a2a171f59f739d885e2893a86c5ba9700b33677f56624f0c9422", "extra_info": {"page_label": "66", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2283, "_node_type": "1"}, "relationships": {"1": "09e818fc-385c-40cb-93f7-712fdc1b278c"}}, "__type__": "1"}, "f0d6ae37-fe7a-4230-b381-9b4b54f17336": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 67\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\n\u2022Laboratory and diagnostic tests billed by the hospital\n\u2022Mental health care, including care in a partial-hospitalization program, if \na doctor certifies that inpatient treatment would be required without it\n\u2022X-rays and other radiology services billed by the hospital\n\u2022Medical supplies such as splints and casts\n\u2022Certain drugs and biologicals that you can't give yourself\nNote: Unless the provider has written an order to admit you as an inpatient \nto the hospital, you are an outpatient and pay the cost-sharing amounts \nfor outpatient hospital services. Even if you stay in the hospital overnight, \nyou might still be considered an \"outpatient.\" If you are not sure if you are \nan outpatient, you should ask the hospital staff.\nYou can also find more information in a Medicare fact sheet called \"Are You \na Hospital Inpatient or Outpatient? If You Have Medicare - Ask!\" This fact \nsheet is available on the Web at \nhttps://www.medicare.gov/sites/default/files/2021-10/11435-Inpatient-o\nr-Outpatient.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY \nusers call 1-877-486-2048. You can call these numbers for free, 24 hours a \nday, 7 days a week.\nPrior authorization requirements may apply.\u2013Outpatient Hospital\nNuclear Medicine Services\n$245 copayment\n\u2013Outpatient Hospital\nBasic Radiological Services\n$35 copayment\n\u2013Outpatient Hospital\nDiagnostic Mammography\n$0 copayment\n\u2013Outpatient Hospital\nRadiation Therapy\n$35 copayment\n\u2013Outpatient Hospital\nLab Services\n$0 copayment\n\u2013Outpatient Hospital\nSurgery Services\n$245 copayment\n\u2013Outpatient Hospital\nMental Health Services\n$35 copayment\n\u2013Outpatient Hospital\n\u2013Partial Hospitalization\nWound Care\n$35 copayment\n\u2013Outpatient Hospital\nFacility Based Sleep Study\n$35 copayment\n\u2013Outpatient Hospital\nEmergency Services\n$125 copayment\n\u2013Emergency Room\nDiagnostic Colonoscopy\n$0 copayment\n\u2013Outpatient Hospital\nOutpatient mental health care In-Network:", "doc_id": "f0d6ae37-fe7a-4230-b381-9b4b54f17336", "embedding": null, "doc_hash": "e54d41e085aec7ffe0781270c7a21a01b3b1786fac13f59c916bbe5cf802be6b", "extra_info": {"page_label": "67", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2107, "_node_type": "1"}, "relationships": {"1": "30edcdcf-0697-41f2-9946-196bc9ba443d"}}, "__type__": "1"}, "f9ae405e-8bbf-4bb6-a374-55ac499efff3": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 68\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\nCovered services include:\nMental health services provided by a state-licensed psychiatrist or doctor, \nclinical psychologist, clinical social worker, clinical nurse specialist, nurse \npractitioner, physician assistant, or other Medicare-qualified mental health \ncare professional as allowed under applicable state laws.\nPrior authorization requirements may apply. Mental Health Services\n$40 copayment\n\u2013Specialist's Office\n$35 copayment\n\u2013Outpatient Hospital\n\u2013Partial Hospitalization\nOutpatient rehabilitation services\nCovered services include: physical therapy, occupational therapy, and \nspeech language therapy.\nOutpatient rehabilitation services are provided in various outpatient \nsettings, such as hospital outpatient departments, independent therapist \noffices, and Comprehensive Outpatient Rehabilitation Facilities (CORFs).\nPrior authorization requirements may apply.In-Network:\nPhysical Therapy\n$35 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Comprehensive Outpatient \nRehab Facility\nSpeech Therapy\n$35 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Comprehensive Outpatient \nRehab Facility\nOccupational Therapy\n$35 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Comprehensive Outpatient \nRehab Facility\nOutpatient substance abuse services\nYou are covered for treatment of substance abuse, as covered by Original \nMedicare.\nPrior authorization requirements may apply.In-Network:\nSubstance Abuse Services\n$40 copayment\n\u2013Specialist's Office\n$35 copayment\n\u2013Outpatient Hospital\n\u2013Partial Hospitalization\nOutpatient surgery, including services provided at hospital \noutpatient facilities and ambulatory surgical centers\nNote: If you are having surgery in a hospital facility, you should check with \nyour provider about whether you will be an inpatient or outpatient. Unless \nthe provider writes an order to admit you as an inpatient to the hospital, \nyou are an outpatient and pay the cost-sharing amounts for outpatient \nsurgery. Even if you stay in the hospital overnight, you might still be \nconsidered an \"outpatient.\"In-Network:\nSurgery Services\n$245 copayment\n\u2013Outpatient Hospital\n$195 copayment\n\u2013Ambulatory Surgical Center", "doc_id": "f9ae405e-8bbf-4bb6-a374-55ac499efff3", "embedding": null, "doc_hash": "9c20bca27eb21ff9912367707b5be031d7c53dfe6fb061ee1653181c76c3039c", "extra_info": {"page_label": "68", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2369, "_node_type": "1"}, "relationships": {"1": "1a6cdde4-18c3-4946-a53f-dae2a6d0f588"}}, "__type__": "1"}, "efec72e5-115f-4a57-b63c-70d72eb5fb0c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 69\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\nPrior authorization requirements may apply.Diagnostic Colonoscopy\n$0 copayment\n\u2013Ambulatory Surgical Center\n\u2013Outpatient Hospital\n* Over-the-Counter (OTC) Allowance\nYou will receive a quarterly $75 allowance on an over-the-counter (OTC) \nprepaid card that will allow you to purchase health and wellness items \nfrom an approved list at participating retail locations.\n\u2022Available items include many daily use over-the-counter products\n\u2022$75 allowance is available to use at the beginning of each quarter of the \nplan year (January, April, July, and October)\n\u2022Any amount of the quarterly allowance that is not used does not carry \nover to the next quarter\nPlease see the information which accompanies your card for a sample list \nof approved item categories and for ways to find locations where you can \nuse your OTC allowance.\nSee Humana Spending Account Card section in this chart for more \ninformation.In-Network:\n$0 copayment\nPartial hospitalization services\n\"Partial hospitalization\" is a structured program of active psychiatric \ntreatment provided as a hospital outpatient service, or by a community \nmental health center, that is more intense than the care received in your \ndoctor\u2019s or therapist\u2019s office and is an alternative to inpatient \nhospitalization.\nPrior authorization requirements may apply.In-Network:\n$35 copayment\n\u2013Partial Hospitalization\n* Physical exam (Routine)\nIn addition to the Annual Wellness Visit or the \"Welcome to Medicare\" \nphysical exam, you are covered for the following exam once per year:\n\u2022Comprehensive preventive medicine evaluation and management, \nincluding an age and gender appropriate history, examination, and \ncounseling/anticipatory guidance/risk factor reduction interventions\nNote: Any lab or diagnostic procedures that are ordered are not covered \nunder this benefit and you pay your plan cost-sharing amount for those \nservices separately.In-Network:\n$0 copayment\n\u2013PCP's Office\nPhysician/Practitioner services, including doctor's office visits\nCovered services include:\n\u2022Medically-necessary medical care or surgery services furnished in a \nphysician\u2019s office, certified ambulatory surgical center, hospital In-Network:\nProvider and Professional Services\n$0 copayment\n\u2013PCP's Office", "doc_id": "efec72e5-115f-4a57-b63c-70d72eb5fb0c", "embedding": null, "doc_hash": "b0d85c4593619cf46d77bf8066c399c6862ea6cf9d7bec87715e0bb71bd1f697", "extra_info": {"page_label": "69", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2443, "_node_type": "1"}, "relationships": {"1": "ad2cfc73-37bb-4b7b-8287-97522bc256f6"}}, "__type__": "1"}, "154e534d-9007-413b-ad76-31a27c70c1a4": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 70\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\noutpatient department, or any other location\n\u2022Consultation, diagnosis, and treatment by a specialist\n\u2022Basic hearing and balance exams performed by your specialist, if your \ndoctor orders it to see if you need medical treatment\n\u2022Certain telehealth services, including services by primary care providers \n(PCPs) and specialists; individual sessions for mental health specialty \nservices and psychiatric services; individual sessions for outpatient \nsubstance abuse; and urgently needed services.\n\u2013You have the option of getting these services through an in-person \nvisit or by telehealth. If you choose to get one of these services by \ntelehealth, you must use a network provider who offers the service \nvia telehealth.\n\u2013You may use a phone, computer, tablet, or other video technology.\n\u2022Some telehealth services including consultation, diagnosis, and \ntreatment by a physician or practitioner, for patients in certain rural \nareas or other places approved by Medicare.\n\u2022Telehealth services for monthly end-stage renal disease-related visits \nfor home dialysis members in a hospital-based or critical access \nhospital-based renal dialysis center, renal dialysis facility, or the \nmember\u2019s home.\n\u2022Telehealth services to diagnose, evaluate, or treat symptoms of a \nstroke, regardless of your location.\n\u2022Telehealth services for members with a substance use disorder or \nco-occurring mental health disorder, regardless of their location.\n\u2022Telehealth services for diagnosis, evaluation, and treatment of mental \nhealth disorders if:\n\u2013You have an in-person visit within 6 months prior to your first \ntelehealth visit\n\u2013You have an in-person visit every 12 months while receiving these \ntelehealth services\n\u2013Exceptions can be made to the above for certain circumstances\n\u2022Telehealth services for mental health visits provided by Rural Health \nClinics and Federally Qualified Health Centers\n\u2022Virtual check-ins (for example, by phone or video chat) with your doctor \nfor 5-10 minutes if:\n\u2013You\u2019re not a new patient and\n\u2013The check-in isn\u2019t related to an office visit in the past 7 days and\n\u2013The check-in doesn\u2019t lead to an office visit within 24 hours or the \nsoonest available appointment\n\u2022Evaluation of video and/or images you send to your doctor, and \ninterpretation and follow-up by your doctor within 24 hours if:\n\u2013You\u2019re not a new patient and\n\u2013The evaluation isn\u2019t related to an office visit in the past 7 days and\n\u2013The evaluation doesn\u2019t lead to an office visit within 24 hours or the \nsoonest available appointment\n\u2022Consultation your doctor has with other doctors by phone, internet, or \nelectronic health record$25 copayment\n\u2013Specialist's Office\nTelehealth Services\n$0 copayment\n\u2013PCP Virtual\n\u2013Mental Health Care and \nSubstance Abuse Treatment \nVirtual\n\u2013Urgent Care Virtual\n$25 copayment\n\u2013Specialist Virtual\nAdvanced Imaging Services\n$180 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\nSurgery Services\n$0 copayment\n\u2013PCP's Office\n$25 copayment\n\u2013Specialist's Office\nRadiation Therapy\n$25 copayment\n\u2013Specialist's Office\nUrgently Needed Services\n$0 copayment\n\u2013PCP's Office\n$25 copayment\n\u2013Specialist's Office", "doc_id": "154e534d-9007-413b-ad76-31a27c70c1a4", "embedding": null, "doc_hash": "41892d718cb404bd9dfc0574c700ebb8ff32af6c53fa81ff432b500c525ceb86", "extra_info": {"page_label": "70", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3312, "_node_type": "1"}, "relationships": {"1": "e60b55ef-bf2a-4951-b66e-a215a4162631"}}, "__type__": "1"}, "6472b42d-1fc2-4204-a085-a91e9e3e77fd": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 71\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\n\u2022Second opinion by another network provider prior to surgery\n\u2022Non-routine dental care (covered services are limited to surgery of the \njaw or related structures, setting fractures of the jaw or facial bones, \nextraction of teeth to prepare the jaw for radiation treatments of \nneoplastic cancer disease, or services that would be covered when \nprovided by a physician)\n\u2022Urgently needed services furnished in a physician\u2019s office\nPrior authorization requirements may apply. \nPodiatry services\nCovered services include:\n\u2022Diagnosis and the medical or surgical treatment of injuries and diseases \nof the feet (such as hammer toe or heel spurs)\n\u2022Routine foot care for members with certain medical conditions affecting \nthe lower limbs\nPrior authorization requirements may apply.In-Network:\nMedicare Covered Podiatry Services\n$25 copayment\n\u2013Specialist's Office\n Prostate cancer screening exams\nFor men aged 50 and older, covered services include the following - once \nevery 12 months:\n\u2022Digital rectal exam\n\u2022Prostate Specific Antigen (PSA) testIn-Network:\nThere is no coinsurance, \ncopayment, or deductible for an \nannual PSA test.\nProsthetic devices and related supplies\nDevices (other than dental) that replace all or part of a body part or \nfunction. These include, but are not limited to: colostomy bags and \nsupplies directly related to colostomy care, pacemakers, braces, prosthetic \nshoes, artificial limbs, and breast prostheses (including a surgical brassiere \nafter a mastectomy). Includes certain supplies related to prosthetic \ndevices, and repair and/or replacement of prosthetic devices. Also includes \nsome coverage following cataract removal or cataract surgery \u2013 see \n\"Vision Care\" later in this section for more detail.\nPrior authorization requirements may apply.In-Network:\n20% coinsurance\n\u2013Prosthetics Provider\nPulmonary rehabilitation services\nComprehensive programs of pulmonary rehabilitation are covered for \nmembers who have moderate to very severe chronic obstructive \npulmonary disease (COPD) and an order for pulmonary rehabilitation from \nthe doctor treating the chronic respiratory disease.\nPrior authorization requirements may apply. In-Network:\n$20 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n Screening and counseling to reduce alcohol misuse In-Network:\nThere is no coinsurance, ", "doc_id": "6472b42d-1fc2-4204-a085-a91e9e3e77fd", "embedding": null, "doc_hash": "7fc1ab9167f0ee4a3cbebda12cdd1d3afa6f4c51bc573c8816d186d568ace5c8", "extra_info": {"page_label": "71", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2531, "_node_type": "1"}, "relationships": {"1": "9e7d1fd9-0ab5-423c-b6fb-10464d6473dc"}}, "__type__": "1"}, "a5e294a6-d3f6-4560-a5d6-eb01847c4275": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 72\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\nWe cover one alcohol misuse screening for adults with Medicare (including \npregnant women) who misuse alcohol, but aren't alcohol dependent.\nIf you screen positive for alcohol misuse, you can get up to 4 brief \nface-to-face counseling sessions per year (if you're competent and alert \nduring counseling) provided by a qualified primary care doctor or \npractitioner in a primary care setting.copayment, or deductible for the \nMedicare-covered screening and \ncounseling to reduce alcohol \nmisuse preventive benefit.\n Screening for lung cancer with low dose computed tomography\n(LDCT) \nFor qualified individuals, a LDCT is covered every 12 months.\nEligible members are: people aged 50 \u2013 77 years who have no signs or \nsymptoms of lung cancer, but who have a history of tobacco smoking of at \nleast 20 pack-years and who currently smoke or have quit smoking within \nthe last 15 years, who receive a written order for LDCT during a lung cancer \nscreening counseling and shared decision-making visit that meets the \nMedicare criteria for such visits and be furnished by a physician or qualified \nnon-physician practitioner.\nFor LDCT lung cancer screenings after the initial LDCT screening: the member \nmust receive a written order for the LDCT lung cancer screening, which \nmay be furnished during any appropriate visit with a physician or qualified \nnon-physician practitioner. If a physician or qualified non-physician \npractitioner elects to provide a lung cancer screening counseling and \nshared decision making visit for subsequent lung cancer screenings with \nLDCT, the visit must meet the Medicare criteria for such visits.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \nMedicare covered counseling and \nshared decision making visit or for \nthe LDCT.\n Screening for sexually transmitted infections (STIs) and counseling\nto prevent STIs\nWe cover sexually transmitted infection (STI) screenings for chlamydia, \ngonorrhea, syphilis, and Hepatitis B. These screenings are covered for \npregnant women and for certain people who are at increased risk for an \nSTI when the tests are ordered by a primary care provider. We cover these \ntests once every 12 months or at certain times during pregnancy.\nWe also cover up to 2 individual 20 to 30 minute, face-to-face \nhigh-intensity behavioral counseling sessions each year for sexually active \nadults at increased risk for STIs. We will only cover these counseling \nsessions as a preventive service if they are provided by a primary care \nprovider and take place in a primary care setting, such as a doctor's office.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \nMedicare-covered screening for \nSTIs and counseling for STIs \npreventive benefit.\nServices to treat kidney disease\nCovered services include:\n\u2022Kidney disease education services to teach kidney care and help \nmembers make informed decisions about their care. For members with In-Network:\nKidney Disease Education Services\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office", "doc_id": "a5e294a6-d3f6-4560-a5d6-eb01847c4275", "embedding": null, "doc_hash": "522aecd1f385bb82082f54d98385538b37f08f1333e5819e368ea40da8ee7da4", "extra_info": {"page_label": "72", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3237, "_node_type": "1"}, "relationships": {"1": "a4dcecf6-1b5e-4629-823c-f817d01251cc"}}, "__type__": "1"}, "8fedf6c8-e429-4977-8b3e-668544d9716b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 73\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\nstage IV chronic kidney disease when referred by their doctor, we cover \nup to six sessions of kidney disease education services per lifetime\n\u2022Outpatient dialysis treatments (including dialysis treatments when \ntemporarily out of the service area, as explained in Chapter 3, or when \nyour provider for this service is temporarily unavailable or inaccessible)\n\u2022Inpatient dialysis treatments (if you are admitted as an inpatient to a \nhospital for special care)\n\u2022Self-dialysis training (includes training for you and anyone helping you \nwith your home dialysis treatments)\n\u2022Home dialysis equipment and supplies\n\u2022Certain home support services (such as, when necessary, visits by \ntrained dialysis workers to check on your home dialysis, to help in \nemergencies, and check your dialysis equipment and water supply)\nCertain drugs for dialysis are covered under your Medicare Part B drug \nbenefit. For information about coverage for Part B Drugs, please go to the \nsection, \"Medicare Part B prescription drugs.\"\nPrior authorization requirements may apply.Renal Dialysis Services\n20% coinsurance\n\u2013Dialysis Center\n\u2013Outpatient Hospital\nDurable Medical Equipment\n20% coinsurance\n\u2013Durable Medical Equipment \nProvider\nHome Health Care\n$0 copayment\n\u2013Member's Home\n* SilverSneakers\u00ae Fitness program\nSilverSneakers\u00ae is a fitness program for seniors that is included at no \nadditional charge with qualifying Medicare health plans. Members have \naccess to 15,000+ fitness locations across the country that may include \nweights and machines plus group exercise classes led by trained \ninstructors at select locations. Access online education on \nSilverSneakers.com, watch workout videos on SilverSneakers \nOn-DemandTM or download the SilverSneakers GOTM fitness app, for \nadditional workout ideas.\nAny fitness center services that usually have an extra fee are not included \nin your membership.In-Network:\n$0 copayment\nSkilled nursing facility (SNF) care\n(For a definition of \"skilled nursing facility care,\" see Chapter 12 of this \ndocument. Skilled nursing facilities are sometimes called \"SNFs.\")\nYou are covered for up to 100 medically necessary days per benefit period. \nPrior hospital stay is not required. Covered services include but are not \nlimited to:\n\u2022Semiprivate room (or a private room if medically necessary)\n\u2022Meals, including special diets\n\u2022Skilled nursing services\n\u2022Physical therapy, occupational therapy, and speech therapy\n\u2022Drugs administered to you as part of your plan of care (This includes \nsubstances that are naturally present in the body, such as blood clotting \nfactors.)A new benefit period will begin on \nday one when you first enroll in a \nMedicare Advantage plan, or when \nyou have been discharged from \nskilled care in a skilled nursing \nfacility for 60 consecutive days.\nPer Benefit Period, you pay:\nIn-Network:\n$0 copayment per day, days 1 to 20\n\u2013Skilled Nursing Facility\n$196 copayment per day, days 21 \nto 100\n\u2013Skilled Nursing Facility", "doc_id": "8fedf6c8-e429-4977-8b3e-668544d9716b", "embedding": null, "doc_hash": "e408e29dc2642d555c39c15ae203521b12b1eaaa33444421535558348df1f16e", "extra_info": {"page_label": "73", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3170, "_node_type": "1"}, "relationships": {"1": "02911eb1-2714-4d45-bf2a-4fe19fc55871"}}, "__type__": "1"}, "73f306e7-edf9-4126-98ad-923a8e39022f": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 74\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\n\u2022Blood - including storage and administration. Coverage of whole blood \nand packed red cells begins with the first pint of blood you need.\n\u2022Medical and surgical supplies ordinarily provided by SNFs\n\u2022Laboratory tests ordinarily provided by SNFs\n\u2022X-rays and other radiology services ordinarily provided by SNFs\n\u2022Use of appliances such as wheelchairs ordinarily provided by SNFs\n\u2022Physician/Practitioner services\nGenerally, you will get your SNF care from network facilities. However, \nunder certain conditions listed below, you may be able to get your care \nfrom a facility that isn't a network provider, if the facility accepts our plan's \namounts for payment.\n\u2022A nursing home or continuing care retirement community where you \nwere living right before you went to the hospital (as long as it provides \nskilled nursing facility care)\n\u2022A SNF where your spouse is living at the time you leave the hospital\nPrior authorization requirements may apply.\n Smoking and tobacco use cessation (counseling to stop smoking or\ntobacco use)\nIf you use tobacco, but do not have signs or symptoms of tobacco-related \ndisease: We cover two counseling quit attempts within a 12-month period \nas a preventive service with no cost to you. Each counseling attempt \nincludes up to four face-to-face visits.\nIf you use tobacco and have been diagnosed with a tobacco-related \ndisease or are taking medicine that may be affected by tobacco: We cover \ncessation counseling services. We cover two counseling quit attempts \nwithin a 12-month period, however, you will pay the applicable cost \nsharing. Each counseling attempt includes up to four face-to-face visits.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \nMedicare-covered smoking and \ntobacco use cessation preventive \nbenefits.\n* Special Supplemental Benefits for the Chronically Ill\nVital Support\u2122 Benefits\nTo help you achieve your best health, Humana offers members with \ncertain chronic conditions, who meet eligibility criteria, additional support \nthrough our Vital Support\u2122 Benefits. Please read, below, for benefits \navailable on this plan.\nWorry Free\u2122 Meals - The Worry Free\u2122 Meals program may be available to \nchronically ill members diagnosed with Chronic Obstructive Pulmonary \nDisease (COPD), Diabetes, or Congestive Heart Failure (CHF), who are \nparticipating in care management , have had an inpatient hospital or \nskilled nursing facility stay within the last 30 days, and meet program \ncriteria. Eligible members may receive 2 meals per day for 12 weeks, 168 \nmeals total. Members may receive an additional 12 weeks of meals if they \ncontinue to meet program criteria as determined by the plan. Members In-Network:\nThere is no coinsurance, \ncopayment, or deductible to \nparticipate.", "doc_id": "73f306e7-edf9-4126-98ad-923a8e39022f", "embedding": null, "doc_hash": "10ab72e5e69364f72f773ff4bf7d93537340b5d4d325a96d6401b509c86d542c", "extra_info": {"page_label": "74", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2969, "_node_type": "1"}, "relationships": {"1": "6f6de8f1-566a-4a1a-bc12-b7a11691b387"}}, "__type__": "1"}, "03df2935-407d-427e-a42e-a3fd633559cf": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 75\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\nmay qualify for the Worry Free\u2122 Meals program up to 2 times per plan \nyear. Authorization may be required.\nHumana Flexible Care Assistance - Humana Flexible Care Assistance is \navailable to chronically ill members who are participating with care \nmanagement services and meet program criteria. Benefits are limited up \nto $1,000 per year and must be coordinated and authorized by a care \nmanager. Eligible members may receive primarily health related and \nnon-primarily health related additional benefits to address the individual's \nunique needs, including but not limited to:\n\u2022Medical expense assistance\n\u2022Meal delivery services\n\u2022Caregiver services\n\u2022Adult day care\n\u2022Utilities \n\u2022Non-medical transportation\n\u2022Medical supplies and prosthetics\n\u2022Pest control\n\u2022Alternative therapies\n\u2022Home and bathroom safety devices\nMembers may discuss full list of items and services with their care \nmanager.\nSupervised Exercise Therapy (SET)\nSET is covered for members who have symptomatic peripheral artery \ndisease (PAD).\nUp to 36 sessions over a 12-week period are covered if the SET program \nrequirements are met.\nThe SET program must:\n\u2022Consist of sessions lasting 30-60 minutes, comprising a therapeutic \nexercise-training program for PAD in patients with claudication\n\u2022Be conducted in a hospital outpatient setting or a physician\u2019s office\n\u2022Be delivered by qualified auxiliary personnel necessary to ensure \nbenefits exceed harms, and who are trained in exercise therapy for PAD\n\u2022Be under the direct supervision of a physician, physician assistant, or \nnurse practitioner/clinical nurse specialist who must be trained in both \nbasic and advanced life support techniques\nSET may be covered beyond 36 sessions over 12 weeks for an additional 36 \nsessions over an extended period of time if deemed medically necessary \nby a health care provider.\nPrior authorization requirements may apply.In-Network:\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital", "doc_id": "03df2935-407d-427e-a42e-a3fd633559cf", "embedding": null, "doc_hash": "c9d68634c0f57d2d4f09d8fdbfd4aa2ab26a57bb7a03ddac7cb218d416d007ef", "extra_info": {"page_label": "75", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2155, "_node_type": "1"}, "relationships": {"1": "49a431a9-503f-4da5-8753-d2ddf82c09c0"}}, "__type__": "1"}, "f91f877c-47fd-4727-80b9-11b0855096a6": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 76\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\n* Transportation\nYou are covered for 24 one-way, non-emergency trips to plan-approved \nlocations within the plan service area. There is a maximum allowed travel \ndistance of 50 miles per trip.\nPlease contact Customer Care for information on how to arrange \ntransportation. Customer Care will confirm your benefits and guide you to \nthe transportation provider to plan your trip.In-Network:\n$0 copayment\nUrgently needed services\nUrgently needed services are provided to treat a non-emergency, \nunforeseen medical illness, injury, or condition that requires immediate \nmedical care, but given your circumstances, it is not possible, or it is \nunreasonable, to obtain services from network providers. Examples of \nurgently needed services that the plan must cover out of network are i) you \nneed immediate care during the weekend, or ii) you are temporarily \noutside the service area of the plan. Services must be immediately needed \nand medically necessary. If it is unreasonable given your circumstances to \nimmediately obtain the medical care from the network provider then your \nplan will cover the urgently needed services from a provider \nout-of-network. \nYou are covered for urgently needed services world-wide. If you have an \nurgent need for care while outside of the U.S. and its territories, you will be \nresponsible to pay for the services rendered upfront. You must submit \nproof of payment to Humana for reimbursement. For more information \nplease see Chapter 7. We may not reimburse you for all out of pocket \nexpenses. This is because our contracted rates may be lower than provider \nrates outside of the U.S. and its territories. You are responsible for any costs \nexceeding our contracted rates as well as any applicable member \ncost-share.\nSee \"Physician/Practitioner services, including doctor\u2019s office visits\" for \nadditional information about urgently needed services provided in a \nphysician\u2019s office.In-Network:\nUrgently Needed Services\n$30 copayment\n\u2013Urgent Care Center\n Vision care\nCovered services include:\n\u2022Outpatient physician services for the diagnosis and treatment of \ndiseases and injuries of the eye, including treatment for age-related \nmacular degeneration. Original Medicare doesn't cover routine eye \nexams (eye refractions) for eyeglasses/contacts\n\u2022For people who are at high risk of glaucoma, we will cover one \nglaucoma screening each year. People at high risk of glaucoma include: \npeople with a family history of glaucoma, people with diabetes, \nAfrican-Americans who are age 50 and older, and Hispanic Americans \nwho are 65 or olderIn-Network:\nMedicare Covered Vision Services\n$25 copayment\n\u2013Specialist's Office\nGlaucoma Screening\n$0 copayment\n\u2013Specialist's Office\nDiabetic Eye Exam\n$0 copayment", "doc_id": "f91f877c-47fd-4727-80b9-11b0855096a6", "embedding": null, "doc_hash": "7fe869fec9316d8774d88805f1a06083a3d5670617c820299484bb797c8e6667", "extra_info": {"page_label": "76", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2953, "_node_type": "1"}, "relationships": {"1": "309537af-1378-4104-8f65-94d2640eb42c"}}, "__type__": "1"}, "4ee02e6a-4e64-469b-bec0-23f120bd140a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 77\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices that are covered for you What you must pay when you get  \nthese services\n\u2022For people with diabetes, screening for diabetic retinopathy is covered \nonce per year\n\u2022One pair of eyeglasses or contact lenses after each cataract surgery that \nincludes insertion of an intraocular lens. (If you have two separate \ncataract operations, you cannot reserve the benefit after the first \nsurgery and purchase two eyeglasses after the second surgery.)\n\u2022Covered eyeglasses after cataract surgery includes standard frames \nand lenses as defined by Medicare; any upgrades are not covered \n(including, but not limited to, deluxe frames, tinting, progressive lenses, \nor anti-reflective coating).\nThe  (preventive service) only applies to Glaucoma Screening.\nPrior authorization requirements may apply.\u2013All Places of Treatment\nEyewear (Post Cataract Surgery)\n$0 copayment\n\u2013All Places of Treatment\nSupplemental vision benefits\n*You are covered for supplemental \nvision benefits. See the \nsupplemental vision benefit \ndescription at the end of this chart \nfor details.\nPlease note: the network of \nproviders for your supplemental \nvision benefits may be different \nthan the network of providers for \nthe Original Medicare vision \nbenefits listed above.\n \"Welcome to Medicare\" preventive visit\nThe plan covers the one-time \"Welcome to Medicare\" preventive visit. The \nvisit includes a review of your health, as well as education and counseling \nabout the preventive services you need (including certain screenings and \nshots), and referrals for other care if needed.\nImportant: We cover the \"Welcome to Medicare\" preventive visit only \nwithin the first 12 months you have Medicare Part B. When you make your \nappointment, let your doctor's office know you would like to schedule your \n\"Welcome to Medicare\" preventive visit.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \n\"Welcome to Medicare\" preventive \nvisit.\n* Wellness and Health Care Planning (WHP) Services\nAs a Humana member, you have access to an online advance care  \nplanning resource called, MyDirectives\u00ae on MyHumana. This resource helps  \nyou to create an advance directive where you can combine the elements  \nof a living will, medical power of attorney, do not attempt resuscitation,  \nand an organ donation form.There is no coinsurance,  \ncopayment, or deductible to  \nparticipate.\nMandatory Supplemental Dental Benefit DEN337\nCoverage Description\nYou may receive the following non-Medicare covered routine dental-related services:\nDeductible $0\nAnnual Maximum $2,000", "doc_id": "4ee02e6a-4e64-469b-bec0-23f120bd140a", "embedding": null, "doc_hash": "881a236b0f2ca9e2cb57cffe36ef9d848652357942645d228408cd06eb50042e", "extra_info": {"page_label": "77", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2681, "_node_type": "1"}, "relationships": {"1": "b7bb677d-5c59-4983-b2b6-c2b90239a7d2"}}, "__type__": "1"}, "ebb702b1-bf3d-4ebc-9803-f3d64062d14c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 78\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nDescription of BenefitIn-Network  \nYou Pay*Out-of- \nNetwork  \nYou Pay\nPreventive Services\nExams \u2013 Frequency/Limitation - 2 procedure codes per calendar year\nPeriodic oral exam 0% 100%\nExams \u2013 Frequency/Limitations - 1 procedure code per calendar year\nEmergency diagnostic exam 0% 100%\nBitewing X-rays \u2013 Frequency/Limitations - 1 set per calendar year\nBitewing x-rays 0% 100%\nIntraoral X-rays (inside the mouth)\u2013 Frequency/Limitations - 1 procedure code per calendar year\nPeriapical x-rays 0% 100%\nOcclusal x-rays 0% 100%\nFull Mouth or Panoramic X-rays \u2013 Frequency/Limitations - 1 procedure code every 5 calendar years\nComplete series 0% 100%\nPanoramic film 0% 100%\nProphylaxis (Cleaning) \u2013 Frequency/Limitations - 2 procedure codes per calendar year\nProphylaxis (cleaning) 0% 100%\nPeriodontal Maintenance \u2013 Frequency/Limitations - 4 procedure codes per calendar year\nPeriodontal maintenance following periodontal therapy 0% 100%\nFluoride \u2013 Frequency/Limitations - 2 procedure codes per calendar year\nTopical fluoride application 0% 100%\nComprehensive Services\nRestorations (Fillings) - Amalgam and/or Composite \u2013 Frequency/Limitations - Unlimited procedure codes  \nper calendar year\nAmalgam (silver) \u2013 primary or permanent 0% 100%\nResin-based composite (white) \u2013 anterior (front) or posterior (back) 0% 100%\nExtractions (Pulling Teeth) \u2013 Frequency/Limitations - Unlimited procedure codes per calendar year\nExtraction, erupted tooth, or exposed root 0% 100%\nSurgical removal of erupted tooth 0% 100%\nScaling- Generalized Inflammation- Frequency/Limitations - 1 procedure code every 3 calendar years\nScaling - moderate or severe gingival inflammation 0% 100%\nScaling and Root Planing \u2013 Frequency/Limitations - 1 procedure code every 3 calendar years, per quadrant\nPeriodontal scaling and root planing 0% 100%\nRoot Canal \u2013 Frequency/Limitations - 1 procedure code per tooth per lifetime\nRoot canal 0% 100%\nRoot Canal Retreatment \u2013 Frequency/Limitations - 1 procedure code per tooth per lifetime\nRetreatment of previous root canal therapy 0% 100%", "doc_id": "ebb702b1-bf3d-4ebc-9803-f3d64062d14c", "embedding": null, "doc_hash": "8ef82ddc48f9a707cc4bea3e748d46c8ad818fc5da4f0c5f2147b6d6e6bec684", "extra_info": {"page_label": "78", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2177, "_node_type": "1"}, "relationships": {"1": "2de9dc72-a627-458f-9305-fe7108028a51"}}, "__type__": "1"}, "45407d03-1f95-4dfe-85b9-8aad40068924": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 79\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nDescription of BenefitIn-Network  \nYou Pay*Out-of- \nNetwork  \nYou Pay\nCrowns \u2013 Frequency/Limitations - 1 procedure code per tooth per lifetime\nCrowns 0% 100%\nOnlay 0% 100%\nInlay - alternate benefit only 0% 100%\nBridges - Frequency/Limitations - 1 procedure code every 5 calendar years\nPontic and retainer crown 0% 100%\nComplete Dentures \u2013 Frequency/Limitations - 1 upper complete and/or 1 lower complete denture every 5  \ncalendar years, including routine post-delivery care\nComplete denture \u2013 maxillary (upper) or mandibular (lower) 0% 100%\nImmediate denture \u2013 maxillary (upper) or mandibular (lower) 0% 100%\nRemovable Partial Dentures (including routine post-delivery care) \u2013 Frequency/Limitations - 1 upper and/or  \n1 lower partial denture every 5 calendar years\nPartial dentures \u2013 resin or metal, maxillary (upper) or mandibular (lower) 0% 100%\nUnilateral partial denture 0% 100%\nPartial denture - maxillary (upper) or mandibular (lower) 0% 100%\nRemovable unilateral partial denture 0% 100%\nOral Surgery \u2013 Frequency/Limitations - 2 procedure codes per calendar year\nOral surgery 0% 100%\nDenture Adjustments (not covered if within six months of initial placement) \u2013 Frequency/Limitations - 1  \nprocedure code per calendar year\nComplete denture adjustment\u2013 maxillary (upper) or mandibular (lower) 0% 100%\nPartial denture adjustment - maxillary (upper) or mandibular (lower) 0% 100%\nDenture Reline (not allowed on spare dentures or if within six months of initial placement) -  \nFrequency/Limitations - 1 procedure code per calendar year\nReline complete denture \u2013 maxillary (upper) or mandibular (lower) 0% 100%\nReline partial denture - maxillary (upper) or mandibular (lower) 0% 100%\nDenture Repairs \u2013 Frequency/Limitations - 1 procedure code per calendar year\nRepair complete denture base - maxillary (upper) or mandibular (lower) 0% 100%\nRepair partial denture base - maxillary (upper) or mandibular (lower) 0% 100%\nRepair partial denture framework - maxillary (upper) or mandibular (lower) 0% 100%\nReplace missing or broken tooth 0% 100%\nAdd tooth or clasp to partial denture 0% 100%\nReplace all teeth/acrylic \u2013 maxillary (upper) or mandibular (lower) 0% 100%\nDenture Rebase (not covered if within six months of initial placement) \u2013 Frequency/Limitations - 1  \nprocedure code per calendar year\nRebase complete denture \u2013 maxillary (upper) or mandibular (lower) 0% 100%\nRebase partial denture - maxillary (upper) or mandibular (lower) 0% 100%", "doc_id": "45407d03-1f95-4dfe-85b9-8aad40068924", "embedding": null, "doc_hash": "77996b3176b80ac4ef93a92872609a2f004712c135c62b0763c6312be97e3d1d", "extra_info": {"page_label": "79", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2580, "_node_type": "1"}, "relationships": {"1": "c6dc1253-7056-4dd8-a98d-da1ea0cabc43"}}, "__type__": "1"}, "013cbf3b-168f-43e5-988c-0c119b990d7a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 80\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nDescription of BenefitIn-Network  \nYou Pay*Out-of- \nNetwork  \nYou Pay\nTissue Conditioning (not covered if within six months of initial placement) \u2013 Frequency/Limitations - 1  \nprocedure code per calendar year\nTissue conditioning - maxillary (upper) or mandibular (lower) 0% 100%\nOcclusal Adjustments (not covered if within six months of initial placement) \u2013 Frequency/Limitations - 1  \nprocedure code every 3 calendar years\nOcclusal adjustment - limited 0% 100%\nOcclusal adjustment - complete 0% 100%\nPain Management \u2013 Frequency/Limitations - 2 procedure codes per calendar year\nPalliative (emergency) treatment of dental pain 0% 100%\nAnesthesia \u2013 Frequency/Limitations - As needed with covered procedures\nAnalgesia, anxiolysis, inhalation of nitrous oxide 0% 100%\nDeep sedation/general anesthesia 0% 100%\nIntravenous moderate (conscious) sedation/analgesia 0% 100%\nApplication of desensitizing medicament 0% 100%\nRecementation of Crown \u2013 Frequency/Limitations - 1 procedure code every 5 calendar years\nRecement inlay, onlay or partial coverage restoration 0% 100%\nRecement indirectly fabricated or prefabricated post and core 0% 100%\nRecement crown 0% 100%\nRecementation of Bridge \u2013 Frequency/Limitations - 1 procedure code every 5 calendar years\nRecement fixed partial denture (bridge) 0% 100%\nDiagnostic Services \u2013 Frequency/Limitations - 1 procedure code every 3 calendar years\nPeriodontal exam 0% 100%\nComprehensive oral evaluation 0% 100%\nLimitations and exclusions may apply. Subject to the claims review process which may include a clinical review.\nDental services are subject to our standard claims review procedures which could include dental history to approve \ncoverage. Dental benefits under this plan may not cover all American Dental Association procedure codes. \nInformation regarding each plan is available at Humana.com/sb.\nThe Mandatory Supplemental Dental benefits are provided through the Humana Dental Medicare Network. The \nprovider locator can be found at Humana.com > Find a doctor > Select the Dentist icon from the menu > From \nthe Distance drop down select preferred distance > Enter Zip code > From the look up method select All \nDental Networks > Then select HumanaDental Medicare.\nFor more information about Mandatory Supplemental Dental benefits contact HumanaDental for details \n(1-800-669-6614), TTY 711.\nHow Payments to You or Your Dentist Are Calculated\nFor covered dental services, we will pay as follows:", "doc_id": "013cbf3b-168f-43e5-988c-0c119b990d7a", "embedding": null, "doc_hash": "f2daa8262de83b1014f9a8293921669c20ddf558e245650c75ee6a6813031750", "extra_info": {"page_label": "80", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2577, "_node_type": "1"}, "relationships": {"1": "833bb4ed-8f5b-4f6e-98a2-8981f3fcd4f3"}}, "__type__": "1"}, "b1dba3cb-33ab-431f-b2c8-55d2dc74a442": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 81\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\n\u2022We will determine the total covered expense.\n\u2022We will review the covered expense against the maximum benefits allowed.\n\u2022We will check to see if you have met your deductible, if applicable. If you have not, you will be required to pay \nthe covered expense up to the amount of the deductible.\n\u2022We will pay the remaining expense to you or your dentist, minus any coinsurance you owe (the procedure \nyou received may require you to pay a percentage of the cost).\nFor dental conditions that have two or more possible treatments, Humana will cover the lowest cost treatment, as \nlong as it is proven to provide satisfactory results. If you choose to receive a higher cost treatment, you will be \nresponsible to pay for the difference.\nSubmitting Pretreatment Plans\nIf the dental care you need is expected to exceed $300, we suggest you or your dentist send a dental treatment \nplan for us to review ahead of time so that we can provide you with an estimate for services. The pretreatment plan \nshould include:\n1. A list of services you will receive, using American Dental Association nomenclature and codes.\n2. Your dentist's written description of the proposed treatment.\n3. X-rays that show your dental needs.\n4. Itemized cost of the proposed treatment.\n5. Any other diagnostic materials we request.\nMandatory Supplemental Hearing Benefit HER955\nCoverage Description\nTo use your benefit, you must call TruHearing at 1-844-255-7144 to schedule an appointment.\nDescription of Benefit You Pay\nRoutine hearing exam (1 per year) $0\nUp to 2 TruHearing-branded hearing aids every year (1 per ear per year). \nBenefit is limited to the TruHearing Advanced and Premium hearing aids, \nwhich come in various styles and colors. Advanced and Premium hearing \naids are available in rechargeable style options for an additional $50 per \naid. You must see a TruHearing provider to use this benefit. Call \n1-844-255-7144 to schedule an appointment (for TTY, dial 711).\nHearing aid purchase includes:\n\u2013Unlimited follow-up provider visits during first year following \nTruHearing hearing aid purchase\n\u201360-day trial period\n\u20133-year extended warranty\n\u201380 batteries per aid for non-rechargeable models\nBenefit does not include or cover any of the following:\n\u2013Additional cost for optional hearing aid rechargeability\n\u2013Ear molds\n\u2013Hearing aid accessories\n\u2013Additional provider visits$299 per Advanced Aid\nor \n$599 per Premium Aid", "doc_id": "b1dba3cb-33ab-431f-b2c8-55d2dc74a442", "embedding": null, "doc_hash": "20bb405bd0cda48290751c31117dd0ffa3247815a228d0fdb6bfbb74570233f7", "extra_info": {"page_label": "81", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2532, "_node_type": "1"}, "relationships": {"1": "facdb65f-d37a-40ad-8360-87994a1e99f2"}}, "__type__": "1"}, "112d3444-8043-4126-9254-6140993fc310": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 82\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nDescription of Benefit You Pay\n\u2013Additional batteries (or batteries when a rechargeable hearing aid is \npurchased)\n\u2013Hearing aids that are not TruHearing-branded hearing aids\n\u2013Costs associated with loss & damage warranty claims\nCosts associated with excluded items are the responsibility of the member \nand are not covered by the plan.\nMandatory Supplemental Vision Benefit VIS735\nCoverage Description\nVision benefit through EyeMed Vision Care \nYou may receive the following non-Medicare covered routine vision-related services:\nDescription of BenefitIn-Network \nYou Pay\n\u2022Routine Eye Exam (includes refraction) (1 per calendar year) by a \nHumana Medicare Insight Network optical provider$0*\nOR\n\u2022Refraction exam (1 per calendar year) when completed at the same  \nappointment as a Medicare covered comprehensive eye exam by a  \nHumana network medical optical provider.$0 for refraction exam in addition to  \nthe Medical Specialist cost-share for  \nthe medical exam\n\u2022Frames and Lens Package\nYou have a choice of:\n\u2013$200 Benefit toward the purchase and fitting of eyeglasses and pair \nof lenses or contact lenses (1 per calendar year)\nContact lenses will include conventional or disposable.\nUltraviolet protection and scratch resistant coating are included in the \neyeglass allowance benefit.\nThe benefit can only be used one time. Any remaining benefit dollars do \nnot \"roll over\" to a future purchase.Any amount over\n$200 retail price\nN/A\n*Your routine exam charge will not exceed $0 at a Humana Medicare Insight Network optical provider. Please \ninform the network provider that you are part of the Humana Medicare Insight Network. NOTE: The network of \nproviders for your supplemental vision benefits through EyeMed Vision Care may be different than the network of \nproviders for the Medicare-covered vision benefits.\nThe provider locator for routine vision can be found at Humana.com > Find a Doctor > Select Vision care icon > \nVision coverage through Medicare Advantage plans.\n\u2022Copayments, coinsurances, and deductibles paid for supplemental benefits do not count toward your \nmaximum out-of-pocket amount.", "doc_id": "112d3444-8043-4126-9254-6140993fc310", "embedding": null, "doc_hash": "a28304b6110f9da0ffe876bed628de4a4e33279641bd05cd9a14915d72c347a4", "extra_info": {"page_label": "82", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2241, "_node_type": "1"}, "relationships": {"1": "d2f989bf-23df-4a52-aca4-fdaf3c61e40c"}}, "__type__": "1"}, "071edec4-d744-431b-86ec-9db1db5c5aef": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 83\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\n\u2022Note: Benefits are offered on a calendar year basis. If these benefits are changed or eliminated next year or the \nyear after and you have not used these benefits, you are no longer eligible for the benefits described above.", "doc_id": "071edec4-d744-431b-86ec-9db1db5c5aef", "embedding": null, "doc_hash": "03bacadbb0db74f770e06bec6cbf905e7c4286a4bb907d77d94bcf2464010a07", "extra_info": {"page_label": "83", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 360, "_node_type": "1"}, "relationships": {"1": "859dcc04-6c25-4e38-a92e-ab31569fb10e"}}, "__type__": "1"}, "c914225a-7fe2-437f-9100-e91a8d5edc00": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 84\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nSection 2.2 Getting care using our plan\u2019s optional visitor/traveler benefit\nThe HMO Travel Benefit is available to you as a member of Humana Gold Plus H0028-014 (HMO). You can already \naccess emergency and urgently needed care when outside the service area. However, when traveling within the \nUnited States or Puerto Rico, the HMO Travel Benefit enables you to receive plan covered services, including \npreventive care. Covered services must be provided by providers within the National Medicare HMO or SNP network. \nYou may use \"Find a Doctor\" on Humana.com by using the \"Just Looking \"feature or contact Customer Care for \nassistance in locating a network provider when using the HMO Travel Benefit. If you receive care from a provider \nwithin the National Medicare HMO or SNP network, you will pay the same in-network copay or coinsurance you \nwould pay if you received care within your home service area.\nIf you are planning to travel outside of your service area and anticipate needing to use the HMO Travel Benefit, it is \nrecommended that you notify your primary care provider. It is also recommended that you check to see if the \nprovider or providers you wish to see while traveling are in the National Medicare HMO or SNP network using the \n\"Find a Doctor\" on Humana.com by using the \"Just Looking\" feature or contact Customer Care for assistance.\nSECTION 3 What services are not covered by the plan?\nSection 3.1 Services we do not cover (exclusions)\nThis section tells you what services are \"excluded\" from Medicare coverage and therefore, are not covered by this \nplan.\nThe chart below lists services and items that either are not covered under any condition or are covered only under \nspecific conditions.\nIf you get services that are excluded (not covered), you must pay for them yourself except under the specific \nconditions listed below. Even if you receive the excluded services at an emergency facility, the excluded services \nare still not covered and our plan will not pay for them. The only exception is if the service is appealed and decided \nupon to be a medical service that we should have paid for or covered because of your specific situation. (For \ninformation about appealing a decision we have made to not cover a medical service, go to Chapter 9, Section 5.3 \nin this document.)\nServices not covered by Medicare Not covered under any  \nconditionCovered only under specific conditions\nAcupuncture N/A Available for people with chronic low  \nback pain under certain circumstances. \nCharges for equipment which is primarily  \nand customarily used for a nonmedical  \npurpose, even though the item has some  \nremote medically related use.N/A Covered only when medically necessary.", "doc_id": "c914225a-7fe2-437f-9100-e91a8d5edc00", "embedding": null, "doc_hash": "ee7dcab555c60f46d086b5fb5a67cef8aff4dcf32d1c219f28f872979eeb6c45", "extra_info": {"page_label": "84", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2842, "_node_type": "1"}, "relationships": {"1": "a0758f96-3e2a-484b-96db-7cde00181ef7"}}, "__type__": "1"}, "e76ed89d-629a-4d20-88cd-531dddf6eb41": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 85\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices not covered by Medicare Not covered under any  \nconditionCovered only under specific conditions\nCosmetic surgery or procedures N/A\n\u2022Covered in cases of an accidental  \ninjury or for improvement of the  \nfunctioning of a malformed body  \nmember.\n\u2022Covered for all stages of  \nreconstruction for a breast after a  \nmastectomy, as well as for the  \nunaffected breast to produce a  \nsymmetrical appearance.\nCustodial care \nCustodial care is personal care that does  \nnot require the continuing attention of  \ntrained medical or paramedical  \npersonnel, such as care that helps you  \nwith activities of daily living, such as  \nbathing or dressing. N/                  A\nExperimental medical and surgical  \nprocedures, equipment, and  \nmedications. \nExperimental procedures and items are  \nthose items and procedures determined  \nby Original Medicare to not be generally  \naccepted by the medical community.N/A May be covered by Original Medicare  \nunder a Medicare-approved clinical  \nresearch study or by our plan. \n(See Chapter 3, Section 5 for more  \ninformation on clinical research studies.)\nFees charged for care by your immediate  \nrelatives or members of your household.N/A                    \nFull-time nursing care in your home. N/A                    \nHomemaker services include basic  \nhousehold assistance, including light  \nhousekeeping or light meal preparation. N/A                    \nNaturopath services (uses natural or  \nalternative treatments).N/A                    \nNon-routine dental care N/A Dental care required to treat illness or  \ninjury may be covered as inpatient or  \noutpatient care.\nOrthopedic shoes or supportive devices  \nfor the feetN/A Shoes that are part of a leg brace and are  \nincluded in the cost of the brace.  \nOrthopedic or the therapeutic shoes for a  \npeople with diabetic foot disease.", "doc_id": "e76ed89d-629a-4d20-88cd-531dddf6eb41", "embedding": null, "doc_hash": "68b43a85a7c0f8bce3ed65ca1596f8626cea11a631e5d1c16a5ecb9fa6a7b207", "extra_info": {"page_label": "85", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1972, "_node_type": "1"}, "relationships": {"1": "19f9203a-c83f-454f-98c4-7fda199da842"}}, "__type__": "1"}, "220bc180-6b42-44b7-8024-d0a1b9f93173": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 86\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\nServices not covered by Medicare Not covered under any  \nconditionCovered only under specific conditions\nPersonal items in your room at a hospital  \nor a skilled nursing facility, such as a  \ntelephone or a television.N/A\nPrivate room in a hospital. Covered only when medically necessary.\nReversal of sterilization procedures and  \nor non-prescription contraceptive  \nsupplies.N/A\nRoutine chiropractic care N/A Manual manipulation of the spine to  \ncorrect a subluxation is covered.\nRoutine foot care N/A Some limited coverage provided  \naccording to Medicare guidelines,(e.g., if  \nyou have diabetes).\nServices considered not reasonable and  \nnecessary, according to Original  \nMedicare standardsN/A                     \nIn addition to any exclusions or limitations described in the Benefits Chart, or anywhere else in this Evidence of  \nCoverage, the following items and services aren't covered under Original Medicare or by our plan:\n\u2022Radial keratotomy, LASIK surgery, and other low vision aids and services. \n\u2022Services provided to veterans in Veterans Affairs (VA) facilities. However, when emergency services are received \nat VA hospital and the VA cost-sharing is more than the cost-sharing under our plan, we will reimburse veterans \nfor the difference. Members are still responsible for our cost-sharing amounts.\nDental Mandatory Supplemental Benefit Exclusions include, but not limited to, the following:\n\u2022Network dentists have agreed to provide services at contracted fees (the in-network fee schedules, or INFS). If a \nmember visits a participating network dentist, the member will not receive a bill for charges more than the \nnegotiated fee schedule on covered services (coinsurance payment still applies).\n\u2022Services received from an out-of-network dentist are not covered benefits.\n\u2022Initial placement or replacement of a prior denture that is unserviceable and cannot be made serviceable. Spare \ndentures are not covered. \n\u2022Dental reline may not be covered within six months of initial denture placement or on spare dentures.\n\u2022Dental adjustments may not be covered within six months of initial denture placement or on spare dentures. \n\u2022Expenses incurred while you qualify for any workers\u2019 compensation or occupational disease act or law, whether \nor not you applied for coverage.\n\u2022Services that are:\n\u2013Free or that you would not be required to pay for if you did not have this insurance, unless charges are \nreceived from and reimbursable to the U.S. government or any of its agencies as required by law.\n\u2013Furnished by, or payable under, any plan or law through any government or any political subdivision \u2013 this \ndoes not include Medicare or Medicaid.\n\u2013Furnished by any U.S. government-owned or operated hospital/institution/agency for any service connected \nwith sickness or bodily injury.\n\u2022Any loss caused or contributed by war or any act of war, whether declared or not; any act of international armed \nconflict; or any conflict involving armed forces of any international authority.", "doc_id": "220bc180-6b42-44b7-8024-d0a1b9f93173", "embedding": null, "doc_hash": "fcd616d775318050549eac53caa0d0bd52675d07c35106265fe919db575a4a72", "extra_info": {"page_label": "86", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3135, "_node_type": "1"}, "relationships": {"1": "57837dcc-6cb4-4636-bd65-75849f1527b8"}}, "__type__": "1"}, "f0a30b99-16e7-41b7-b3b6-ef30e67777ce": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 87\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\n\u2022Any expense arising from the completion of forms.\n\u2022Your failure to keep an appointment with the dentist.\n\u2022Any service we consider cosmetic dentistry unless it is necessary as a result of an accidental injury sustained \nwhile you are covered under this policy. We consider the following cosmetic dentistry procedures: \n\u2013Facings on crowns or pontics \u2013 the portion of a fixed bridge between the abutments \u2013 posterior to the second \nbicuspid.\n\u2013Any service to correct congenital malformation.\n\u2013Any service performed primarily to improve appearance; or characterization and personalization of prosthetic \ndevices.\n\u2022Charges for any type of implant and all related services, including crowns or the prosthetic device attached to it; \nprecision or semi-precision attachments; over-dentures and any endodontic treatment associated with \nover-dentures; other customized attachments.\n\u2022Any service related to:\n\u2013Altering vertical dimension of teeth.\n\u2013Restoration or maintenance of occlusion.\n\u2013Splinting teeth, including multiple abutments, or any service to stabilize periodontally weakened teeth.\n\u2013Replacing tooth structures lost as a result of abrasion, attrition, erosion or abfraction.\n\u2013Bite registration or bite analysis.\n\u2022Infection control, including but not limited to sterilization techniques.\n\u2022Fees for treatment performed by someone other than a dentist, except for scaling, teeth cleaning and the \ntopical application of fluoride, which can be performed by a licensed dental hygienist. The treatment must be \nrendered under the supervision of the dentist in accordance with generally accepted dental standards.\n\u2022Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist.\n\u2022Prescription drugs or pre-medications, whether dispensed or prescribed.\n\u2022Any service not specifically listed in the Coverage Information.\n\u2022Any service that we determine is not a dental necessity; does not offer a favorable prognosis; does not have \nuniform professional endorsement; or is deemed to be experimental or investigational in nature.\n\u2022Orthodontic services.\n\u2022Any expense incurred before your effective date or after the date this supplemental benefit terminates.\n\u2022Services provided by someone who ordinarily lives in your home or who is a family member.\n\u2022Charges exceeding the reimbursement limit for the service.\n\u2022Treatment resulting from any intentionally self-inflicted injury or bodily illness.\n\u2022Local anesthetics, irrigation, bases, pulp caps, temporary dental services, study models, treatment plans, or \ntissue preparation associated with the impression or placement of a restoration when charged as a separate \nservice. These services are considered an integral part of the entire dental service.\n\u2022Repair and replacement of orthodontic appliances.\n\u2022Any surgical or nonsurgical treatment for any jaw joint problems, including any temporomandibular joint \ndisorder, craniomaxillary, craniomandibular disorder, or other conditions of the joint linking the jaw bone and \nskull; or treatment of the facial muscles used in expression and chewing functions, for symptoms including, but \nnot limited to, headaches.\nHearing Mandatory Supplemental Benefit Exclusions include, but not limited to, the following:\n\u2022Any fees for exams, tests, evaluations or any services in excess of the stated maximums.\n\u2022Any expenses which are covered by Medicare or any other government program or insurance plan, or for which \nyou are not legally required to pay.\n\u2022Services provided for clearance/consultation by a provider.\n\u2022Any refitting fees for lost or damaged hearing aids. \n\u2022Any fees for any services rendered by a non-network hearing aid provider. In-network hearing aid providers \nreserve the right", "doc_id": "f0a30b99-16e7-41b7-b3b6-ef30e67777ce", "embedding": null, "doc_hash": "2abd4d08733e743d88ee5a2be68b62c4f7299112d377b37d93925e66e2412d21", "extra_info": {"page_label": "87", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3844, "_node_type": "1"}, "relationships": {"1": "01fc81ba-2b6f-494d-a19e-5ff325ee76d2", "3": "5253cfee-3f87-45b1-adc8-6976c33ab3c7"}}, "__type__": "1"}, "5253cfee-3f87-45b1-adc8-6976c33ab3c7": {"__data__": {"text": "hearing aid provider. In-network hearing aid providers \nreserve the right to only service devices purchased from in-network providers. ", "doc_id": "5253cfee-3f87-45b1-adc8-6976c33ab3c7", "embedding": null, "doc_hash": "b73ccb4f2d121b49edadc695d348a0157b0f0602bb3812c4a4c107ac8c7a775d", "extra_info": {"page_label": "87", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 3771, "end": 3906, "_node_type": "1"}, "relationships": {"1": "01fc81ba-2b6f-494d-a19e-5ff325ee76d2", "2": "f0a30b99-16e7-41b7-b3b6-ef30e67777ce"}}, "__type__": "1"}, "5eb2d40d-0b6d-4dfd-b345-52988e864863": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 88\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\n\u2022Hearing aids and provider visits to service hearing aids (except as specifically described in the Covered Benefits), \near molds, hearing aid accessories, warranty claim fees, and hearing aid batteries (beyond the covered limit).\nVision Mandatory Supplemental Benefit Exclusions include, but not limited to, the following:\n\u2022Any benefits received at a non-network optical provider.\n\u2022Refitting or change in lens design after initial fitting.\n\u2022Any expense arising from the completion of forms.\n\u2022Any service not specifically listed in your supplemental benefit.\n\u2022Orthoptic or vision training.\n\u2022Subnormal vision aids and associated testing.\n\u2022Aniseikonic lenses.\n\u2022Athletic or industrial lenses.         \n\u2022Prisms (not covered with allowance, but may be available at a discounted rate off retail price; check with \nprovider for details)\n\u2022Any service we consider cosmetic.\n\u2022Any expense incurred before your effective date or after the date this supplemental benefit terminates.\n\u2022Services provided by someone who ordinarily lives in your home or who is a family member.\n\u2022Charges exceeding the allowance for the service.\n\u2022Treatment resulting from any intentionally self-inflicted injury or bodily illness.\n\u2022Plano lenses.\n\u2022Medical or surgical treatment of eye, eyes or supporting structures.\n\u2022Non-prescription sunglasses.\n\u2022Two pair of glasses in lieu of bifocals.\n\u2022Services or materials provided by any other group benefit plans providing vision care.\n\u2022Corrective vision treatment of an experimental nature.\n\u2022Solutions and/or cleaning products for glasses or contact lenses.\n\u2022Non-prescription items.\n\u2022Costs associated with securing materials.\n\u2022Pre- and post-operative services.\n\u2022Orthokeratology.\n\u2022Routine maintenance of materials.\n\u2022Artistically painted lenses.\n\u2022Any expenses incurred while you qualify for any workers' compensation or occupational disease act or law, \nwhether or not you applied for coverage.\n\u2022Services that are:\n\u2013Free or that you would not be required to pay for if you did not have this insurance, unless charges are \nreceived from and reimbursable to the U.S. government or any of its agencies as required by law.\n\u2013Furnished by, or payable under, any plan or law through any government or any political subdivision (this \ndoes not include Medicare or Medicaid).\n\u2013Furnished by any U.S. government-owned or operated hospital/institution/agency for any service connected \nwith sickness or bodily injury.\n\u2022Any loss caused or contributed by war or any act of war, whether declared or not; any act of international armed \nconflict; or any conflict involving armed forces of any international authority.\n\u2022Your failure to keep an appointment.\n\u2022Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist.\n\u2022Prescription drugs or pre-medications, whether dispensed or prescribed.\n\u2022Any service that we determine is not a visual necessity; does not offer a favorable prognosis; does not have \nuniform professional endorsement; or is deemed to be experimental or investigational in nature.\n\u2022Replacement of lenses or eyeglass frames furnished under this supplemental benefit that are lost or broken, \nunless otherwise available under the supplemental benefit.", "doc_id": "5eb2d40d-0b6d-4dfd-b345-52988e864863", "embedding": null, "doc_hash": "1020cd1936396582ee63ff3db3644b13b1a29dcf835308e6b7da4538117dcc5a", "extra_info": {"page_label": "88", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3328, "_node_type": "1"}, "relationships": {"1": "9ed539ad-4de5-49be-b369-8be2de44fb0a"}}, "__type__": "1"}, "6bc29b05-15b2-4b2e-acd5-85d808044379": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 89\nChapter 4. Medical Benefits Chart (what is covered and what you pay)\n\u2022Any examination or material required by an employer as a condition of employment or safety eyewear.\n\u2022Pathological treatment.\nThe plan will not cover the excluded services listed above. Even if you receive the services at an emergency facility, \nthe excluded services are still not covered.", "doc_id": "6bc29b05-15b2-4b2e-acd5-85d808044379", "embedding": null, "doc_hash": "9a06affd609e592218e177d7b62895f1ae0a47c68e5379701ecc6f1b2465fe5d", "extra_info": {"page_label": "89", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 425, "_node_type": "1"}, "relationships": {"1": "bc786873-541c-4b3f-85c7-0955ad2f451d"}}, "__type__": "1"}, "b748a419-773b-42f4-a160-81034e18d135": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 90\nChapter 5. Using the plan's coverage for Part D prescription drugsEOC082\nCHAPTER 5:\nUsing the plan's coverage for Part D  \nprescription drugs", "doc_id": "b748a419-773b-42f4-a160-81034e18d135", "embedding": null, "doc_hash": "48571d81208932d18c255ed574a94a7466f20cfbafa74f2985a0486fc17bee7e", "extra_info": {"page_label": "90", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 207, "_node_type": "1"}, "relationships": {"1": "e87cca45-641c-4d94-86e0-edc884c57306"}}, "__type__": "1"}, "fea787c6-736a-4c2f-9b44-d47778cac787": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 91\nChapter 5. Using the plan's coverage for Part D prescription drugs\nSECTION 1 Introduction\nThis chapter explains rules for using your coverage for Part D drugs. Please see Chapter 4 for Medicare Part B \ndrug benefits and hospice drug benefits.\nSection 1.1 Basic rules for the plan's Part D drug coverage\nThe plan will generally cover your drugs as long as you follow these basic rules:\n\u2022You must have a provider (a doctor, dentist or other prescriber) write you a prescription which must be valid \nunder applicable state law.\n\u2022Your prescriber must not be on Medicare\u2019s Exclusion or Preclusion Lists.\n\u2022You generally must use a network pharmacy to fill your prescription. (See Section 2, Fill your prescriptions at a \nnetwork pharmacy or through the plan's mail-order service.)\n\u2022Your drug must be in the plan's Prescription Drug Guide (Formulary) (we call it the \"Drug Guide\" for short). (See \nSection 3, Your drugs need to be in the plan's \"Drug Guide.\")\n\u2022Your drug must be used for a medically accepted indication. A \"medically accepted indication\" is a use of the \ndrug that is either approved by the Food and Drug Administration or supported by certain reference books. \n(See Section 3 for more information about a medically accepted indication.)\nSECTION 2 Fill your prescription at a network pharmacy or through the  \nplan's mail-order service\nSection 2.1 Use a network pharmacy\nIn most cases, your prescriptions are covered only if they are filled at the plan's network pharmacies. (See Section \n2.5 for information about when we would cover prescriptions filled at out-of-network pharmacies.)\nA network pharmacy is a pharmacy that has a contract with the plan to provide your covered prescription drugs. \nThe term \"covered drugs\" means all of the Part D prescription drugs that are in the plan's Drug Guide.\nSection 2.2 Network pharmacies\nHow do you find a network pharmacy in your area?\nTo find a network pharmacy, you can look in your Provider Directory, visit our website \n(Humana.com/PlanDocuments), and/or call Customer Care.\nYou may go to any of our network pharmacies. Contact us to find out more about how your out-of-pocket costs \ncould vary for different drugs.", "doc_id": "fea787c6-736a-4c2f-9b44-d47778cac787", "embedding": null, "doc_hash": "2a55eaccb634e2f29e9ab2d526c37733aef343fd97e0fbc3687f7a23021a3822", "extra_info": {"page_label": "91", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2241, "_node_type": "1"}, "relationships": {"1": "26f23882-bf36-452b-af54-54b53ed5960a"}}, "__type__": "1"}, "179b3807-9368-44f0-af1e-af74a1faca28": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 92\nChapter 5. Using the plan's coverage for Part D prescription drugs\nWhat if the pharmacy you have been using leaves the network?\nIf the pharmacy you have been using leaves the plan's network, you will have to find a new pharmacy that is in the \nnetwork. To find another pharmacy in your area, you can get help from Customer Care or use the Provider Directory. \nYou can also find information on our website at Humana.com/PlanDocuments.\nWhat if you need a specialized pharmacy?\nSome prescriptions must be filled at a specialized pharmacy. Specialized pharmacies include:\n\u2022Pharmacies that supply drugs for home infusion therapy.\n\u2022Pharmacies that supply drugs for residents of a long-term care (LTC) facility. Usually, a LTC facility (such as a \nnursing home) has its own pharmacy. If you have any difficulty accessing your Part D benefits in an LTC \nfacility, please contact Customer Care.\n\u2022Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Program (not available in \nPuerto Rico). Except in emergencies, only Native Americans or Alaska Natives have access to these \npharmacies in our network.\n\u2022Pharmacies that dispense drugs that are restricted by the FDA to certain locations or that require special \nhandling, provider coordination, or education on their use. (Note: This scenario should happen rarely.)\nTo locate a specialized pharmacy, look in your Provider Directory or call Customer Care.\nSection 2.3 Using the plan's mail-order service\nFor certain kinds of drugs, you can use the plan's network mail-order service. Generally, the drugs provided through \nmail-order are drugs that you take on a regular basis, for a chronic or long-term medical condition. These drugs are \nmarked as \"mail-order\" drugs in our Drug Guide.\nOur plan's mail-order service allows you to order up to a 90-day supply. \nWithin the pharmacy network, there are mail-order pharmacies which provide preferred cost-sharing. You may \npay more at other mail-order pharmacies.\nTo get order forms and information about filling your prescriptions by mail, please contact Customer Care.\nUsually, a mail-order pharmacy order will be delivered to you in no more than 10 business days. When you plan to \nuse a mail-order pharmacy, it's a good precaution to ask your doctor to write two prescriptions for your drugs: one \nyou'll send for ordering by mail, and one you can fill in person at an in-network pharmacy if your mail-order doesn't \narrive on time. That way, you won't have a gap in your medication if your mail-order is delayed. If you have trouble \nfilling your drug while waiting for mail-order, please call Customer Care.\nNew prescriptions the pharmacy receives directly from your doctor's office. \nThe pharmacy will automatically fill and deliver new prescriptions it receives from health care providers, without \nchecking with you first, if either:\n\u2022You used mail-order services with this plan in the past, or\n\u2022You sign up for automatic delivery of all new prescriptions received directly from health care providers. You \nmay request automatic delivery of all new prescriptions at any time by calling Customer Care.", "doc_id": "179b3807-9368-44f0-af1e-af74a1faca28", "embedding": null, "doc_hash": "4365b48859dec229bfcc7c385f6c90b91c6104af1372ca76fdd4f017c43a6843", "extra_info": {"page_label": "92", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3187, "_node_type": "1"}, "relationships": {"1": "4ae098b9-96ea-4d5f-8223-bcfb092929cd"}}, "__type__": "1"}, "60b8661c-efd8-432d-a143-8ecfbbf3edcd": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 93\nChapter 5. Using the plan's coverage for Part D prescription drugs\nIf you receive a prescription automatically by mail that you do not want, and you were not contacted to see if \nyou wanted it before it shipped, you may be eligible for a refund.\nIf you used mail-order in the past and do not want the pharmacy to automatically fill and ship each new \nprescription, please contact us by calling Customer Care.\nIf you have never used our mail-order delivery and/or decide to stop automatic fills of new prescriptions, the \npharmacy will contact you each time it gets a new prescription from a health care provider to see if you want \nthe medication filled and shipped immediately. It is important that you respond each time you are contacted by \nthe pharmacy, to let them know whether to ship, delay, or cancel the new prescription.\nTo opt out of automatic deliveries of new prescriptions received directly from your health care provider's office, \nplease contact us by calling Customer Care at 1-800-379-0092, TTY 711.\nRefills on mail-order prescriptions. For refills of your drugs, you have the option to sign up for an automatic \nrefill program. Under this program we will start to process your next refill automatically when our records show \nyou should be close to running out of your drug. The pharmacy will contact you prior to shipping each refill to \nmake sure you need more medication, and you can cancel scheduled refills if you have enough of your \nmedication or if your medication has changed. \nIf you choose not to use our auto-refill program but still want the mail-order pharmacy to send you your \nprescription, please contact your pharmacy 14 business days before your current prescription will run out. This \nwill ensure your order is shipped to you in time.\nTo opt out of our program that automatically prepares mail-order refills, please contact us.\nIf you receive a refill automatically by mail that you do not want, you may be eligible for a refund.\nSection 2.4 How can you get a long-term supply of drugs?\nWhen you get a long-term supply of drugs, your cost sharing may be lower. The plan offers two ways to get a \nlong-term supply (also called an \"extended supply\") of \"maintenance\" drugs in our plan's Drug Guide. \n(Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.)\n1. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs. Your Provider \nDirectory tells you which pharmacies in our network can give you a long-term supply of maintenance drugs. You \ncan also call Customer Care for more information.\n2. You may also receive maintenance drugs through our mail-order program. Please see Section 2.3 for more \ninformation.\nSection 2.5 When can you use a pharmacy that is not in the plan's network?\nYour prescription may be covered in certain situations\nGenerally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network \npharmacy. To help you, we have network pharmacies outside of our service area where you can get your \nprescriptions filled as a member of our plan. Please check first with Customer Care to see if there is a network \npharmacy nearby. You will most likely be required to pay the difference between what you pay for the drug at the \nout-of-network pharmacy and the cost that we would cover at an in-network pharmacy.", "doc_id": "60b8661c-efd8-432d-a143-8ecfbbf3edcd", "embedding": null, "doc_hash": "43a479966479e5cd4788d693259a9c8277e38b03775df159f3a1141ff789b442", "extra_info": {"page_label": "93", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3460, "_node_type": "1"}, "relationships": {"1": "3903c9a9-23fc-4532-ab00-8b72b2b6c86d"}}, "__type__": "1"}, "23f95865-cf3a-4d94-b3ed-87e0a00d5299": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 94\nChapter 5. Using the plan's coverage for Part D prescription drugs\nHere are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:\n\u2022If you need a prescription because of a medical emergency\n\u2013We will cover prescriptions that are filled at an out-of-network pharmacy (up to a 30-day supply) if the \nprescriptions are related to care for a medical emergency. In this situation, you will have to pay the full \ncost (rather than paying just your copayment or coinsurance) when you fill your prescription. You can ask \nus to reimburse you for our share of the cost by submitting a paper claim form. If the prescription is \ncovered, it will be covered at an out-of-network rate. If you go to an out-of-network pharmacy, you may \nbe responsible for paying the difference between what we would pay for a prescription filled at an \nin-network pharmacy and what the out-of-network pharmacy charged for your prescription. (Chapter 7, \nSection 2.1 explains how to ask the plan to pay you back.)\n\u2022If you need coverage while you are traveling away from the plan's service area\n\u2013If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply \nof the drug before you leave. When possible, take along all the medication you will need. You may be able \nto order your prescription drugs ahead of time through our prescription mail-order service or through a \nnetwork retail pharmacy that offers an extended supply. If you are traveling outside of your plan's service \narea but within the United States and territories and become ill, or run out of your prescription drugs, call \nCustomer Care to find a network pharmacy in your area where you can fill your prescription. If a network \npharmacy is not available, we will cover prescriptions that are filled at an out-of-network pharmacy (up to \na 30-day supply) if you follow all other coverage rules identified within this document. In this situation, \nyou will have to pay the full cost (rather than paying just your copayment or coinsurance) when you fill \nyour prescription.\n\u2013If the prescription is covered, it will be covered at an out-of-network rate. You may be responsible for \npaying the difference between what we would pay for a prescription filled at an in-network pharmacy and \nwhat the out-of-network pharmacy charged for your prescription. You can ask us to reimburse you for our \nshare of the cost by submitting a paper claim form. (Chapter 7, Section 2.1 explains how to ask the plan to \npay you back.)\n\u2013Please recognize, however, that multiple non-emergency occurrences of out-of-network pharmacy \nclaims will result in claim denials. In addition, we cannot pay for any stolen medications or \nprescriptions that are filled by pharmacies outside the United States and territories, even for a \nmedical emergency, for example on a cruise ship when outside of the United States.\nOther times you can get your prescription covered if you go to an out-of-network pharmacy. These situations will \nbe covered at an out-of-network rate. In these situations, you will have to pay the full cost (rather than paying just \nyour copayment or coinsurance) when you fill your prescription. You can ask us to reimburse you for our share of \nthe cost by submitting a paper claim form. If you go to an out-of-network pharmacy or provider, you may be \nresponsible for paying the difference between what we would pay for a prescription filled at an in-network \npharmacy and what the out-of-network pharmacy charged for your prescription. (Chapter 7, Section 2.1 explains \nhow to ask the plan to pay you back.) We will cover your prescription at an out-of-network pharmacy if at least one \nof the following applies:\n\u2022You can't get a covered drug that you need immediately because there are no open in-network pharmacies \nwithin a reasonable driving distance\n\u2022Your prescription is for a", "doc_id": "23f95865-cf3a-4d94-b3ed-87e0a00d5299", "embedding": null, "doc_hash": "e5e8f142a12ae65cb637cb7c98a5c6fbb76634893accd1efdb1d513957a66e75", "extra_info": {"page_label": "94", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3956, "_node_type": "1"}, "relationships": {"1": "4bdaae58-2b10-452b-aafb-2f17de3f6bbf", "3": "11d2a024-ac9d-4451-ae00-146eb1a781d5"}}, "__type__": "1"}, "11d2a024-ac9d-4451-ae00-146eb1a781d5": {"__data__": {"text": "in-network pharmacies \nwithin a reasonable driving distance\n\u2022Your prescription is for a specialty drug in-network pharmacies don't usually keep in stock", "doc_id": "11d2a024-ac9d-4451-ae00-146eb1a781d5", "embedding": null, "doc_hash": "e8d6a32b112e80c877a680f06459d87f9da488e4d8f68fa20d825cbda2eb00fa", "extra_info": {"page_label": "94", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 3869, "end": 4021, "_node_type": "1"}, "relationships": {"1": "4bdaae58-2b10-452b-aafb-2f17de3f6bbf", "2": "23f95865-cf3a-4d94-b3ed-87e0a00d5299"}}, "__type__": "1"}, "2690e8f1-0d9d-48fe-9464-64e9be7f2fdf": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 95\nChapter 5. Using the plan's coverage for Part D prescription drugs\n\u2022You were eligible for Medicaid at the time you got the prescription, even if you weren't enrolled yet. This is \ncalled retroactive enrollment\n\u2022You're evacuated from your home because of a state, federal, or public health emergency and don't have \naccess to an in-network pharmacy\n\u2022If you get a covered prescription drug from an institutional based pharmacy while a patient in an emergency \nroom, provider based clinic, outpatient surgery clinic, or other outpatient setting.\nHow do you ask for reimbursement from the plan?\nIf you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal \ncost share) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. (Chapter \n7, Section 2.1 explains how to ask the plan to pay you back.)\nSECTION 3 Your drugs need to be in the plan's \"Drug Guide\"\nSection 3.1 The \"Drug Guide\" tells which Part D drugs are covered\nThe plan has a \"Prescription Drug Guide (Formulary).\" In this Evidence of Coverage, we call it the \"Drug Guide\" for \nshort.\nThe drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list meets \nMedicare\u2019s requirements and has been approved by Medicare.\nThe drugs in the Drug Guide are only those covered under Medicare Part D.\nWe will generally cover a drug in the plan's Drug Guide as long as you follow the other coverage rules explained in \nthis chapter and the use of the drug is a medically accepted indication. A \"medically accepted indication\" is a use \nof the drug that is either:\n\u2022Approved by the Food and Drug Administration for the diagnosis or condition for which it is being prescribed.\n\u2022-- or --Supported by certain references, such as the American Hospital Formulary Service Drug Information \nand the DRUGDEX Information System.\nThe Drug Guide includes brand name drugs, generic drugs, and biosimilars.\nA brand name drug is a prescription drug that is sold under a trademarked name owned by the drug manufacturer. \nBrand name drugs that are more complex than typical drugs (for example drugs that are based on a protein) are \ncalled biological products. In the Drug Guide, when we refer to \"drugs\" this could mean a drug or biological \nproduct.\nA generic drug is a prescription drug that has the same active ingredients as the brand name drug. Since biological \nproducts are more complex than typical drugs, instead of having a generic form, they have alternatives that are \ncalled biosimilars. Generally, generics and biosimilars work just as well as the brand name drug or biological \nproduct and usually costs less. There are generic drug substitutes or biosimilar alternatives available for many \nbrand name drugs and some biological products. ", "doc_id": "2690e8f1-0d9d-48fe-9464-64e9be7f2fdf", "embedding": null, "doc_hash": "4c4f273f297d581093a8a9f11b75503311d57d12eafa9d2452bc14cbe1dafd40", "extra_info": {"page_label": "95", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2889, "_node_type": "1"}, "relationships": {"1": "49c4b941-19bc-478d-909e-9a948b55b01f"}}, "__type__": "1"}, "a4538c45-9cc6-4cde-9176-f5d8ef9d641c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 96\nChapter 5. Using the plan's coverage for Part D prescription drugs\nOver-the-Counter Drugs\nOur plan also covers certain over-the-counter drugs. Some over-the-counter drugs are less expensive than \nprescription drugs and work just as well. For more information, call Customer Care.\nWhat is not in the Drug Guide?\nThe plan does not cover all prescription drugs.\n\u2022In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more \ninformation about this, see Section 7.1 in this chapter).\n\u2022In other cases, we have decided not to include a particular drug in the Drug Guide. In some cases, you may \nbe able to obtain a drug that is not in the Drug Guide. For more information, please see Chapter 9.\nSection 3.2 There are five \"cost-sharing tiers\" for drugs in the Drug Guide\nEvery drug in the plan's Drug Guide is in one of five cost-sharing tiers. In general, the higher the cost-sharing tier, \nthe higher your cost for the drug:\n\u2022Cost-Sharing Tier 1 \u2013 Preferred Generic: Generic or brand drugs that are available at the lowest cost share \nfor this plan\n\u2022Cost-Sharing Tier 2 \u2013 Generic: Generic or brand drugs that the plan offers at a higher cost to you than Tier 1 \nPreferred Generic drugs\n\u2022Cost-Sharing Tier 3 \u2013 Preferred Brand: Generic or brand drugs that the plan offers at a lower cost to you \nthan Tier 4 Non-Preferred Drug drugs. Select Insulins as part of the Insulins Savings Program are included \non this tier. You can identify Select Insulins by the \"ISP\" indicator in the Drug Guide.\n\u2022Cost-Sharing Tier 4 \u2013 Non-Preferred Drug: Generic or brand drugs that the plan offers at a higher cost to \nyou than Tier 3 Preferred Brand drugs\n\u2022Cost-Sharing Tier 5 \u2013 Specialty Tier: Some injectables and other high-cost drugs\nTo find out which cost-sharing tier your drug is in, look it up in the plan's Drug Guide.\nThe amount you pay for drugs in each cost-sharing tier is shown in Chapter 6 (What you pay for your Part D \nprescription drugs).\nSection 3.3 How can you find out if a specific drug is in the Drug Guide?\nYou have three ways to find out:\n1. Check the most recent Drug Guide we provided electronically. (Please note: The Drug Guide we provide includes \ninformation for the covered drugs that are most commonly used by our members. However, we cover \nadditional drugs that are not included in the provided Drug Guide. If one of your drugs is not listed in the Drug \nGuide, you should visit our website or contact Customer Care to find out if we cover it.)\n2. Visit the plan's website (Humana.com/PlanDocuments). The Drug Guide on the website is always the most \ncurrent.", "doc_id": "a4538c45-9cc6-4cde-9176-f5d8ef9d641c", "embedding": null, "doc_hash": "e0167c6532c719b6cb98ee4fd4dff2d94cdcd9af919d59340a7ec9db07d2aa23", "extra_info": {"page_label": "96", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2674, "_node_type": "1"}, "relationships": {"1": "654bd8d8-b21f-4ffb-bfd6-72213b3647d7"}}, "__type__": "1"}, "4979f2f0-b279-495f-b7ba-d66e56e902d1": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 97\nChapter 5. Using the plan's coverage for Part D prescription drugs\n3. Call Customer Care to find out if a particular drug is in the plan's Drug Guide or to ask for a copy of the list.\nSECTION 4 There are restrictions on coverage for some drugs\nSection 4.1 Why do some drugs have restrictions?\nFor certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and \npharmacists developed these rules to encourage you and your provider to use drugs in the most effective ways. To \nfind out if any of these restrictions apply to a drug that you take or want to take, check the Drug Guide. If a safe, \nlower-cost drug will work just as well medically as a higher-cost drug, the plan\u2019s rules are designed to encourage \nyou and your provider to use that lower-cost option.\nPlease note that sometimes a drug may appear more than once in our Drug Guide. This is because the same drugs \ncan differ based on strength, amount, or form of the drug prescribed by your health care provider, and different \nrestrictions or cost sharing may apply to the different versions of the drug (for instance, 10 mg versus 100 mg; one \nper day versus two per day; tablet versus liquid).\nSection 4.2 What kinds of restrictions?\nThe sections below tell you more about the types of restrictions we use for certain drugs.\nIf there is a restriction for your drug, it usually means that you or your provider will have to take extra \nsteps in order for us to cover the drug. Contact Customer Care to learn what you or your provider would need to \ndo to get coverage for the drug. If you want us to waive the restriction for you, you will need to use the coverage \ndecision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See \nChapter 9)\nRestricting brand name drugs when a generic version is available\nGenerally, a \"generic\" drug works the same as a brand name drug and usually costs less. When a generic version \nof a brand name drug is available, our network pharmacies will provide you the generic version instead of \nthe brand name drug. However, if your provider has told us the medical reason that neither the generic drug nor \nother covered drugs that treat the same condition will work for you, then we will cover the brand name drug. (Your \nshare of the cost may be greater for the brand name drug than for the generic drug.)\nGetting plan approval in advance\nFor certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for \nyou. This is called \"prior authorization.\" This is put in place to ensure medication safety and help guide \nappropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.\nTrying a different drug first\nThis requirement encourages you to try less costly but usually just as effective drugs before the plan covers \nanother drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try \nDrug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug \nfirst is called \"step therapy.\"\nQuantity limits", "doc_id": "4979f2f0-b279-495f-b7ba-d66e56e902d1", "embedding": null, "doc_hash": "306adc27b22fbd6e381f5ab1393974d8b9a517c38c2e40fa9920b7c775c5c246", "extra_info": {"page_label": "97", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3257, "_node_type": "1"}, "relationships": {"1": "080d7dbc-6178-4cd6-af31-e968bc1c3968"}}, "__type__": "1"}, "f769df96-a3c8-4aed-9271-4a5f9bdaf536": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 98\nChapter 5. Using the plan's coverage for Part D prescription drugs\nFor certain drugs, we limit how much of a drug you can get each time you fill your prescription. For example, if it is \nnormally considered safe to take only one pill per day for a certain drug, we may limit coverage for your \nprescription to no more than one pill per day.\nSECTION 5 What if one of your drugs is not covered in the way you'd like it  \nto be covered?\nSection 5.1 There are things you can do if your drug is not covered in the way you'd  \nlike it to be covered\nThere are situations where there is a prescription drug you are taking, or one that you and your provider think you \nshould be taking that is not on our formulary or is on our formulary with restrictions. For example:\n\u2022The drug might not be covered at all. Or maybe a generic version of the drug is covered but the brand name \nversion you want to take is not covered.\n\u2022The drug is covered, but there are extra rules or restrictions on coverage for that drug, as explained in Section \n4.\n\u2022The drug is covered, but it is in a cost-sharing tier that makes your cost sharing more expensive than you \nthink it should be.\n\u2022There are things you can do if your drug is not covered in the way that you'd like it to be covered. If your drug \nis not in the Drug Guide or if your drug is restricted, go to Section 5.2 to learn what you can do.\n\u2022If your drug is in a cost-sharing tier that makes your cost more expensive than you think it should be, go to \nSection 5.3 to learn what you can do.\nSection 5.2 What can you do if your drug is not in the Drug Guide or if the drug is  \nrestricted in some way?\nIf your drug is not in the Drug Guide or is restricted, here are options:\n\u2022You may be able to get a temporary supply of the drug.\n\u2022You can change to another drug.\n\u2022You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.\nYou may be able to get a temporary supply\nUnder certain circumstances, the plan must provide a temporary supply of a drug that you are already taking. This \ntemporary supply gives you time to talk with your provider about the change in coverage and decide what to do.\nTo be eligible for a temporary supply, the drug you have been taking must no longer be in the plan\u2019s Drug Guide \nOR is now restricted in some way.", "doc_id": "f769df96-a3c8-4aed-9271-4a5f9bdaf536", "embedding": null, "doc_hash": "4198fab5e67999fe6ae50e650cc828dddbf50b83da661b7335be4b0f261296ce", "extra_info": {"page_label": "98", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2381, "_node_type": "1"}, "relationships": {"1": "10bb9270-5549-4eb1-a5f9-a531e9b25c0c"}}, "__type__": "1"}, "759ce702-6918-4bb3-ae74-f21c19f78a8a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 99\nChapter 5. Using the plan's coverage for Part D prescription drugs\n\u2022If you are a new member, we will cover a temporary supply of your drug during the first 90 days of your \nmembership in the plan.\n\u2022If you were in the plan last year, we will cover a temporary supply of your drug during the first 90 days of \nthe calendar year.\n\u2022This temporary supply will be for a maximum of 30 days. If your prescription is written for fewer days, we will \nallow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be \nfilled at a network pharmacy. (Please note that the long-term care pharmacy may provide the drug in \nsmaller amounts at a time to prevent waste.)\n\u2022For those members who have been in the plan for more than 90 days and reside in a long-term care \nfacility and need a supply right away:\nWe will cover one emergency 31-day supply of a particular drug, or less if your prescription is written for \nfewer days. This is in addition to the above temporary supply.\n\u2022Transition Supply for Current Members with changes in treatment setting:\nIf the setting where you receive treatment changes during the plan year, you may need a short-term supply \nof your drugs during the transition. For example:\n\u2013You're discharged from a hospital or skilled nursing facility (where your Medicare Part A payments include \ndrug costs) and need a prescription from a pharmacy to continue taking a drug at home (using your Part D \nplan benefit); or\n\u2013You transfer from one skilled nursing facility to another\nIf you do change treatment settings and need to fill a prescription at a pharmacy, we'll cover up to a 31-day \nsupply of a drug covered by Medicare Part D, so your drug treatment won't be interrupted.\nIf you change treatment settings multiple times within the same month, you may have to request an \nexception or prior authorization for continued coverage of your drug.\nPolicies for Temporary Drug Supplies During the Transition Period\nWe consider the first 90 days of the 2023 plan year a transition period if you're a new member, you changed \nplans, or there were changes in your drug coverage. As described above, there are several ways we make \nsure you can get a temporary supply of your drugs, if needed, during the transition period.\nDuring the first 90 days, you can get a temporary supply if you have a current prescription for a drug that's \nnot in our Drug Guide or requires prior authorization because of restrictions. The conditions for getting a \ntemporary supply are described below.\nOne-Time Transition Supply at a Retail or Mail-Order Pharmacy\nWe'll cover up to a 30-day supply of a drug covered by Medicare Part D. While you have your temporary \nsupply, talk to your doctor about what to do after you use the temporary supply. You may be able to switch to \na covered drug that would work just as well for you. You and your doctor can request an exception if you \nbelieve it's medically necessary to continue the same drug.\nTransition Supply if you're in a Long-Term Care Facility", "doc_id": "759ce702-6918-4bb3-ae74-f21c19f78a8a", "embedding": null, "doc_hash": "87ddde35e319e4414a8991a71b4485099f51ece331f34ff90dfc18c9575e3904", "extra_info": {"page_label": "99", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3091, "_node_type": "1"}, "relationships": {"1": "ef4ecd3b-89e2-4a16-a5ef-20558ce1fc7d"}}, "__type__": "1"}, "9d2d8d50-c7d1-4645-8d13-9f83c1400161": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 100\nChapter 5. Using the plan's coverage for Part D prescription drugs\nWe'll cover up to a 31-day supply of a drug covered by Medicare Part D. This coverage is available anytime \nduring the 90 day transition period, as long as your current prescription is filled at a pharmacy in a long-term \ncare facility.\nIf you have a problem getting a prescribed drug later in the plan year (after the 90 day transition period), \nwe'll cover up to a 31-day emergency supply of a drug covered by Medicare Part D. The emergency supply \nwill let you continue your drug treatment while you and your doctor request an exception or prior \nauthorization to continue.\nTransition Period Extension\nIf you have requested an exception or made an appeal for drug coverage, it may be possible to extend the \ntemporary transition period while we're processing your request. Call Customer Care (phone numbers are \nprinted on the back cover of this booklet) if you believe we need to extend the transition period to make sure \nyou continue to receive your drugs as needed.\nCosts for Temporary Supplies\nYour copayment or coinsurance for a temporary drug supply will be based on your plan's approved drug \ncost-sharing tiers. If you're eligible for the low-income subsidy (LIS) in 2023, your copayment or coinsurance \nwon't exceed your LIS limit.\nFor questions about a temporary supply, call Customer Care.\nDuring the time when you are using a temporary supply of a drug, you should talk with your provider to decide \nwhat to do when your temporary supply runs out. You have two options:\n1. You can change to another drug\nTalk with your provider about whether there is a different drug covered by the plan that may work just as well for \nyou. You can call Customer Care to ask for a list of covered drugs that treat the same medical condition. This list \ncan help your provider find a covered drug that might work for you.\n2. You can ask for an exception\nYou and your provider can ask the plan to make an exception and cover the drug in the way you would like it \ncovered. If your provider says that you have medical reasons that justify asking us for an exception, your provider \ncan help you request an exception. For example, you can ask the plan to cover a drug even though it is not in the \nplan\u2019s Drug Guide. Or you can ask the plan to make an exception and cover the drug without restrictions.\nIf you are a current member and a drug you are taking will be removed from the formulary or restricted in some \nway for next year, we will tell you about any change prior to the new year. You can ask for an exception before next \nyear and we will give you an answer within 72 hours after we receive your request (or your prescriber\u2019s supporting \nstatement). If we approve your request, we will authorize the coverage before the change takes effect.\nIf you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells you what to do. It explains the \nprocedures and deadlines that have been set by Medicare to make sure your request is handled promptly and \nfairly.", "doc_id": "9d2d8d50-c7d1-4645-8d13-9f83c1400161", "embedding": null, "doc_hash": "24497870e281a8ad226b4223780418ec2f9708665fae9ca9426a7ee63721a9d5", "extra_info": {"page_label": "100", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3113, "_node_type": "1"}, "relationships": {"1": "61773825-8cb5-4f7d-b774-aa1b4f79353f"}}, "__type__": "1"}, "0b7622e2-aa2f-48e6-8942-f5d76b87da44": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 101\nChapter 5. Using the plan's coverage for Part D prescription drugs\nSection 5.3 What can you do if your drug is in a cost-sharing tier you think is too high?\nIf your drug is in a cost-sharing tier you think is too high, here are things you can do:\nYou can change to another drug\nIf your drug is in a cost-sharing tier you think is too high, talk to your provider. There may be a different drug in a \nlower cost-sharing tier that might work just as well for you. Call Customer Care to ask for a list of covered drugs that \ntreat the same medical condition. This list can help your provider find a covered drug that might work for you.\nYou can ask for an exception\nYou and your provider can ask the plan to make an exception in the cost-sharing tier for the drug so that you pay \nless for it. If your provider says that you have medical reasons that justify asking us for an exception, your provider \ncan help you request an exception to the rule.\nIf you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what to do. It explains the \nprocedures and deadlines that have been set by Medicare to make sure your request is handled promptly and \nfairly.\nDrugs in our Specialty Tier are not eligible for this type of exception. We do not lower the cost-sharing amount for \ndrugs in this tier. \nSECTION 6 What if your coverage changes for one of your drugs?\nSection 6.1 The Drug Guide can change during the year\nMost of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, \nthe plan can make some changes to the Drug Guide. For example, the plan might:\n\u2022Add or remove drugs from the Drug Guide.\n\u2022Move a drug to a higher or lower cost-sharing tier.\n\u2022Add or remove a restriction on coverage for a drug.\n\u2022Replace a brand name drug with a generic drug.\nWe must follow Medicare requirements  before we change the plan\u2019s Drug Guide.\nSection 6.2 What happens if coverage changes for a drug you are taking?\nInformation on changes to drug coverage\nWhen changes to the Drug Guide occur, we post information on our website about those changes. We also update \nour online Drug Guide on a regularly scheduled basis. Below we point out the times that you would get direct notice \nif changes are made to a drug that you are taking.\nChanges to your drug coverage that affect you during the current plan year", "doc_id": "0b7622e2-aa2f-48e6-8942-f5d76b87da44", "embedding": null, "doc_hash": "40e826083aa556d6ba8465931f36795541641ea682d1b7958cc91e710aaf2131", "extra_info": {"page_label": "101", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2427, "_node_type": "1"}, "relationships": {"1": "384c3c45-4c1e-4d8f-8008-4a5a3d99a820"}}, "__type__": "1"}, "f508d885-8a23-4195-bf24-c1cd60e2063c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 102\nChapter 5. Using the plan's coverage for Part D prescription drugs\n\u2022A new generic drug replaces a brand name drug in the Drug Guide (or we change the cost-sharing tier \nor add new restrictions to the brand name drug or both)\n\u2013We may immediately remove a brand name drug in our Drug Guide if we are replacing it with a newly \napproved generic version of the same drug. The generic drug will appear on the same or lower \ncost-sharing tier and with the same or fewer restrictions. We may decide to keep the brand name drug in \nour Drug Guide, but immediately move it to a higher cost sharing tier or add new restrictions or both when \nthe new generic is added.\n\u2013We may not tell you in advance before we make that change\u2014even if you are currently taking the brand \nname drug. If you are taking the brand name drug at the time we make the change, we will provide you \nwith information about the specific change(s). This will also include information on the steps you may \ntake to request an exception to cover the brand name drug. You may not get this notice before we make \nthe change.\n\u2013You or your prescriber can ask us to make an exception and continue to cover the brand name drug for \nyou. For information on how to ask for an exception, see Chapter 9.\n\u2022Unsafe drugs and other drugs in the Drug Guide that are withdrawn from the market\n\u2013Sometimes a drug may be deemed unsafe or taken off the market for another reason. If this happens, we \nmay immediately remove the drug from the Drug Guide. If you are taking that drug, we will tell you right \naway.\n\u2013Your prescriber will also know about this change and can work with you to find another drug for your \ncondition.\n\u2022Other changes to drugs in the Drug Guide\n\u2013We may make other changes once the year has started that affect drugs you are taking. For example, we \nmight add a generic drug that is not new to the market to replace a brand name drug in the Drug Guide or \nchange the cost-sharing tier or add new restrictions to the brand name drug or both. We also might make \nchanges based on FDA boxed warnings or new clinical guidelines recognized by Medicare.\n\u2013For these changes, we must give you at least 30 days\u2019 advance notice of the change or give you notice of \nthe change and a 30-day refill of the drug you are taking at a network pharmacy.\n\u2013After you receive notice of the change, you should work with your prescriber to switch to a different drug \nthat we cover or to satisfy any new restrictions on the drug you are taking.\n\u2013You or your prescriber can ask us to make an exception and continue to cover the drug for you. For \ninformation on how to ask for an exception, see Chapter 9.\nChanges to the Drug Guide that do not affect you during this plan year\nWe may make certain changes to the Drug Guide that are not described above. In these cases, the changes will not \napply to you if you are taking the drug when the change is made; however, these changes will likely affect you \nstarting January 1 of the next plan year if you stay in the same plan.\nIn general, changes that will not affect you during the current plan year are:\n\u2022We move your drug into a higher cost-sharing tier.", "doc_id": "f508d885-8a23-4195-bf24-c1cd60e2063c", "embedding": null, "doc_hash": "a726f0d209e47e856848a95378664e0ea0f7f6caa006f78ce0d74b7607139dc6", "extra_info": {"page_label": "102", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3209, "_node_type": "1"}, "relationships": {"1": "b4a2fcfb-fa1c-429b-ad31-67e32e895782"}}, "__type__": "1"}, "c3faa421-db77-4c2e-83d5-bfd28e3e4e11": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 103\nChapter 5. Using the plan's coverage for Part D prescription drugs\n\u2022We put a new restriction on use of your drug.\n\u2022We remove your drug from the Drug Guide.\nIf any of these changes happen for a drug you are taking (except for market withdrawal, a generic drug \nreplacing a brand name drug, or other change noted in the sections above), then the change won\u2019t affect your \nuse or what you pay as your share of the cost until January 1 of the next year. Until that date, you probably \nwon\u2019t see any increase in your payments or restrictions to your use of the drug.\nWe will not tell you about these types of changes directly during the current plan year. You will need to check \nthe Drug Guide for the next plan year (when the list is available during the open enrollment period) to see if \nthere are any changes to the drugs you are taking that will impact you during the next plan year.\nSECTION 7 What types of drugs are not covered by the plan?\nSection 7.1 Types of drugs we do not cover\nThis section tells you what kinds of prescription drugs are \"excluded.\" This means Medicare does not pay for these \ndrugs.\nIf you get drugs that are excluded, you must pay for them yourself (except for certain excluded drugs covered \nunder our enhanced drug coverage). If you appeal and the requested drug is found not to be excluded under Part \nD, we will pay for or cover it. (For information about appealing a decision, go to Chapter 9.)\nHere are three general rules about drugs that Medicare drug plans will not cover under Part D:\n\u2022Our plan's Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B.\n\u2022Our plan cannot cover a drug purchased outside the United States or its territories.\n\u2022Our plan usually cannot cover off-label use. \"Off-label use\" is any use of the drug other than those indicated \non a drug's label as approved by the Food and Drug Administration.\n\u2013Coverage for \"off-label use\" is allowed only when the use is supported by certain references, such as the \nAmerican Hospital Formulary Service Drug Information and the DRUGDEX Information System.\nIn addition, by law, the following categories of drugs are not covered by Medicare drug plans. (Our plan covers \ncertain drugs listed below through our enhanced drug coverage, for which you may be charged an additional \npremium. More information is provided below.):\n\u2022Non-prescription drugs (also called over-the-counter drugs)\n\u2022Drugs used to promote fertility\n\u2022Drugs used for the relief of cough or cold symptoms\n\u2022Drugs used for cosmetic purposes or to promote hair growth\n\u2022Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations\n\u2022Drugs used for the treatment of sexual or erectile dysfunction", "doc_id": "c3faa421-db77-4c2e-83d5-bfd28e3e4e11", "embedding": null, "doc_hash": "639df1e09ebbfe8835883592a1b41d2802bb5c8886640eadbdcce45e3b513b48", "extra_info": {"page_label": "103", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2794, "_node_type": "1"}, "relationships": {"1": "19245fe9-5920-4588-b097-3e3037210b38"}}, "__type__": "1"}, "38acc63e-1d3b-4bf8-a406-a3eccd07da18": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 104\nChapter 5. Using the plan's coverage for Part D prescription drugs\n\u2022Drugs used for treatment of anorexia, weight loss, or weight gain\n\u2022Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be \npurchased exclusively from the manufacturer as a condition of sale\nWe offer additional coverage of some prescription drugs (enhanced drug coverage) not normally covered in a \nMedicare prescription drug plan.\n\u2022Erectile Dysfunction drugs\n\u2022Anti-Obesity Medication\nThe amount you pay for these drugs does not count towards qualifying you for the Catastrophic Coverage Stage. \n(The Catastrophic Coverage Stage is described in Chapter 6, Section 7 of this document.)\nIn addition, if you are receiving \"Extra Help\" to pay for your prescriptions, the \"Extra Help\" program will not pay for \nthe drugs not normally covered. However, if you have drug coverage through Medicaid, your state Medicaid \nprogram may cover some prescription drugs not normally covered in a Medicare drug plan. Please contact your \nstate Medicaid program to determine what drug coverage may be available to you. (You can find phone numbers \nand contact information for Medicaid in Chapter 2, Section 6.)\nSECTION 8 Filling a prescription\nSection 8.1 Provide your membership information\nTo fill your prescription, provide your plan membership information, which can be found on your membership card, \nat the network pharmacy you choose. The network pharmacy will automatically bill the plan for our share of your \ndrug cost. You will need to pay the pharmacy your share of the cost when you pick up your prescription.\nSection 8.2 What if you don\u2019t have your membership information with you?\nIf you don\u2019t have your plan membership information with you when you fill your prescription, you or the pharmacy \ncan call the plan to get the necessary information.\nIf the pharmacy is not able to get the necessary information, you may have to pay the full cost of the \nprescription when you pick it up. (You can then ask us to reimburse you for our share. See Chapter 7, Section 2 \nfor information about how to ask the plan for reimbursement.)\nSECTION 9 Part D drug coverage in special situations\nSection 9.1 What if you're in a hospital or a skilled nursing facility for a stay that is  \ncovered by the plan?\nIf you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we will generally cover \nthe cost of your prescription drugs during your stay. Once you leave the hospital or skilled nursing facility, the plan \nwill cover your prescription drugs as long as the drugs meet all of our rules for coverage described in this Chapter.", "doc_id": "38acc63e-1d3b-4bf8-a406-a3eccd07da18", "embedding": null, "doc_hash": "f57b3ab7f286a24cf72c51b773728340da447ec8f599d91252057e4fef2d9d7c", "extra_info": {"page_label": "104", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2739, "_node_type": "1"}, "relationships": {"1": "0222444a-79c4-409b-ab08-8cc11b5350d1"}}, "__type__": "1"}, "eeb21716-7d5b-4820-be79-1c896039f5ff": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 105\nChapter 5. Using the plan's coverage for Part D prescription drugs\nSection 9.2 What if you're a resident in a long-term care (LTC) facility?\nUsually, a long-term care (LTC) facility (such as a nursing home) has its own pharmacy or uses a pharmacy that \nsupplies drugs for all of its residents. If you are a resident of a LTC facility, you may get your prescription drugs \nthrough the facility\u2019s pharmacy or the one it uses, as long as it is part of our network.\nCheck your Provider Directory to find out if your LTC facility\u2019s pharmacy or the one that it uses is part of our network. \nIf it isn\u2019t, or if you need more information or assistance, please contact Customer Care. If you are in an LTC facility, \nwe must ensure that you are able to routinely receive your Part D benefits through our network of LTC pharmacies.\nWhat if you\u2019re a resident in a long-term care (LTC) facility and need a drug that is not in our Drug Guide or \nis restricted in some way?\nPlease refer to Section 5.2 about a temporary or emergency supply.\nSection 9.3 What if you're also getting drug coverage from an employer or retiree  \ngroup plan?\nIf you currently have other prescription drug coverage through your (or your spouse\u2019s) employer or retiree group \nplease contact that group\u2019s benefits administrator. He or she can help you determine how your current \nprescription drug coverage will work with our plan.\nIn general, if you have employee or retiree group coverage, the drug coverage you get from us will be secondary to \nyour group coverage. That means your group coverage would pay first.\nSpecial note about 'creditable coverage':\nEach year your employer or retiree group should send you a notice that tells if your prescription drug coverage for \nthe next calendar year is \"creditable.\"\nIf the coverage from the group plan is \"creditable,\" it means that the plan has drug coverage that is expected to \npay, on average, at least as much as Medicare's standard prescription drug coverage.\nKeep this notice about creditable coverage because you may need it later. If you enroll in a Medicare plan that \nincludes Part D drug coverage, you may need these notices to show that you have maintained creditable coverage. \nIf you didn\u2019t get the creditable coverage notice, request a copy from your employer or retiree plan\u2019s benefits \nadministrator or the employer or union.\nSection 9.4 What if you're in Medicare-certified hospice?\nHospice and our plan do not cover the same drug at the same time. If you are enrolled in Medicare hospice and \nrequire certain drugs (e.g., anti-nausea, laxative, pain medication or anti-anxiety drugs) that are not covered by \nyour hospice because it is unrelated to your terminal illness and related conditions, our plan must receive \nnotification from either the prescriber or your hospice provider that the drug is unrelated before our plan can cover \nthe drug. To prevent delays in receiving these drugs that should be covered by our plan, ask your hospice provider \nor prescriber to provide notification before your prescription is filled.", "doc_id": "eeb21716-7d5b-4820-be79-1c896039f5ff", "embedding": null, "doc_hash": "ade30a815be6a83be9b03e83bf89732136b0252990d1d4b39d6db848f5f9a4ea", "extra_info": {"page_label": "105", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3122, "_node_type": "1"}, "relationships": {"1": "381adc2c-39d4-496a-b659-c8f9e006baf9"}}, "__type__": "1"}, "87abc490-c3bd-4135-8ccb-7b01e64b9dce": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 106\nChapter 5. Using the plan's coverage for Part D prescription drugs\nIn the event you either revoke your hospice election or are discharged from hospice our plan should cover your \ndrugs as explained in this document. To prevent any delays at a pharmacy when your Medicare hospice benefit \nends, bring documentation to the pharmacy to verify your revocation or discharge.\nSECTION 10 Programs on drug safety and managing medications\nSection 10.1 Programs to help members use drugs safely\nWe conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care.\nWe do a review each time you fill a prescription. We also review our records on a regular basis. During these \nreviews, we look for potential problems such as:\n\u2022Possible medication errors\n\u2022Drugs that may not be necessary because you are taking another drug to treat the same condition\n\u2022Drugs that may not be safe or appropriate because of your age or gender\n\u2022Certain combinations of drugs that could harm you if taken at the same time\n\u2022Prescriptions for drugs that have ingredients you are allergic to\n\u2022Possible errors in the amount (dosage) of a drug you are taking\n\u2022Unsafe amounts of opioid pain medications\nIf we see a possible problem in your use of medications, we will work with your provider to correct the problem.\nSection 10.2 Drug Management Program (DMP) to help members safely use their opioid  \nmedications\nWe have a program that helps make sure members safely use prescription, opioids and other medications that are \nfrequently abused medications. This program is called a Drug Management Program (DMP). If you use opioid \nmedications that you get from several doctors or pharmacies, or if you had a recent opioid overdose, we may talk \nto your doctors to make sure your use of opioid medications is appropriate and medically necessary. Working with \nyour doctors, if we decide your use of prescription opioid or benzodiazepine medications is not safe, we may limit \nhow you can get those medications. If we place you in our DMP, the limitations may be:\n\u2022Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain \npharmacy(ies)\n\u2022Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain doctor(s)\n\u2022Limiting the amount of opioid or benzodiazepine medications we will cover for you\nIf we plan on limiting how you may get these medications or how much you can get, we will send you a letter in \nadvance. The letter will explain the limitations we think should apply to you. You will also have an opportunity to \ntell us which doctors or pharmacies you prefer to use, and about any other information you think is important for \nus to know. After you\u2019ve had the opportunity to respond, if we decide to limit your coverage for these medications, ", "doc_id": "87abc490-c3bd-4135-8ccb-7b01e64b9dce", "embedding": null, "doc_hash": "b70ad2ac4680119b73bb9e4e3276da81853048463c5ee02031d6ca1955565a50", "extra_info": {"page_label": "106", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2902, "_node_type": "1"}, "relationships": {"1": "e669b8a5-8b94-401c-87ca-c455bec2cccf"}}, "__type__": "1"}, "22e02dd4-7e74-4b48-9cef-362395414e29": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 107\nChapter 5. Using the plan's coverage for Part D prescription drugs\nwe will send you another letter confirming the limitation. If you think we made a mistake or you disagree with our \ndetermination or with limitation, you and your prescriber have the right to appeal. If you appeal, we will review \nyour case and give you a decision. If we continue to deny any part of your request related to the limitations that \napply to your access to medications, we will automatically send your case to an independent reviewer outside of \nour plan. See Chapter 9 for information about how to ask for an appeal.\nYou will not be placed in our DMP if you have certain medical conditions, such as active cancer-related pain or \nsickle cell disease, you are receiving hospice, palliative, or end-of-life care, or live in a long-term care facility.\nSection 10.3 Medication Therapy Management (MTM) and other programs to help  \nmembers manage their medications\nWe have programs that can help our members with complex health needs.\nOne program is called a Medication Therapy Management (MTM) program. These programs are voluntary and free. \nA team of pharmacists and doctors developed the programs for us to help make sure that our members get the \nmost benefit from the drugs they take.\nSome members who take medications for different medical conditions and have high drug costs, or are in a DMP to \nhelp members use their opioids safely may be able to get services through a MTM program. A pharmacist or other \nhealth professional will give you a comprehensive review of all your medications. During the review, you can talk \nabout your medications, your costs, and any problems or questions you have about your prescription and \nover-the-counter medications. You\u2019ll get a written summary which has a recommended to-do list that includes \nsteps you should take to get the best results from your medications. You\u2019ll also get a medication list that will \ninclude all the medications you\u2019re taking, how much you take, and when and why you take them. In addition, \nmembers in the MTM program will receive information on the safe disposal of prescription medications that are \ncontrolled substances.\nIt\u2019s a good idea to talk to your doctor about your recommended to-do list and medication list. Bring the summary \nwith you to your visit or anytime you talk with your doctors, pharmacists, and other health care providers. Also, \nkeep your medication list up to date with you (for example, with your ID) in case you go to the hospital or \nemergency room.\nIf we have a program that fits your needs, we will automatically enroll you in the program and send you \ninformation. If you decide not to participate, please notify us and we will withdraw you. If you have any questions \nabout these programs, please contact Customer Care.", "doc_id": "22e02dd4-7e74-4b48-9cef-362395414e29", "embedding": null, "doc_hash": "9eee2528f0b65b48b5ff70844b3a0218b0813d6f263b0cf7561268633fe4c98a", "extra_info": {"page_label": "107", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2871, "_node_type": "1"}, "relationships": {"1": "04e0ee8e-1549-4fd0-81b5-8362d5063f1c"}}, "__type__": "1"}, "a36ac4df-bee2-4a9e-b518-ce9c1611c037": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 108\nChapter 6. What you pay for your Part D prescription drugsEOC082\nCHAPTER 6:\nWhat you pay for your Part D \nprescription drugs", "doc_id": "a36ac4df-bee2-4a9e-b518-ce9c1611c037", "embedding": null, "doc_hash": "f24f74d783f4fee1b7819a221bc8a4b06527fe465443431fb6c550717527eca1", "extra_info": {"page_label": "108", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 191, "_node_type": "1"}, "relationships": {"1": "fa3dd9c2-37d8-4212-98bc-ff33a78d13ef"}}, "__type__": "1"}, "dacaac01-2f84-44ba-8426-4e8694381653": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 109\nChapter 6. What you pay for your Part D prescription drugs\nAre you currently getting help to pay for your drugs?\nIf you are in a program that helps pay for your drugs, some information in this Evidence of Coverage about the  \ncosts for Part D prescription drugs may not apply to you. We sent you a separate insert, called the \"Evidence of  \nCoverage Rider for People Who Get Extra Help Paying for Prescription Drugs\" (also known as the \"Low Income  \nSubsidy Rider\" or the \"LIS Rider\"), which tells you about your drug coverage. If you don't have this insert, please call  \nCustomer Care and ask for the \"LIS Rider.\" Your LIS rider may not explain enhanced insulin coverage that is now  \npart of this plan. Under this plan you will pay no more than $35 for a one-month (up to 30-day) supply of Part D  \ncovered insulin even if you receive \u201cExtra Help\u201d. \nSECTION 1 Introduction\nSection 1.1 Use this chapter together with other materials that explain your drug  \ncoverage\nThis chapter focuses on what you pay for Part D prescription drugs. To keep things simple, we use \"drug\" in this \nchapter to mean a Part D prescription drug. As explained in Chapter 5, not all drugs are Part D drugs \u2013 some drugs \nare covered under Medicare Part A or Part B and other drugs are excluded from Medicare coverage by law.\nTo understand the payment information, you need to know what drugs are covered, where to fill your \nprescriptions, and what rules to follow when you get your covered drugs. Chapter 5, Sections 1 through 4 explain \nthese rules.\nSection 1.2 Types of out-of-pocket costs you may pay for covered drugs\nThere are different types of out-of-pocket costs for Part D drugs. The amount that you pay for a drug is called \u201ccost \nsharing\u201d and there are three ways you may be asked to pay.\n\u2022The \"deductible\" is the amount you pay for drugs before our plan begins to pay its share.\n\u2022\"Copayment\" is a fixed amount you pay each time you fill a prescription.\n\u2022\"Coinsurance\" is a percentage of the total cost you pay each time you fill a prescription.\nSection 1.3 How Medicare calculates your out-of-pocket costs\nMedicare has rules about what counts and what does not count toward your out-of-pocket costs. Here are the \nrules we must follow to keep track of your out-of-pocket costs.\nThese payments are included in your out-of-pocket costs\nYour out-of-pocket costs include the payments listed below (as long as they are for Part D covered drugs, and \nyou followed the rules for drug coverage that are explained in Chapter 5):\n\u2022The amount you pay for drugs when you are in any of the following drug payment stages:", "doc_id": "dacaac01-2f84-44ba-8426-4e8694381653", "embedding": null, "doc_hash": "7768cdbd289e8f1dc7c88cd0c2b743217388d1e78b961a206e65947247fcdf4e", "extra_info": {"page_label": "109", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2665, "_node_type": "1"}, "relationships": {"1": "e6f6cb78-0499-45b4-b641-dcf9ec1313c9"}}, "__type__": "1"}, "b2d761a4-a95c-4224-8cf1-ec16720bf831": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 110\nChapter 6. What you pay for your Part D prescription drugs\n\u2013The Initial Coverage Stage\n\u2013The Coverage Gap Stage\n\u2022Any payments you made during this calendar year as a member of a different Medicare prescription drug plan \nbefore you joined our plan.\nIt matters who pays:\n\u2022If you make these payments yourself, they are included in your out-of-pocket costs. \n\u2022These payments are also included if they are made on your behalf by certain other individuals or \norganizations. This includes payments for your drugs made by a friend or relative, by most charities, by AIDS \ndrug assistance programs, by a State Pharmaceutical Assistance Program that is qualified by Medicare, or by the \nIndian Health Service. Payments made by Medicare\u2019s \u201cExtra Help\u201d Program are also included. \n\u2022Some of the payments made by the Medicare Coverage Gap Discount Program are included. The amount the \nmanufacturer pays for your brand name drugs is included. But the amount the plan pays for your generic drugs \nis not included.\nMoving on to the Catastrophic Coverage Stage:\nWhen you (or those paying on your behalf) have spent a total of $7,400 in out-of-pocket costs within the calendar \nyear, you will move from the Coverage Gap Stage to the Catastrophic Coverage Stage.\nThese payments are not included in your out-of-pocket costs\nYour out-of-pocket costs do not include any of these types of payments:\n\u2022Drugs you buy outside the United States and its territories.\n\u2022Drugs that are not covered by our plan.\n\u2022Drugs you get at an out-of-network pharmacy that do not meet the plan\u2019s requirements for out-of-network \ncoverage.\n\u2022Prescription drugs covered by Part A or Part B.\n\u2022Payments you make toward drugs covered under our additional coverage but not normally covered in a \nMedicare Prescription Drug Plan.\n\u2022Payments you make toward prescription drugs not normally covered in a Medicare Prescription Drug Plan.\n\u2022Payments made by the plan for your brand or generic drugs while in the Coverage Gap. \n\u2022Payments for your drugs that are made by group health plans including employer health plans.\n\u2022Payments for your drugs that are made by certain insurance plans and government-funded health programs \nsuch as TRICARE and the Veterans Affairs.\n\u2022Payments for your drugs made by a third-party with a legal obligation to pay for prescription costs (for example, \nWorkers\u2019 Compensation).", "doc_id": "b2d761a4-a95c-4224-8cf1-ec16720bf831", "embedding": null, "doc_hash": "062aea63641a0dfe43b25163acdd3d2463bd3463998dd6b70b70d50552cd28c5", "extra_info": {"page_label": "110", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2417, "_node_type": "1"}, "relationships": {"1": "1051bc8e-760f-458d-a7c3-8607998f6544"}}, "__type__": "1"}, "fd3f0856-28df-4ba9-ac9a-210687af160f": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 111\nChapter 6. What you pay for your Part D prescription drugs\nReminder: If any other organization such as the ones listed above pays part or all of your out-of-pocket costs for \ndrugs, you are required to tell our plan by calling Customer Care.\nHow can you keep track of your out-of-pocket total?\n\u2022We will help you. The SmartSummary you receive includes the current amount of your out-of-pocket costs. \nWhen this amount reaches $7,400, this report will tell you that you have left the Coverage Gap Stage and \nhave moved on to the Catastrophic Coverage Stage.\n\u2022Make sure we have the information we need. Section 3.2 tells what you can do to help make sure that our \nrecords of what you have spent are complete and up to date.\nSECTION 2 What you pay for a drug depends on which \"drug payment  \nstage\" you are in when you get the drug\nSection 2.1 What are the drug payment stages for Humana Gold Plus H0028-014  \n(HMO) members?\nThere are four \u201cdrug payment stages\u201d for your prescription drug coverage under Humana Gold Plus H0028-014  \n(HMO). How much you pay depends on what stage you are in when you get a prescription filled or refilled. Details of  \neach stage are in Sections 4 through 7 of this chapter. The stages are:\nStage 1: Yearly Deductible Stage\nStage 2: Initial Coverage Stage\nStage 3: Coverage Gap Stage\nStage 4: Catastrophic Coverage Stage\nImportant Message About What You Pay for Insulin - You won\u2019t pay more than $35 for a one-month (up to  \n30-day) supply of each Part D insulin product covered by our plan, no matter what cost-sharing tier it\u2019s on. This  \napplies to all Part D covered insulins, including the Select Insulins covered under the Insulin Savings Program as  \ndescribed below. If you receive \u201cExtra Help\u201d, you will still pay no more than $35 for a one-month supply for each  \nPart D covered insulin. Please see your Prescription Drug Guide to find all Part D insulins covered by your plan.\nSECTION 3 We send you reports that explain payments for your drugs and  \nwhich payment stage you are in\nSection 3.1 We send you a monthly summary called the SmartSummary\nOur plan keeps track of the costs of your prescription drugs and the payments you have made when you get your \nprescriptions filled or refilled at the pharmacy. This way, we can tell you when you have moved from one drug \npayment stage to the next. In particular, there are two types of costs we keep track of:", "doc_id": "fd3f0856-28df-4ba9-ac9a-210687af160f", "embedding": null, "doc_hash": "2d4599c3e72bd23b494e35ee55dad47b190c013bf3574c3b9079184654636c86", "extra_info": {"page_label": "111", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2464, "_node_type": "1"}, "relationships": {"1": "3716dcb5-ef79-418e-9cef-fc42d6698941"}}, "__type__": "1"}, "484ac50d-ff47-4260-b14f-2717093fafcb": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 112\nChapter 6. What you pay for your Part D prescription drugs\n\u2022We keep track of how much you have paid. This is called your \"out-of-pocket\" cost.\n\u2022We keep track of your \"total drug costs.\" This is the amount you pay out-of-pocket, or others pay on your \nbehalf plus the amount paid by the plan.\nIf you have had one or more prescriptions filled through the plan during the previous month, we will send you a \nSmartSummary. The SmartSummary includes:\n\u2022Information for that month. This report gives the payment details about the prescriptions you have filled \nduring the previous month. It shows the total drug costs, what the plan paid, and what you and others on \nyour behalf paid.\n\u2022Totals for the year since January 1. This is called \"year-to-date\" information. It shows the total drug costs \nand total payments for your drugs since the year began.\n\u2022Drug price information. This information will display the total drug price, and information about increases in \nprice from first fill for each prescription claim of the same quantity.\n\u2022Available lower cost alternative prescriptions. This will include information about other available drugs \nwith lower cost sharing for each prescription claim.\nSection 3.2 Help us keep our information about your drug payments up to date\nTo keep track of your drug costs and the payments you make for drugs, we use records we get from pharmacies. \nHere is how you can help us keep your information correct and up to date:\n\u2022Show your membership card every time you get a prescription filled. This helps us make sure we know \nabout the prescriptions you are filling and what you are paying.\n\u2022Make sure we have the information we need. There are times you may pay for the entire cost of a \nprescription drug. In these cases, we will not automatically get the information we need to keep track of your \nout-of-pocket costs. To help us keep track of your out-of-pocket costs, give us copies of your receipts. Here \nare examples of when you should give us copies of your drug receipts:\n\u2013When you purchase a covered drug at a network pharmacy at a special price or using a discount card that \nis not part of our plan's benefit.\n\u2013When you made a copayment for drugs that are provided under a drug manufacturer patient assistance \nprogram.\n\u2013Any time you have purchased covered drugs at out-of-network pharmacies or other times you have paid \nthe full price for a covered drug under special circumstances.\n\u2013If you are billed for a covered drug, you can ask our plan to pay our share of the cost. For instructions on \nhow to do this, go to Chapter 7, Section 2.\n\u2022Send us information about the payments others have made for you. Payments made by certain other \nindividuals and organizations also count toward your out-of-pocket costs. For example, payments made by a \nState Pharmaceutical Assistance Program, an AIDS drug assistance program (ADAP), the Indian Health \nService, and most charities count toward your out-of-pocket costs. Keep a record of these payments and \nsend them to us so we can track your costs.", "doc_id": "484ac50d-ff47-4260-b14f-2717093fafcb", "embedding": null, "doc_hash": "4d94f46a35ce4d397c968cdb17e91cb0e5339d01d618c52d6996099119937235", "extra_info": {"page_label": "112", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3101, "_node_type": "1"}, "relationships": {"1": "a9ad9932-f173-42bf-a2a0-274329934761"}}, "__type__": "1"}, "ab95a1b6-f6a2-43ab-ad33-dbb78c6c0d04": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 113\nChapter 6. What you pay for your Part D prescription drugs\n\u2022Check the written report we send you. When you receive the SmartSummary look it over to be sure the \ninformation is complete and correct. If you think something is missing or you have any questions, please call \nus at Customer Care. Be sure to keep these reports.\nSECTION 4 There is no deductible for Humana Gold Plus H0028-014 (HMO)\nThere is no deductible for Humana Gold Plus H0028-014 (HMO). You begin in the Initial Coverage Stage when you \nfill your first prescription of the year. See Section 5 for information about your coverage in the Initial Coverage \nStage.\nSECTION 5 During the Initial Coverage Stage, the plan pays its share of your  \ndrug costs and you pay your share\nSection 5.1 What you pay for a drug depends on the drug and where you fill your  \nprescription\nDuring the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription drugs, and you \npay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug \nand where you fill your prescription.\nThe plan has five cost-sharing tiers\nEvery drug in the plan's Drug Guide is in one of five cost-sharing tiers. In general, the higher the cost-sharing tier \nnumber, the higher your cost for the drug:\n\u2022Cost-Sharing Tier 1 \u2013 Preferred Generic: Generic or brand drugs that are available at the lowest cost-share \nfor this plan.\n\u2022Cost-Sharing Tier 2 \u2013 Generic: Generic or brand drugs that the plan offers at a higher cost to you than Tier 1 \nPreferred Generic drugs.\n\u2022Cost-Sharing Tier 3 \u2013 Preferred Brand: Generic or brand drugs that the plan offers at a lower cost to you \nthan Tier 4 Non-Preferred Drug drugs.\n\u2022Cost-Sharing Tier 4 \u2013 Non-Preferred Drug: Generic or brand drugs that the plan offers at a higher cost to \nyou than Tier 3 Preferred Brand drugs.\n\u2022Cost-Sharing Tier 5 \u2013 Specialty Tier: Some injectables and other high-cost drugs.\nTo find out which cost-sharing tier your drug is in, look it up in the plan's Drug Guide.\nYour pharmacy choices\nHow much you pay for a drug depends on whether you get the drug from:\n\u2022A network retail pharmacy that offers standard cost sharing. ", "doc_id": "ab95a1b6-f6a2-43ab-ad33-dbb78c6c0d04", "embedding": null, "doc_hash": "643e3c79702f3c4bf59b0161cb17cc64186537bd6128766943c71f85e3aae77c", "extra_info": {"page_label": "113", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2252, "_node_type": "1"}, "relationships": {"1": "23b4b4d3-c20a-4125-aaa3-3001c1391991"}}, "__type__": "1"}, "da9de516-30a6-40d7-bbf1-252182cc593d": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 114\nChapter 6. What you pay for your Part D prescription drugs\n\u2022A pharmacy that is not in the plan's network. We cover prescriptions filled at out-of-network pharmacies in \nonly limited situations. Please see Chapter 5, Section 2.5 to find out when we will cover a prescription filled at \nan out-of-network pharmacy.\n\u2022The plan's mail-order pharmacy\nFor more information about these pharmacy choices and filling your prescriptions, see Chapter 5 and the plan's \nProvider Directory.\nSection 5.2 A table that shows your costs for a one-month supply of a drug\nDuring the Initial Coverage Stage, your share of the cost of a covered drug will be either a copayment or \ncoinsurance.\nAs shown in the table below, the amount of the copayment or coinsurance depends on the cost-sharing tier.\nSometimes the cost of the drug is lower than your copayment. In these cases, you pay the lower price for the drug \ninstead of the copayment.\nYour share of the cost when you get a one-month supply of a covered Part D prescription drug:\nTierRetail cost  \nsharing  \n(in-network) \n(up to a 30-day  \nsupply)Standard  \nmail-order  \ncost sharing  \n(in-network) \n(up to a 30-day  \nsupply)Preferred  \nmail-order cost  \nsharing  \n(in-network) \n(up to a 30-day  \nsupply)Long-term care  \n(LTC) cost  \nsharing  \n(in-network) \n(up to a 31-day  \nsupply)*Out-of-  \nnetwork cost  \nsharing  \n(Coverage is  \nlimited to  \ncertain  \nsituations; see  \nChapter 5 for  \ndetails.) (up to a  \n30-day supply)\nCost-Sharing  \nTier 1\nPreferred  \nGeneric$0 $10 $0 $0 $0\nCost-Sharing  \nTier 2 \nGeneric$0 $20 $0 $0 $0\nCost-Sharing  \nTier 3\nPreferred  \nBrand$47 $47 $47 $47 $47\nCost-Sharing  \nTier 3 \nInsulin Savings  \nProgram Select  \nInsulins$35 $35 $35 $35 $35\nN/A", "doc_id": "da9de516-30a6-40d7-bbf1-252182cc593d", "embedding": null, "doc_hash": "85845f6c66ed14db18ef5ba49213448aa4a8ecdb6ae62c9671192198774bf643", "extra_info": {"page_label": "114", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1778, "_node_type": "1"}, "relationships": {"1": "36983539-293c-4fb5-ba1c-498c660d378c"}}, "__type__": "1"}, "8f1eb2f7-4888-46a0-b529-4a7eb3d5fa25": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 115\nChapter 6. What you pay for your Part D prescription drugs\nTierRetail cost  \nsharing  \n(in-network) \n(up to a 30-day  \nsupply)Standard  \nmail-order  \ncost sharing  \n(in-network) \n(up to a 30-day  \nsupply)Preferred  \nmail-order cost  \nsharing  \n(in-network) \n(up to a 30-day  \nsupply)Long-term care  \n(LTC) cost  \nsharing  \n(in-network) \n(up to a 31-day  \nsupply)*Out-of-  \nnetwork cost  \nsharing  \n(Coverage is  \nlimited to  \ncertain  \nsituations; see  \nChapter 5 for  \ndetails.) (up to a  \n30-day supply)\nCost-Sharing  \nTier 4\nNon-Preferred  \nDrug$99 $100 $99 $99 $99\nCost-Sharing  \nTier 5\nSpecialty Tier33% 33% 33% 33% 33%\n* You pay the in-network cost-share plus the difference between the in-network cost and the out-of-network cost  \nfor covered prescription drugs received from a non-network pharmacy.\nN/A\nOur plan covers most Part D vaccines at no cost to you. Call Customer Care for more information. \nIn addition to the cost sharing listed above for your Part D prescription drugs, the table below tells you what you  \nwill pay for a one-month (up to a 30-day) supply of Part D covered insulin while in the Initial Coverage Stage.\nTierRetail cost  \nsharing  \n(in-network) (up  \nto a 30-day  \nsupply)Standard  \nmail-order cost  \nsharing  \n(in-network) (up  \nto a 30-day  \nsupply)Preferred  \nmail-order cost  \nsharing  \n(in-network) (up  \nto a 30-day  \nsupply)Long-term care  \n(LTC) cost  \nsharing  \n(in-network) (up  \nto a 31-day  \nsupply)Out-of-network  \ncost sharing  \n(Coverage is  \nlimited to  \ncertain  \nsituations; see  \nChapter 5 for  \ndetails.) (up to a  \n30-day supply)\nCost-Sharing  \nTier 5 Insulin33% up to $35 33% up to $35 33% up to $35 33% up to $35 33% up to $35\nN/A\nSection 5.3 If your doctor prescribes less than a full month's supply, you may not have  \nto pay the cost of the entire month's supply\nTypically, the amount you pay for a prescription drug covers a full month\u2019s supply. There may be times when you or \nyour doctor would like you to have less than a month\u2019s supply of a drug (for example, when you are trying a \nmedication for the first time). You can also ask your doctor to prescribe, and your pharmacist to dispense, less than \na full month\u2019s supply of your drugs, if this will help you better plan refill dates for different prescriptions. \nIf you receive less than a full month\u2019s supply of certain drugs, you will not have to pay for the full month\u2019s supply.", "doc_id": "8f1eb2f7-4888-46a0-b529-4a7eb3d5fa25", "embedding": null, "doc_hash": "312a6909684f9883519f4e67fdee37e3b804982af520339ade9a1c7c1722dd1a", "extra_info": {"page_label": "115", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2468, "_node_type": "1"}, "relationships": {"1": "4e41c544-0e85-4158-9a71-03caf334c5d1"}}, "__type__": "1"}, "31cc5e95-0380-4683-83e0-de0839d844ce": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 116\nChapter 6. What you pay for your Part D prescription drugs\n\u2022If you are responsible for coinsurance, you pay a percentage of the total cost of the drug. Since the \ncoinsurance is based on the total cost of the drug, your cost will be lower since the total cost for the drug will \nbe lower.\n\u2022If you are responsible for a copayment for the drug, you will only pay for the number of days of the drug that \nyou receive instead of the whole month. We will calculate the amount you pay per day for your drug (the \n\u201cdaily cost-sharing rate\u201d) and multiply it by the number of days of the drug you receive.\nSection 5.4 A table that shows your costs for a long-term (up to a 90-day) supply of a  \ndrug\nFor some drugs, you can get a long-term supply (also called an \"extended supply\"). A long-term supply is up to a \n90-day supply.\nSpecialty drugs or other drugs deemed ineligible by the plan do not qualify for an extended supply. Please see your \nPrescription Drug Guide to find out what drugs are restricted. \nThe table below shows what you pay when you get a long-term supply of a drug.\n\u2022Sometimes the cost of the drug is lower than your copayment. In these cases, you pay the lower price for the \ndrug instead of the copayment.\nYour share of the cost when you get a long-term supply of a covered Part D prescription drug:\nTierRetail cost sharing  \n(in-network) \n(up to a 90-day supply)Standard mail-order cost  \nsharing (in-network) \n(up to a 90-day supply)Preferred mail-order cost  \nsharing (in-network) \n(up to a 90-day supply)\nCost-Sharing Tier 1\nPreferred Generic$0 $30 $0\nCost-Sharing Tier 2 \nGeneric$0 $60 $0\nCost-Sharing Tier 3\nPreferred Brand$141 $141 $131\nCost-Sharing Tier 3 \nInsulin Savings  \nProgram Select  \nInsulins$105 $105 $95\nCost-Sharing Tier 4\nNon-Preferred Drug$297 $300 $287\nCost-Sharing Tier 5 \nSpecialty TierA long-term supply is not available for drugs in Tier 5\nN/A", "doc_id": "31cc5e95-0380-4683-83e0-de0839d844ce", "embedding": null, "doc_hash": "948722028d03ba49860b5c2f75b28d85ca85f1cdfc3396bd0b1ee707899f9022", "extra_info": {"page_label": "116", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1951, "_node_type": "1"}, "relationships": {"1": "0fbb0971-ca86-4553-99fd-24290ea96b73"}}, "__type__": "1"}, "62ac95de-0c07-49a1-948b-c7830e94a273": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 117\nChapter 6. What you pay for your Part D prescription drugs\nSection 5.5 You stay in the Initial Coverage Stage until your total drug costs for the  \nyear reach $4,660\nYou stay in the Initial Coverage Stage until the total amount for the prescription drugs you have filled reaches the \n$4,660 limit for the Initial Coverage Stage.\nWe offer additional coverage on some prescription drugs that are not normally covered in a Medicare Prescription \nDrug Plan. Payments made for these drugs will not count towards your initial coverage limit or total out-of-pocket \ncosts.\nThe SmartSummary that you receive will help you keep track of how much you, the plan, and any third parties, have \nspent on your behalf during the year. Many people do not reach the $4,660 limit in a year. \nWe will let you know if you reach this amount. If you do reach this amount, you will leave the Initial Coverage \nStage and move on to the Coverage Gap Stage. See Section 1.3 on how Medicare calculates your out-of-pocket \ncosts.\nSECTION 6 Cost in the Coverage Gap Stage\nOur plan provides additional coverage after you leave the Initial Coverage Stage (described above) and enter the \nMedicare Coverage Gap Stage. The table below shows the drugs that are covered and your costs for a one-month \nsupply.\nFor brand name drugs covered during your Coverage Gap Stage, you can get discounts from the drug makers \nthrough the Coverage Gap Discount Program. Through the program, you pay no more than 25% of the plan price \nfor brand name drugs. You may also have to pay some additional charges, such as dispensing or vaccine fees. The \nfull plan fee (both the amount you pay and the discounted amount) count toward your total out-of-pocket-costs, \nwhich helps move you through the Coverage Gap Stage.\nYou also receive some coverage for generic drugs in the Coverage Gap. You pay no more than 25% of the cost for \ngeneric drugs and the plan pays the rest. For generic drugs, the amount paid by the plan (75%) does not count \ntoward your out-of-pocket costs. Only the amount you pay counts and moves you through the coverage gap.\nIf your out-of-pocket total reaches $7,400, you'll enter the Catastrophic Coverage Stage, where your plan will pay \nmost of the cost of your drugs for the rest of the year.\nMedicare has rules about what counts and what does not count as your out-of-pocket costs (Section 1.3).\nThe table below shows what you pay when you get a one-month supply (or less) of a drug.", "doc_id": "62ac95de-0c07-49a1-948b-c7830e94a273", "embedding": null, "doc_hash": "f54e510ad36ae550e4dc164991b9588f629f6064f64aed1f86f7a0553b15f4dc", "extra_info": {"page_label": "117", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2523, "_node_type": "1"}, "relationships": {"1": "5ac865b7-d61c-40e1-a8bd-193b81176674"}}, "__type__": "1"}, "0d57ff7b-7339-4911-841a-8bf0148067f4": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 118\nChapter 6. What you pay for your Part D prescription drugs\nTierRetail cost  \nsharing  \n(in-network) \n(up to a 30-day  \nsupply)Standard  \nmail-order cost  \nsharing  \n(in-network) \n(up to a 30-day  \nsupply)Preferred  \nmail-order cost  \nsharing  \n(in-network) \n(up to a 30-day  \nsupply)Long-term care  \n(LTC) cost  \nsharing  \n(in-network) \n(up to a 31-day  \nsupply)*Out-of-  \nnetwork cost  \nsharing \n(Coverage is  \nlimited to  \ncertain  \nsituations; see  \nChapter 5 for  \ndetails.) (up to a  \n30-day supply)\nCost-Sharing Tier 1\nPreferred  \nGeneric$0 $10 $0 $0 $0\nCost-Sharing Tier 2\nGeneric $0 $20 $0 $0 $0\nCost-Sharing Tier 3\nAll Other   \nPreferred  \nBrand Drugs25% 25% 25% 25% 25%\nInsulin  \nSavings  \nProgram  \nSelect Insulins$35 $35 $35 $35 $35\nCost-Sharing Tier 4\nNon-Preferred  \nDrug25% 25% 25% 25% 25%\nCost-Sharing Tier 5\nSpecialty Tier 25% 25% 25% 25% 25%\n* You pay the in-network cost-share plus the difference between the in-network cost and the out-of-network cost  \nfor covered prescription drugs received from a non-network pharmacy.\nN/A\nOur plan covers most Part D vaccines at no cost to you. Call Customer Care for more information. \nIn addition to the cost sharing listed above for your Part D prescription drugs,  the table below tells you what you  \nwill pay for a one-month (up to 30-day) supply of Part D covered insulin while in the Coverage Gap Stage.", "doc_id": "0d57ff7b-7339-4911-841a-8bf0148067f4", "embedding": null, "doc_hash": "aece1f405ccae134d4493a1c4e3d9aa3feb9d416485416c990a881395cae3f52", "extra_info": {"page_label": "118", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1436, "_node_type": "1"}, "relationships": {"1": "bc5e2b1f-acd1-4d64-8129-5adf07008f1a"}}, "__type__": "1"}, "f42c6431-d698-48a9-82f2-b6c69ca42235": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 119\nChapter 6. What you pay for your Part D prescription drugs\nTierRetail cost  \nsharing  \n(in-network) (up  \nto a 30-day  \nsupply)Standard  \nmail-order cost  \nsharing  \n(in-network) (up  \nto a 30-day  \nsupply)Preferred \nmail-order cost  \nsharing  \n(in-network) (up  \nto a 30-day  \nsupply)Long-term care  \n(LTC) cost  \nsharing  \n(in-network) (up  \nto a 31-day  \nsupply)Out-of-network  \ncost sharing  \n(Coverage is  \nlimited to  \ncertain  \nsituations; see  \nChapter 5 for  \ndetails.) (up to a  \n30-day supply)\nCost-Sharing  \nTier 5 Insulin25% up to $35 25% up to $35 25% up to $35 25% up to $35 25% up to $35\nN/A\nThe table below shows what you pay when you get a long-term (up to a 90-day) supply of a drug.\nTierRetail cost sharing  \n(in-network) \n(up to a 90-day supply)Standard mail-order cost  \nsharing (in-network) \n(up to a 90-day supply)Preferred mail-order cost  \nsharing (in-network) \n(up to a 90-day supply)\nCost-Sharing Tier 1\nPreferred Generic $0 $30 $0\nCost-Sharing Tier 2\nGeneric $0 $60 $0\nCost-Sharing Tier 3\nAll Other Preferred  \nBrand Drugs25% 25% 25%\nInsulin Savings  \nProgram Select  \nInsulins$105 $105 $95\nCost-Sharing Tier 4\nNon-Preferred Drug 25% 25% 25%\nCost-Sharing Tier 5\nSpecialty Tier A long-term supply is not available for drugs in Tier 5\nN/A\nHumana Gold Plus H0028-014 (HMO) offers additional gap coverage for Select Insulins as part of the Insulin  \nSavings Program. During the Coverage Gap stage, your out-of-pocket costs for Select Insulins will be $35 for a  \none-month (up to a 30-day) supply. To find out which drugs are Select Insulins, review the most recent Drug Guide  \nwe provided electronically. You can identify Select Insulins by the \"ISP\" indicator in the Drug Guide. If you have  \nquestions about the Drug Guide, you can also call Customer Care (Phone numbers for Customer Care are printed on  \nthe back cover of this booklet).\nYour plan also provides enhanced insulin coverage which means you will pay no more than $35 for a one-month  \n(up to 30-day) supply for all Part D insulins covered by our plan, including select insulins, no matter what  \ncost-sharing tier it\u2019s on. The enhanced insulin coverage is available, even if you receive \u201cExtra Help\u201d. ", "doc_id": "f42c6431-d698-48a9-82f2-b6c69ca42235", "embedding": null, "doc_hash": "26b367ca32f2bcaa0823e15b37252bf1671de800e85bf8ed96694e51a5f3a4aa", "extra_info": {"page_label": "119", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2261, "_node_type": "1"}, "relationships": {"1": "e5acc09e-b152-4060-9ac6-7b1db967cca3"}}, "__type__": "1"}, "5dc98b08-ceae-479b-8827-f1abc460c90f": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 120\nChapter 6. What you pay for your Part D prescription drugs\nSECTION 7 During the Catastrophic Coverage Stage, the plan pays most of  \nthe cost for your drugs\nYou enter the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $7,400 limit for the \ncalendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of \nthe calendar year.\nDuring this stage, the plan will pay most of the cost for your drugs. You will pay:\n\u2022Your share of the cost for a covered drug will be either coinsurance or a copayment, whichever is the larger \namount:\n\u2013\u2013either \u2013 coinsurance of 5% of the cost of the drug\n\u2013\u2013or \u2013 $4.15 copayment for a generic drug or a drug that is treated like a generic and $10.35 copayment for \nall other drugs.\nOur plan covers most Part D vaccines at no cost to you. Call Customer Care for more information. \nYou won\u2019t pay more than $35 for a one-month (up to 30-day) supply of each Part D insulin product covered by our \nplan, no matter what cost-sharing tier it\u2019s on. \nYour Anti-Obesity Medication and Erectile Dysfunction drugs costs will be based on your cost-shares in the Initial \nCoverage Stage. \nSECTION 8 Additional benefits information\nOur plan offers additional benefits for the following:\n\u2022Select Erectile Dysfunction drugs are covered at Tier 1 cost-share based on location\n\u2022Select Anti-Obesity drugs are covered at Tier 2 cost-share based on location\nPlease refer to your Prescription Drug Guide for information about coverage of additional prescription drugs or call \nCustomer Care if you have any questions. Dispensing limits may apply.\nSECTION 9 Part D Vaccines. What you pay for depends on how and where  \nyou get them\nImportant Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. \nCall Customer Care for more information. \nThere are two parts to our coverage of Part D vaccinations:\n\u2022The first part of coverage is the cost of the vaccine itself. \n\u2022The second part of coverage is for the cost of giving you the vaccine. (This is sometimes called the \n\"administration\" of the vaccine.)", "doc_id": "5dc98b08-ceae-479b-8827-f1abc460c90f", "embedding": null, "doc_hash": "3431c30e39503690985cf8d0586b697308d5182b0abcb95922f0445b05532d0c", "extra_info": {"page_label": "120", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2191, "_node_type": "1"}, "relationships": {"1": "050dc063-032a-4c64-a2af-45edc8873841"}}, "__type__": "1"}, "a878079b-f288-422a-874c-7dbea044a803": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 121\nChapter 6. What you pay for your Part D prescription drugs\nYour costs for a Part D vaccination depend on three things:\n1. The type of vaccine (what you are being vaccinated for).\n\u2022Some vaccines are considered medical benefits. (See the Medical Benefits Chart, (what is covered and what \nyou pay) in Chapter 4.)\n\u2022Other vaccines are considered Part D drugs. You can find these vaccines listed in the plan's Drug Guide \n(Formulary).\n2. Where you get the vaccine.\n\u2022The vaccine itself may be dispensed by a pharmacy or provided by the doctor\u2019s office.\n3. Who gives you the vaccine.\n\u2022A pharmacist may give you the vaccine in the pharmacy, or another provider may give it in the doctor\u2019s \noffice.\nWhat you pay at the time you get the Part D vaccination can vary depending on the circumstances and what Drug \nStage you are in.\n\u2022Sometimes when you get a vaccination, you have to pay for the entire cost for both the vaccine itself and the \ncost for the provider to give you the vaccine. You can ask our plan to pay you back for our share of the cost.\n\u2022Other times, when you get the vaccination, you will pay only your share of the cost under your Part D benefit.\nBelow are three examples of ways you might get a Part D vaccine.\nYou get your vaccination at the network pharmacy. (Whether you have this choice depends on \nwhere you live. Some states do not allow pharmacies to give vaccines.)\n\u2022You will pay the pharmacy your coinsurance or copayment for the vaccine itself which \nincludes the cost of giving you the vaccine.\n\u2022Our plan will pay the remainder of the costs.Situation 1:\nYou get the Part D vaccination at your doctor's office.\n\u2022When you get the vaccine, you will pay for the entire cost of the vaccine itself and the cost \nfor the provider to give it to you.\n\u2022You can then ask our plan to pay our share of the cost by using the procedures that are \ndescribed in Chapter 7.\n\u2022You will be reimbursed the amount you paid less your normal coinsurance or copayment for \nthe vaccine (including administration) less any difference between the amount the doctor \ncharges and what we normally pay. (If you get \"Extra Help,\" we will reimburse you for this \ndifference.)Situation 2:\nYou buy the Part D vaccine itself at your pharmacy, and then take it to your doctor's office where \nthey give you the vaccine.\n\u2022You will have to pay the pharmacy your coinsurance or copayment for the vaccine itself.Situation 3:", "doc_id": "a878079b-f288-422a-874c-7dbea044a803", "embedding": null, "doc_hash": "39a6c3855e1e137bfa3cbac8dbafc6ee864a09c1739063d9f7cccc1b94e0a182", "extra_info": {"page_label": "121", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2467, "_node_type": "1"}, "relationships": {"1": "6f4e2028-596c-4f3a-9e3e-2554cd28a671"}}, "__type__": "1"}, "3aebffd5-5f9b-4f75-9c1b-fe6cf474a26e": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 122\nChapter 6. What you pay for your Part D prescription drugs\n\u2022When your doctor gives you the vaccine, you will pay the entire cost for this service. You can \nthen ask our plan to pay our share of the cost by using the procedures described in Chapter \n7.\n\u2022You will be reimbursed the amount charged by the doctor for administering the vaccine less \nany difference between the amount the doctor charges and what we normally pay. (If you \nget \"Extra Help,\" we will reimburse you for this difference.)", "doc_id": "3aebffd5-5f9b-4f75-9c1b-fe6cf474a26e", "embedding": null, "doc_hash": "55a95c1a8d5290d4149f6f6e134f494e550eff6db3039ac3eaf19f379ca23a89", "extra_info": {"page_label": "122", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 561, "_node_type": "1"}, "relationships": {"1": "225e94cf-350e-405a-b3e2-61df0ec86773"}}, "__type__": "1"}, "f1622148-d0dc-4719-a93b-03b6c14603ff": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 123\nChapter 7 Asking us to pay our share of a bill you have received for covered medical services or drugsEOC082\nCHAPTER 7: \nAsking us to pay our share of a bill  \nyou have received for covered  \nmedical services or drugs", "doc_id": "f1622148-d0dc-4719-a93b-03b6c14603ff", "embedding": null, "doc_hash": "a9d67eb09a5ed9bb072fbcb4c02813f15fd04fca39e6b89c22c3c5d7b0f47c56", "extra_info": {"page_label": "123", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 284, "_node_type": "1"}, "relationships": {"1": "6d6c2bfa-f8d2-45aa-bf85-01619cc04fc9"}}, "__type__": "1"}, "ec3fb8c8-6feb-4e67-8b96-c3df4f051896": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 124\nChapter 7 Asking us to pay our share of a bill you have received for covered medical services or drugs\nSECTION 1 Situations in which you should ask us to pay our share of the  \ncost of your covered services or drugs\nSometimes when you get medical care or a prescription drug, you may need to pay the full cost. Other times, you \nmay find that you have paid more than you expected under the coverage rules of the plan. In these cases, you can \nask our plan to pay you back (paying you back is often called \"reimbursing\" you). It is your right to be paid back by \nour plan whenever you've paid more than your share of the cost for medical services or drugs that are covered by \nour plan. There may be deadlines that you must meet to get paid back. Please see Section 2 of this chapter.\nThere may also be times when you get a bill from a provider for the full cost of medical care you have received or \npossibly for more than your share of cost sharing as discussed in the document. First try to resolve the bill with the \nprovider. If that does not work, send the bill to us instead of paying it. We will look at the bill and decide whether \nthe services should be covered. If we decide they should be covered, we will pay the provider directly. If we decide \nnot to pay it, we will notify the provider. You should never pay more than plan-allowed cost sharing. If this provider \nis contracted, you still have the right to treatment.\nHere are examples of situations in which you may need to ask our plan to pay you back or to pay a bill you have \nreceived:\n1. When you've received emergency or urgently needed medical care from a provider who is not in our \nplan's network\nYou can receive emergency or urgently needed services from any provider, whether or not the provider is a part \nof our network. In these cases, \n\u2022You are only responsible for paying your share of the cost for emergency or urgently needed services. \nEmergency providers are legally required to provide emergency care. If you accidentally pay the entire \namount yourself at the time you receive the care, you need to ask us to pay you back for our share of the \ncost. Send us the bill, along with documentation of any payments you have made.\n\u2022You may get a bill from the provider asking for payment that you think you do not owe. Send us this bill, \nalong with documentation of any payments you have already made.\n\u2013If the provider is owed anything, we will pay the provider directly.\n\u2013If you have already paid more than your share of the cost of the service, we will determine how much you \nowed and pay you back for our share of the cost.\n2. When a network provider sends you a bill you think you should not pay\nNetwork providers should always bill the plan directly and ask you only for your share of the cost. But \nsometimes they make mistakes, and ask you to pay more than your share.\n\u2022You only have to pay your cost-sharing amount when you get covered services. We do not allow providers to \nadd additional separate charges, called \u201cbalance billing.\u201d This protection (that you never pay more than your \ncost-sharing amount) applies even if we pay the provider less than the provider charges for a service and \neven if there is a dispute and we don\u2019t pay certain provider charges.", "doc_id": "ec3fb8c8-6feb-4e67-8b96-c3df4f051896", "embedding": null, "doc_hash": "2f9d1c3f251a3fd7dd1f0378861d5bb2559959721b4a4c78716b1e317cd65c00", "extra_info": {"page_label": "124", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3320, "_node_type": "1"}, "relationships": {"1": "467a2faa-e226-478e-a1af-a51c2b915c56"}}, "__type__": "1"}, "ba0cbae4-fa99-403b-889d-23e7125a701b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 125\nChapter 7 Asking us to pay our share of a bill you have received for covered medical services or drugs\n\u2022Whenever you get a bill from a network provider that you think is more than you should pay, send us the bill. \nWe will contact the provider directly and resolve the billing problem.\n\u2022If you have already paid a bill to a network provider, but you feel that you paid too much, send us the bill \nalong with documentation of any payment you have made and ask us to pay you back the difference \nbetween the amount you paid and the amount you owed under the plan.\n3. If you are retroactively enrolled in our plan\nSometimes a person's enrollment in the plan is retroactive. (This means that the first day of their enrollment has \nalready passed. The enrollment date may even have occurred last year.)\nIf you were retroactively enrolled in our plan and you paid out-of-pocket for any of your covered services or \ndrugs after your enrollment date, you can ask us to pay you back for our share of the costs. You will need to \nsubmit paperwork such as receipts and bills for us to handle the reimbursement.\n4. When you use an out-of-network pharmacy to get a prescription filled\nIf you go to an out-of-network pharmacy, the pharmacy may not be able to submit the claim directly to us.  \nWhen that happens, you will have to pay the full cost of your prescription.\nSave your receipt and send a copy to us when you ask us to pay you back for our share of the cost. Remember  \nthat we only cover out of network pharmacies in limited circumstances. See Chapter 5, Section 2.5 for a  \ndiscussion of these circumstances.\n5. When you pay the full cost for a prescription because you don't have your plan membership card with you\nIf you do not have your plan membership card with you, you can ask the pharmacy to call the plan or to look up  \nyour plan enrollment information. However, if the pharmacy cannot get the enrollment information they need  \nright away, you may need to pay the full cost of the prescription yourself. \nSave your receipt and send a copy to us when you ask us to pay you back for our share of the cost.\n6. When you pay the full cost for a prescription in other situations\nYou may pay the full cost of the prescription because you find that the drug is not covered for some reason.\n\u2022For example, the drug may not be on the plan's Prescription Drug Guide (Formulary); or it could have a  \nrequirement or restriction that you didn't know about or don't think should apply to you. If you decide to get  \nthe drug immediately, you may need to pay the full cost for it.\n\u2022Save your receipt and send a copy to us when you ask us to pay you back. In some situations, we may need  \nto get more information from your doctor in order to pay you back for our share of the cost.\nAll of the examples above are types of coverage decisions. This means that if we deny your request for payment, \nyou can appeal our decision. Chapter 9 of this document has information about how to make an appeal.", "doc_id": "ba0cbae4-fa99-403b-889d-23e7125a701b", "embedding": null, "doc_hash": "e8752fd7bf14f428903a93fb8939cda7dc61954829387df007c3de62e8a7cfd3", "extra_info": {"page_label": "125", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3054, "_node_type": "1"}, "relationships": {"1": "9295b091-d5ea-4707-90d4-5ee7c350b671"}}, "__type__": "1"}, "2259b1f7-ee78-4467-ad1e-59d7afe9f521": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 126\nChapter 7 Asking us to pay our share of a bill you have received for covered medical services or drugs\nSECTION 2 How to ask us to pay you back or to pay a bill you have received\nYou may request us to pay you back by sending us a request in writing. If you send a request in writing, send your \nbill and documentation of any payment you have made. It\u2019s a good idea to make a copy of your bill and receipts \nfor your records.\nMail your request for payment together with any bills or paid receipts to us at this address:\nRequests for payment for Medical Services:\nHumana, P.O. Box 14601, Lexington, KY 40512-4601\nYou must submit your Part C (medical) claim to us within 12 months of the date you received the service, item, \nor Part B drug.\nRequests for payment for Part D drugs: \nHumana \nP.O. Box 14140 \nLexington, KY 40512-4140\nYou must submit your Part D (prescription drug) claim to us within 36 months of the date you received the \ndrug.\nSECTION 3 We will consider your request for payment and say yes or no\nSection 3.1 We check to see whether we should cover the service or drug and how  \nmuch we owe\nWhen we receive your request for payment, we will let you know if we need any additional information from you. \nOtherwise, we will consider your request and make a coverage decision.\n\u2022If we decide that the medical care or drug is covered and you followed all the rules, we will pay for our share \nof the cost. If you have already paid for the service or drug, we will mail your reimbursement of our share of \nthe cost to you. If you have not paid for the service or drug yet, we will mail the payment directly to the \nprovider.\n\u2022If we decide that the medical care or drug is not covered, or you did not follow all the rules, we will not pay for \nour share of the cost. We will send you a letter explaining the reasons why we are not sending the payment \nand your right to appeal that decision.\nSection 3.2 If we tell you that we will not pay for all or part of the medical care or  \ndrug, you can make an appeal\nIf you think we have made a mistake in turning down your request for payment or the amount we are paying, you \ncan make an appeal. If you make an appeal, it means you are asking us to change the decision we made when we \nturned down your request for payment. The appeals process is a formal process with detailed procedures and \nimportant deadlines. For the details on how to make this appeal, go to Chapter 9 of this document.", "doc_id": "2259b1f7-ee78-4467-ad1e-59d7afe9f521", "embedding": null, "doc_hash": "d5e54c511b6496ac0e6627965b720da59850cefea8a36e1dd261918273520cf7", "extra_info": {"page_label": "126", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2510, "_node_type": "1"}, "relationships": {"1": "ffaf2043-50a9-4108-892e-686ccc034040"}}, "__type__": "1"}, "8ac91f58-2f65-4ef0-a3be-57b8f184922a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 127\nChapter 8. Your rights and responsibilitiesEOC082\nCHAPTER 8:\nYour rights and responsibilities", "doc_id": "8ac91f58-2f65-4ef0-a3be-57b8f184922a", "embedding": null, "doc_hash": "8fbe21defeccdd47a358b59e729b723f569183b474782cd6933d932120189975", "extra_info": {"page_label": "127", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 160, "_node_type": "1"}, "relationships": {"1": "311b2664-abdf-4d5a-8a5c-bcd3d84dad1b"}}, "__type__": "1"}, "325cd1de-ecc7-40b3-9dba-5576cfecb4c7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 128\nChapter 8. Your rights and responsibilities\nSECTION 1Our plan must honor your rights and cultural sensitivities as a  \nmember of the plan\nSection 1.1 We must provide information in a way that works for you and consistent  \nwith your cultural sensitivities (in languages other than English, in braille,  \nin large print, or other alternate formats, etc.)\nYour plan is required to ensure that all services, both clinical and non-clinical, are provided in a culturally \ncompetent manner and are accessible to all enrollees, including those with limited English proficiency, limited \nreading skills, hearing incapacity, or those with diverse cultural and ethnic backgrounds. Examples of how a plan \nmay meet these accessibility requirements include, but are not limited to: provision of translator services, \ninterpreter services, teletypewriters, or TTY (text telephone or teletypewriter phone) connection.\nOur plan has free interpreter services available to answer questions from non-English speaking members. We can \nalso give you information in braille, in large print, or other alternate formats at no cost if you need it. We are \nrequired to give you information about the plan\u2019s benefits in a format that is accessible and appropriate for you. To \nget information from us in a way that works for you, please call Customer Care .\nOur plan is required to give female enrollees the option of direct access to a women\u2019s health specialist within the \nnetwork for women\u2019s routine and preventive health care services.\nIf providers in the plan\u2019s network for a specialty are not available, it is the plan\u2019s responsibility to locate specialty \nproviders outside the network who will provide you with the necessary care. In this case, you will only pay \nin-network cost sharing. If you find yourself in a situation where there are no specialists in the plan\u2019s network that \ncover a service you need, call the plan for information on where to go to obtain this service at in-network cost \nsharing.\nIf you have any trouble getting information from our plan in a format that is accessible and appropriate for you, \nseeing a women\u2019s health specialists or finding a network specialist, please call to file a grievance with Humana \nGrievances and Appeals Dept. at 1-800-457-4708, TTY 711. You may also file a complaint with Medicare by calling \n1-800-MEDICARE (1-800-633-4227) or directly with the Office for Civil Rights 1-800-368-1019 or TTY \n1-800-537-7697.\nSu plan debe garantizar que todos los servicios, tanto cl\u00ednicos como no cl\u00ednicos, se brinden de manera competente \ndesde el punto de vista cultural y sean accesibles para todos los afiliados, incluidos aquellos con dominio limitado \ndel ingl\u00e9s, habilidades de lectura limitadas, incapacidad auditiva o aquellos con or\u00edgenes culturales y \u00e9tnicos \ndiversos. Algunos ejemplos de c\u00f3mo un plan puede cumplir con estos requisitos de accesibilidad incluyen, entre \notros, la prestaci\u00f3n de servicios de traducci\u00f3n, servicios de interpretaci\u00f3n, telem\u00e1quinas de escribir o conexi\u00f3n TTY \n(tel\u00e9fono de texto o tel\u00e9fono de telem\u00e1quina).\nNuestro plan cuenta con servicios gratuitos de int\u00e9rpretes disponibles para responder preguntas de afiliados que \nno hablan ingl\u00e9s.Tambi\u00e9n podemos darle informaci\u00f3n en braille, en letra grande o en otros formatos alternativos \nsin costo en caso de ser necesario. Se nos exige darle informaci\u00f3n sobre los beneficios del plan en un formato que \nsea accesible y apropiado para usted. Para obtener informaci\u00f3n de", "doc_id": "325cd1de-ecc7-40b3-9dba-5576cfecb4c7", "embedding": null, "doc_hash": "f05c8f74783a993619a6679a6db56519a1675445748d202755742bccee39d7eb", "extra_info": {"page_label": "128", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3546, "_node_type": "1"}, "relationships": {"1": "1aaf53aa-d230-4f36-98df-5dcbf12a7122", "3": "129b86bc-f928-43d3-a81b-ed56094a5fb7"}}, "__type__": "1"}, "129b86bc-f928-43d3-a81b-ed56094a5fb7": {"__data__": {"text": "y apropiado para usted. Para obtener informaci\u00f3n de parte de nosotros de una forma que se ajuste a \nsus necesidades, llame a Atenci\u00f3n al cliente.\nNuestro plan debe brindarles a las mujeres inscritas la opci\u00f3n de acceso directo a un especialista en salud \nfemenina dentro de la red para servicios de cuidado de la salud preventivos y de rutina para mujeres.", "doc_id": "129b86bc-f928-43d3-a81b-ed56094a5fb7", "embedding": null, "doc_hash": "59e2d1be1f6e51e100162fdfa8574d39af7dd699fedf8d5814b77f2c88035e94", "extra_info": {"page_label": "128", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 3495, "end": 3851, "_node_type": "1"}, "relationships": {"1": "1aaf53aa-d230-4f36-98df-5dcbf12a7122", "2": "325cd1de-ecc7-40b3-9dba-5576cfecb4c7"}}, "__type__": "1"}, "44b1842b-bdef-48c4-baa0-4d3ec8d67778": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 129\nChapter 8. Your rights and responsibilities\nSi no hay disponibles proveedores de la red del plan para una especialidad, es responsabilidad del plan localizar \nproveedores especializados fuera de la red que le proporcionen el cuidado necesario. En este caso, solo pagar\u00e1 el \ncosto compartido dentro de la red. Si se encuentra en una situaci\u00f3n en la cual no hay especialistas en la red del \nplan que cubran un servicio que usted necesita, llame al plan para obtener informaci\u00f3n sobre d\u00f3nde ir para \nobtener este servicio al costo compartido dentro de la red.\nSi tiene alguna dificultad para obtener informaci\u00f3n de nuestro plan en un formato que sea accesible y apropiado, \nllame para presentar una queja formal ante el Departamento de quejas formales y apelaciones de Humana al \n1-800-457-4708, TTY 711. Tambi\u00e9n puede presentar una queja ante Medicare llamando al 1-800-MEDICARE \n(1-800-633-4227) o directamente ante la Oficina de Derechos Civiles. al 1-800-368-1019 o TTY 1-800-537-7697.\nSection 1.2 We must ensure that you get timely access to your covered services and  \ndrugs\nYou have the right to choose a primary care provider (PCP) in the plan's network to provide and arrange for your \ncovered services. We do not require you to get referrals to go to network providers. \nYou have the right to get appointments and covered services from the plan's network of providers within a \nreasonable amount of time. This includes the right to get timely services from specialists when you need that care. \nYou also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long \ndelays.\nIf you think that you are not getting your medical care or Part D drugs within a reasonable amount of time, Chapter \n9 tells what you can do.\nSection 1.3 We must protect the privacy of your personal health information\nFederal and state laws protect the privacy of your medical records and personal health information. We protect \nyour personal health information as required by these laws.\n\u2022Your \"personal health information\" includes the personal information you gave us when you enrolled in this \nplan as well as your medical records and other medical and health information.\n\u2022You have rights related to your information and controlling how your health information is used. We give you a \nwritten notice, called a \"Notice of Privacy Practice,\" that tells about these rights and explains how we protect the \nprivacy of your health information.\nHow do we protect the privacy of your health information?\n\u2022We make sure that unauthorized people don't see or change your records.\n\u2022Except for the circumstances noted below, if we intend to give your health information to anyone who isn\u2019t \nproviding your care or paying for your care, we are required to get written permission from you or someone you \nhave given legal power to make decisions for you first.\n\u2022There are certain exceptions that do not require us to get your written permission first. These exceptions are \nallowed or required by law.\n\u2013We are required to release health information to government agencies that are checking on quality of care.", "doc_id": "44b1842b-bdef-48c4-baa0-4d3ec8d67778", "embedding": null, "doc_hash": "d59be6ea103910ebe948331f307cb42510b8e20e112954e5624da817d31f8d17", "extra_info": {"page_label": "129", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3194, "_node_type": "1"}, "relationships": {"1": "186aae32-e1a3-40db-b9a8-1a5546a1c5d6"}}, "__type__": "1"}, "8556cc11-140c-4e2c-8597-8d0b17924cef": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 130\nChapter 8. Your rights and responsibilities\n\u2013Because you are a member of our plan through Medicare, we are required to give Medicare your health \ninformation including information about your Part D prescription drugs. If Medicare releases your information \nfor research or other uses, this will be done according to Federal statutes and regulations; typically, this \nrequires that information that uniquely identifies you not be shared.\nYou can see the information in your records and know how it has been shared with others\nYou have the right to look at your medical records held by the plan, and to get a copy of your records. We are \nallowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to \nyour medical records. If you ask us to do this, we will work with your health care provider to decide whether the \nchanges should be made.\nYou have the right to know how your health information has been shared with others for any purposes that are not \nroutine.\nIf you have questions or concerns about the privacy of your personal health information, please call Customer \nCare.\nNotice of Privacy Practices\nFor your personal health information\nTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW \nYOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.\nThe privacy of your personal and health information is important. You don't need to do anything unless you have a \nrequest or complaint.\nWe may change our privacy practices and the terms of this notice at any time, as allowed by law. Including \ninformation we created or received before we made the changes. When we make a significant change in our \nprivacy practices, we will change this notice and send the notice to our health plan subscribers.\nWhat is personal and health information?\nPersonal and health information includes both medical information and personal information, like your name, \naddress, telephone number, or Social Security number. The term \u201cinformation\u201d in this notice includes any personal \nand health information. This includes information created or received by a healthcare provider or health plan. The \ninformation relates to your physical or mental health or condition, providing healthcare to you, or the payment for \nsuch healthcare.\nHow do we protect your information?\nWe have a responsibility to protect the privacy of your information in all formats including electronic, written and \noral information. We have safeguards in place to protect your information in various ways including:\n\u2022Limiting who may see your information\n\u2022Limiting how we use or disclose your information\n\u2022Informing you of our legal duties about your information\n\u2022Training our employees about our privacy policies and programs\nHow do we use and disclose your information?\nWe use and disclose your information:\n\u2022To you or someone who has the legal right to act on your behalf\n\u2022To the Secretary of the Department of Health and Human Services\nWe have the right to use and disclose your information:\n\u2022To a doctor, a hospital, or other healthcare provider so you can receive medical care", "doc_id": "8556cc11-140c-4e2c-8597-8d0b17924cef", "embedding": null, "doc_hash": "a02bfe9df4b1ee0947a643590e05a78825fc7b776a230d472172bbd7fd1a1e46", "extra_info": {"page_label": "130", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3209, "_node_type": "1"}, "relationships": {"1": "bbf2c993-92ac-4d0a-a0e3-9abca7772803"}}, "__type__": "1"}, "46073802-2153-4625-8066-84f5759459d9": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 131\nChapter 8. Your rights and responsibilities\n\u2022For payment activities, including claims payment for covered services provided to you by healthcare providers \nand for health plan premium payments\n\u2022For healthcare operation activities. Including processing your enrollment, responding to your inquiries, \ncoordinating your care, improving quality, and determining premiums\n\u2022For performing underwriting activities. However, we will not use any results of genetic testing or ask questions \nregarding family history.\n\u2022To your plan sponsor to permit them to perform, plan administration functions such as eligibility, enrollment \nand disenrollment activities. We may share summary level health information about you with your plan sponsor \nin certain situations. For example, to allow your plan sponsor to obtain bids from other health plans. Your \ndetailed health information will not be shared with your plan sponsor. We will ask your permission or your plan \nsponsor has to certify they agree to maintain the privacy of your information.\n\u2022To contact you with information about health-related benefits and services, appointment reminders, or \ntreatment alternatives that may be of interest to you. If you have opted out as described below, we will not \ncontact you. \n\u2022To your family and friends if you are unavailable to communicate, such as in an emergency. To your family and \nfriends or any other person you identify. This applies if the information is directly relevant to their involvement \nwith your health care or payment for that care. For example, if a family member or a caregiver calls us with prior \nknowledge of a claim, we may confirm if the claim has been received and paid.\n\u2022To provide payment information to the subscriber for Internal Revenue Service substantiation.\n\u2022To public health agencies if we believe that there is a serious health or safety threat.\n\u2022To appropriate authorities when there are issues about abuse, neglect, or domestic violence.\n\u2022In response to a court or administrative order, subpoena, discovery request, or other lawful process.\n\u2022For law enforcement purposes, to military authorities, and as otherwise required by law.\n\u2022To help with disaster relief efforts.\n\u2022For compliance programs and health oversight activities.\n\u2022To fulfill our obligations under any workers' compensation law or contract.\n\u2022To avert a serious and imminent threat to your health or safety or the health or safety of others.\n\u2022For research purposes in limited circumstances.\n\u2022For procurement, banking, or transplantation of organs, eyes, or tissue.\n\u2022To a coroner, medical examiner, or funeral director.\nWill we use your information for purposes not described in this notice?\nWe will not use or disclose your information for any reason that is not described in this notice, without your written \npermission. You may cancel your permission at any time by notifying us in writing.\nThe following uses and disclosures will require your written permission:\n\u2022Most uses and disclosures of psychotherapy notes\n\u2022Marketing purposes \n\u2022Sale of protected health information\nWhat do we do with your information when you are no longer a member?\nYour information may continue to be used for purposes described in this notice. This includes when you do not \nobtain coverage through us. After the required legal retention period, we destroy the information following strict \nprocedures to maintain the confidentiality.\nWhat are my rights concerning my information?\nWe are committed to responding to your rights request in a timely manner:\n\u2022Access \u2013 You have the right to review and obtain a copy of your information that may be used to make decisions \nabout you. You also may receive a summary of this health information. If you request copies, we may charge \nyou a fee for the labor for copying, supplies for creating the copy (paper or electronic), and postage.\n\u2022Adverse Underwriting Decision \u2013 If we decline your application for insurance, you have the right to be provided a \nreason for the denial. *", "doc_id": "46073802-2153-4625-8066-84f5759459d9", "embedding": null, "doc_hash": "89b0cb141b7de363b1dec24e0bff7a472cd74b4426a756a7d1a13dfa441c110e", "extra_info": {"page_label": "131", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 4055, "_node_type": "1"}, "relationships": {"1": "3f359dd5-73f9-41b9-a83f-52233b605e52"}}, "__type__": "1"}, "1e584c9e-9282-4090-a4b6-53b7e6e85283": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 132\nChapter 8. Your rights and responsibilities\n\u2022Alternate Communications \u2013 To avoid a life- threatening situation, you have the right to receive your \ninformation in a different manner or at a different place. We will accommodate your request if it is reasonable.\n\u2022Amendment \u2013 You have the right to request correction of any of this personal information through amendment \nor deletion. Within 30 business days of receipt of your written request, we will notify you of our amendment or \ndeletion of the information in dispute, or of our refusal to make such correction after further investigation. In the \nevent that we refuse to amend or delete the information in dispute, you have the right to submit to us a written \nstatement of the reasons for your disagreement with our assessment of the information in dispute and what \nyou consider to be the correct information. We shall make such a statement accessible to any and all parties \nreviewing the information in dispute.*\n\u2022Disclosure \u2013 You have the right to receive a listing of instances in which we or our business associates have \ndisclosed your information. This does not apply to treatment, payment, health plan operations, and certain \nother activities. We maintain this information and make it available to you for six years. If you request this list \nmore than once in a 12-month period, we may charge you a reasonable, cost-based fee.\n\u2022Notice \u2013 You have the right to request and receive a written copy of this notice any time.\n\u2022Restriction \u2013 You have the right to ask to limit how your information is used or disclosed. We are not required to \nagree to the limit, but if we do, we will abide by our agreement. You also have the right to agree to or terminate \na previously submitted limitation.\n* This right applies only to our Massachusetts residents in accordance with state regulations.\nWhat types of communications can I opt out of that are made to me?\n\u2022Appointment reminders\n\u2022Treatment alternatives or other health-related benefits or services\n\u2022Fundraising activities\nHow do I exercise my rights or obtain a copy of this notice?\nAll of your privacy rights can be exercised by obtaining the applicable forms. You may obtain any of the forms by:\n\u2022Contacting us at 1-866-861-2762\n\u2022Accessing our Website at Humana.com and going to the Privacy Practices link\n\u2022Send completed request form to:\nHumana Inc.\nPrivacy Office 003/10911\n101 E. Main Street\nLouisville, KY 40202\nIf I believe my privacy has been violated, what should I do?\nIf you believe that your privacy has been violated, you may file a complaint with us by calling us at: \n1-866-861-2762 any time.\nYou may also submit a written complaint to the U.S. Department of Health and Human Services, Office for Civil \nRights (OCR). We will give you the appropriate OCR regional address on request. You can also e-mail your complaint \nto OCRComplaint@hhs.gov. If you elect to file a complaint, your benefits will not be affected and we will not punish \nor retaliate against you in any way.\nWe support your right to protect the privacy of your personal and health information.\nWe follow all federal and state laws, rules, and regulations addressing the protection of personal and health \ninformation. In situations when federal and state laws, rules, and regulations conflict, we follow the law, rule, or \nregulation which provides greater protection.", "doc_id": "1e584c9e-9282-4090-a4b6-53b7e6e85283", "embedding": null, "doc_hash": "40ce151c3c35c16c2d1e5e14148b6ec1703906ad534bbd368b861a8f328321b1", "extra_info": {"page_label": "132", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3427, "_node_type": "1"}, "relationships": {"1": "6967c86c-1a7a-4622-b37d-c149cb25b9a4"}}, "__type__": "1"}, "4cacccf6-32b8-49d8-ae5c-611df2293acd": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 133\nChapter 8. Your rights and responsibilities\nWe are required by law to abide by the terms of this notice currently in effect.\nWhat will happen if my information is used or disclosed inappropriately?\nWe are required by law to provide individuals with notice of our legal duties and privacy practices regarding \npersonal and health information. If a breach of unsecured personal and health information occurs, we will notify \nyou in a timely manner.\nThe following affiliates and subsidiaries also adhere to our privacy programs and procedures:\nArcadian Health Plan, Inc.\nCarePlus Health Plans, Inc.\nCariten Health Plan, Inc.\nCHA HMO, Inc.\nCompBenefits Company\nCompBenefits Dental, Inc.\nCompBenefits Insurance Company\nDentiCare, Inc.\nEmphesys Insurance Company\nHumanaDental Insurance Company\nHumana Benefit Plan of Illinois, Inc.\nHumana Benefit Plan of South Carolina, Inc. \nHumana Benefit Plan of Texas, Inc.\nHumana Employers Health Plan of Georgia, Inc.\nHumana Health Benefit Plan of Louisiana, Inc.\nHumana Health Company of New York, Inc.\nHumana Health Insurance Company of Florida, Inc.\nHumana Health Plan of California, Inc.\nHumana Health Plan of Ohio, Inc.\nHumana Health Plan of Texas, Inc.\nHumana Health Plan, Inc.\nHumana Health Plans of Puerto Rico, Inc.\nHumana Insurance Company\nHumana Insurance Company of Kentucky\nHumana Insurance Company of New York\nHumana Insurance of Puerto Rico, Inc.\nHumana Medical Plan, Inc.\nHumana Medical Plan of Michigan, Inc.\nHumana Medical Plan of Pennsylvania, Inc.\nHumana Medical Plan of Utah, Inc.\nHumana Regional Health Plan, Inc.\nHumana Wisconsin Health Organization Insurance Corporation\nGo365 by Humana for Healthy Horizons\nManaged Care Indemnity, Inc.\nThe Dental Concern, Inc.\nEffective 9/2013\nA more complete picture of your health\nHumana has developed programs that have the ability to deliver your electronic healthcare history to authorized \nhealthcare providers. These healthcare providers can view your medical claims, pharmacy claims, laboratory \nclaims and results and radiology claims and results via various information exchange programs. In addition, some ", "doc_id": "4cacccf6-32b8-49d8-ae5c-611df2293acd", "embedding": null, "doc_hash": "b08354662e5cd257f1c2f532922388f2b8423358a8edf6fa908a6065a28f1ed9", "extra_info": {"page_label": "133", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2177, "_node_type": "1"}, "relationships": {"1": "ca796061-17d2-4a54-8690-7a689866464c"}}, "__type__": "1"}, "0f8b91ef-d661-4b3d-a30f-b1fc1685c398": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 134\nChapter 8. Your rights and responsibilities\nof the medical information systems used by your healthcare providers may download your information to provide \na more complete view of your health condition. For privacy reasons, records from psychiatric, substance abuse, or \nHIV-related treatment will not be shared.\nThe benefit of this information exchange is that healthcare providers receive a complete view of the healthcare \nservices you have received. This information is available to a broad range of healthcare providers, including but not \nlimited to:\n\u2022Primary Care Providers\n\u2022Medical Specialists\n\u2022Hospitals\n\u2022Urgent Care Centers\n\u2022Dental Providers\n\u2022Emergency Medical Service (EMS) Providers\n\u2022Selected Alternative and Complementary Medical Practices\nYou may use any of the methods listed below to decline your participation in the information sharing program *.\n1. Log in to MyHumana - the secure section of Humana.com\n\u2022Select \"My Profile\" option located in the upper right-hand corner of the webpage\n\u2022Select the \"Communications Preferences\" option within the dropdown list.\n\u2022Within the \"Privacy and Sharing\" section, select \"No\" to \"Primary Care Physician (PCP) and Treating \nHealthcare Providers.\"\n\u2022Click the \"Save Changes\" button at the bottom of the webpage.\n2. Call the automated response line at 1-800-733-9203.\n3. For TTY service, call 711. Our hours are Monday - Friday, 8 a.m. - 8 p.m. and Saturday, 8 a.m. - 3 p.m., Eastern \ntime.\n* There may be cases where Humana must exchange your health information to comply with regulatory requests \nand/or contractual agreements executed between Humana and a treating healthcare provider.\nWe may share information with affiliated companies as permitted by law. A list of our affiliates can be found in the \nback of our Notice of Privacy Practices found above. We may share information with third parties that Humana \ncontracts with to perform services on our behalf. As part of the work we do together, we may reach out to your \ndoctors and other healthcare providers. This helps us have the most up-to-date information about your treatment \nplans and health information to best support your doctors\u2019 plan of care. The disclosure of sensitive health \ninformation is strictly prohibited to any party other than the subject of the information or the provider who \noriginated the treatment or claims activity unless the member/patient is given an opportunity to provide \ninformed, written consent permitting Humana to release the information to a third party. \nIf you have any questions about how Humana protects your privacy, please access \nHumana.com/about/legal/privacy. If you do not have computer access, you can receive a copy of your Notice of \nPrivacy Practices by calling the customer service phone number located on the back of your Humana ID card.\nSection 1.4 We must give you information about the plan, its network of providers,  \nand your covered services\nAs a member of Humana Gold Plus H0028-014 (HMO), you have the right to get several kinds of information from \nus.\nIf you want any of the following kinds of information, please call Customer Care:", "doc_id": "0f8b91ef-d661-4b3d-a30f-b1fc1685c398", "embedding": null, "doc_hash": "3f8d6aaab26aa8e479ee2938f274222b4f2555f882c376c9bc3021bd591bd125", "extra_info": {"page_label": "134", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3181, "_node_type": "1"}, "relationships": {"1": "c36bf82a-afcf-435b-a3d0-a2da3b23dfec"}}, "__type__": "1"}, "6b8f034e-ad9a-4543-9af9-54c6bf4874a7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 135\nChapter 8. Your rights and responsibilities\n\u2022Information about our plan. This includes, for example, information about the plan's financial condition.\n\u2022Information about our network providers and pharmacies. You have the right to get information about the \nqualifications of the providers and pharmacies in our network and how we pay the providers in our network.\n\u2022Information about your coverage and the rules you must follow when using your coverage. Chapters 3 and \n4 provide information regarding medical services. Chapter 5 and 6 provide information about Part D prescription \ndrug coverage. \n\u2022Information about why something is not covered and what you can do about it. Chapter 9 provides \ninformation on asking for a written explanation on why a medical service or Part D drug is not covered or if your \ncoverage is restricted. Chapter 9 also provides information on asking us to change a decision, also called an \nappeal.\nSection 1.5 We must support your right to make decisions about your care\nYou have the right to know your treatment options and participate in decisions about your health care\nYou have the right to get full information from your doctors and other health care providers. Your providers must \nexplain your medical condition and your treatment choices in a way that you can understand.\nYou also have the right to participate fully in decisions about your health care. To help you make decisions with \nyour doctors about what treatment is best for you, your rights include the following:\n\u2022To know about all of your choices. You have the right to be told about all of the treatment options that are \nrecommended for your condition, no matter what they cost or whether they are covered by our plan. It also \nincludes being told about programs our plan offers to help members manage their medications and use drugs \nsafely.\n\u2022To know about the risks. You have the right to be told about any risks involved in your care. You must be told in \nadvance if any proposed medical care or treatment is part of a research experiment. You always have the choice \nto refuse any experimental treatments.\n\u2022The right to say \"no.\" You have the right to refuse any recommended treatment. This includes the right to \nleave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to \nstop taking your medication. Of course, if you refuse treatment or stop taking medication, you accept full \nresponsibility for what happens to your body as a result.\nYou have the right to give instructions about what is to be done if you are not able to make medical \ndecisions for yourself\nSometimes people become unable to make health care decisions for themselves due to accidents or serious \nillness. You have the right to say what you want to happen if you are in this situation. This means that, if you want \nto, you can:\n\u2022Fill out a written form to give someone the legal authority to make medical decisions for you if you ever \nbecome unable to make decisions for yourself.\n\u2022Give your doctors written instructions about how you want them to handle your medical care if you become \nunable to make decisions for yourself.", "doc_id": "6b8f034e-ad9a-4543-9af9-54c6bf4874a7", "embedding": null, "doc_hash": "6c76dc00620c52981fc37a77fea16bf224061edb597d80b27625bbaa501166c2", "extra_info": {"page_label": "135", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3233, "_node_type": "1"}, "relationships": {"1": "784e52ed-599c-4027-af5e-595073e8c393"}}, "__type__": "1"}, "9d216aad-8fc4-43b8-8ede-8a5498b9f123": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 136\nChapter 8. Your rights and responsibilities\nThe legal documents that you can use to give your directions in advance of these situations are called \"advance \ndirectives.\" There are different types of advance directives and different names for them. Documents called \n\"living will\" and \"power of attorney for health care\" are examples of advance directives.\nIf you want to use an \"advance directive\" to give your instructions, here is what to do:\n\u2022Get the form. You can get an advance directive form from your lawyer, from a social worker, or from some \noffice supply stores. You can sometimes get advance directive forms from organizations that give people \ninformation about Medicare.\n\u2022Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You \nshould consider having a lawyer help you prepare it.\n\u2022Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you \nname on the form who can make decisions for you if you can\u2019t. You may want to give copies to close friends or \nfamily members. Keep a copy at home.\nIf you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a \ncopy with you to the hospital.\n\u2022The hospital will ask you whether you have signed an advance directive form and whether you have it with you.\n\u2022If you have not signed an advance directive form, the hospital has forms available and will ask if you want to \nsign one.\nRemember, it is your choice whether you want to fill out an advance directive (including whether you want to \nsign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based \non whether or not you have signed an advance directive.\nWhat if your instructions are not followed?\nIf you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in \nit, you may file a complaint with your state's Quality Improvement Organization (QIO). Contact information can be \nfound in \"Exhibit A\" in the back of this book.\nSection 1.6 You have the right to make complaints and to ask us to reconsider  \ndecisions we have made\nAt Humana, a process called Utilization Management (UM) is used to determine whether a service or treatment is \ncovered and appropriate for payment under your benefit plan. Humana does not reward or provide financial \nincentives to doctors, other individuals or Humana employees for denying coverage or encouraging under use of \nservices. In fact, Humana works with your doctors and other providers to help you get the most appropriate care \nfor your medical condition. If you have questions or concerns related to Utilization Management, staff are available \nat least eight hours a day during normal business hours. Humana has free language interpreter services available \nto answer questions related to Utilization Management from non-English speaking members. Members may call \n1-800-457-4708 (TTY:711).\nHumana decides about coverage of new medical procedures and devices on an ongoing basis. This is done by \nchecking peer-reviewed medical literature and consulting with medical experts to see if the new technology is \neffective and safe. Humana also relies on guidance from the Centers for Medicare & Medicaid Services (CMS), which \noften makes national coverage decisions for new medical procedures or devices.", "doc_id": "9d216aad-8fc4-43b8-8ede-8a5498b9f123", "embedding": null, "doc_hash": "8ee7f059fbcd80d15fa23a42bec1f35573cc4a07a759a65f5964e2985b464548", "extra_info": {"page_label": "136", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3481, "_node_type": "1"}, "relationships": {"1": "07a5fd13-ba12-4aea-b14e-520f3bbd5ad7"}}, "__type__": "1"}, "8a6c743b-2d3c-418c-ba56-4c42fca45a19": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 137\nChapter 8. Your rights and responsibilities\nIf you have any problems, concerns, or complaints and need to request coverage, or make an appeal, Chapter 9 of \nthis document tells what you can do. Whatever you do \u2013 ask for a coverage decision, make an appeal, or make a \ncomplaint \u2013 we are required to treat you fairly.\nSection 1.7 What can you do if you believe you are being treated unfairly or your  \nrights are not being respected?\nIf it is about discrimination, call the Office for Civil Rights\nIf you believe you have been treated unfairly or your rights have not been respected due to your race, disability, \nreligion, sex, health, ethnicity, creed (beliefs), age, sexual orientation, or national origin, you should call the \nDepartment of Health and Human Services' Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or \ncall your local Office for Civil Rights.\nIs it about something else?\nIf you believe you have been treated unfairly or your rights have not been respected, and it's not about \ndiscrimination, you can get help dealing with the problem you are having:\n\u2022You can call Customer Care.\n\u2022You can call the SHIP. For details, go to Chapter 2, Section 3.\n\u2022Or, you can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY \n1-877-486-2048).\nSection 1.8 How to get more information about your rights\nThere are several places where you can get more information about your rights:\n\u2022You can call Customer Care.\n\u2022You can call the SHIP. For details, go to Chapter 2, Section 3.\n\u2022You can contact Medicare.\n\u2013You can visit the Medicare website to read or download the publication \"Medicare Rights & Protections.\" (The \npublication is available at: www.medicare.gov/Pubs/pdf/11534-Medicare-Rights-and-Protections.pdf.)\n\u2013Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048).\nSECTION 2 You have some responsibilities as a member of the plan\nThings you need to do as a member of the plan are listed below. If you have any questions, please call Customer \nCare.\n\u2022Get familiar with your covered services and the rules you must follow to get these covered services. Use \nthis Evidence of Coverage to learn what is covered for you and the rules you need to follow to get your covered \nservices.", "doc_id": "8a6c743b-2d3c-418c-ba56-4c42fca45a19", "embedding": null, "doc_hash": "4c9819c046aabcba11757dcd6d4d744e945a476be19c1e02f0059dc0e5a3d962", "extra_info": {"page_label": "137", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2350, "_node_type": "1"}, "relationships": {"1": "9f269857-45fc-46a1-bf17-446c6772f562"}}, "__type__": "1"}, "3f447eb0-f55a-4e82-9c57-9639348c2062": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 138\nChapter 8. Your rights and responsibilities\n\u2013Chapters 3 and 4 give the details about your medical services.\n\u2013Chapters 5 and 6 give the details about your Part D prescription drug coverage.\n\u2022If you have any other health insurance coverage or prescription drug coverage in addition to our plan, \nyou are required to tell us. Chapter 1 tells you about coordinating these benefits.\n\u2022Tell your doctor and other health care providers that you are enrolled in our plan. Show your plan \nmembership card whenever you get your medical care or Part D prescription drugs.\n\u2022Help your doctors and other providers help you by giving them information, asking questions, and \nfollowing through on your care.\n\u2013To help get the best care, tell your doctors and other health providers about your health problems. Follow the \ntreatment plans and instructions that you and your doctors agree upon.\n\u2013Make sure your doctors know all of the drugs you are taking, including over-the-counter drugs, vitamins, and \nsupplements.\n\u2013If you have any questions, be sure to ask and get an answer you can understand.\n\u2022Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in \na way that helps the smooth running of your doctor's office, hospitals, and other offices.\n\u2022Pay what you owe. As a plan member, you are responsible for these payments: \n\u2013You must continue to pay a premium for your Medicare Part B to remain a member of the plan.\n\u2013For most of your medical services or drugs covered by the plan, you must pay your share of the cost when \nyou get the service or drug.\n\u2013If you are required to pay a late enrollment penalty, you must pay the penalty to keep your prescription drug \ncoverage.\n\u2013If you are required to pay the extra amount for Part D because of your yearly income, you must continue to \npay the extra amount directly to the government to remain a member of the plan.\n\u2022If you move within our service area, we need to know so we can keep your membership record up to date and \nknow how to contact you.\n\u2022If you move outside of our plan service area, you cannot remain a member of our plan.\n\u2022If you move, it is also important to tell Social Security (or the Railroad Retirement Board).", "doc_id": "3f447eb0-f55a-4e82-9c57-9639348c2062", "embedding": null, "doc_hash": "5fd9ba105e31d667cf27867af90003a77182c9b4ee6631a5f39e35ad844e8fe4", "extra_info": {"page_label": "138", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2284, "_node_type": "1"}, "relationships": {"1": "0330562b-976d-4a14-8514-faadd4b93e9c"}}, "__type__": "1"}, "4917786c-3b91-4bc7-989b-40c6bbe8d73c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 139\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)EOC082\nCHAPTER 9:\nWhat to do if you have a problem\nor complaint (coverage decisions,  \nappeals, complaints)", "doc_id": "4917786c-3b91-4bc7-989b-40c6bbe8d73c", "embedding": null, "doc_hash": "b1b727916c179af2ab470c8dee462c018a604dcb809a54a7200bc5cb4dfd2744", "extra_info": {"page_label": "139", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 272, "_node_type": "1"}, "relationships": {"1": "223d09d7-7f17-4a4c-9b8f-38a5a78bf3fd"}}, "__type__": "1"}, "2a44c392-fb76-4735-9e81-6ab41fdda4f9": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 140\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSECTION 1 Introduction\nSection 1.1 What to do if you have a problem or concern\nThis chapter explains two types of processes for handling problems and concerns:\n\u2022For some problems, you need to use the process for coverage decisions and appeals.\n\u2022For other problems, you need to use the process for making complaints; also called grievances.\nBoth of these processes have been approved by Medicare. Each process has a set of rules, procedures, and \ndeadlines that must be followed by us and by you.\nThe guide in Section 3 will help you identify the right process to use and what you should do.\nSection 1.2 What about the legal terms?\nThere are legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. Many of \nthese terms are unfamiliar to most people and can be hard to understand. To make things easier, this chapter:\n\u2022Uses simpler words in place of certain legal terms. For example, this chapter generally says, \"making a \ncomplaint\" rather than \"filing a grievance,\" \"coverage decision\" rather than \"organization determination,\" or \n\"coverage determination\" or \"at-risk determination,\" and \"independent review organization\" instead of \n\"Independent Review Entity.\" \n\u2022It also uses abbreviations as little as possible.\nHowever, it can be helpful \u2013 and sometimes quite important \u2013 for you to know the correct legal terms. Knowing \nwhich terms to use will help you communicate more accurately to get the right help or information for your \nsituation. To help you know which terms to use, we include legal terms when we give the details for handling \nspecific types of situations.\nSECTION 2 Where to get more information and personalized assistance \nWe are always available to help you. Even if you have a complaint about our treatment of you, we are obligated to \nhonor your right to complain. Therefore, you should always reach out to Customer Care for help. But in some \nsituations, you may also want help or guidance from someone who is not connected with us. Below are two \nentities that can assist you.\nState Health Insurance Assistance Program (SHIP)\nEach state has a government program with trained counselors. The program is not connected with us or with any \ninsurance company or health plan. The counselors at this program can help you understand which process you \nshould use to handle a problem you are having. They can also answer your questions, give you more information, \nand offer guidance on what to do.", "doc_id": "2a44c392-fb76-4735-9e81-6ab41fdda4f9", "embedding": null, "doc_hash": "79683ffea35c4a79a3e53872c96f9818273c06cc2c12b7688e06c966f4c1b6bd", "extra_info": {"page_label": "140", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2624, "_node_type": "1"}, "relationships": {"1": "bab5d1ee-f912-489c-802e-f05a01e9e615"}}, "__type__": "1"}, "a6862ba4-21fc-4b4f-8f7c-3a0e1111a7b3": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 141\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nThe services of SHIP counselors are free. You will find phone numbers and website URLs in Chapter 2, Section 3 of \nthis document.\nMedicare\nYou can also contact Medicare to get help. To contact Medicare:\n\u2022You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call \n1-877-486-2048.\n\u2022You can also visit the Medicare website (www.medicare.gov).\nSECTION 3 To deal with your problem, which process should you use?\nIf you have a problem or concern, you only need to read the parts of this chapter that apply to your situation. The \nguide that follows will help.\nIs your problem or concern about your benefits or coverage?\nThis includes problems about whether medical care or prescription drugs are covered or not, the way they are  \ncovered, and problems related to payment for medical care or prescription drugs.\nYes.\nGo on to the next section of this chapter, Section 4, \"A  \nguide to the basics of coverage decisions and  \nappeals.\"No.\nSkip ahead to Section 10 at the end of this chapter:  \n\"How to make a complaint about quality of care,  \nwaiting times, customer service or other concerns.\"\nCOVERAGE DECISIONS AND APPEALS\nSECTION 4 A guide to the basics of coverage decisions and appeals\nSection 4.1 Asking for coverage decisions and making appeals: the big picture\nCoverage decisions and appeals deals with problems related to your benefits and coverage for medical services \nand prescription drugs, including payment. This is the process you use for issues such as whether something is \ncovered or not and the way in which something is covered.\nAsking for coverage decisions prior to receiving services\nA coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for \nyour medical services or drugs. For example, if your plan network doctor refers you to a medical specialist, this is a \n(favorable) coverage decision for you whenever you receive medical care from him or her or if your network doctor \nrefers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your \ndoctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think \nthat you need. In other words, if you want to know if we will cover a medical service before you receive it, you can \nask us to make a coverage decision for you. In limited circumstances a request for a coverage decision will be \ndismissed, which means we won\u2019t review the request. Examples of when a request will be dismissed include if the \nrequest is incomplete, if someone makes the request on your behalf but isn\u2019t legally authorized to do so or if you ", "doc_id": "a6862ba4-21fc-4b4f-8f7c-3a0e1111a7b3", "embedding": null, "doc_hash": "fc0205905c80fd8a0bb99ad0354b3d71e58876cef3211f532ddbc306ddbc7ecb", "extra_info": {"page_label": "141", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2844, "_node_type": "1"}, "relationships": {"1": "add48fdb-f87c-4242-afbf-d6c5855f31a1"}}, "__type__": "1"}, "e45b2d47-3ad0-4906-b6a4-dab3a2f99b34": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 142\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nask for your request to be withdrawn. If we dismiss a request for a coverage decision, we will send a notice \nexplaining why the request was dismissed and how to ask for a review of the dismissal.\nWe are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In \nsome cases, we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you \ndisagree with this coverage decision, you can make an appeal.\nMaking an appeal\nIf we make a coverage decision, whether before or after a service is received, and you are not satisfied, you can \n\"appeal\" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have \nmade. Under certain circumstances, which we discuss later, you can request an expedited or \"fast appeal\" of a \ncoverage decision. Your appeal is handled by different reviewers than those who made the original decision.\nWhen you appeal a decision for the first time, this is called a Level 1 appeal. In this appeal, we review the coverage \ndecision we made to check to see if we were properly following the rules. When we have completed the review, we \ngive you our decision. In limited circumstances a request for a Level 1 appeal will be dismissed, which means we \nwon\u2019t review the request. Examples of when a request will be dismissed include if the request is incomplete, if \nsomeone makes the request on your behalf but isn\u2019t legally authorized to do so or if you ask for your request to be \nwithdrawn. If we dismiss a request for a Level 1 appeal, we will send a notice explaining why the request was \ndismissed and how to ask for a review of the dismissal.\nIf we do not dismiss your case but say no to all or part of your Level 1 appeal, you can go on to a Level 2 appeal. The \nLevel 2 appeal is conducted by an independent review organization that is not connected to us. (Appeals for \nmedical services and Part B drugs will be automatically sent to the independent review organization for a Level 2 \nappeal \u2013 you do not need to do anything. For Part D drug appeals, if we say no to all or part of your appeal you will \nneed to ask for a Level 2 appeal. Part D appeals are discussed further in Section 6 of this chapter). If you are not \nsatisfied with the decision at the Level 2 appeal, you may be able to continue through additional levels of appeal \n(Section 9 in this chapter explains the Level 3, 4, and 5 appeals processes).\nSection 4.2 How to get help when you are asking for a coverage decision or making an  \nappeal\nHere are resources if you decide to ask for any kind of coverage decision or appeal a decision:\n\u2022You can call us at Customer Care.\n\u2022You can get free help from your State Health Insurance Assistance Program.\n\u2022Your doctor can make a request for you. If your doctor helps with an appeal past Level 2, they will need to \nbe appointed as your representative. Please call Customer Care and ask for the \"Appointment of \nRepresentative\" form. (The form is also available on Medicare\u2019s website at \nwww.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf.)\n\u2013For medical care or Part B prescription drugs, your doctor can request a coverage decision or a Level 1 \nappeal on your behalf. If your appeal is denied at Level 1, it will be automatically forwarded to Level 2.\n\u2013For Part D prescription drugs, your doctor or other prescriber can request a coverage decision or a Level 1 \nappeal on your behalf. If your Level 1 appeal is denied your doctor or prescriber can request a Level 2 \nappeal.", "doc_id": "e45b2d47-3ad0-4906-b6a4-dab3a2f99b34", "embedding": null, "doc_hash": "cc19145828543c4df6b9eebf675fccdf1f2ebfa35a821cbdde28f4fac12a9b42", "extra_info": {"page_label": "142", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3715, "_node_type": "1"}, "relationships": {"1": "22a839b0-dd01-46cb-b359-e664363c7b65"}}, "__type__": "1"}, "9c1bd46e-70bc-4fdf-9a8f-3500f6bf7ba0": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 143\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022You can ask someone to act on your behalf. If you want to, you can name another person to act for you as \nyour \"representative\" to ask for a coverage decision or make an appeal.\n\u2013If you want a friend, relative, or other person to be your representative, call Customer Care and ask for the \n\"Appointment of Representative\" form. (The form is also available on Medicare's website at \nwww.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf.) The form gives that person \npermission to act on your behalf. It must be signed by you and by the person who you would like to act on \nyour behalf. You must give us a copy of the signed form.\n\u2013While we can accept an appeal request without the form, we cannot begin or complete our review until \nwe receive it. If we do not receive the form within 44 calendar days after receiving your appeal request \n(our deadline for making a decision on your appeal), your appeal request will be dismissed. If this happens, \nwe will send you a written notice explaining your right to ask the independent review organization to \nreview our decision to dismiss your appeal.\n\u2022You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name \nof a lawyer from your local bar association or other referral service. There are also groups that will give you \nfree legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of \ncoverage decision or appeal a decision.\nSection 4.3 Which section of this chapter gives the details for your situation?\nThere are four different types of situations that involve coverage decisions and appeals. Since each situation has  \ndifferent rules and deadlines, we give the details for each one in a separate section:\n\u2022Section 5 of this chapter: \"Your medical care: How to ask for a coverage decision or make an appeal\"\n\u2022Section 6 of this chapter: \"Your Part D prescription drugs: How to ask for a coverage decision or make an  \nappeal\"\n\u2022Section 7 of this chapter: \"How to ask us to cover a longer inpatient hospital stay if you think the doctor is  \ndischarging you too soon\"\n\u2022Section 8 of this chapter: \"How to ask us to keep covering certain medical services if you think your coverage  \nis ending too soon\" (Applies only to these services: home health care, skilled nursing facility care, and  \nComprehensive Outpatient Rehabilitation Facility (CORF) services)\nIf you're not sure which section you should be using, please call Customer Care. You can also get help or  \ninformation from government organizations such as your SHIP.\nSECTION 5 Your medical care: How to ask for a coverage decision or make  \nan appeal of a coverage decision\nSection 5.1 This section tells what to do if you have problems getting coverage for  \nmedical care or if you want us to pay you back for our share of the cost of  \nyour care", "doc_id": "9c1bd46e-70bc-4fdf-9a8f-3500f6bf7ba0", "embedding": null, "doc_hash": "51f994c313f740e37153a71c7260c042fc5f4126bf466cb05c6a67c01884e6ab", "extra_info": {"page_label": "143", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3020, "_node_type": "1"}, "relationships": {"1": "8205764f-8b54-4ccc-bc44-d96bec6e74e6"}}, "__type__": "1"}, "fb8a82a1-2a91-45c9-bcdd-9f6de6df59bd": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 144\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nThis section is about your benefits for medical care and services. These benefits are described in Chapter 4 of this \ndocument: Medical Benefits Chart (what is covered and what you pay). To keep things simple, we generally refer to \n\"medical care coverage\" or \"medical care\" which includes medical items and services as well as Medicare Part B \nprescription drugs. In some cases, different rules apply to a request for a Part B prescription drug. In those cases, \nwe will explain how the rules for Part B prescription drugs are different from the rules for medical items and \nservices.\nThis section tells what you can do if you are in any of the five following situations:\n1. You are not getting certain medical care you want, and you believe that this care is covered by our plan. Ask \nfor a coverage decision. Section 5.2.\n2. Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you \nbelieve that this care is covered by the plan. Ask for a coverage decision. Section 5.2.\n3. You have received medical care that you believe should be covered by the plan, but we have said we will not \npay for this care. Make an appeal. Section 5.3. \n4. You have received and paid for medical care that you believe should be covered by the plan, and you want to \nask our plan to reimburse you for this care. Send us the bill. Section 5.5.\n5. You are being told that coverage for certain medical care you have been getting that we previously approved \nwill be reduced or stopped, and you believe that reducing or stopping this care could harm your health. Make \nan appeal. Section 5.3.\nNOTE: If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility \ncare, or Comprehensive Outpatient Rehabilitation Facility (CORF) services, you need to read sections 7 and 8 \nof this Chapter. Special rules apply to these types of care.\nSection 5.2 Step-by-step: How to ask for a coverage decision \nLegal Terms\nWhen a coverage decision involves your medical care, it is called an \"organization determination.\"\nA \"fast coverage decision\" is called an \"expedited determination.\"\nStep 1: Decide if you need a \"standard coverage decision\" or a \"fast coverage decision.\"\nA \"standard coverage decision\" is usually made within 14 days or 72 hours for Part B drugs. A \"fast coverage \ndecision\" is generally made within 72 hours, for medical services, or 24 hours for Part B drugs. In order to \nget a fast coverage decision, you must meet two requirements:\n\u2022You may only ask for coverage for medical care you have not yet received.\n\u2022You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your \nhealth or hurt your ability to function.\n\u2022If your doctor tells us that your health requires a \"fast coverage decision,\" we will automatically \nagree to give you a fast coverage decision.", "doc_id": "fb8a82a1-2a91-45c9-bcdd-9f6de6df59bd", "embedding": null, "doc_hash": "f626b69bbf8c916c8eea7cc528895c841c0f264456a80170b12054f4c304389f", "extra_info": {"page_label": "144", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3048, "_node_type": "1"}, "relationships": {"1": "e17503da-2fe7-4b9e-ab95-ec5cd4adef92"}}, "__type__": "1"}, "f6531598-96b4-43cd-a905-41c98c647d1c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 145\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022If you ask for a fast coverage decision on your own, without your doctor\u2019s support, we will decide \nwhether your health requires that we give you a fast coverage decision. If we do not approve a fast \ncoverage decision, we will send you a letter that:\n\u2013Explains that we will use the standard deadlines.\n\u2013Explains if your doctor asks for the fast coverage decision, we will automatically give you a fast coverage \ndecision.\n\u2013Explains that you can file a \"fast complaint\" about our decision to give you a standard coverage decision \ninstead of the fast coverage decision you requested.\nStep 2: Ask our plan to make a coverage decision or fast coverage decision.\n\u2022Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for \nthe medical care you want. You, your doctor, or your representative can do this. Chapter 2 has contact \ninformation.\nStep 3: We consider your request for medical care coverage and give you our answer.\nFor standard coverage decisions we use the standard deadlines.\nThis means we will give you an answer within 14 calendar days after we receive your request for a medical \nitem or service. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 \nhours after we receive your request.\n\u2022However, if you ask for more time, or if we need more information that may benefit you we can take up to \n14 more days if your request is for a medical item or service. If we take extra days, we will tell you in writing. \nWe can\u2019t take extra time to make a decision if your request is for a Medicare Part B prescription drug.\n\u2022If you believe we should not take extra days, you can file a \"fast complaint.\" We will give you an answer to \nyour complaint as soon as we make the decision. (The process for making a complaint is different from the \nprocess for coverage decisions and appeals. See Section 10 of this chapter for information on complaints.)\nFor Fast Coverage decisions we use an expedited timeframe\nA fast coverage decision means we will answer within 72 hours if your request is for a medical item or \nservice. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours.\n\u2022However, if you ask for more time, or if we need more that may benefit you, we can take up to 14 more \ndays. If we take extra days, we will tell you in writing. We can\u2019t take extra time to make a decision if your \nrequest is for a Medicare Part B prescription drug. \n\u2022If you believe we should not take extra days, you can file a \"fast complaint.\" (See Section 10 of this chapter \nfor information on complaints.) We will call you as soon as we make the decision. \n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no.\nStep 4: If we say no to your request for coverage for medical care, you can appeal.\n\u2022If we say no, you have the right to ask us to reconsider this decision by making an appeal. This means asking \nagain to get the medical care coverage you want. If you make an appeal, it means you are going on to Level \n1 of the appeals process.", "doc_id": "f6531598-96b4-43cd-a905-41c98c647d1c", "embedding": null, "doc_hash": "f81cc621882e541a3b174cb595838000ec49609b763d604be0d14aadd15522d9", "extra_info": {"page_label": "145", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3298, "_node_type": "1"}, "relationships": {"1": "16ac06f2-a3b4-43e8-b3d1-5f3690d392d8"}}, "__type__": "1"}, "2f8e5cbc-d709-4f97-9eb3-c33c4f6089b5": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 146\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSection 5.3 Step-by-step: How to make a Level 1 appeal\nLegal Terms\nAn appeal to the plan about a medical care coverage decision is called a plan \"reconsideration.\"\nA \"fast appeal\" is also called an \"expedited reconsideration.\"\nStep 1: Decide if you need a \"standard appeal\" or a \"fast appeal.\"\nA \"standard appeal\" is usually made within 30 days. A \"fast appeal\" is generally made within 72 hours.\n\u2022If you are appealing a decision, we made about coverage for care that you have not yet received, you and/or \nyour doctor will need to decide if you need a \"fast appeal.\" If your doctor tells us that your health requires a \n\"fast appeal,\" we will give you a fast appeal.\n\u2022The requirements for getting a \"fast appeal\" are the same as those for getting a \"fast coverage decision\" in \nSection 5.2 of this chapter.\nStep 2: Ask our plan for an appeal or a Fast appeal\n\u2022If you are asking for a standard appeal, submit your standard appeal in writing. You may also ask for an \nappeal by calling us. Chapter 2 has contact information.\n\u2022If you are asking for a fast appeal, make your appeal in writing or call us. Chapter 2 has contact \ninformation.\n\u2022You must make your appeal request within 60 calendar days from the date on the written notice we sent \nto tell you our answer on the coverage decision. If you miss this deadline and have a good reason for missing \nit, explain the reason your appeal is late when you make your appeal. We may give you more time to make \nyour appeal. Examples of good cause may include a serious illness that prevented you from contacting us or \nif we provided you with incorrect or incomplete information about the deadline for requesting an appeal.\n\u2022You can ask for a copy of the information regarding your medical decision. You and your doctor may \nadd more information to support your appeal. We are allowed to charge a fee for copying and sending \nthis information to you.\nStep 3: We consider your appeal and we give you our answer.\n\u2022When our plan is reviewing your appeal, we take a careful look at all of the information. We check to see if we \nwere following all the rules when we said no to your request.\n\u2022We will gather more information if needed possibly contacting you or your doctor.\nDeadlines for a \"fast appeal\"\n\u2022For fast appeals, we must give you our answer within 72 hours after we receive your appeal. We will give \nyou our answer sooner if your health requires us to.\n\u2013However, if you ask for more time, or if we need more information that may benefit you, we can take up \nto 14 more calendar days if your request is for a medical item or service. If we take extra days, we will tell \nyou in writing. We can\u2019t take extra time if your request is for a Medicare Part B prescription drug. ", "doc_id": "2f8e5cbc-d709-4f97-9eb3-c33c4f6089b5", "embedding": null, "doc_hash": "dda35918a7bd8c1ef34dd3354505fc1d3ce289c06ff2705e2fd3c5dbdb4daeb3", "extra_info": {"page_label": "146", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2891, "_node_type": "1"}, "relationships": {"1": "4098719c-bc0b-43dc-a9a9-8dec11ca74ea"}}, "__type__": "1"}, "aba44502-f6a3-445c-b105-92557e2cb376": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 147\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2013If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra \ndays), we are required to automatically send your request on to Level 2 of the appeals process, where it \nwill be reviewed by an independent review organization. Section 5.4 explains the Level 2 appeal process.\n\u2022If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we \nhave agreed to provide within 72 hours after we receive your appeal.\n\u2022If our answer is no to part or all of what you requested, we will send you our decision in writing and \nautomatically forward your appeal to the independent review organization for a Level 2 appeal. The \nindependent review organization will notify you in writing when it receives your appeal.\nDeadlines for a \"standard appeal\"\n\u2022For standard appeals, we must give you our answer within 30 calendar days after we receive your appeal. If \nyour request is for a Medicare Part B prescription drug you have not yet received, we will give you our answer \nwithin 7 calendar days after we receive your appeal. We will give you our decision sooner if your health \ncondition requires us to.\n\u2013However, if you ask for more time, or if we need more information that may benefit you, we can take up \nto 14 more calendar days if your request is for a medical item or service. If we take extra days, we will tell \nyou in writing. We can\u2019t take extra time to make a decision if your request is for a Medicare Part B \nprescription drug. \n\u2013If you believe we should not take extra days, you can file a \"fast complaint.\" When you file a fast \ncomplaint, we will give you an answer to your complaint within 24 hours. (See Section 10 of this chapter \nfor information on complaints.) \n\u2013If we do not give you an answer by the deadline (or by the end of the extended time period), we will send \nyour request to a Level 2 appeal, where an independent review organization will review the appeal. \nSection 5.4 explains the Level 2 appeal process.\n\u2022If our answer is yes to part or all of what you requested, we must authorize or provide the coverage \nwithin 30 calendar days if your request is for a medical item or service, or within 7 calendar days if your \nrequest is for a Medicare Part B prescription drug.\n\u2022If our plan says no to part or all of your appeal, we will automatically send your appeal to the \nindependent review organization for a Level 2 appeal.\nSection 5.4 Step-by-step: How a Level 2 appeal is done\nLegal Terms\nThe formal name for the \"independent review organization\" is the \"Independent Review Entity.\" It is  \nsometimes called the \"IRE.\"\nThe independent review organization is an independent organization hired by Medicare. It is not connected \nwith us and is not a government agency. This organization decides whether the decision we made is correct or if it \nshould be changed. Medicare oversees its work.\nStep 1: The independent review organization reviews your appeal.", "doc_id": "aba44502-f6a3-445c-b105-92557e2cb376", "embedding": null, "doc_hash": "415e01f1b09a5418368ba06f0229e0f4291a6bdc7e9f42ea7672149c69c049f6", "extra_info": {"page_label": "147", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3128, "_node_type": "1"}, "relationships": {"1": "db0f6059-bc1e-4c5e-9470-6d80717499c4"}}, "__type__": "1"}, "ac9137ef-7c1e-46e3-9143-beafcd3da67a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 148\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022We will send the information about your appeal to this organization. This information is called your \"case \nfile.\" You have the right to ask us for a copy of your case file. We are allowed to charge you a fee for \ncopying and sending this information to you.\n\u2022You have a right to give the independent review organization additional information to support your appeal.\n\u2022Reviewers at the independent review organization will take a careful look at all of the information related to \nyour appeal.\nIf you had a \"fast appeal\" at Level 1, you will also have a \"fast appeal\" at Level 2\n\u2022For the \"fast appeal\" the review organization must give you an answer to your Level 2 appeal within 72 \nhours of when it receives your appeal.\n\u2022However, if your request is for a medical item or service and the independent review organization needs to \ngather more information that may benefit you, it can take up to 14 more calendar days. The independent \nreview organization can\u2019t take extra time to make a decision if your request is for a Medicare Part B \nprescription drug.\nIf you had a \"standard appeal\" at Level 1, you will also have a \"standard appeal\" at Level 2\n\u2022For the \"standard appeal\" if your request is for a medical item or service, the review organization must give \nyou an answer to your Level 2 appeal within 30 calendar days of when it receives your appeal. If your \nrequest is for a Medicare Part B prescription drug, the review organization must give you an answer to your \nLevel 2 appeal within 7 calendar days of when it receives your appeal.\n\u2022However, if your request is for a medical item or service and the independent review organization needs to \ngather more information that may benefit you, it can take up to 14 more calendar days. The independent \nreview organization can\u2019t take extra time to make a decision if your request is for a Medicare Part B \nprescription drug.\nStep 2: The independent review organization gives you their answer.\nThe independent review organization will tell you it's decision in writing and explain the reasons for it.\n\u2022If the review organization says yes to part or all of a request for a medical item or service, we must \nauthorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we \nreceive the decision from the review organization for standard requests. For expedited requests, we have 72 \nhours from the date we receive the decision from the review organization.\n\u2022If the review organization says yes to part or all of a request for a Medicare Part B prescription drug, \nwe must authorize or provide the Part B prescription drug under dispute within 72 hours after we receive the \ndecision from the review organization for standard requests. For expedited requests we have 24 hours \nfrom the date we receive the decision from the review organization.\n\u2022If this organization says no to part or all of your appeal, it means they agree with us that your request (or \npart of your request) for coverage for medical care should not be approved. (This is called \"upholding the \ndecision.\" It is also called \"turning down your appeal.\") In this case, the independent review organization will \nsend you a letter:\n\u2013Explaining its decision.", "doc_id": "ac9137ef-7c1e-46e3-9143-beafcd3da67a", "embedding": null, "doc_hash": "a151ba4201e9d7f0db9bb0f6b2a0201cb710803918e6b4f3af921dd9ac46a32c", "extra_info": {"page_label": "148", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3385, "_node_type": "1"}, "relationships": {"1": "395d74e0-4a3d-4909-af58-21190d5aac47"}}, "__type__": "1"}, "c292920c-cb99-4c20-8d68-9dcb732d5bac": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 149\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2013Notifying you of the right to a Level 3 appeal if the dollar value of the medical care coverage meets a \ncertain minimum. The written notice you get from the independent review organization will tell you the \ndollar amount you must meet to continue the appeals process.\n\u2013Telling you how to file a Level 3 appeal.\nStep 3: If your case meets the requirements, you choose whether you want to take your appeal further.\n\u2022There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If you \nwant to go to a Level 3 appeal the details on how to do this are in the written notice you get after your Level 2 \nappeal.\n\u2022The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 in this \nchapter explains the Level 3, 4, and 5 of the appeals processes.\nSection 5.5 What if you are asking us to pay you for our share of a bill you have  \nreceived for medical care?\nChapter 7 describes when you may need to ask for reimbursement or to pay a bill you have received from a \nprovider. It also tells how to send us the paperwork that asks us for payment.\nAsking for reimbursement is asking for a coverage decision from us\nIf you send us the paperwork asking for reimbursement, you are asking for a coverage decision. To make this \ndecision, we will check to see if the medical care you paid for is a covered service. We will also check to see if you \nfollowed all the rules for using your coverage for medical care.\n\u2022If we say yes to your request: If the medical care is covered and you followed all the rules, we will send you \nthe payment for our share of the cost within 60 calendar days after we receive your request. If you haven\u2019t \npaid for the services, we will send the payment directly to the provider. \n\u2022If we say no to your request: If the medical care is not covered, or you did not follow all the rules, we will not \nsend payment. Instead, we will send you a letter that says we will not pay for the services and the reasons \nwhy. \nIf you do not agree with our decision to turn you down, you can make an appeal. If you make an appeal, it means \nyou are asking us to change the coverage decision we made when we turned down your request for payment.\nTo make this appeal, follow the process for appeals that we describe in Section 5.3.For appeals concerning \nreimbursement, please note:\n\u2022We must give you our answer within 60 calendar days after we receive your appeal. If you are asking us to \npay you back for medical care you have already received and paid for, you are not allowed to ask for a fast \nappeal.  \n\u2022If the independent review organization decides we should pay, we must send you or the provider the \npayment within 30 calendar days. If the answer to your appeal is yes at any stage of the appeals process \nafter Level 2, we must send the payment you requested to you or to the provider within 60 calendar days.", "doc_id": "c292920c-cb99-4c20-8d68-9dcb732d5bac", "embedding": null, "doc_hash": "0d0431ea64fdf82caffaf4c067449121f7c7b301144656e65bc145f6fbda6dfc", "extra_info": {"page_label": "149", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3073, "_node_type": "1"}, "relationships": {"1": "6eec134f-e7e0-4127-9590-0435c418ab26"}}, "__type__": "1"}, "9eb68db3-8351-4f6a-8d06-e7feef6f823c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 150\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSECTION 6 Your Part D prescription drugs: How to ask for a coverage  \ndecision or make an appeal\nSection 6.1 This section tells you what to do if you have problems getting a Part D  \ndrug or you want us to pay you back for a Part D drug\nYour benefits include coverage for many prescription drugs. To be covered, the drug must be used for a medically \naccepted indication. (See Chapter 5 for more information about a medically accepted indication.) For details about \nPart D drugs, rules, restrictions, and costs please see Chapters 5 and 6. This section is about your Part D drugs \nonly. To keep things simple, we generally say \"drug\" in the rest of this section, instead of repeating \"covered \noutpatient prescription drug\" or \"Part D drug\" every time. We also use the term \"drug guide\" instead of \"List of \nCovered Drugs\" or \"Formulary.\"\n\u2022If you do not know if a drug is covered or if you meet the rules, you can ask us. Some drugs require that you \nget approval from us before we will cover it. \n\u2022If your pharmacy tells you that your prescription cannot be filled as written, the pharmacy will give you a \nwritten notice explaining how to contact us to ask for a coverage decision.  \nPart D coverage decisions and appeals\nLegal Terms\nAn initial coverage decision about your Part D drugs is called a \"coverage determination.\"\nA coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for \nyour drugs. This section tells what you can do if you are in any of the following situations:\n\u2022Asking to cover a Part D drug that is not on the plan\u2019s List of Covered Drugs. Asking for an exception. Section \n6.2\n\u2022Asking to waive a restriction on the plan\u2019s coverage for a drug (such as limits on the amount of the drug you \ncan get). Asking for an exception. Section 6.2\n\u2022Asking to pay a lower cost-sharing amount for a covered drug on a higher cost-sharing tier. Asking for an \nexception. Section 6.2\n\u2022Asking to get pre-approval for a drug. Asking for a coverage decision. Section 6.4\n\u2022Pay for a prescription drug you already bought. Ask us to pay you back. Section 6.4\nIf you disagree with a coverage decision we have made, you can appeal our decision.\nThis section tells you both how to ask for coverage decisions and how to request an appeal.", "doc_id": "9eb68db3-8351-4f6a-8d06-e7feef6f823c", "embedding": null, "doc_hash": "6dbdef6d37fb47fa486d637a17bf356c9fee576a62447b88bc177d0311d3b831", "extra_info": {"page_label": "150", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2452, "_node_type": "1"}, "relationships": {"1": "8e68cf70-da3d-430c-8652-0dfc6b229d81"}}, "__type__": "1"}, "9e11a70c-7933-49b4-a24e-f25595f47383": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 151\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSection 6.2 What is an exception?\nLegal Terms\nAsking for coverage of a drug that is not on the Drug Guide is sometimes called asking for a \"formulary  \nexception.\"\nAsking for removal of a restriction on coverage for a drug is sometimes called asking for a \"formulary  \nexception.\"  \nAsking to pay a lower price for a covered non-preferred drug is sometimes called asking for a \"tiering exception.\"\nIf a drug is not covered in the way you would like it to be covered, you can ask us to make an \"exception.\" An \nexception is a type of coverage decision. \nFor us to consider your exception request, your doctor or other prescriber will need to explain the medical reasons \nwhy you need the exception approved. Here are three examples of exceptions that you or your doctor or other \nprescriber can ask us to make:\n1. Covering a Part D drug for you that is not on our Drug Guide. If we agree to cover a drug not on the Drug \nGuide, you will need to pay the cost-sharing amount that applies to drugs in Cost-Sharing Tier 4 \u2013 Non-Preferred \nDrug. You cannot ask for an exception to the cost-sharing amount we require you to pay for the drug.\n2. Removing a restriction for a covered drug. Chapter 5 describes the extra rules or restrictions that apply to \ncertain drugs on our Drug Guide. If we agree to make an exception and waive a restriction for you, you can ask \nfor an exception to the copayment or coinsurance amount we require you to pay for the drug.\n3. Changing coverage of a drug to a lower cost-sharing tier. Every drug on our Drug Guide is in one of five \ncost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the \ncost of the drug.\n\u2022If our drug guide contains alternative drug(s) for treating your medical condition that are in a lower \ncost-sharing tier than your drug, you can ask us to cover your drug at the cost-sharing amount that applies to \nthe alternative drug(s). \n\u2022If the drug you\u2019re taking is a biological product you can ask us to cover your drug at a lower cost-sharing \namount. This would be the lowest tier that contains biological product alternatives for treating your \ncondition. \n\u2022If the drug you\u2019re taking is a brand name drug you can ask us to cover your drug at the cost-sharing amount \nthat applies to the lowest tier that contains brand name alternatives for treating your condition. \n\u2022If the drug you\u2019re taking is a generic drug you can ask us to cover your drug at the cost-sharing amount that \napplies to the lowest tier that contains either brand or generic alternatives for treating your condition.\n\u2022You cannot ask us to change the cost-sharing tier for any drug in Cost-Sharing Tier 5 \u2013 Specialty Tier.\n\u2022If we approve your tiering exception request and there is more than one lower cost-sharing tier with \nalternative drugs you can\u2019t take, you will usually pay the lowest amount.", "doc_id": "9e11a70c-7933-49b4-a24e-f25595f47383", "embedding": null, "doc_hash": "565fb74c5ccfc51519bea7da803e771963a53ac2f0cf1de9eeb7d534ee846b17", "extra_info": {"page_label": "151", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3039, "_node_type": "1"}, "relationships": {"1": "5c91be46-4c92-468a-a62e-5a58aa1ed438"}}, "__type__": "1"}, "c03da7b4-34e5-49da-bfbb-c4ce47db7701": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 152\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSection 6.3 Important things to know about asking for exceptions\nYour doctor must tell us the medical reasons\nYour doctor or other prescriber must give us a statement that explains the medical reasons for requesting an \nexception. For a faster decision, include this medical information from your doctor or other prescriber when you ask \nfor the exception.\nTypically, our Drug Guide includes more than one drug for treating a particular condition. These different \npossibilities are called \"alternative\" drugs. If an alternative drug would be just as effective as the drug you are \nrequesting and would not cause more side effects or other health problems, we will generally not approve your \nrequest for an exception. If you ask us for a tiering exception, we will generally not approve your request for an \nexception unless all the alternative drugs in the lower cost-sharing tier(s) won't work as well for you or are likely to \ncause an adverse reaction or other harm.\nWe can say yes or no to your request\n\u2022If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is \ntrue as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and \neffective for treating your condition.\n\u2022If we say no to your request, you can ask for a review by making an appeal.\nSection 6.4 Step-by-step: How to ask for a coverage decision, including an exception\nLegal Term\nA \"fast coverage decision\" is called an \"expedited coverage determination.\"\nStep 1: Decide if you need a \"standard coverage decision\" or a \"fast coverage decision.\"\n\"Standard coverage decisions\" are made within 72 hours after we receive your doctor\u2019s statement. \"Fast \ncoverage decisions\" are made within 24 hours after we receive your doctor\u2019s statement.\nIf your health requires it, ask us to give you a \"fast coverage decision.\" To get a fast coverage decision, you \nmust meet two requirements:\n\u2022You must be asking for a drug you have not yet received. (You cannot ask for fast coverage decision to be \npaid back for a drug you have already bought.)\n\u2022Using the standard deadlines could cause serious harm to your health or hurt your ability to function.\n\u2022If your doctor or other prescriber tells us that your health requires a \"fast coverage decision,\" we \nwill automatically give you a fast coverage decision.\n\u2022If you ask for a fast coverage decision on your own, without your doctor or prescriber\u2019s support, we \nwill decide whether your health requires that we give you a fast coverage decision. If we do not \napprove a fast coverage decision, we will send you a letter that:\n\u2013Explains that we will use the standard deadlines.", "doc_id": "c03da7b4-34e5-49da-bfbb-c4ce47db7701", "embedding": null, "doc_hash": "c0517aecd7b5bd68bdac1d18b329e770f18a104a1e6cbedd4f75927d65aa0790", "extra_info": {"page_label": "152", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2842, "_node_type": "1"}, "relationships": {"1": "aff23f75-465e-4de4-9621-545c33fd25db"}}, "__type__": "1"}, "22584e2e-1751-4180-9ea8-cccd1ce346d7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 153\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2013Explains if your doctor or other prescriber asks for the fast coverage decision, we will automatically give \nyou a fast coverage decision.\n\u2013Tells you how you can file a \"fast complaint\" about our decision to give you a standard coverage \ndecision instead of the fast coverage decision you requested. We will answer your complaint within 24 \nhours of receipt.\nStep 2: Request a \"standard coverage decision\" or a \"fast coverage decision.\"\nStart by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the \nmedical care you want. You can also access the coverage decision process through our website. We must accept \nany written request, including a request submitted on the CMS Model Coverage Determination Request Form or on \nour plan\u2019s form, which are available on our website. Chapter 2 has contact information. To assist us in processing \nyour request, please be sure to include your name, contact information, and information identifying which denied \nclaim is being appealed. \nYou, your doctor (or other prescriber), or your representative can do this. You can also have a lawyer act on your \nbehalf. Section 4 of this chapter tells how you can give written permission to someone else to act as your \nrepresentative.\n\u2022If you are requesting an exception, provide the \"supporting statement\" which is the medical reasons for \nthe exception. Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other \nprescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary.\nStep 3: We consider your request and give you our answer.\nDeadlines for a \"fast coverage decision\"\n\u2022We must generally give you our answer within 24 hours after we receive your request. \n\u2013For exceptions, we will give you our answer within 24 hours after we receive your doctor\u2019s supporting \nstatement. We will give you our answer sooner if your health requires us to. \n\u2013If we do not meet this deadline, we are required to send your request to Level 2 of the appeals process, \nwhere it will be reviewed by an independent review organization.\n\u2022If our answer is yes to part or all of what you requested, we must provide the coverage we have \nagreed to provide within 24 hours after we receive your request or doctor\u2019s statement supporting your \nrequest.\n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no. We will also tell you how you can appeal. \nDeadlines for a \"standard coverage decision\" about a drug you have not yet received\n\u2022We must generally give you our answer within 72 hours after we receive your request.  \n\u2013For exceptions, we will give you our answer within 72 hours after we receive your doctor\u2019s supporting \nstatement. We will give you our answer sooner if your health requires us to.\n\u2013If we do not meet this deadline, we are required to send your request to Level 2 of the appeals process, \nwhere it will be reviewed by an independent review organization.", "doc_id": "22584e2e-1751-4180-9ea8-cccd1ce346d7", "embedding": null, "doc_hash": "c1ab0be56fbb9892fd6bf168293c3da5100edfb79ac256ec60e6fa57653124f2", "extra_info": {"page_label": "153", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3201, "_node_type": "1"}, "relationships": {"1": "31f40556-d89e-4618-a099-21378c60ab41"}}, "__type__": "1"}, "c795783e-813d-4782-ad07-1d63c3c0a16a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 154\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022If our answer is yes to part or all of what you requested, we must provide the coverage we have \nagreed to provide within 72 hours after we receive your request or doctor\u2019s statement supporting your \nrequest.\n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no. We will also tell you how you can appeal.\nDeadlines for a \"standard coverage decision\" about payment for a drug you have already bought\n\u2022We must give you our answer within 14 calendar days after we receive your request.\n\u2013If we do not meet this deadline, we are required to send your request to Level 2 of the appeals process, \nwhere it will be reviewed by an independent review organization.\n\u2022If our answer is yes to part or all of what you requested, we are also required to make payment to you \nwithin 14 calendar days after we receive your request.\n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no. We will also tell you how you can appeal.\nStep 4: If we say no to your coverage request, you can make an appeal.\n\u2022If we say no, you have the right to ask us to reconsider this decision by making an appeal. This means \nasking again to get the drug coverage you want. If you make an appeal, it means you are going to Level 1 \nof the appeals process.\nSection 6.5 Step-by-step: How to make a Level 1 appeal\nLegal Terms\nAn appeal to the plan about a Part D drug coverage decision is called a plan \"redetermination.\"\nA \"fast appeal\" is also called an \"expedited redetermination.\"\nStep 1: Decide if you need a \"standard appeal\" or a \"fast appeal.\"\nA \"standard appeal\" is usually made within 7 days. A \"fast appeal\" is generally made within 72 hours. If your \nhealth requires it, ask for a \"fast appeal\"\n\u2022If you are appealing a decision, we made about a drug you have not yet received, you and your doctor or \nother prescriber will need to decide if you need a \"fast appeal.\" \n\u2022The requirements for getting a \"fast appeal\" are the same as those for getting a \"fast coverage decision\" \nin Section 6.4 of this chapter. \nStep 2: You, your representative, doctor, or other prescriber must contact us and make your Level 1 appeal. \nIf your health requires a quick response, you must ask for a \"fast appeal.\"\n\u2022For standard appeals, submit a written request. Chapter 2 has contact information.\n\u2022For fast appeals either submit your appeal in writing or call us at 1-800-867-6601. Chapter 2 has \ncontact information.", "doc_id": "c795783e-813d-4782-ad07-1d63c3c0a16a", "embedding": null, "doc_hash": "75230314ccf2287dde4a7519f45c7bb8c54458a718e45fb5f72db40e9823fb5c", "extra_info": {"page_label": "154", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2681, "_node_type": "1"}, "relationships": {"1": "515ce81b-4cb9-4c33-8692-d963dc07dd1a"}}, "__type__": "1"}, "cd1c2873-0830-4be7-bb76-f2bd378549be": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 155\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022We must accept any written request, including a request submitted on the CMS Model Coverage \nDetermination Request Form, which is available on our website. Please be sure to include your name, \ncontact information, and information regarding your claim to assist us in processing your request.\n\u2022You must make your appeal request within 60 calendar days from the date on the written notice we \nsent to tell you our answer on the coverage decision. If you miss this deadline and have a good reason for \nmissing it, explain the reason your appeal is late when you make your appeal. We may give you more time \nto make your appeal. Examples of good cause may include a serious illness that prevented you from \ncontacting us or if we provided you with incorrect or incomplete information about the deadline for \nrequesting an appeal.\n\u2022You can ask for a copy of the information in your appeal and add more information. You and your \ndoctor may add more information to support your appeal. We are allowed to charge a fee for copying and \nsending this information to you. \nStep 3: We consider your appeal and we give you our answer.\n\u2022When we are reviewing your appeal, we take another careful look at all of the information about your \ncoverage request. We check to see if we were following all the rules when we said no to your request. We \nmay contact you or your doctor or other prescriber to get more information.\nDeadlines for a \"fast appeal\" \n\u2022For fast appeals, we must give you our answer within 72 hours after we receive your appeal. We will give \nyou our answer sooner if your health requires us to. \n\u2013If we do not give you an answer within 72 hours, we are required to send your request to Level 2 of the \nappeals process, where it will be reviewed by an independent review organization. Section 6.6 explains the \nLevel 2 appeal process.\n\u2022If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed \nto provide within 72 hours after we receive your appeal. \n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no and how you can appeal our decision. \nDeadlines for a \"standard appeal\" for a drug you have not yet received\n\u2022For standard appeals, we must give you our answer within 7 calendar days after we receive your appeal. \nWe will give you our decision sooner if you have not received the drug yet and your health condition requires \nus to do so. \n\u2013If we do not give you a decision within 7 calendar days, we are required to send your request to Level 2 of \nthe appeals process, where it will be reviewed by an independent review organization. Section 6.6 explains \nthe Level 2 appeal process.\n\u2022If our answer is yes to part or all of what you requested, we must provide the coverage as quickly as your \nhealth requires, but no later than 7 calendar days after we receive your appeal. \n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no and how you can appeal our decision. \nDeadlines for a \"standard appeal\" about payment for a drug you have already bought", "doc_id": "cd1c2873-0830-4be7-bb76-f2bd378549be", "embedding": null, "doc_hash": "9364c4c6d6b921517dcb8795a319af749970ae2fd9068bf8883be1dbd78112af", "extra_info": {"page_label": "155", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3316, "_node_type": "1"}, "relationships": {"1": "cf7dffa8-b7ae-4665-b417-e3c40fbe1eae"}}, "__type__": "1"}, "be998169-9cb9-44d2-981d-3b067fcb16da": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 156\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022We must give you our answer within 14 calendar days after we receive your request.\n\u2013If we do not meet this deadline, we are required to send your request to Level 2 of the appeals process, \nwhere it will be reviewed by an independent review organization.\n\u2022If our answer is yes to part or all of what you requested, we are also required to make payment to you \nwithin 30 calendar days after we receive your request. \n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no. We will also tell you how you can appeal. \nStep 4: If we say no to your appeal, you decide if you want to continue with the appeals process and make \nanother appeal.\n\u2022If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process.\nSection 6.6 Step-by-step: How to make a Level 2 appeal\nLegal Terms\nThe formal name for the \"independent review organization\" is the \"Independent Review Entity.\" It is  \nsometimes called the \"IRE.\"\nThe independent review organization is an independent organization hired by Medicare. It is not connected \nwith us and is not a government agency. This organization decides whether the decision we made is correct or if it \nshould be changed. Medicare oversees its work.\nStep 1: You (or your representative or your doctor or other prescriber) must contact the independent review \norganization and ask for a review of your case.\n\u2022If we say no to your Level 1 appeal, the written notice we send you will include instructions on how to make \na Level 2 appeal with the independent review organization. These instructions will tell who can make this \nLevel 2 appeal, what deadlines you must follow, and how to reach the review organization. If, however, we \ndid not complete our review within the applicable timeframe, or make an unfavorable decision regarding \n\"at-risk\" determination under our drug management program, we will automatically forward your claim to \nthe IRE.\n\u2022We will send the information about your appeal to this organization. This information is called your \"case \nfile.\" You have the right to ask us for a copy of your case file. We are allowed to charge you a fee for \ncopying and sending this information to you. \n\u2022You have a right to give the independent review organization additional information to support your appeal.\nStep 2: The independent review organization reviews your appeal.\nReviewers at the independent review organization will take a careful look at all of the information related to \nyour appeal.\nDeadlines for \"fast appeal\"\n\u2022If your health requires it, ask the independent review organization for a \"fast appeal.\"", "doc_id": "be998169-9cb9-44d2-981d-3b067fcb16da", "embedding": null, "doc_hash": "fdcb58701b4662ded95ac7edffd991e82b4a81e979cf0ba3e21f50026c7b9828", "extra_info": {"page_label": "156", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2826, "_node_type": "1"}, "relationships": {"1": "2ce169af-9c75-4954-bd8c-61e9e547d4d8"}}, "__type__": "1"}, "88bb1d0d-10f9-47af-98bd-7b2ebca567a0": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 157\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022If the organization agrees to give you a \"fast appeal,\" the organization must give you an answer to your \nLevel 2 appeal within 72 hours after it receives your appeal request.\nDeadlines for \"standard appeal\"\n\u2022For standard appeals, the review organization must give you an answer to your Level 2 appeal within 7 \ncalendar days after it receives your appeal if it is for a drug you have not yet received. If you are \nrequesting that we pay you back for a drug you have already bought, the review organization must give \nyou an answer to your Level 2 appeal within 14 calendar days after it receives your request.\nStep 3: The independent review organization gives you their answer.\nFor \"fast appeals\":\n\u2022If the independent review organization says yes to part or all of what you requested, we must provide \nthe drug coverage that was approved by the review organization within 24 hours after we receive the \ndecision from the review organization.\nFor \"standard appeals\":\n\u2022If the independent review organization says yes to part or all of your request for coverage, we must \nprovide the drug coverage that was approved by the review organization within 72 hours after we receive \nthe decision from the review organization.\n\u2022If the independent review organization says yes to part or all of your request to pay you back for a \ndrug you already bought, we are required to send payment to you within 30 calendar days after we \nreceive the decision from the review organization.\nWhat if the review organization says no to your appeal? \nIf this organization says no to part or all of your appeal, it means they agree with our decision not to approve your \nrequest (or part of your request). (This is called \"upholding the decision.\" It is also called \"turning down your \nappeal.\"). In this case, the independent review organization will send you a letter: \n\u2022Explaining its decision.\n\u2022Notifying you of the right to a Level 3 appeal if the dollar value of the drug coverage you are requesting meets \na certain minimum. If the dollar value of the drug coverage you are requesting is too low, you cannot make \nanother appeal and the decision at Level 2 is final.\n\u2022Telling you the dollar value that must be in dispute to continue with the appeals process.\nStep 4: If your case meets the requirements, you choose whether you want to take your appeal further.\n\u2022There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).\n\u2022If you want to go on to a Level 3 appeal the details on how to do this are in the written notice you got after \nyour Level 2 appeal decision. \n\u2022The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 in this \nchapter tells more about Levels 3, 4, and 5 of the appeals process.", "doc_id": "88bb1d0d-10f9-47af-98bd-7b2ebca567a0", "embedding": null, "doc_hash": "f075af929f3bbbbee1274a4b3126a20bc48cceb4c9ec0352af92048739204972", "extra_info": {"page_label": "157", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2939, "_node_type": "1"}, "relationships": {"1": "88efc990-3a38-4ce1-bcbc-e0dcc9dbf796"}}, "__type__": "1"}, "d3687edb-7690-4a3d-81a9-fc5713f3ae3b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 158\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSECTION 7 How to ask us to cover a longer inpatient hospital stay if you  \nthink the doctor is discharging you too soon\nWhen you are admitted to a hospital, you have the right to get all of your covered hospital services that are \nnecessary to diagnose and treat your illness or injury.\nDuring your covered hospital stay, your doctor and the hospital staff will be working with you to prepare for the day \nwhen you will leave the hospital. They will help arrange for care you may need after you leave.\n\u2022The day you leave the hospital is called your \"discharge date. \"\n\u2022When your discharge date is decided, your doctor or the hospital staff will tell you.\n\u2022If you think you are being asked to leave the hospital too soon, you can ask for a longer hospital stay, and \nyour request will be considered.\nSection 7.1 During your inpatient hospital stay, you will get a written notice from  \nMedicare that tells about your rights\nWithin two days of being admitted to the hospital, you will be given a written notice called An Important Message \nfrom Medicare about Your Rights. Everyone with Medicare gets a copy of this notice. If you do not get the notice \nfrom someone at the hospital (for example, a caseworker or nurse), ask any hospital employee for it. If you need \nhelp, please call Customer Care or 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY \n1-877-486-2048).\n1. Read this notice carefully and ask questions if you don't understand it. It tells you:\n\u2022Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your \ndoctor. This includes the right to know what these services are, who will pay for them, and where you can \nget them.\n\u2022Your right to be involved in any decisions about your hospital stay.\n\u2022Where to report any concerns you have about the quality of your hospital care. \n\u2022Your right to request an immediate review of the decision to discharge you if you think you are being \ndischarged from the hospital too soon. This is a formal, legal way to ask for a delay in your discharge date \nso that we will cover your hospital care for a longer time.\n2. You will be asked to sign the written notice to show that you received it and understand your rights.\n\u2022You or someone who is acting on your behalf will be asked to sign the notice.\n\u2022Signing the notice shows only that you have received the information about your rights. The notice does \nnot give your discharge date. Signing the notice does not mean you are agreeing on a discharge date.\n3. Keep your copy of the notice so you will have the information about making an appeal (or reporting a \nconcern about quality of care) handy if you need it.", "doc_id": "d3687edb-7690-4a3d-81a9-fc5713f3ae3b", "embedding": null, "doc_hash": "e1fb0352c16ef54084d409c0a7c6b0b8e86604c1d6a11aec42fcc2a0874fd510", "extra_info": {"page_label": "158", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2839, "_node_type": "1"}, "relationships": {"1": "9e7f1bb1-68c7-46e9-a1cf-6bbacc756325"}}, "__type__": "1"}, "69f65619-31a5-436e-8514-5a3358d7cc8a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 159\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022If you sign the notice more than two days before the day you leave the hospital, you will get another copy \nbefore you are scheduled to be discharged.\n\u2022To look at a copy of this notice in advance, you can call Customer Care or 1-800 MEDICARE \n(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also \nsee the notice online at \nwww.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.\nSection 7.2 Step-by-step: How to make a Level 1 appeal to change your hospital  \ndischarge date\nIf you want to ask for your inpatient hospital services to be covered by us for a longer time, you will need to use the \nappeals process to make this request. Before you start, understand what you need to do and what the deadlines \nare.\n\u2022Follow the process.\n\u2022Meet the deadlines.\n\u2022Ask for help if you need it. If you have questions or need help at any time, please call Customer Care. Or call \nyour State Health Insurance Assistance Program, a government organization that provides personalized \nassistance.\nDuring a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It checks to see if your \nplanned discharge date is medically appropriate for you.\nThe Quality Improvement Organization is a group of doctors and other health care professionals paid by the \nFederal government to check on and help improve the quality of care for people with Medicare. This includes \nreviewing hospital discharge dates for people with Medicare. These experts are not part of our plan.\nStep 1: Contact the Quality Improvement Organization for your state and ask for an immediate review of \nyour hospital discharge. You must act quickly.\nHow can you contact this organization?\n\u2022The written notice you received (An Important Message from Medicare About Your Rights) tells you how to \nreach this organization. Or find the name, address, and phone number of the Quality Improvement \nOrganization for your state in Chapter 2.\nAct quickly:\n\u2022To make your appeal, you must contact the Quality Improvement Organization before you leave the \nhospital and no later than midnight the day of your discharge.\n\u2013If you meet this deadline, you may stay in the hospital after your discharge date without paying for it \nwhile you wait to get the decision on your appeal from the Quality Improvement Organization.\n\u2013If you do not meet this deadline, and you decide to stay in the hospital after your planned discharge \ndate, you may have to pay all of the costs for hospital care you receive after your planned discharge \ndate.", "doc_id": "69f65619-31a5-436e-8514-5a3358d7cc8a", "embedding": null, "doc_hash": "8f9794c59a413a310fa761ac3cf3e56acc9d876c220afa4f1b94c97492c0fcf3", "extra_info": {"page_label": "159", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2730, "_node_type": "1"}, "relationships": {"1": "f2e4249d-e15d-405f-97f6-d8018e31a218"}}, "__type__": "1"}, "a339d175-9f2f-4286-8df8-b827aa8052e4": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 160\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2013If you miss the deadline for contacting the Quality Improvement Organization, and you still wish to \nappeal, you must make an appeal directly to our plan instead. For details about this other way to make \nyour appeal, see Section 7.4.\nOnce you request an immediate review of your hospital discharge the Quality Improvement Organization will \ncontact us. By noon of the day after we are contacted, we will give you a Detailed Notice of Discharge. This notice \ngives your planned discharge date and explains in detail the reasons why your doctor, the hospital, and we think it \nis right (medically appropriate) for you to be discharged on that date.\nYou can get a sample of the Detailed Notice of Discharge by calling Customer Care or 1-800-MEDICARE \n(1-800-633-4227), 24 hours a day, 7 days a week. (TTY users should call 1-877-486-2048.) Or you can see a \nsample notice online at \nwww.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.\nStep 2: The Quality Improvement Organization conducts an independent review of your case.\n\u2022Health professionals at the Quality Improvement Organization (\"the reviewers\") will ask you (or your \nrepresentative) why you believe coverage for the services should continue. You don't have to prepare \nanything in writing, but you may do so if you wish. \n\u2022The reviewers will also look at your medical information, talk with your doctor, and review information that \nthe hospital and we have given to them.\n\u2022By noon of the day after the reviewers told us of your appeal, you will get a written notice from us that gives \nyour planned discharge date. This notice also explains in detail the reasons why your doctor, the hospital, \nand we think it is right (medically appropriate) for you to be discharged on that date.\nStep 3: Within one full day after it has all the needed information, the Quality Improvement Organization \nwill give you its answer to your appeal.\nWhat happens if the answer is yes?\n\u2022If the review organization says yes, we must keep providing your covered inpatient hospital services \nfor as long as these services are medically necessary. \n\u2022You will have to keep paying your share of the costs (such as deductibles or copayments if these apply). In \naddition, there may be limitations on your covered hospital services.\nWhat happens if the answer is no?\n\u2022If the review organization says no, they are saying that your planned discharge date is medically \nappropriate. If this happens, our coverage for your inpatient hospital services will end at noon on the \nday after the Quality Improvement Organization gives you its answer to your appeal. \n\u2022If the review organization says no to your appeal and you decide to stay in the hospital, then you may \nhave to pay the full cost of hospital care you receive after noon on the day after the Quality \nImprovement Organization gives you its answer to your appeal.\nStep 4: If the answer to your Level 1 appeal is no, you decide if you want to make another appeal.\n\u2022If the Quality Improvement Organization has said no to your appeal, and you stay in the hospital after your \nplanned discharge date, then you can make another appeal. Making another appeal means you are going on \nto \"Level 2\" of the appeals process.", "doc_id": "a339d175-9f2f-4286-8df8-b827aa8052e4", "embedding": null, "doc_hash": "827964a421a3eaa463b9821caa09150a6dc30b3ddfd46c37f782c0ab4dd86d54", "extra_info": {"page_label": "160", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3402, "_node_type": "1"}, "relationships": {"1": "df0bc6fe-91d7-4636-8ca4-3cb82145452c"}}, "__type__": "1"}, "5c356633-8bd2-4c3b-96cd-dc3090a51ee2": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 161\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSection 7.3 Step-by-step: How to make a Level 2 appeal to change your hospital  \ndischarge date\nDuring a Level 2 appeal, you ask the Quality Improvement Organization to take another look at their decision on \nyour first appeal. If the Quality Improvement Organization turns down your Level 2 appeal, you may have to pay \nthe full cost for your stay after your planned discharge date.\nStep 1: Contact the Quality Improvement Organization again and ask for another review.\n\u2022You must ask for this review within 60 calendar days after the day the Quality Improvement Organization \nsaid no to your Level 1 appeal. You can ask for this review only if you stay in the hospital after the date that \nyour coverage for the care ended.\nStep 2: The Quality Improvement Organization does a second review of your situation.\n\u2022Reviewers at the Quality Improvement Organization will take another careful look at all of the information \nrelated to your appeal.\nStep 3: Within 14 calendar days of receipt of your request for a Level 2 appeal, the reviewers will decide on \nyour appeal and tell you their decision.\nIf the review organization says yes:\n\u2022We must reimburse you for our share of the costs of hospital care you have received since noon on the \nday after the date your first appeal was turned down by the Quality Improvement Organization. We must \ncontinue providing coverage for your inpatient hospital care for as long as it is medically necessary. \n\u2022You must continue to pay your share of the costs and coverage limitations may apply.\nIf the review organization says no:\n\u2022It means they agree with the decision they made on your Level 1 appeal. This is called \"upholding the \ndecision.\" \n\u2022The notice you get will tell you in writing what you can do if you wish to continue with the review process.\nStep 4: If the answer is no, you will need to decide whether you want to take your appeal further by going \non to Level 3.\n\u2022There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If you \nwant to go to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level \n2 appeal decision.\n\u2022The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 in this \nchapter tells more about Levels 3, 4, and 5 of the appeals process.", "doc_id": "5c356633-8bd2-4c3b-96cd-dc3090a51ee2", "embedding": null, "doc_hash": "b8b8961a0e199dcbfc4a4ae811424615d192ba1edda2e132083c488be3f08f79", "extra_info": {"page_label": "161", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2506, "_node_type": "1"}, "relationships": {"1": "1b6692f0-8a9d-41a3-a424-2ab79a89e903"}}, "__type__": "1"}, "d035fb34-e0bd-4473-b28c-e077f6366d26": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 162\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSection 7.4 What if you miss the deadline for making your Level 1 appeal?\nLegal Terms\nA \"fast review\" (or \"fast appeal\") is also called an \"expedited appeal.\"\nYou can appeal to us instead\nAs explained above, you must act quickly to start your Level 1 appeal of your hospital discharge date. If you miss \nthe deadline for contacting the Quality Improvement Organization, there is another way to make your appeal. \nIf you use this other way of making your appeal, the first two levels of appeal are different. \nStep-by-Step: How to make a Level 1 Alternate Appeal \nStep 1: Contact us and ask for a \"fast review.\"\n\u2022Ask for a \"fast review.\" This means you are asking us to give you an answer using the \"fast\" deadlines \nrather than the \"standard\" deadlines. Chapter 2 has contact information.\nStep 2: We do a \"fast review\" of your planned discharge date, checking to see if it was medically \nappropriate.\n\u2022During this review, we take a look at all of the information about your hospital stay. We check to see if your \nplanned discharge date was medically appropriate. We see if the decision about when you should leave \nthe hospital was fair and followed all the rules.\nStep 3: We give you our decision within 72 hours after you ask for a \"fast review.\"\n\u2022If we say yes to your fast appeal, it means we have agreed with you that you still need to be in the \nhospital after the discharge date. We will keep providing your covered inpatient hospital services for as \nlong as it is medically necessary. It also means that we have agreed to reimburse you for our share of the \ncosts of care you have received since the date when we said your coverage would end. (You must pay \nyour share of the costs and there may be coverage limitations that apply.)\n\u2022If we say no to your fast appeal, we are saying that your planned discharge date was medically \nappropriate. Our coverage for your inpatient hospital services ends as of the day we said coverage would \nend.\n\u2013If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost \nof hospital care you received after the planned discharge date.\nStep 4: If we say no to your appeal, your case will automatically be sent on to the next level of the appeals \nprocess.\nStep-by-Step: Level 2 Alternate Appeal Process", "doc_id": "d035fb34-e0bd-4473-b28c-e077f6366d26", "embedding": null, "doc_hash": "4d552aa934fce7e7e597a7814fb38653f18a208fd734a2226efdcb64e1d28807", "extra_info": {"page_label": "162", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2453, "_node_type": "1"}, "relationships": {"1": "4532fb0b-cf8b-4269-b405-503f8fb21bfb"}}, "__type__": "1"}, "4d64e628-d162-4f7f-b951-aab596d6ac8a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 163\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nLegal Terms\nThe formal name for the \"independent review organization\" is the \"Independent Review Entity.\" It is  \nsometimes called the \"IRE.\"\nThe independent review organization is an independent organization hired by Medicare. It is not connected \nwith our plan and is not a government agency. This organization decides whether the decision we made is correct \nor if it should be changed. Medicare oversees its work.\nStep 1: We will automatically forward your case to the independent review organization.\n\u2022We are required to send the information for your Level 2 appeal to the independent review organization \nwithin 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not \nmeeting this deadline or other deadlines, you can make a complaint. Section 10 of this chapter tells how to \nmake a complaint.)\nStep 2: The independent review organization does a \"fast review\" of your appeal. The reviewers give you an \nanswer within 72 hours.\n\u2022Reviewers at the independent review organization will take a careful look at all of the information related to \nyour appeal of your hospital discharge. \n\u2022If this organization says yes to your appeal, then we must pay you back for our share of the costs of \nhospital care you received since the date of your planned discharge. We must also continue the plan's \ncoverage of your inpatient hospital services for as long as it is medically necessary. You must continue to pay \nyour share of the costs. If there are coverage limitations, these could limit how much we would reimburse or \nhow long we would continue to cover your services.\n\u2022If this organization says no to your appeal, it means they agree that your planned hospital discharge date \nwas medically appropriate.\n\u2013The written notice you get from the independent review organization will tell how to start a Level 3 appeal \nwith the review process, which is handled by an Administrative Law Judge or attorney adjudicator.\nStep 3: If the independent review organization turns down your appeal, you choose whether you want to \ntake your appeal further.\n\u2022There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If \nreviewers say no to your Level 2 appeal, you decide whether to accept their decision or go on to Level 3 \nappeal.\n\u2022Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.\nSECTION 8 How to ask us to keep covering certain medical services if you  \nthink your coverage is ending too soon\nSection 8.1This section is only about three services:\nHome health care, skilled nursing facility care, and Comprehensive  \nOutpatient Rehabilitation Facility (CORF) services", "doc_id": "4d64e628-d162-4f7f-b951-aab596d6ac8a", "embedding": null, "doc_hash": "e15036e86785139319010d4f67582802ad7004f0136b6b6c2cf9d0c923182413", "extra_info": {"page_label": "163", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2855, "_node_type": "1"}, "relationships": {"1": "ca0defeb-721d-472e-ba3e-e8c97b63728d"}}, "__type__": "1"}, "315b0654-5bc1-4674-8414-2c3e87a31f7a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 164\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nWhen you are getting home health services, skilled nursing care, or rehabilitation care (Comprehensive \nOutpatient Rehabilitation Facility), you have the right to keep getting your covered services for that type of care \nfor as long as the care is needed to diagnose and treat your illness or injury.\nWhen we decide it is time to stop covering any of the three types of care for you, we are required to tell you in \nadvance. When your coverage for that care ends, we will stop paying our share of the cost for your care. \nIf you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you \nhow to ask for an appeal.\nSection 8.2 We will tell you in advance when your coverage will be ending\nLegal Term\n\"Notice of Medicare Non-Coverage.\" It tells you how you can request a \"fast-track appeal.\" Requesting a  \nfast-track appeal is a formal, legal way to request a change to our coverage decision about when to stop your  \ncare.\n1. You receive a notice in writing at least two days before our plan is going to stop covering your care. The \nnotice tells you:\n\u2022The date when we will stop covering the care for you. \n\u2022How to request a \"fast track appeal\" to request us to keep covering your care for a longer period of time.\n2. You, or someone who is acting on your behalf, will be asked to sign the written notice to show that you \nreceived it. Signing the notice shows only that you have received the information about when your coverage \nwill stop. Signing it does not mean you agree with the plan\u2019s decision to stop care.\nSection 8.3 Step-by-step: How to make a Level 1 appeal to have our plan cover your  \ncare for a longer time\nIf you want to ask us to cover your care for a longer period of time, you will need to use the appeals process to \nmake this request. Before you start, understand what you need to do and what the deadlines are.\n\u2022Follow the process.\n\u2022Meet the deadlines.\n\u2022Ask for help if you need it. If you have questions or need help at any time, please call Customer Care. Or call \nyour State Health Insurance Assistance Program, a government organization that provides personalized \nassistance.\nDuring a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It decides if the end \ndate for your care is medically appropriate.\nThe Quality Improvement Organization is a group of doctors and other health care experts paid by the Federal \ngovernment to check on and help improve the quality of care for people with Medicare. This includes reviewing ", "doc_id": "315b0654-5bc1-4674-8414-2c3e87a31f7a", "embedding": null, "doc_hash": "ceb53152e0073cac778c699ea2667e4b8bf81bb120071cbc780c9693a885c9a0", "extra_info": {"page_label": "164", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2693, "_node_type": "1"}, "relationships": {"1": "a7a37174-b2de-4619-83cb-e3b5b2880308"}}, "__type__": "1"}, "3d0ba866-d086-4bd5-870d-5b2f92d40455": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 165\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nplan decisions about when it\u2019s time to stop covering certain kinds of medical care. These experts are not part of our \nplan.\nStep 1: Make your Level 1 appeal: contact the Quality Improvement Organization and ask for a fast-track \nappeal. You must act quickly.\nHow can you contact this organization?\n\u2022The written notice you received (Notice of Medicare Non-Coverage) tells you how to reach this organization. \nOr find the name, address, and phone number of the Quality Improvement Organization for your state in \nChapter 2.\nAct quickly:\n\u2022You must contact the Quality Improvement Organization to start your appeal by noon of the day before \nthe effective date on the Notice of Medicare Non-Coverage.\nYour deadline for contacting this organization.\n\u2022If you miss the deadline for contacting the Quality Improvement Organization, and you still wish to file an \nappeal, you must make an appeal directly to us instead. For details about this other way to make your \nappeal, see Section 8.5.\nStep 2: The Quality Improvement Organization conducts an independent review of your case.\nLegal Terms\n\"Detailed Explanation of Non-Coverage.\" Notice that provides details on reasons for ending coverage.\nWhat happens during this review?\n\u2022Health professionals at the Quality Improvement Organization (\"the reviewers\") will ask you (or your \nrepresentative) why you believe coverage for the services should continue. You don\u2019t have to prepare \nanything in writing, but you may do so if you wish. \n\u2022The review organization will also look at your medical information, talk with your doctor, and review \ninformation that our plan has given to them.\n\u2022By the end of the day the reviewers tell us of your appeal, and you will get the Detailed Explanation of \nNon-Coverage from us that explains in detail our reasons for ending our coverage for your services. \nStep 3: Within one full day after they have all the information they need, the reviewers will tell you their \ndecision.\nWhat happens if the reviewers say yes?\n\u2022If the reviewers say yes to your appeal, then we must keep providing your covered services for as long \nas it is medically necessary.\n\u2022You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). \nThere may be limitations on your covered services.\nWhat happens if the reviewers say no?", "doc_id": "3d0ba866-d086-4bd5-870d-5b2f92d40455", "embedding": null, "doc_hash": "c03814a1a101150706d2a7e1c4fd18c0bc6d0c9bd87339546022b3f6931bc9ec", "extra_info": {"page_label": "165", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2491, "_node_type": "1"}, "relationships": {"1": "a650ba24-99fa-4529-a655-6a9758b749b4"}}, "__type__": "1"}, "6582dcb7-595e-40a3-a6c0-1aadef7ddf84": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 166\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022If the reviewers say no, then your coverage will end on the date we have told you.\n\u2022If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive \nOutpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, then you will \nhave to pay the full cost of this care yourself.\nStep 4: If the answer to your Level 1 appeal is no, you decide if you want to make another appeal.\n\u2022If reviewers say no to your Level 1 appeal \u2013 and you choose to continue getting care after your coverage \nfor the care has ended \u2013 then you can make a Level 2 appeal.\nSection 8.4 Step-by-step: How to make a Level 2 appeal to have our plan cover your  \ncare for a longer time\nDuring a Level 2 appeal, you ask the Quality Improvement Organization to take another look at the decision on \nyour first appeal. If the Quality Improvement Organization turns down your Level 2 appeal, you may have to pay \nthe full cost for your home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation \nFacility (CORF) services after the date when we said your coverage would end.\nStep 1: Contact the Quality Improvement Organization again and ask for another review.\n\u2022You must ask for this review within 60 days after the day when the Quality Improvement Organization \nsaid no to your Level 1 appeal. You can ask for this review only if you continued getting care after the date \nthat your coverage for the care ended.\nStep 2: The Quality Improvement Organization does a second review of your situation.\n\u2022Reviewers at the Quality Improvement Organization will take another careful look at all of the information \nrelated to your appeal.\nStep 3: Within 14 days of receipt of your appeal request, reviewers will decide on your appeal and tell you \ntheir decision.\nWhat happens if the review organization says yes?\n\u2022We must reimburse you for our share of the costs of care you have received since the date when we said \nyour coverage would end. We must continue providing coverage for the care for as long as it is medically \nnecessary.\n\u2022You must continue to pay your share of the costs and there may be coverage limitations that apply.\nWhat happens if the review organization says no?\n\u2022It means they agree with the decision we made to your Level 1 appeal and will not change it. \n\u2022The notice you get will tell you in writing what you can do if you wish to continue with the review process. \nIt will give you the details about how to go on to the next level of appeal, which is handled by an \nAdministrative Law Judge or attorney adjudicator.\nStep 4: If the answer is no, you will need to decide whether you want to take your appeal further.", "doc_id": "6582dcb7-595e-40a3-a6c0-1aadef7ddf84", "embedding": null, "doc_hash": "1b294c88fe0331856c5e18960246c17eee44100d7a81c898001add2bf350597d", "extra_info": {"page_label": "166", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2864, "_node_type": "1"}, "relationships": {"1": "9aaafd07-0dbe-46de-a807-db2bddb5a1ef"}}, "__type__": "1"}, "c1e0c52a-c5b5-4370-b827-d53c2b3a867c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 167\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If you want to go \non to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 \nappeal decision.\n\u2022The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 in this \nchapter tells more about Levels 3, 4, and 5 of the appeals process.\nSection 8.5 What if you miss the deadline for making your Level 1 appeal?\nYou can appeal to us instead\nAs explained above, you must act quickly to contact the Quality Improvement Organization to start your first \nappeal (within a day or two, at the most). If you miss the deadline for contacting this organization, there is another \nway to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different.\nStep-by-Step: How to make a Level 1 Alternate Appeal\nLegal Terms\nA \"fast review\" (or \"fast appeal\") is also called an \"expedited appeal.\"\nStep 1: Contact us and ask for a \"fast review.\"\n\u2022Ask for a \"fast review.\" This means you are asking us to give you an answer using the \"fast\" deadlines rather \nthan the \"standard\" deadlines. Chapter 2 has contact information.\nStep 2: We do a \"fast review\" of the decision we made about when to end coverage for your services.\n\u2022During this review, we take another look at all of the information about your case. We check to see if we were \nfollowing all the rules when we set the date for ending the plan's coverage for services you were receiving.\nStep 3: We give you our decision within 72 hours after you ask for a \"fast review\".\n\u2022If we say yes to your fast appeal, it means we have agreed with you that you need services longer, and will \nkeep providing your covered services for as long as it is medically necessary. It also means that we have \nagreed to reimburse you for our share of the costs of care you have received since the date when we said \nyour coverage would end. (You must pay your share of the costs and there may be coverage limitations that \napply.) \n\u2022If we say no to your fast appeal, then your coverage will end on the date we told you and we will not pay \nany share of the costs after this date.\n\u2022If you continued to get home health care, or skilled nursing facility care, or Comprehensive Outpatient \nRehabilitation Facility (CORF) services after the date when we said your coverage would end, then you will \nhave to pay the full cost of this care.\nStep 4: If we say no to your fast appeal, your case will automatically go on to the next level of the appeals \nprocess.", "doc_id": "c1e0c52a-c5b5-4370-b827-d53c2b3a867c", "embedding": null, "doc_hash": "e2f5c3afc8a789fef020ebd8462d7f39d78bbde4170d9c727c31e753280ddcdc", "extra_info": {"page_label": "167", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2765, "_node_type": "1"}, "relationships": {"1": "a7bd2634-f8bb-4d1b-ac1b-35dfa5812c95"}}, "__type__": "1"}, "6a611048-b180-40c6-bd2a-02336d3e8f15": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 168\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nLegal Terms\nThe formal name for the \"independent review organization\" is the \"Independent Review Entity.\" It is  \nsometimes called the \"IRE.\"\nStep-by-Step: Level 2 Alternate appeal Process\nDuring the Level 2 appeal, the independent review organization reviews the decision we made to your \"fast \nappeal.\" This organization decides whether the decision should be changed. The independent review \norganization is an independent organization that is hired by Medicare. This organization is not connected with \nour plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job \nof being the independent review organization. Medicare oversees its work.\nStep 1: We will automatically forward your case to the independent review organization.\n\u2022We are required to send the information for your Level 2 appeal to the independent review organization \nwithin 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not \nmeeting this deadline or other deadlines, you can make a complaint. Section 10 of this chapter tells how to \nmake a complaint.)\nStep 2: The independent review organization does a \"fast review\" of your appeal. The reviewers give you an \nanswer within 72 hours.\n\u2022Reviewers at the independent review organization will take a careful look at all of the information related to \nyour appeal. \n\u2022If this organization says yes to your appeal, then we must pay you back for our share of the costs of care \nyou have received since the date when we said your coverage would end. We must also continue to cover \nthe care for as long as it is medically necessary. You must continue to pay your share of the costs. If there are \ncoverage limitations, these could limit how much we would reimburse or how long we would continue to \ncover your services. \n\u2022If this organization says no to your appeal, it means they agree with the decision our plan made to your \nfirst appeal and will not change it. \n\u2022The notice you get from the independent review organization will tell you in writing what you can do if you \nwish to go on to a Level 3 appeal.\nStep 3: If the independent review organization says no to your appeal, you choose whether you want to take \nyour appeal further.\n\u2022There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If you want to go \non to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal \ndecision. \n\u2022A level 3 appeal is reviewed by an Administrative Law Judge or attorney adjudicator. Section 9 in this chapter \ntells more about Levels 3, 4, and 5 of the appeals process.", "doc_id": "6a611048-b180-40c6-bd2a-02336d3e8f15", "embedding": null, "doc_hash": "eb90671ecd8e2fd8a553bc0cfef20028eb2d618f12580aae82e60dfffaeaf4fc", "extra_info": {"page_label": "168", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2831, "_node_type": "1"}, "relationships": {"1": "d34d95b8-067b-42f3-b33c-37f03d4c5084"}}, "__type__": "1"}, "350e660c-cc0a-4404-9499-c244ad0d4894": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 169\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSECTION 9 Taking your appeal to Level 3 and beyond\nSection 9.1 Appeal Levels 3, 4 and 5 for Medical Service Requests\nThis section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal, and both of your \nappeals have been turned down.\nIf the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be \nable to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal \nany further. The written response you receive to your Level 2 appeal will explain how to make a Level 3 appeal.\nFor most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who \nhandles the review of your appeal at each of these levels. \nLevel 3 appeal:An Administrative Law Judge or an attorney adjudicator who works for the Federal  \ngovernment will review your appeal and give you an answer.\n\u2022If the Administrative Law Judge or attorney adjudicator says yes to your appeal, the appeals process \nmay or may not be over. Unlike a decision at Level 2 appeal, we have the right to appeal a Level 3 decision \nthat is favorable to you. If we decide to appeal, it will go to a Level 4 appeal.\n\u2013If we decide not to appeal, we must authorize or provide you with the service within 60 calendar days after \nreceiving the Administrative Law Judge\u2019s or attorney adjudicator\u2019s decision.\n\u2013If we decide to appeal the decision, we will send you a copy of the Level 4 appeal request with any \naccompanying documents. We may wait for the Level 4 appeal decision before authorizing or providing \nthe service in dispute.\n\u2022If the Administrative Law Judge or attorney adjudicator says no to your appeal, the appeals process \nmay or may not be over. \n\u2013If you decide to accept this decision that turns down your appeal, the appeals process is over. \n\u2013If you do not want to accept the decision, you can continue to the next level of the review process. The \nnotice you get will tell you what to do for a Level 4 appeal. \nLevel 4 appeal: The Medicare Appeals Council (Council) will review your appeal and give you an answer. The  \nCouncil is part of the Federal government.\n\u2022If the answer is yes, or if the Council denies our request to review a favorable Level 3 appeal decision, \nthe appeals process may or may not be over. Unlike a decision at Level 2, we have the right to appeal a \nLevel 4 decision that is favorable to you. We will decide whether to appeal this decision to Level 5.\n\u2013If we decide not to appeal the decision, we must authorize or provide you with the service within 60 \ncalendar days after receiving the Council's decision.\n\u2013If we decide to appeal the decision, we will let you know in writing.\n\u2022If the answer is no or if the Council denies the review request, the appeals process may or may not be \nover.", "doc_id": "350e660c-cc0a-4404-9499-c244ad0d4894", "embedding": null, "doc_hash": "c35f3ff4bc3b9590b412fcfca110ff15a6f677ae7b6d95c08ce5ba8b1ca21c93", "extra_info": {"page_label": "169", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3007, "_node_type": "1"}, "relationships": {"1": "c5600311-5653-473d-9907-f058f7dc1ef7"}}, "__type__": "1"}, "02b27095-f917-4771-a801-c877a05f42cd": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 170\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2013If you decide to accept this decision that turns down your appeal, the appeals process is over.\n\u2013If you do not want to accept the decision, you may be able to continue to the next level of the review \nprocess. If the Council says no to your appeal, the notice you get will tell you whether the rules allow you \nto go on to a Level 5 appeal and how to continue with a Level 5 appeal. \nLevel 5 appeal: A judge at the Federal District Court will review your appeal. \n\u2022A judge will review all of the information and decide yes or no to your request. This is a final answer. There are \nno more appeal levels after the Federal District Court.\nSection 9.2 Appeal Levels 3, 4 and 5 for Part D Drug Requests\nThis section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal, and both of your \nappeals have been turned down.\nIf the value of the drug you have appealed meets a certain dollar amount, you may be able to go on to additional \nlevels of appeal. If the dollar amount is less, you cannot appeal any further. The written response you receive to \nyour Level 2 appeal will explain who to contact and what to do to ask for a Level 3 appeal.\nFor most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who \nhandles the review of your appeal at each of these levels.\nLevel 3 appeal:An Administrative Law Judge or an attorney adjudicator who works for the Federal  \ngovernment will review your appeal and give you an answer.\n\u2022If the answer is yes, the appeals process is over. We must authorize or provide the drug coverage that \nwas approved by the Administrative Law Judge or attorney adjudicator within 72 hours (24 hours for \nexpedited appeals) or make payment no later than 30 calendar days after we receive the decision.\n\u2022If the answer is no, the appeals process may or may not be over. \n\u2013If you decide to accept this decision that turns down your appeal, the appeals process is over. \n\u2013If you do not want to accept the decision, you can continue to the next level of the review process. The \nnotice you get will tell you what to do for a Level 4 appeal.\nLevel 4 appeal The Medicare Appeals Council (Council) will review your appeal and give you an answer. The  \nCouncil is part of the Federal government.\n\u2022If the answer is yes, the appeals process is over. We must authorize or provide the drug coverage that \nwas approved by the Council within 72 hours (24 hours for expedited appeals) or make payment no later \nthan 30 calendar days after we receive the decision.\n\u2022If the answer is no, the appeals process may or may not be over.\n\u2013If you decide to accept this decision that turns down your appeal, the appeals process is over.\n\u2013If you do not want to accept the decision, you may be able to continue to the next level of the review \nprocess. If the Council says no to your appeal or denies your request to review the appeal, the notice you ", "doc_id": "02b27095-f917-4771-a801-c877a05f42cd", "embedding": null, "doc_hash": "266cf08d4885581d2129f6d7e2b7325636f29790355a05574139b993176fb92e", "extra_info": {"page_label": "170", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3086, "_node_type": "1"}, "relationships": {"1": "f82acea8-6960-4f77-a05c-8f0c29235005"}}, "__type__": "1"}, "3ac32094-2721-4188-99f0-daeee4218072": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 171\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nget will tell you whether the rules allow you to go on to a Level 5 appeal. It will also tell you who to contact \nand what to do next if you choose to continue with your appeal.\nLevel 5 appeal A judge at the Federal District Court will review your appeal. \n\u2022A judge will review all of the information and decide yes or no to your request. This is a final answer. There are \nno more appeal levels after the Federal District Court.\nMAKING COMPLAINTS\nSECTION 10 How to make a complaint about quality of care, waiting times,  \ncustomer service, or other concerns\nSection 10.1 What kinds of problems are handled by the complaint process?\nThe complaint process is only used for certain types of problems. This includes problems related to quality of care, \nwaiting times, and the customer service. Here are examples of the kinds of problems handled by the complaint \nprocess.\nComplaint Example\nQuality of your  \nmedical care\u2022Are you unhappy with the quality of the care you have received (including care in the  \nhospital)?\nRespecting your  \nprivacy\u2022Did someone not respect your right to privacy or share confidential information?\nDisrespect, poor  \ncustomer service, or  \nother negative  \nbehaviors\u2022Has someone been rude or disrespectful to you?\n\u2022Are you unhappy with our Customer Care?\n\u2022Do you feel you are being encouraged to leave the plan?\nWaiting times \u2022Are you having trouble getting an appointment, or waiting too long to get it?\n\u2022Have you been kept waiting too long by doctors, pharmacists, or other health  \nprofessionals? Or by our Customer Care or other staff at the plan?\n\u2013Examples include waiting too long on the phone, in the waiting or exam room, or  \ngetting a prescription.\nCleanliness \u2022Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor's  \noffice?\nInformation you get  \nfrom us\u2022Did we fail to give you a required notice?\n\u2022Is our written information hard to understand?", "doc_id": "3ac32094-2721-4188-99f0-daeee4218072", "embedding": null, "doc_hash": "89ee5d4bcd0610ee5b457f48dfa86a2b75c734218b1d16d493da8f9be7f687c6", "extra_info": {"page_label": "171", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2080, "_node_type": "1"}, "relationships": {"1": "80a4a387-9259-4822-833d-f441f61427c0"}}, "__type__": "1"}, "5ddd90b6-0ef1-4a86-b1bc-866f8a652e91": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 172\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nComplaint Example\nTimeliness \n(These types of  \ncomplaints are all  \nrelated to the  \ntimeliness of our  \nactions related to  \ncoverage decisions  \nand appeals)If you have asked for a coverage decision or made an appeal, and you think that we are  \nnot responding quickly enough, you can also make a complaint about our slowness.  \nHere are examples:\n\u2022You asked us for a \"fast coverage decision\" or a \"fast appeal,\" and we have said no;  \nyou can make a complaint.\n\u2022You believe we are not meeting the deadlines for coverage decisions or appeals; you  \ncan make a complaint.\n\u2022You believe we are not meeting deadlines for covering or reimbursing you for certain  \nmedical services or drugs that were approved; you can make a complaint.\n\u2022You believe we failed to meet required deadlines for forwarding your case to the  \nindependent review organization; you can make a complaint.\nSection 10.2 How to make a complaint\nLegal Terms\n\u2022A \"complaint\" is also called a \"grievance.\" \n\u2022\"Making a complaint\" is also called \"filing a grievance.\" \n\u2022\"Using the process for complaints\" is also called \"using the process for filing a grievance.\"\n\u2022A \"fast complaint\" is also called an \"expedited grievance.\"\nSection 10.3 Step-by-step: Making a complaint\nStep 1: Contact us promptly \u2013 either by phone or in writing.\n\u2022Usually, calling Customer Care is the first step. If there is anything else you need to do, Customer Care will \nlet you know. Call 1-800-457-4708, TTY 711, from 8 a.m. to 8 p.m. seven days a week from Oct. 1 - Mar. 31 \nand 8 a.m. to 8 p.m. Monday-Friday from Apr. 1 - Sept. 30. \n\u2022If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing \nand send it to us. If you put your complaint in writing, we will respond to your complaint in writing.\n\u2022Grievance Filing Instructions\nFile a verbal grievance by calling Customer Care at 1-800-457-4708 TTY 711.\nSend a written grievance to:\nHumana Grievances and Appeals Dept. \nP.O. Box 14165 \nLexington, KY 40512\u20134165", "doc_id": "5ddd90b6-0ef1-4a86-b1bc-866f8a652e91", "embedding": null, "doc_hash": "3778b2177e09326885a3a8e887b19eb4f42764c7ef300e1f98ddb1997040e6da", "extra_info": {"page_label": "172", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2164, "_node_type": "1"}, "relationships": {"1": "5042599c-c5b2-41c4-865f-294fd1925747"}}, "__type__": "1"}, "6d31e838-0687-4217-bea7-3fb781aa3955": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 173\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nWhen filing a grievance, please provide:\n  Name\n  Address\n  Telephone number\n  Member identification number\n  A summary of the complaint and any previous contact with us related to the complaint\n  The action you are requesting from us\nA signature from you or your authorized representative and the date. If you want a friend, relative, your  \ndoctor or other provider, or other person to be your representative, call Customer Care and ask for the  \n\"Appointment of Representative\" form. (The form is also available on Medicare's website at \nhttps://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf). The form gives that  \nperson permission to act on your behalf. It must be signed by you and by the person who you would like  \nto act on your behalf. You must give us a copy of the signed form.\n\u2022The deadline for making a complaint is 60 calendar days from the time you had the problem you want to \ncomplain about.\nStep 2: We look into your complaint and give you our answer.\n\u2022If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an \nanswer on the same phone call.\n\u2022Most complaints are answered within 30 calendar days. If we need more information and the delay is in \nyour best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days \ntotal) to answer your complaint. If we decide to take extra days, we will tell you in writing.\n\u2022If you are making a complaint because we denied your request for a \"fast coverage decision\" or a \"fast \nappeal,\" we will automatically give you a \"fast complaint.\" If you have a \"fast complaint,\" it means we \nwill give you an answer within 24 hours.\n\u2022If we do not agree with some or all of your complaint or don\u2019t take responsibility for the problem you are \ncomplaining about, we will include our reasons in our response to you.\nSection 10.4 You can also make complaints about quality of care to the Quality  \nImprovement Organization\nWhen your complaint is about quality of care, you also have two extra options: \n\u2022You can make your complaint directly to the Quality Improvement Organization. The Quality \nImprovement Organization is a group of practicing doctors and other health care experts paid by the Federal \ngovernment to check and improve the care given to Medicare patients. Chapter 2 has contact information.\n                                                                                                         Or\n\u2022You can make your complaint to both the Quality Improvement Organization and us at the same time.", "doc_id": "6d31e838-0687-4217-bea7-3fb781aa3955", "embedding": null, "doc_hash": "e06a0012501f84f79d3deea9c761d982dcb29c178bfdfb5e982b8b80c3adda6e", "extra_info": {"page_label": "173", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2729, "_node_type": "1"}, "relationships": {"1": "2e6e0ddb-3fb5-43f6-8ff2-6ff2db2bc415"}}, "__type__": "1"}, "086d644f-2fa3-4f06-89a8-eaed7cd72d66": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 174\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSection 10.5 You can also tell Medicare about your complaint\nYou can submit a complaint about Humana Gold Plus H0028-014 (HMO) directly to Medicare. To submit a \ncomplaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. You may also call \n1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048. ", "doc_id": "086d644f-2fa3-4f06-89a8-eaed7cd72d66", "embedding": null, "doc_hash": "5131b4735036f72b438006ab59c03659550c32323f355c0a9618cc5b346f5dfc", "extra_info": {"page_label": "174", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 498, "_node_type": "1"}, "relationships": {"1": "97fe2a42-c7f5-4791-ad62-fed15a8a09af"}}, "__type__": "1"}, "46b636c7-e330-44a9-9aa0-780a8766a29f": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 175\nChapter 10. Ending your membership in the planEOC082\nCHAPTER 10:\nEnding your membership in the plan", "doc_id": "46b636c7-e330-44a9-9aa0-780a8766a29f", "embedding": null, "doc_hash": "ff66f4f481d9345d245ef91800e6f6ba20370adbb2d8b6c7b4823a8db6b7eee2", "extra_info": {"page_label": "175", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 166, "_node_type": "1"}, "relationships": {"1": "c47da29f-03e2-4faf-8ef2-3ac153b0b948"}}, "__type__": "1"}, "cd21c50f-3f89-4a54-b70f-7407feb6c49d": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 176\nChapter 10. Ending your membership in the plan\nSECTION 1 Introduction to ending your membership in our plan\nEnding your membership in Humana Gold Plus H0028-014 (HMO) may be voluntary (your own choice) or \ninvoluntary (not your own choice):\n\u2022You might leave our plan because you have decided that you want to leave. Section 2 and 3 provide information \non ending your membership voluntarily.\n\u2022There are also limited situations where we are required to end your membership. Section 5 tells you about \nsituations when we must end your membership.\nIf you are leaving our plan, our plan must continue to provide your medical care and prescription drugs and you will \ncontinue to pay your cost share until your membership ends.\nSECTION 2 When can you end your membership in our plan?\nSection 2.1 You can end your membership during the Annual Enrollment Period\nYou can end your membership during the Annual Enrollment Period (also known as the \"Annual Open Enrollment \nPeriod\"). During this time, review your health and drug coverage and decide about your coverage for the upcoming \nyear.\n\u2022The Annual Enrollment Period is from October 15 to December 7.\n\u2022Choose to keep your current coverage or make changes to your coverage for the upcoming year. If you \ndecide to change to a new plan, you can choose any of the following types of plans:\n\u2013Another Medicare health plan, with or without prescription drug coverage.\n\u2013Original Medicare with a separate Medicare prescription drug plan.\n\u2013Original Medicare without a separate Medicare prescription drug plan.\n>If you choose this option, Medicare may enroll you in a drug plan, unless you have opted out of automatic \nenrollment.\nNote: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug \ncoverage for 63 or more days in a row, you may have to pay a Part D late enrollment penalty if you join a \nMedicare drug plan later. \n\u2022Your membership will end in our plan when your new plan's coverage begins on January 1.\nSection 2.2 You can end your membership during the Medicare Advantage Open  \nEnrollment Period\nYou have the opportunity to make one change to your health coverage during the Medicare Advantage Open \nEnrollment Period.", "doc_id": "cd21c50f-3f89-4a54-b70f-7407feb6c49d", "embedding": null, "doc_hash": "adfacf2b1bad8265b2355cdfae18ec9b4db1449fd159bf6ed292d2d279e59ae2", "extra_info": {"page_label": "176", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2283, "_node_type": "1"}, "relationships": {"1": "921179c8-13e4-4498-a53e-7da71168f8c1"}}, "__type__": "1"}, "0d9138ab-2b79-408f-9a80-d54b2858e3c0": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 177\nChapter 10. Ending your membership in the plan\n\u2022The annual Medicare Advantage Open Enrollment Period is from January 1 to March 31.\n\u2022During the annual Medicare Advantage Open Enrollment Period you can:\n\u2013Switch to another Medicare Advantage plan with or without prescription drug coverage.\n\u2013Disenroll from our plan and obtain coverage through Original Medicare. If you choose to switch to Original \nMedicare during this period, you can also join a separate Medicare prescription drug plan at that time.\n\u2022Your membership will end on the first day of the month after you enroll in a different Medicare Advantage plan \nor we get your request to switch to Original Medicare. If you also choose to enroll in a Medicare prescription drug \nplan, your membership in the drug plan will begin the first day of the month after the drug plan gets your \nenrollment request.\nSection 2.3 In certain situations, you can end your membership during a Special  \nEnrollment Period\nIn certain situations, members of Humana Gold Plus H0028-014 (HMO) may be eligible to end their membership at \nother times of the year. This is known as a Special Enrollment Period.\nYou may be eligible to end your membership during a Special Enrollment Period if any of the following \nsituations apply to you. These are just examples, for the full list you can contact the plan, call Medicare, or visit the \nMedicare website (www.medicare.gov):\n\u2022Usually, when you have moved.\n\u2022If you have Medicaid.\n\u2022If you are eligible for \"Extra Help\" with paying for your Medicare prescriptions.\n\u2022If we violate our contract with you.\n\u2022If you are getting care in an institution, such as a nursing home or long-term care (LTC) hospital.\n\u2022If you enroll in the Program of All-inclusive Care for the Elderly (PACE).\nNote: If you\u2019re in a drug management program, you may not be able to change plans. Chapter 5, Section 10 \ntells you more about drug management programs.\nThe enrollment periods vary depending on your situation.\nTo find out if you are eligible for a Special Enrollment Period, please call Medicare at 1-800-MEDICARE \n(1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048. If you are eligible to end your \nmembership because of a special situation, you can choose to change both your Medicare health coverage and \nprescription drug coverage. You can choose:\n\u2022Another Medicare health plan with or without prescription drug coverage.\n\u2022Original Medicare with a separate Medicare prescription drug plan.\n   OR\n\u2022Original Medicare without a separate Medicare prescription drug plan.", "doc_id": "0d9138ab-2b79-408f-9a80-d54b2858e3c0", "embedding": null, "doc_hash": "62630af1d3bc204747715191d78ed36a8d909a4f47a82c64f69814e9511e5970", "extra_info": {"page_label": "177", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2622, "_node_type": "1"}, "relationships": {"1": "820b7bb8-8cc0-4e8c-8361-b073814eccf6"}}, "__type__": "1"}, "2b8574ae-5832-4318-9b35-9bfe1848d4d3": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 178\nChapter 10. Ending your membership in the plan\nNote: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug \ncoverage for 63 days or more in a row, you may have to pay a Part D late enrollment penalty if you join a \nMedicare drug plan later.\nYour membership will usually end on the first day of the month after your request to change your plan is \nreceived.\nIf you receive \"Extra Help\" from Medicare to pay for your prescription drugs: If you switch to Original Medicare \nand do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you \nhave opted out of automatic enrollment.\nSection 2.4 Where can you get more information about when you can end your  \nmembership?\nIf you have any questions about ending your membership you can:\n\u2022Call Customer Care.\n\u2022You can find the information in the Medicare & You 2023 handbook.\n\u2022Contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. (TTY \n1-877-486-2048).", "doc_id": "2b8574ae-5832-4318-9b35-9bfe1848d4d3", "embedding": null, "doc_hash": "40f69c2d88bd7796d89a37c38630397da74d08f5166d5cde9677b72662ff060a", "extra_info": {"page_label": "178", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1091, "_node_type": "1"}, "relationships": {"1": "1a5bd254-3c5f-49e4-9bfa-0ea7c3d3b5d6"}}, "__type__": "1"}, "048e91f7-1f34-4108-8461-7357f411ec8c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 179\nChapter 10. Ending your membership in the plan\nSECTION 3 How do you end your membership in our plan?\nThe table below explains how you should end your membership in our plan.\nIf you would like to switch from our plan to: This is what you should do:\n\u2022Another Medicare health plan. \u2022Enroll in the new Medicare health plan.\n\u2022You will automatically be disenrolled from Humana \nGold Plus H0028-014 (HMO) when your new plan's \ncoverage begins.\n\u2022Original Medicare with a separate Medicare \nprescription drug plan.\u2022Enroll in the new Medicare prescription drug plan. \n\u2022You will automatically be disenrolled from Humana  \nGold Plus H0028-014 (HMO) when your new plan's  \ncoverage begins.\n\u2022Original Medicare without a separate Medicare \nprescription drug plan.\u2022Send us a written request to disenroll. Contact \nCustomer Care if you need more information on how \nto do this. \n\u2022You can also contact Medicare, at 1-800-MEDICARE \n(1-800-633-4227), 24 hours a day, 7 days a week, \nand ask to be disenrolled. TTY users should call \n1-877-486-2048.\n\u2022You will be disenrolled from Humana Gold Plus \nH0028-014 (HMO) when your coverage in Original \nMedicare begins.\nSECTION 4 Until your membership ends, you must keep getting your  \nmedical services and drugs through our plan\nUntil your membership ends, and your new Medicare coverage begins, you must continue to get your medical care \nand prescription drugs through our plan.\n\u2022Continue to use our network providers to receive medical care.\n\u2022Continue to use our network pharmacies or mail order to get your prescriptions filled until your \nmembership in our plan ends. \n\u2022If you are hospitalized on the day that your membership ends, your hospital stay will usually be covered \nby our plan until you are discharged (even if you are discharged after your new health coverage begins).", "doc_id": "048e91f7-1f34-4108-8461-7357f411ec8c", "embedding": null, "doc_hash": "c523f996152b654596641229fcc179733d0cc27c33f53e9decc8f493eaf886ee", "extra_info": {"page_label": "179", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1876, "_node_type": "1"}, "relationships": {"1": "9e634128-7380-4a31-a476-e59b006ae219"}}, "__type__": "1"}, "fdb3d070-5f97-42dc-b203-42e13a390eb3": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 180\nChapter 10. Ending your membership in the plan\nSECTION 5 Humana Gold Plus H0028-014 (HMO) must end your membership  \nin the plan in certain situations\nSection 5.1 When must we end your membership in the plan?\nHumana Gold Plus H0028-014 (HMO) must end your membership in the plan if any of the following happen:\n\u2022If you no longer have Medicare Part A and Part B.\n\u2022If you move out of our service area.\n\u2022If you are away from our service area for more than six months.\n\u2013If you move or take a long trip, call Customer Care to find out if the place you are moving or traveling to is in \nour plan's area. \n\u2022If you become incarcerated (go to prison).\n\u2022If you are no longer a United States citizen or lawfully present in the United States.\n\u2022If you lie about or withhold information about other insurance you have that provides prescription drug \ncoverage.\n\u2022If you intentionally give us incorrect information when you are enrolling in our plan and that information affects \nyour eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from \nMedicare first.)\n\u2022If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for \nyou and other members of our plan. (We cannot make you leave our plan for this reason unless we get \npermission from Medicare first.)\n\u2022If you let someone else use your membership card to get medical care. (We cannot make you leave our plan for \nthis reason unless we get permission from Medicare first.)\n\u2013If we end your membership because of this reason, Medicare may have your case investigated by the \nInspector General.\n\u2022If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will \ndisenroll you from our plan and you will lose prescription drug coverage.\nWhere can you get more information?\nIf you have questions or would like more information on when we can end your membership call Customer Care.\nSection 5.2 We cannot ask you to leave our plan for any health-related reason\nHumana Gold Plus H0028-014 (HMO) is not allowed to ask you to leave our plan for any health-related reason.\nWhat should you do if this happens?", "doc_id": "fdb3d070-5f97-42dc-b203-42e13a390eb3", "embedding": null, "doc_hash": "9303bb9bec1ca9692336aa22d58f04df5bc52f9791b9816084b7d083f320df8f", "extra_info": {"page_label": "180", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2251, "_node_type": "1"}, "relationships": {"1": "c95dadce-0036-46f6-b922-f1f7b144ab7b"}}, "__type__": "1"}, "79964e7d-753c-4bcf-9ccc-0857a8ec6fdd": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 181\nChapter 10. Ending your membership in the plan\nIf you feel that you are being asked to leave our plan because of a health-related reason, you should call Medicare \nat 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. (TTY 1-877-486-2048).\nSection 5.3 You have the right to make a complaint if we end your membership in our  \nplan\nIf we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We \nmust also explain how you can file a grievance or make a complaint about our decision to end your membership. ", "doc_id": "79964e7d-753c-4bcf-9ccc-0857a8ec6fdd", "embedding": null, "doc_hash": "1f0ea1e5f21593bd2d88e8a1a15bf67d6c55e143ae72ee2e54fa9115a5f4cacd", "extra_info": {"page_label": "181", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 631, "_node_type": "1"}, "relationships": {"1": "b282b006-a3a4-4a9a-9568-1d3813d96331"}}, "__type__": "1"}, "36599981-7c10-4754-bcbc-fa8c3a4c5250": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 182\nChapter 11. Legal noticesEOC082\nCHAPTER 11:\nLegal notices", "doc_id": "36599981-7c10-4754-bcbc-fa8c3a4c5250", "embedding": null, "doc_hash": "b30fcd93708f124315c1f37790e08d84fc2ceb59e02badacdfec521f41686a56", "extra_info": {"page_label": "182", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 124, "_node_type": "1"}, "relationships": {"1": "5083885a-9e33-4ae2-be1f-52c17e1fa7f8"}}, "__type__": "1"}, "768cde1b-338a-449b-ae05-e9bf33a98c95": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 183\nChapter 11. Legal notices\nSECTION 1 Notice about governing law\nThe principal law that applies to this Evidence of Coverage document is Title XVIII of the Social Security Act and the \nregulations created under the Social Security Act by the Centers for Medicare & Medicaid Services, or CMS. In \naddition, other Federal laws may apply and, under certain circumstances, the laws of the state you live in. This may \naffect your rights and responsibilities even if the laws are not included or explained in this document.\nSECTION 2 Notice about nondiscrimination\n We don't discriminate based on race, ethnicity, national origin, color, religion, sex, gender, age, sexual \norientation, mental or physical disability, health status, claims experience, medical history, genetic information, \nevidence of insurability, or geographic location within the service area. All organizations that provide Medicare \nAdvantage plans, like our plan, must obey Federal laws against discrimination, including Title VI of the Civil Rights \nAct of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, \nSection 1557 of the Affordable Care Act, all other laws that apply to organizations that get Federal funding, and \nany other laws and rules that apply for any other reason.\nIf you want more information or have concerns about discrimination or unfair treatment, please call the \nDepartment of Health and Human Services\u2019 Office for Civil Rights at 1-800-368-1019 (TTY 1-800-537-7697) or \nyour local Office for Civil Rights. You can also review information from the Department of Health and Human \nServices\u2019 Office for Civil Rights at https://www.hhs.gov/ocr/index.\nIf you have a disability and need help with access to care, please call us at Customer Care. If you have a complaint, \nsuch as a problem with wheelchair access, Customer Care can help.\nSECTION 3 Notice about Medicare Secondary Payer Subrogation rights\nWe have the right and responsibility to collect for covered Medicare services for which Medicare is not the primary \npayer. According to CMS regulations at 42 CFR sections 422.108 and 423.462, Humana Gold Plus H0028-014 \n(HMO), as a Medicare Advantage Organization, will exercise the same rights of recovery that the Secretary \nexercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this \nsection supersede any State laws.\nSECTION 4 Additional Notice about Subrogation (Recovery from a Third  \nParty)\nOur right to recover payment\nIf we pay a claim for you, we have subrogation rights. This is a very common insurance provision that means we \nhave the right to recover the amount we paid for your claim from any third party that is responsible for the medical \nexpenses or benefits related to your injury, illness, or condition. You assign to us your right to take legal action \nagainst any responsible third party, and you agree to:\n1. Provide any relevant information that we request; and\n2. Participate in any phase of legal action, such as discovery, depositions, and trial testimony, if needed.", "doc_id": "768cde1b-338a-449b-ae05-e9bf33a98c95", "embedding": null, "doc_hash": "96d408b47f58b79774a41d7754588ffc1c9fd2f86128c638a0cd581907594be1", "extra_info": {"page_label": "183", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3169, "_node_type": "1"}, "relationships": {"1": "09a94798-b5dd-4e28-9466-2b11935e44c6"}}, "__type__": "1"}, "437ca213-3e31-4af5-a4af-ba1545617685": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 184\nChapter 11. Legal notices\nIf you don't cooperate with us or our representatives, or you do anything that interferes with our rights, we may \ntake legal action against you. You also agree not to assign your right to take legal action to someone else without \nour written consent.\nOur right of reimbursement\nWe also have the right to be reimbursed if a responsible third party pays you directly. If you receive any amount as \na judgment, settlement, or other payment from any third party, you must immediately reimburse us, up to the \namount we paid for your claim. \nOur rights take priority\nOur rights of recovery and reimbursement have priority over other claims, and will not be affected by any equitable \ndoctrine. This means that we're entitled to recover the amount we paid, even if you haven't been compensated by \nthe responsible third party for all costs related to your injury or illness. If you disagree with our efforts to recover \npayment, you have the right to appeal, as explained in Chapter 9.\nWe are not obligated to pursue reimbursement or take legal action against a third party, either for our own benefit \nor on your behalf. Our rights under Medicare law and this Evidence of Coverage will not be affected if we don't \nparticipate in any legal action you take related to your injury, illness, or condition.\nSECTION 5 Notice of coordination of benefits\nWhy do we need to know if you have other coverage?\nWe coordinate benefits in accordance with the Medicare Secondary Payer rules, which allow us to bill, or authorize \na provider of services to bill, other insurance carriers, plans, policies, employers, or other entities when the other \npayer is responsible for payment of services provided to you. We are also authorized to charge or bill you for \namounts the other payer has already paid to you for such services. We shall have all the rights accorded to the \nMedicare Program under the Medicare Secondary Payer rules.\nWho pays first when you have other coverage?\nWhen you have additional coverage, how we coordinate your coverage depends on your situation. With \ncoordination of benefits, you will often get your care as usual through our plan providers, and the other plan or \nplans you have will simply help pay for the care you receive. If you have group health coverage, you may be able to \nmaximize the benefits available to you if you use providers who participate in your group plan and our plan. In \nother situations, such as for benefits that are not covered by our plan, you may get your care outside of our plan. \nEmployer and employee organization group health plans\nSometimes, a group health plan must provide health benefits to you before we will provide health benefits to you. \nThis happens if:\n\u2022You have coverage under a group health plan (including both employer and employee organization plans), \neither directly or through your spouse, and \n\u2022The employer has twenty (20) or more employees (as determined by Medicare rules), and\n\u2022You are not covered by Medicare due to disability or End-Stage Renal Disease (ESRD). ", "doc_id": "437ca213-3e31-4af5-a4af-ba1545617685", "embedding": null, "doc_hash": "0e1fa2c470a8627b0d480a186f370c359979947ae3e6278a101444d310baf052", "extra_info": {"page_label": "184", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3125, "_node_type": "1"}, "relationships": {"1": "a85ae421-1251-43ab-8257-3fab2e49558d"}}, "__type__": "1"}, "208ec19a-4dd1-4e8f-808b-3ee20326c850": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 185\nChapter 11. Legal notices\nIf the employer has fewer than twenty (20) employees, generally we will provide your primary health benefits. If \nyou have retiree coverage under a group health plan, either directly or through your spouse, generally we will \nprovide primary health benefits. Special rules apply if you have or develop ESRD.\nEmployer and employee organization group health plans for people who are disabled\nIf you have coverage under a group health plan, and you have Medicare because you are disabled, generally we \nwill provide your primary health benefits. This happens if:\n\u2022You are under age 65, and\n\u2022You do not have ESRD, and\n\u2022You do not have coverage directly or through your spouse under a large group health plan.\nA large group health plan is a health plan offered by an employer with 100 or more employees, or by an employer \nwho is part of a multiple-employer plan where any employer participating in the plan has 100 or more employees. \nIf you have coverage under a large group health plan, either directly or through your spouse, your large group \nhealth plan must provide health benefits to you before we will provide health benefits to you. This happens if:\n\u2022You do not have ESRD, and\n\u2022Are under age 65 and have Medicare based on a disability.\nIn such cases, we will provide only those benefits not covered by your large employer group plan. Special rules \napply if you have or develop ESRD.\nEmployer and employee organization group health plans for people with End-Stage Renal Disease (ESRD)\nIf you are or become eligible for Medicare because of ESRD and have coverage under an employer or employee \norganization group health plan, either directly or through your spouse, your group health plan is responsible for \nproviding primary health benefits to you for the first thirty (30) months after you become eligible for Medicare due \nto your ESRD. We will provide secondary coverage to you during this time, and we will provide primary coverage to \nyou thereafter. If you are already on Medicare because of age or disability when you develop ESRD, we will provide \nprimary coverage. \nWorkers' Compensation and similar programs\nIf you have suffered a job-related illness or injury and workers' compensation benefits are available to you, \nworkers' compensation must provide its benefits first for any healthcare costs related to your job-related illness or \ninjury before we will provide any benefits under this Evidence of Coverage for services rendered in connection with \nyour job-related illness or injury. \nAccidents and injuries\nThe Medicare Secondary Payer rules apply if you have been in an accident or suffered an injury. If benefits under \n\"Med Pay,\" no-fault, automobile, accident, or liability coverage are available to you, the \"Med Pay,\" no-fault, \nautomobile, accident, or liability coverage carrier must provide its benefits first for any healthcare costs related to \nthe accident or injury before we will provide any benefits for services related to your accident or injury. \nLiability insurance claims are often not settled promptly. We may make conditional payments while the liability \nclaim is pending. We may also receive a claim and not know that a liability or other claim is pending. In these ", "doc_id": "208ec19a-4dd1-4e8f-808b-3ee20326c850", "embedding": null, "doc_hash": "5e435aee6b975be2a888b6baecc939e11b54008386f6340c46c720657bd67cac", "extra_info": {"page_label": "185", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3307, "_node_type": "1"}, "relationships": {"1": "4f75d18a-c65d-463d-9461-119a7a3b82fe"}}, "__type__": "1"}, "dba5a09e-73ff-4b8a-8324-6d947a264f4d": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 186\nChapter 11. Legal notices\nsituations, our payments are conditional. Conditional payments must be refunded to us upon receipt of the \ninsurance or liability payment. \nIf you recover from a third party for medical expenses, we are entitled to recovery of payments we have made \nwithout regard to any settlement agreement stipulations. Stipulations that the settlement does not include \ndamages for medical expenses will be disregarded. We will recognize allocations of liability payments to \nnon-medical losses only when payment is based on a court order on the merits of the case. We will not seek \nrecovery from any portion of an award that is appropriately designated by the court as payment for losses other \nthan medical services (e.g., property losses). \nWhere we provide benefits in the form of services, we shall be entitled to reimbursement on the basis of the \nreasonable value of the benefits provided.\nNon-duplication of benefits\nWe will not duplicate any benefits or payments you receive under any automobile, accident, liability, or other \ncoverage. You agree to notify us when such coverage is available to you, and it is your responsibility to take any \nactions necessary to receive benefits or payments under such automobile, accident, liability, or other coverage. We \nmay seek reimbursement of the reasonable value of any benefits we have provided in the event that we have \nduplicated benefits to which you are entitled under such coverage. You are obligated to cooperate with us in \nobtaining payment from any automobile, accident, or liability coverage or other carrier. \nIf we do provide benefits to you before any other type of health coverage you may have, we may seek recovery of \nthose benefits in accordance with the Medicare Secondary Payer rules. Please also refer to the Additional Notice \nabout Subrogation (Recovery from a Third Party) section for more information on our recovery rights.\nMore information\nThis is just a brief summary. Whether we pay first or second - or at all - depends on what types of additional \ninsurance you have and the Medicare rules that apply to your situation. For more information, consult the brochure \npublished by the government called \"Medicare & Other Health Benefits: Your Guide to Who Pays First.\" It is CMS Pub. \nNo. 02179. Be sure to consult the most current version. Other details are explained in the Medicare Secondary \nPayer rules, such as the way the number of persons employed by an employer for purposes of the coordination of \nbenefits rules is to be determined. The rules are published in the Code of Federal Regulations.\nAppeal rights\nIf you disagree with any decision or action by our plan in connection with the coordination of benefits and \npayment rules outlined above, you must follow the procedures explained in Chapter 9 What to do if you have a \nproblem or complaint (coverage decisions, appeals, complaints) in this Evidence of Coverage.", "doc_id": "dba5a09e-73ff-4b8a-8324-6d947a264f4d", "embedding": null, "doc_hash": "22d00a0647ee8aa8ab8f90fe787ffc3972f5d3873eb4ee1d1dc3a5fe5a1e2290", "extra_info": {"page_label": "186", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2993, "_node_type": "1"}, "relationships": {"1": "f716064f-54d7-4f7c-870d-db6731765726"}}, "__type__": "1"}, "146f4ac1-4a75-400e-b4ed-a42d86c03abb": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 187\nChapter 12. Definitions of important wordsEOC082\nCHAPTER 12:\nDefinitions of important words", "doc_id": "146f4ac1-4a75-400e-b4ed-a42d86c03abb", "embedding": null, "doc_hash": "fc2c5d130f51027b6486264dc24c1b663165a8b68caf716c8f8b6e9b2f3fae71", "extra_info": {"page_label": "187", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 158, "_node_type": "1"}, "relationships": {"1": "74b779e1-c56e-49a1-8d6f-f85520d7b423"}}, "__type__": "1"}, "afbdbf0b-6cb8-4278-a79c-ebba78488041": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 188\nChapter 12. Definitions of important words\nChapter 12  Definitions of important words\nAdvanced Imaging Services - Specialized imaging method that takes more detailed images than standard x-rays. \nThere are several kinds of imaging services, including Computed Tomography Imaging (CT/CAT) Scan, Magnetic \nResonance Angiography (MRA), Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET) \nScan or other similar technology.\nAllowed Amount - The maximum amount a plan will pay for a health care benefit.\nAmbulatory Surgical Center - An Ambulatory Surgical Center is an entity that operates exclusively for the purpose \nof furnishing outpatient surgical services to patients not requiring hospitalization and whose expected stay in the \ncenter does not exceed 24 hours.\nAnnual Enrollment Period - The time period of October 15 until December 7 of each year when members can \nchange their health or drug plans or switch to Original Medicare. \nAppeal - An appeal is something you do if you disagree with our decision to deny a request for coverage of health  \ncare services or prescription drugs or payment for services or drugs you already received. You may also make an  \nappeal if you disagree with our decision to stop services that you are receiving. \nBalance Billing - When a provider (such as a doctor or hospital) bills a patient more than the plan's allowed \ncost-sharing amount. As a member of Humana Gold Plus H0028-014 (HMO), you only have to pay our plan's \ncost-sharing amounts when you get services covered by our plan. We do not allow providers to \"balance bill\" or \notherwise charge you more than the amount of cost-sharing your plan says you must pay. \nBenefit Period - The way that Original Medicare measures your use of skilled nursing facility (SNF) services. For our \nplan, you will have a benefit period for your skilled nursing facility benefits. A SNF benefit period begins the day you \ngo into a skilled nursing facility. The benefit period will accumulate one day for each day you are at a SNF. The \nbenefit period ends when you haven\u2019t received any skilled care in a SNF for 60 days in a row. If you go into a skilled \nnursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of \nbenefit periods.\nBrand Name Drug - A prescription drug that is manufactured and sold by the pharmaceutical company that \noriginally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the \ngeneric version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and \nare generally not available until after the patent on the brand name drug has expired.\nCatastrophic Coverage Stage - The stage in the Part D Drug Benefit where you pay a low copayment or \ncoinsurance for your drugs after you or other qualified parties on your behalf have spent $7,400 in covered drugs \nduring the covered year.\nCenters for Medicare & Medicaid Services (CMS) - The Federal agency that administers Medicare. Chapter 2 \nexplains how to contact CMS.\nCoinsurance - An amount you may be required to pay, expressed as a percentage (for example 20%) as your share \nof the cost for services or prescription drugs. \nComplaint - The formal name for \"making a complaint\" is \"filing a grievance.\" The complaint process is used only  \nfor certain types of problems. This includes problems related to quality of care, waiting times, and the customer  \nservice you receive. It also includes complaints if your plan does not follow the time periods in the appeal process.", "doc_id": "afbdbf0b-6cb8-4278-a79c-ebba78488041", "embedding": null, "doc_hash": "cfaa619ece89cb4a0fd69191c593f45cf813d7061137836c3d3b5dfb1bee35b8", "extra_info": {"page_label": "188", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3659, "_node_type": "1"}, "relationships": {"1": "da89ba99-0217-4f36-bd95-dec10a8a8807"}}, "__type__": "1"}, "9c3c0c97-2d33-42b1-8414-2833b98aa0a0": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 189\nChapter 12. Definitions of important words\nComprehensive Outpatient Rehabilitation Facility (CORF) - A facility that mainly provides rehabilitation services \nafter an illness or injury, including physical therapy, social or psychological services, respiratory therapy, \noccupational therapy and speech-language pathology services, and home environment evaluation services.\nComputed Tomography Imaging (CT/CAT) Scan - Combines the use of a digital computer together with a rotating \nX-ray device to create detailed cross-sectional images of different organs and body parts.\nContracted Rate - The rate the health plan pays to an in-network doctor, provider or pharmacy for covered \nservices or prescription drugs.\nCopayment (or \"copay\") - An amount you may be required to pay as your share of the cost for a medical service or \nsupply, like a doctor's visit, hospital outpatient visit, or a prescription drug. A copayment is a set amount (for \nexample $10), rather than a percentage. \nCost-sharing - Cost-sharing refers to amounts that a member has to pay when services or drugs are received. \nCost-sharing includes any combination of the following three types of payments: (1) any deductible amount a plan \nmay impose before services or drugs are covered; (2) any fixed \"copayment\" amount that a plan requires when a \nspecific service or drug is received; or (3) any \"coinsurance\" amount, a percentage of the total amount paid for a \nservice or drug, that a plan requires when a specific service or drug is received. \nCost-Sharing Tier - Every drug on the list of covered drugs is in one of five cost-sharing tiers. In general, the higher \nthe cost-sharing tier, the higher your cost for the drug.\nCoverage Determination - A decision about whether a drug prescribed for you is covered by the plan and the \namount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy \nand the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You \nneed to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are \ncalled \"coverage decisions\" in this document. \nCovered Drugs - The term we use to mean all of the prescription drugs covered by our plan.\nCovered Services - The term we use to mean all of the health care services and supplies that are covered by our \nplan.\nCreditable Prescription Drug Coverage - Prescription drug coverage (for example, from an employer or union) \nthat is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. People \nwho have this kind of coverage when they become eligible for Medicare can generally keep that coverage without \npaying a penalty, if they decide to enroll in Medicare prescription drug coverage later.\nCustodial Care - Custodial care is personal care provided in a nursing home, hospice, or other facility setting when \nyou do not need skilled medical care or skilled nursing care. Custodial care, provided by people who do not have \nprofessional skills or training, includes help with activities of daily living like bathing, dressing, eating, getting in or \nout of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care \nthat most people do themselves, like using eye drops. Medicare doesn\u2019t pay for custodial care.\nCustomer Care - A department within our plan responsible for answering your questions about your membership, \nbenefits, grievances, and appeals.", "doc_id": "9c3c0c97-2d33-42b1-8414-2833b98aa0a0", "embedding": null, "doc_hash": "74096bee67e24bd37a117d8d3d8e18c6098b55b45697010a57c641c7d60b2eb8", "extra_info": {"page_label": "189", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3614, "_node_type": "1"}, "relationships": {"1": "fe17b061-dbd2-4cf9-a76d-aed523ba3e70"}}, "__type__": "1"}, "ac44f9b3-890c-48cb-9525-3c59b89daa19": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 190\nChapter 12. Definitions of important words\nDaily cost-sharing rate - A \"daily cost-sharing rate\" may apply when your doctor prescribes less than a full \nmonth's supply of certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate is the \ncopayment divided by the number of days in a month's supply. Here is an example: If your copayment for a \none-month supply of a drug is $30, and a one-month's supply in your plan is 30 days, then your \"daily cost-sharing \nrate\" is $1 per day. \nDeductible - The amount you must pay for health care or prescriptions before our plan pays.\nDiagnostic Mammogram - A specialized x-ray exam given to a patient who shows signs or symptoms of breast \ndisease.\nDiagnostic Procedure - An exam to identify a patient\u2019s strengths and weaknesses in a specific area, in order to find \nout more about their condition, disease, or illness.\nDisenroll or Disenrollment - The process of ending your membership in our plan.\nDispensing Fee - A fee charged each time a covered drug is dispensed to pay for the cost of filling a prescription,  \nsuch as the pharmacist\u2019s time to prepare and package the prescription. \nDurable Medical Equipment (DME) - Certain medical equipment that is ordered by your doctor for medical \nreasons. Examples include: walkers, wheelchairs, crutches, powered mattress systems, diabetic supplies, IV \ninfusion pumps, speech generating devices, oxygen equipment, nebulizers, or hospital beds ordered by a provider \nfor use in the home.\nEmergency - A medical emergency is when you, or any other prudent layperson with an average knowledge of \nhealth and medicine, believe that you have medical symptoms that require immediate medical attention to \nprevent loss of life (and, if you are a pregnant woman, loss of an unborn child), loss of a limb, or loss of function of a \nlimb, or loss of or serious impairment to a bodily function. The medical symptoms may be an illness, injury, severe \npain, or a medical condition that is quickly getting worse.\nEmergency Care - Covered services that are: 1) provided by a provider qualified to furnish emergency services; and \n2) needed to treat, evaluate, or stabilize an emergency medical condition.\nEvidence of Coverage (EOC) and Disclosure Information - This document, along with your enrollment form and \nany other attachments, riders, or other optional coverage selected, which explains your coverage, what we must \ndo, your rights, and what you have to do as a member of our plan.\nException - A type of coverage decision that, if approved, allows you to get a drug that is not on our formulary (a  \nformulary exception), or get a non-preferred drug at a lower cost-sharing level (a tiering exception). You may also  \nrequest an exception if our plan requires you to try another drug before receiving the drug you are requesting, or if  \nour plan limits the quantity or dosage of the drug you are requesting (a formulary exception).\nExtra Help - A Medicare or a State program to help people with limited income and resources pay Medicare  \nprescription drug program costs, such as premiums, deductibles, and coinsurance.\nFormulary - A document that lists all prescription drugs covered by a plan.\nFreestanding Dialysis Center - A licensed health facility, other than a hospital, that provides dialysis treatment \nwith no overnight stay.", "doc_id": "ac44f9b3-890c-48cb-9525-3c59b89daa19", "embedding": null, "doc_hash": "14f72b349e10a186b9402e25d4248a98daef6353271147b562849c33695759a0", "extra_info": {"page_label": "190", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3416, "_node_type": "1"}, "relationships": {"1": "d2de1fa2-3ff9-47cf-a2e0-0ebc5f0b3ab6"}}, "__type__": "1"}, "bd98800b-5875-4fb6-9ab1-4824d1d8fd91": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 191\nChapter 12. Definitions of important words\nFreestanding Lab - A licensed health facility, other than a hospital, that provides lab tests to prevent, identify, or \ntreat an injury or illness, with no overnight stay.\nFreestanding Radiology (Imaging) Center - A licensed health facility, other than a hospital, that provides one or \nmore of the following services to prevent, identify, or treat an injury or illness, with no overnight stay: X-rays; \nnuclear medicine; radiation oncology (including MRIs, CT scans and PET scans).\nGeneric Drug - A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same  \nactive ingredient(s) as the brand name drug. Generally, a \"generic\" drug works the same as a brand name drug  \nand usually costs less.\nGrievance - A type of complaint you make about our plan, providers, or pharmacies, including a complaint \nconcerning the quality of your care. This does not involve coverage or payment disputes.\nHealth Maintenance Organization (HMO) - A type of health insurance plan where members must receive care \nfrom the plan\u2019s network of doctors, hospitals, and other health care providers.\nHome Health Aide - A person who provides services that do not need the skills of a licensed nurse or therapist, \nsuch as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises).\nHome Health Care - Skilled nursing care and certain other health care services given to a patient in their own \nhome for the treatment of an illness or injury. Covered services are listed in Chapter 4 under the heading, \"Home \nhealth agency care.\" If you need home health care services, our plan will cover these services for you, provided the \nMedicare coverage requirements are met. Home health care can include services from a home health aide if the \nservices are part of the home health plan of care for your illness or injury. They aren\u2019t covered unless you are also \ngetting a covered skilled service. Home health services don\u2019t include the services of housekeepers, food service \narrangements, or fulltime nursing care at home.\nHospice - A benefit that provides special treatment for a member who has been medically certified as terminally \nill, meaning having a life expectancy of 6 months or less. We, your plan, must provide you with a list of hospices in \nyour geographic area. If you elect hospice and continue to pay premiums you are still a member of our plan. You \ncan still obtain all medically necessary services as well as the supplemental benefits we offer.\nHospice Care - Specialized care for people who are terminally ill, focused on comfort not cure. This also includes \ncounseling for patients\u2019 families. Depending on the situation, this type of care may be in the home, a hospice \nfacility, a hospital, or a nursing home, and is given by a team of licensed health professionals.\nHospital Inpatient Stay - A hospital stay when you have been formally admitted to the hospital for skilled \nmedical services. Even if you stay in the hospital overnight, you might still be considered an \u201coutpatient.\u201d\nHumana's National Transplant Network (NTN) - A network of Humana-approved facilities all of which are also \nMedicare-approved facilities.\nIncome Related Monthly Adjustment Amount (IRMAA) - If your modified adjusted gross income as reported on \nyour IRS tax return from 2 years ago is above a certain amount, you\u2019ll pay the standard premium amount and an \nIncome Related Monthly Adjustment Amount, also known as IRMAA. IRMAA is an extra charge added to your \npremium. Less than 5% of people with Medicare are affected, so most people will not pay a higher premium.\nInitial Coverage Limit - The maximum limit of coverage under the Initial Coverage Stage.\nInitial Coverage Stage - This is the stage before your out-of-pocket costs for the year have reached $4,660.", "doc_id": "bd98800b-5875-4fb6-9ab1-4824d1d8fd91", "embedding": null, "doc_hash": "87431c88c3200786c5e49dafe5272c9a15fb04d606167d2f4c39ec8a99941323", "extra_info": {"page_label": "191", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3937, "_node_type": "1"}, "relationships": {"1": "884cb8a4-2841-4183-b584-7ff5cda2f74e"}}, "__type__": "1"}, "effa2022-a3d1-4a01-93b9-897f0367d2b4": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 192\nChapter 12. Definitions of important words\nInitial Enrollment Period - When you are first eligible for Medicare, the period of time when you can sign up for  \nMedicare Part A and Part B. If you're eligible for Medicare when you turn 65, your Initial Enrollment Period is the  \n7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3  \nmonths after the month you turn 65.\nInpatient Care - Health care that someone gets when they are admitted to a hospital.\nList of Covered Drugs (Formulary or \"Drug Guide\") - A list of prescription drugs covered by the plan. \nLow Income Subsidy (LIS) - See \"Extra Help.\"\nMagnetic Resonance Angiography (MRA) - A noninvasive method and a form of magnetic resonance imaging \n(MRI) that can measure blood flow through blood vessels.\nMagnetic Resonance Imaging (MRI) - A diagnostic imaging modality method that uses a magnetic field and \ncomputerized analysis of induced radio frequency signals to noninvasively image body tissue.\nMail Order Pharmacy - A pharmacy that fills and sends prescriptions through the mail to the member's home. \nMaximum Out-of-Pocket Amount - The most that you pay out-of-pocket during the calendar year for in-network  \ncovered Part A and Part B services. Amounts you pay for Medicare Part A and Part B premiums, and prescription  \ndrugs do not count toward the maximum out-of-pocket amount. See Chapter 4, Section 1.2 for information about  \nyour maximum out-of-pocket amount.\nMedicaid (or Medical Assistance) - A joint Federal and State program that helps with medical costs for some  \npeople with low incomes and limited resources. State Medicaid programs vary, but most health care costs are  \ncovered if you qualify for both Medicare and Medicaid. \nMedically Accepted Indication - A use of a drug that is either approved by the Food and Drug Administration or  \nsupported by certain reference books. \nMedically Necessary - Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of \nyour medical condition and meet accepted standards of medical practice.\nMedicare - The Federal health insurance program for people 65 years of age or older, some people under age 65 \nwith certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure \nwho need dialysis or a kidney transplant). \nMedicare Advantage Open Enrollment Period - The time period from January 1 until March 31 when members in \na Medicare Advantage plan can cancel their plan enrollment and switch to another Medicare Advantage plan, or \nobtain coverage through Original Medicare. If you choose to switch to Original Medicare during this period, you can \nalso join a separate Medicare prescription drug plan at that time. The Medicare Advantage Open Enrollment Period \nis also available for a 3-month period after an individual is first eligible for Medicare. \nMedicare Advantage Organization - A private company that runs Medicare Advantage Plans to offer members \nmore options, and sometimes extra benefits. Medicare Advantage Plans are also called \u201cPart C.\u201d They provide all \nyour Part A (Hospital) and Part B (Medical) coverage, and some may also provide Part D (prescription drug) \ncoverage.\nMedicare Advantage (MA) Plan - Sometimes called Medicare Part C. A plan offered by a private company that \ncontracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage \nPlan can be an i) HMO, ii) PPO, a iii) Private Fee-for-Service (PFFS) plan, or a iv) Medicare Medical Savings Account ", "doc_id": "effa2022-a3d1-4a01-93b9-897f0367d2b4", "embedding": null, "doc_hash": "b53e571012709ba127d7b0b63e8bebfff21b81d7c11efd3290fbc1a03d5de11a", "extra_info": {"page_label": "192", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3653, "_node_type": "1"}, "relationships": {"1": "3c8f4483-6048-46d5-934b-4b032c978045"}}, "__type__": "1"}, "88c0f168-4f42-4fd8-8cdd-2252ca91cb35": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 193\nChapter 12. Definitions of important words\n(MSA) plan. Besides choosing from these types of plans, a Medicare Advantage HMO or PPO plan can also be a \nSpecial Needs Plan (SNP). In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug \ncoverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. \nMedicare Allowable Charge - The most amount of money that can be charged for a particular medical service \ncovered by Medicare; it is a set amount decided by Medicare.\nMedicare Coverage Gap Discount Program - A program that provides discounts on most covered Part D brand  \nname drugs to Part D members who have reached the Coverage Gap Stage and who are not already receiving  \n\"Extra Help.\" Discounts are based on agreements between the Federal government and certain drug  \nmanufacturers. \nMedicare-Covered Services - Services covered by Medicare Part A and Part B. All Medicare health plans, including \nour plan, must cover all of the services that are covered by Medicare Part A and B. The term Medicare-Covered \nServices does not include the extra benefits, such as vision, dental or hearing, that a Medicare Advantage plan may \noffer.\nMedicare Health Plan - A Medicare health plan is offered by a private company that contracts with Medicare to \nprovide Part A and Part B benefits to people with Medicare who enroll in the plan. This term includes all Medicare \nAdvantage Plans, Medicare Cost Plans, Special Needs Plans, Demonstration/Pilot Programs, and Programs of \nAll-inclusive Care for the Elderly (PACE).\nMedicare Limiting Charge - In the Original Medicare plan, the highest amount of money you can be charged for a \ncovered service by doctors and other health care suppliers who do not accept assignment. The limiting charge is 15 \npercent over Medicare\u2019s approved amount. The limiting charge only applies to certain services and does not apply \nto supplies or equipment.\nMedicare Prescription Drug Coverage (Medicare Part D) - Insurance to help pay for outpatient prescription \ndrugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B.\n\"Medigap\" (Medicare Supplement Insurance) Policy - Medicare supplement insurance sold by private insurance \ncompanies to fill \"gaps\" in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare \nAdvantage Plan is not a Medigap policy.)\nMember (Member of our Plan, or \"Plan Member\") - A person with Medicare who is eligible to get covered \nservices, who has enrolled in our plan, and whose enrollment has been confirmed by the Centers for Medicare & \nMedicaid Services (CMS).\nNetwork - see \u201cNetwork Pharmacy\u201d or \u201cNetwork Provider\u201d\nNetwork Pharmacy - A pharmacy that contracts with our plan where members of our plan can get their  \nprescription drug benefits. In most cases, your prescriptions are covered only if they are filled at one of our network  \npharmacies. \nNetwork Provider - \"Provider\" is the general term for doctors, other health care professionals, hospitals, and other \nhealth care facilities that are licensed or certified by Medicare and by the State to provide health care services. \n\"Network providers\" have an agreement with our plan to accept our payment as payment in full, and in some \ncases to coordinate as well as provide covered services to members of our plan. Network providers are also called \n\"plan providers.\"", "doc_id": "88c0f168-4f42-4fd8-8cdd-2252ca91cb35", "embedding": null, "doc_hash": "276cb9c9ee38ccfa8fe28e0cfc22bfcdf6fc2fb28607d3f2de018dfc1e6f783e", "extra_info": {"page_label": "193", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3471, "_node_type": "1"}, "relationships": {"1": "4b4ab300-c2c6-4867-a345-ebee1456000d"}}, "__type__": "1"}, "56690117-6aed-43c0-baf0-21866cdea389": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 194\nChapter 12. Definitions of important words\nNuclear Medicine - Radiology in which radioisotopes (compounds containing radioactive forms of atoms) are \nintroduced into the body for the purpose of imaging, evaluating organ function, or localizing disease or tumors.\nObservation services - Are hospital outpatient services given to help the doctor decide if a patient needs to be \nadmitted as an inpatient or can be discharged. Observation services may be given in the emergency department or \nanother area of the hospital. Even if you stay overnight in a regular hospital bed, you might be an outpatient.\nOrganization Determination - A decision our plan makes about whether items or services are covered or how \nmuch you have to pay for covered items or services. Organization determinations are called \"coverage decisions\" \nin this document. \nOriginal Medicare (\"Traditional Medicare\" or \"Fee-for-service\" Medicare) - Original Medicare is offered by the \ngovernment, and not a private health plan like Medicare Advantage Plans and prescription drug plans. Under \nOriginal Medicare, Medicare services are covered by paying doctors, hospitals, and other health care providers \npayment amounts established by Congress. You can see any doctor, hospital, or other health care provider that \naccepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and \nyou pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and \nis available everywhere in the United States.\nOur plan - The plan you are enrolled in, Humana Gold Plus H0028-014 (HMO).\nOut-of-Network Pharmacy - A pharmacy that does not have a contract with our plan to coordinate or provide  \ncovered drugs to members of our plan. Most drugs you get from out-of-network pharmacies are not covered by our  \nplan unless certain conditions apply.\nOut-of-Network Provider or Out-of-Network Facility - A provider or facility that does not have a contract with \nour plan to coordinate or provide covered services to members of our plan. Out-of-network providers are providers \nthat are not employed, owned, or operated by our plan. \nOut-of-Pocket Costs - See the definition for \"cost-sharing\" above. A member's cost-sharing requirement to pay \nfor a portion of services or drugs received is also referred to as the member's \"out-of-pocket\" cost requirement.\nPACE plan - A PACE (Program of All-Inclusive Care for the Elderly) plan combines medical, social, and long-term  \ncare services for frail people to help people stay independent and living in their community (instead of moving to a  \nnursing home) as long as possible. People enrolled in PACE plans receive both their Medicare and Medicaid benefits  \nthrough the plan. \nPart C - see \"Medicare Advantage (MA) Plan.\"\nPart D - The voluntary Medicare Prescription Drug Benefit Program. \nPart D Drugs - Drugs that can be covered under Part D. We may or may not offer all Part D drugs. Certain  \ncategories of drugs have been excluded as covered Part D drugs by Congress. Certain categories of Part D drugs  \nmust be covered by every plan. \nPart D Late Enrollment Penalty - An amount added to your monthly premium for Medicare drug coverage if you  \ngo without creditable coverage (coverage that is expected to pay, on average, at least as much as standard  \nMedicare prescription drug coverage) for a continuous period of 63 days or more after you are first eligible to join a  \nPart D plan. \nPlan Provider \u2013 see \"Network Provider\". ", "doc_id": "56690117-6aed-43c0-baf0-21866cdea389", "embedding": null, "doc_hash": "300c3e727dcf0a8140c0521a128a8d3a04dc261602124ce5a65e540ecb0ebc79", "extra_info": {"page_label": "194", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3592, "_node_type": "1"}, "relationships": {"1": "43eaba79-dcfc-43a2-86d9-e67d4fe5b27a"}}, "__type__": "1"}, "a2e94e84-706f-4a8e-84f0-76447c6ade76": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 195\nChapter 12. Definitions of important words\nPositron Emission Tomography (PET) Scan - A medical imaging technique that involves injecting the patient with  \nan isotope and using a PET scanner to detect the radiation emitted.\nPreferred Cost-sharing - Preferred cost-sharing means lower cost-sharing for certain covered Part D drugs at  \ncertain network pharmacies.\nPreferred Provider Organization (PPO) Plan - A Preferred Provider Organization plan is a Medicare Advantage \nPlan that has a network of contracted providers that have agreed to treat plan members for a specified payment \namount. A PPO plan must cover all plan benefits whether they are received from network or out-of-network \nproviders. Member cost-sharing will generally be higher when plan benefits are received from out-of-network \nproviders. PPO plans have an annual limit on your out-of-pocket costs for services received from network \n(preferred) providers and a higher limit on your total combined out-of-pocket costs for services from both network \n(preferred) and out-of-network (non-preferred) providers.\nPremium - The periodic payment to Medicare, an insurance company, or a health care plan for health or \nprescription drug coverage.\nPrescription Drug Guide (Formulary) - A list of covered drugs provided by the plan. The drugs on this list are  \nselected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic  \ndrugs.\nPrimary Care Provider (PCP) - The doctor or other provider you see first for most health problems. In many  \nMedicare health plans, you must see your primary care provider before you see any other health care provider.\nPrior Authorization - Approval in advance to get services or certain drugs. Covered services that need prior  \nauthorization are marked in the Benefits Chart in Chapter 4. Covered drugs that need prior authorization are  \nmarked in the formulary. \nProsthetics and Orthotics \u2013 Medical devices including, but are not limited to: arm, back and neck braces; artificial  \nlimbs; artificial eyes; and devices needed to replace an internal body part or function, including ostomy supplies  \nand enteral and parenteral nutrition therapy.\nQuality Improvement Organization (QIO) - A group of practicing doctors and other health care experts paid by  \nthe Federal government to check and improve the care given to Medicare patients. \nQuantity Limits - A management tool that is designed to limit the use of selected drugs for quality, safety, or  \nutilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period  \nof time.\nRadiology - X-rays and other specialized procedures that use high-energy radiation to identify and treat diseases.\nRehabilitation Services - These services include physical therapy, speech and language therapy, and \noccupational therapy.\nScreening Mammogram - A specialized x-ray procedure to find out early if a patient has breast cancer.\nService Area - A geographic area where you must live to join a particular health plan. For plans that limit which \ndoctors and hospitals you may use, it\u2019s also generally the area where you can get routine (non-emergency) \nservices. The plan may disenroll you if you permanently move out of the plan\u2019s service area.", "doc_id": "a2e94e84-706f-4a8e-84f0-76447c6ade76", "embedding": null, "doc_hash": "02b7ccba0b79986e5134f0d8f7668c81b886918664044fda03bc089c0c1d0764", "extra_info": {"page_label": "195", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3345, "_node_type": "1"}, "relationships": {"1": "af36c7fe-2446-4921-9a75-d542a14d1818"}}, "__type__": "1"}, "d48b967d-868b-453b-94ba-7d2db382b54f": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 196\nChapter 12. Definitions of important words\nSkilled Nursing Facility (SNF) Care - Skilled nursing care and rehabilitation services provided on a continuous, \ndaily basis, in a skilled nursing facility. Examples of care include physical therapy or intravenous injections that can \nonly be given by a registered nurse or doctor.\nSpecial Enrollment Period - A set time when members can change their health or drug plans or return to Original \nMedicare. Situations in which you may be eligible for a Special Enrollment Period include: if you move outside the \nservice area, if you are getting \"Extra Help\" with your prescription drug costs, if you move into a nursing home, or if \nwe violate our contract with you.\nSpecial Needs Plan - A special type of Medicare Advantage Plan that provides more focused health care for \nspecific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or \nwho have certain chronic medical conditions.\nStandard Cost-sharing - Standard cost-sharing is cost-sharing other than preferred cost-sharing offered at a \nnetwork pharmacy.\nStep Therapy - A utilization tool that requires you to first try another drug to treat your medical condition before  \nwe will cover the drug your physician may have initially prescribed.\nSupplemental Security Income (SSI) - A monthly benefit paid by Social Security to people with limited income \nand resources who are disabled, blind, or age 65 and older. SSI benefits are not the same as Social Security \nbenefits.\nUrgent Care Center - A licensed health facility where doctors and nurses provide services to identify and treat a \nsudden injury or illness, with no overnight stay.\nUrgently Needed Services - Covered services that are not emergency services, provided when the network \nproviders are temporarily unavailable or inaccessible or when the enrollee is out of the service area. For example, \nyou need immediate care during the weekend. Services must be immediately needed and medically necessary. ", "doc_id": "d48b967d-868b-453b-94ba-7d2db382b54f", "embedding": null, "doc_hash": "69b58068294d0ba13820656f4c64830cb7bd4b303d03f91511fc794a9106ff09", "extra_info": {"page_label": "196", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2078, "_node_type": "1"}, "relationships": {"1": "807f6830-5174-48b0-85e2-1e4e94baf25e"}}, "__type__": "1"}, "ce03992b-30f2-42f4-aa58-5e12f9caca19": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 197\nExhibit A - State Agency Contact InformationEOC082\nExhibit A- State Agency Contact Information\nThis section provides the contact information for the state agencies referenced in Chapter 2 and in other locations  \nwithin this Evidence of Coverage. If you have trouble locating the information you seek, please contact Customer  \nCare at the phone number on the back cover of this booklet.\nIllinois\nSHIP Name and Contact Information Senior Health Insurance Program (SHIP)\nIllinois Department on Aging\nOne Natural Resources Way, Suite 100\nSpringfield, IL 62702-1271\n1-800-252-8966 (toll free)\n1-888-206-1327 (TTY)\nwww.illinois.gov/aging/SHIP\nQuality Improvement Organization Livanta BFCC-QIO Program\n10820 Guilford Road\nSuite 202\nAnnapolis Junction, MD 20701\n1-888-524-9900\n1-888-985-8775 (TTY)\n1-833-868-4059 (Fax)\nhttps://livantaqio.com/\nState Medicaid Office Medical Assistance Program\n100 South Grand Avenue East\nSpringfield, IL 62762\n1-800-843-6154 (toll free)\n1-217-782-4977(local)\n1-866-324-5553 (Toll Free TTY)\n1-800-547-0466 (TTY)\nhttps://www.dhs.state.il.us\nAIDS Drug Assistance Program Ryan White CARE and HOPWA Services\nIllinois Medication Assistance Program\n525 W. Jefferson Street, 1st Floor\nSpringfield, IL 62761\n1-800-825-3518\n1-217-785-8013 (fax)\nhttps://dph.illinois.gov/topics-services/diseases-and-conditions/hiv-\naids/ryan-white-care-and-hopwa-services\nn/a\nMissouri\nSHIP Name and Contact Information CLAIM\n1105 Lakeview Avenue\nColumbia, MO 65201\n1-800-390-3330 (toll free)\n1-573-817-8300 (local)\nhttp://www.missouriclaim.org", "doc_id": "ce03992b-30f2-42f4-aa58-5e12f9caca19", "embedding": null, "doc_hash": "8e8a0045513dda26d94de89010ce20400931ef9f63dd25d2f708991800d1606c", "extra_info": {"page_label": "197", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1609, "_node_type": "1"}, "relationships": {"1": "4deca681-0f42-45ca-864c-a891f789d3a0"}}, "__type__": "1"}, "0a3db01c-a9db-471c-bab3-85a7345788c0": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus H0028-014 (HMO) 198\nExhibit A - State Agency Contact Information\nMissouri - Continued\nQuality Improvement Organization Livanta BFCC-QIO Program\n10820 Guilford Road\nSuite 202\nAnnapolis Junction, MD 20701\n1-888-755-5580\n1-888-985-9295 (TTY)\n1-833-868-4061 (Fax)\nhttps://livantaqio.com/\nState Medicaid Office MO HealthNet (Medicaid)\n615 Howerton Court\nP.O. Box 6500\nJefferson City, MO 65102-6500\n1-855-373-4636 (toll free)\n1-573-751-3425 (local)\n1-800-735-2966 (TTY)\nhttp://www.dss.mo.gov/mhd/\nState Pharmacy Assistance Program(s) Missouri RX Plan\nPO Box 6500\nJefferson City, MO 65102\n1-800-375-1406 (toll free)\nwww.morx.mo.gov/\nAIDS Drug Assistance Program Missouri AIDS Drug Assistance Program\nBureau of HIV, STD, and Hepatitis, Missouri Department of Health & \nSenior Services\nPO Box 570\nJefferson City, MO 65102\n1-573-751-6439\n1-573-751-6447 (fax)\nhttp://health.mo.gov/living/healthcondiseases/communicable/hivai\nds/casemgmt.php\nn/a", "doc_id": "0a3db01c-a9db-471c-bab3-85a7345788c0", "embedding": null, "doc_hash": "10668657bf09a0d19ddc1d97588fa058d7580faea632d41d20c4bd44c5987a7f", "extra_info": {"page_label": "198", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 980, "_node_type": "1"}, "relationships": {"1": "a3c57a4f-3b7f-4752-854e-1402f2d8e1fe"}}, "__type__": "1"}, "e116152e-ccd1-4eed-aa75-3f3b9803e491": {"__data__": {"text": "EOC082\nImportant\nAt Humana, it is important you are treated fairly.\nHumana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color,  \nnational origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity,  \nmarital status, religion or language. Discrimination is against the law. Humana and its subsidiaries  \ncomply with applicable federal civil rights laws. If you believe that you have been discriminated  \nagainst by Humana or its subsidiaries, there are ways to get help.\n\u2022You may file a complaint, also known as a grievance:  \nDiscrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.  \nIf you need help filing a grievance, call 1-877-320-1235 or if you use a TTY, call 711.\n\u2022You can also file a civil rights complaint with the U.S. Department of Health and Human  \nServices, Office for Civil Rights electronically through their Complaint Portal, available at \nhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at U.S. Department of Health and Human  \nServices, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, \n1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at \nhttps://www.hhs.gov/ocr/office/file/index.html.\n\u2022California residents: You may also call California Department of Insurance toll-free hotline  \nnumber: 1-800-927-HELP (4357), to file a grievance.\nAuxiliary aids and services, free of charge, are available to you.  \n1-877-320-1235 (TTY: 711)\nHumana provides free auxiliary aids and services, such as qualified sign language interpreters,  \nvideo remote interpretation, and written information in other formats to people with disabilities  \nwhen such auxiliary aids and services are necessary to ensure an equal opportunity to participate.\nGCHJV5REN_2020", "doc_id": "e116152e-ccd1-4eed-aa75-3f3b9803e491", "embedding": null, "doc_hash": "89c4a0d6ad2175f0482f832f97a6fbb24a6ba49a9d12e111a1dedf912c8d2d39", "extra_info": {"page_label": "199", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1800, "_node_type": "1"}, "relationships": {"1": "cecc755e-4e1f-4326-b872-70d8416a8089"}}, "__type__": "1"}, "8ef4c21e-70d7-4943-a4b8-cd45d2202813": {"__data__": {"text": "Humana Gold Plus H0028-014 (HMO) Customer Care\nMethod Customer Care \u2013 Contact Information\nCALL 1-800-457-4708 \nCalls to this number are free. You can call us seven days a week, from 8 a.m. to 8  \np.m. \nCustomer Care also has free language interpreter services available for non-English  \nspeakers.\nTTY 711 \nThis number requires special telephone equipment and is only for people who have  \ndifficulties with hearing or speaking.\nCalls to this number are free. Hours of operation are the same as above. \nFAX 1-877-837-7741\nWRITE Humana \nP.O. Box 14168 \nLexington, KY 40512-4168\nWEBSITE Humana.com/customer-support\nState Health Insurance Assistance Program\nThe State Health Insurance Assistance Program (SHIP) is a state program that gets money from the  \nFederal government to give free local health insurance counseling to people with Medicare.\nContact information for your State Health Insurance Assistance Program (SHIP) can be found in  \n\u201cExhibit A\u201d in this document. \nPRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required  \nto respond to a collection of information unless it displays a valid OMB control number. The valid OMB  \ncontrol number for this information collection is 0938-1051. If you have comments or suggestions for  \nimproving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,  \nMail Stop C4-26-05, Baltimore, Maryland 21244-1850.", "doc_id": "8ef4c21e-70d7-4943-a4b8-cd45d2202813", "embedding": null, "doc_hash": "db2634daf3470bae3276423787fa4960fc5e7410f11685b6ea5b7c4eae3874c9", "extra_info": {"page_label": "203", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1439, "_node_type": "1"}, "relationships": {"1": "d6cd24f2-26db-4ed8-a41c-977b84d21f43"}}, "__type__": "1"}, "36039e26-b65d-4e63-8df1-9e8924b4c2d3": {"__data__": {"text": "Humana Inc. \nPO Box 14168 \nLexington, KY 40512-4168H0028014000EOC23Important Plan Information\nHumana.com", "doc_id": "36039e26-b65d-4e63-8df1-9e8924b4c2d3", "embedding": null, "doc_hash": "ad3d91ff2d78ecc46f8efeafddb32895e64b5fc5c05080689725552ff74beb39", "extra_info": {"page_label": "204", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 104, "_node_type": "1"}, "relationships": {"1": "3cab2bf7-6485-4244-a1f2-66a920a972d5"}}, "__type__": "1"}, "399e1b13-9b90-4a13-ba9d-7e770c8316b8": {"__data__": {"text": "Summary of Benefits SBOSB045 \nHumana Gold Plus H0028-014 (HMO) \nSt. Louis \nSt. Louis Metro area \nOur service area includes the following county/counties in Illinois: Bond, Calhoun, \nClinton, Jersey, Macoupin, Madison, St. Clair \nMissouri: Audrain, Boone, Callaway, Crawford, Franklin, Iron, Jefferson, Lincoln, Madison, \nPerry, Pike, St. Charles, St. Francois, St. Louis, St. Louis City, Warren, Washington. 2023 \nGNHH4HIEN_23_C Summary of Benefits H0028014000SB23 ", "doc_id": "399e1b13-9b90-4a13-ba9d-7e770c8316b8", "embedding": null, "doc_hash": "e68c5b583087440b3964b135aa50dc5a37a20c6c6d3412625bcd502b2bf44458", "extra_info": {"page_label": "1", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 465, "_node_type": "1"}, "relationships": {"1": "b545e59c-7d2e-4083-942b-1bb5a07252d9"}}, "__type__": "1"}, "5146e307-0663-4bd3-a4b0-2a78e3c6b455": {"__data__": {"text": "Pre-Enrollment Checklist \nBefore making an enrollment decision, it is important that you fully understand our benefits and rules. If you \nhave any questions, you can call and speak to acustomer service representative at  1-800-833-2364 (TTY: \n711) .\nUnderstanding the Benefits \nThe Evidence of Coverage (EOC) provides acomplete list of all coverage and services. It is important \nto review plan coverage, costs and benefits before you enroll. Visit  Humana.com/medicare or call  \n1-800-833-2364  (TTY: 711) to view acopy of the EOC. \nReview the provider directory (or ask your doctor) to make sure the doctors you see now are in the \nnetwork. If they are not listed, it means you will likely have to select anew doctor. \nReview the pharmacy directory to make sure the pharmacy you use for any prescription medicines is \nin the network. If the pharmacy is not listed, you will likely have to select anew pharmacy for your \nprescriptions. \nReview the formulary to make sure your drugs are covered.  \nUnderstanding Important Rules \nYou must continue to pay your Medicare Part Bpremium. This premium is normally taken out of your \nSocial Security check each month. \nBenefits, premiums and/or copayments/co-insurance may change on January 1, 2024. \nExcept in emergency or urgent situations, we do not cover services by out-of-network providers \n(doctors who are not listed in the provider directory).  ", "doc_id": "5146e307-0663-4bd3-a4b0-2a78e3c6b455", "embedding": null, "doc_hash": "8dadc201e4d53dcde875c02feb9b7a0b1ff62ea73964d14af710429c61a1e56a", "extra_info": {"page_label": "2", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1397, "_node_type": "1"}, "relationships": {"1": "174a73e0-48ee-464f-b096-d42386dce72b"}}, "__type__": "1"}, "2dce3d28-64d9-4aec-b228-7be44916c007": {"__data__": {"text": "Y0040_MAPDPartBIRAamendSB_Template1_C  Gr\neat news \u2014Part B Insulin and Part B drug benefits on Humana\u2019s Medicare Advantage \nplans are getting even better in 2023.  \nAt Humana, we strive to help our members achieve total health so that they may live their \nbest lives, which includes efforts to provide our members with access to more affordable prescription drugs.  \nWith the passing of the Inflation Reduction Act, all Med icare Advantage plans will have \nenhanced benefits in 2023:  \nEffective April 1, 2023, some rebatable Part B drugs may be subject to a lower coinsurance.  \nThis means beginning April 1, 2023, some Part B drugs will have a lower coinsurance than your standard part B drug coinsurance to help avoid increased cost for your Part B drugs.  Any coinsurance adjustments will be made by the pharmacy at the time of purchase.  Note, this does not impact your Part D prescription drug coverage.\n   \nEffective July 1, 2023, cos t sharing for covered Part B Insulin furnished  through a covered \nitem of durable medical equipment will be no more than $35 for a one- month (up to 30 -day) \nsupply and if your plan has a deductible, it does not apply to Part B Insulin.  Part B Insulin is mos t commonly used through an insulin pump.  \nNote, plan information provided in your previous member materials may not reflect these 2023 benefit enhancements from the passing of the Inflation Reduction Act.  ", "doc_id": "2dce3d28-64d9-4aec-b228-7be44916c007", "embedding": null, "doc_hash": "b650e2e1871418b2d57bee7fc21180f568990a07b865113919bbfe5f2748f477", "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1411, "_node_type": "1"}, "relationships": {"1": "b4256e63-cadc-4267-9e50-0d9a3ac6e583"}}, "__type__": "1"}, "054cc4bc-ca4e-4932-8ed2-f176ac82593c": {"__data__": {"text": "Summary of Benefits \nHumana Gold Plus H0028-014 (HMO) \nSt. Louis \nSt. Louis Metro area 2023 \nOur service area includes the following county/counties in Illinois: Bond, Calhoun, \nClinton, Jersey, Macoupin, Madison, St. Clair \nMissouri: Audrain, Boone, Callaway, Crawford, Franklin, Iron, Jefferson, Lincoln, \nMadison, Perry, Pike, St. Charles, St. Francois, St. Louis, St. Louis City, Warren, \nWashington. \nH0028_SB_MAPD_HMO_014000_2023_M Summary of Benefits H0028014000SB23 ", "doc_id": "054cc4bc-ca4e-4932-8ed2-f176ac82593c", "embedding": null, "doc_hash": "dc7a42485eb7b5d8910c78ead41ef4425b405053e69b09fa6f5365f23956af81", "extra_info": {"page_label": "5", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 474, "_node_type": "1"}, "relationships": {"1": "58a98e6c-6583-4c89-9d2a-4f6e3470136c"}}, "__type__": "1"}, "582fe9b4-52be-4449-a8bb-1b0c9424c05a": {"__data__": {"text": "H0028014000SB23 Summary of Benefits 5H0028014000 \nLet's talk about Humana Gold Plus \nH0028-014 (HMO) \nFind out more about the Humana Gold Plus H0028-014 (HMO) plan -including the \nhealth and drug services it covers -in this easy-to-use guide. \nHumana Gold Plus H0028-014 (HMO) is aMedicare Advantage  HMO plan with a \nMedicare contract. Enrollment in this Humana plan depends on contract renewal. \nThe benefit information provided is asummary of what we cover and what you pay. It \ndoesn't list every service that we cover or list every limitation or exclusion. For a \ncomplete list of services we cover, ask us for the \"Evidence of Coverage\". \nTo be eligible \nTo join Humana Gold Plus H0028-014 \n(HMO), you must be entitled to \nMedicare Part A, be enrolled in Medicare \nPart Band live in our service area. \nPlan name: \nHumana Gold Plus H0028-014 (HMO) \nHow to reach us: \nIf you're amember of this plan, call \ntoll-free:  1-800-457-4708 (TTY: 711) .\nIf you're  not amember of this plan, \ncall toll free:  1-800-833-2364 (TTY: \n711) .\nOctober 1-March 31: \nCall 7days aweek from 8a.m. -8p.m. \nApril 1-September 30: \nCall Monday -Friday, 8a.m. -8p.m. \nOr visit our website: \nHumana.com/medicare More about Humana Gold Plus \nH0028-014 (HMO) \nDoyou have Medicare and Medicaid? If you are a \ndual-eligible beneficiary enrolled in both \nMedicare and the state's program, you may not \nhave to pay the medical costs displayed in this \nbooklet and your prescription drug costs will be \nlower, too. \nIf you have Medicaid, be sure to show your \nMedicaid ID card in addition to your Humana \nmembership card to make your provider aware \nthat you may have additional coverage. Your \nservices are paid first by Humana and then by \nMedicaid. \nAs amember you must select an in-network \ndoctor to act as your Primary Care Provider (PCP). \nHumana Gold Plus H0028-014 (HMO) has a \nnetwork of doctors, hospitals, pharmacies and \nother providers. If you use providers who aren't \nin our network, the plan may not pay for these \nservices. \nAhealthy partnership \nGet more from your plan \u2014with extra \nservices and resources provided by \nHumana! ", "doc_id": "582fe9b4-52be-4449-a8bb-1b0c9424c05a", "embedding": null, "doc_hash": "ea9c144f17f6ee2df6f9841a80f9997c81daac2322ceab84478bd9f493929b1c", "extra_info": {"page_label": "7", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 2119, "_node_type": "1"}, "relationships": {"1": "dedd53a2-9955-43a4-b487-b2079a3558eb"}}, "__type__": "1"}, "25954946-06bd-44e0-85d5-cbfa29f7b6b8": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\n6 Summary of Benefits H0028014000SB23 H0028014000 \nMonthly Premium, Deductible and Limits \nMonthly Plan Premium $0 \nYou must keep paying your Medicare Part Bpremium. \nMedical deductible This plan does not have adeductible.  \nPharmacy (Part D) deductible This plan does not have adeductible. \nMaximum out-of-pocket \nresponsibility $2,900 in-network \nThe most you pay for copays, coinsurance and other costs for covered \nmedical services for the year. \nCovered Medical and Hospital Benefits  \nAcute inpatient hospital care $245 copay per day for days 1-8 \n$0 copay per day for days 9-90 \nYour plan covers an unlimited number of days for an inpatient stay. \nOutpatient hospital coverage \u2022Outpatient surgery at Outpatient Hospital:  $245 copay \n\u2022Outpatient surgery at Ambulatory Surgical Center:   $195 copay \nDoctor visits \u2022Primary care provider:  $0 copay \n\u2022Specialist:  $25 copay ", "doc_id": "25954946-06bd-44e0-85d5-cbfa29f7b6b8", "embedding": null, "doc_hash": "2ad860a4a1fe3d3dfad3aad1f28ebc1265c2cd8e3331ff2d0a530bb7fd00a1c6", "extra_info": {"page_label": "8", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1231, "_node_type": "1"}, "relationships": {"1": "5f68319b-4c0d-4d78-8e72-fdaffcc68721"}}, "__type__": "1"}, "97d8ef1b-2cdb-4bbb-bb15-0b00107dee59": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\nH0028014000SB23 Summary of Benefits 7H0028014000 \nCovered Medical and Hospital Benefits (cont.)  \nPreventive care Our plan covers many preventive services at no cost when you see \nan in-network provider including: \n\u2022Abdominal aortic aneurysm screening \n\u2022Alcohol misuse counseling \n\u2022Bone mass measurement \n\u2022Breast cancer screening (mammogram) \n\u2022Cardiovascular disease (behavioral therapy) \n\u2022Cardiovascular screenings \n\u2022Cervical and vaginal cancer screening \n\u2022Colorectal cancer screenings (colonoscopy, fecal occult blood test, \nflexible sigmoidoscopy) \n\u2022Depression screening \n\u2022Diabetes screenings \n\u2022HIV screening \n\u2022Medical nutrition therapy services \n\u2022Obesity screening and counseling \n\u2022Prostate cancer screenings (PSA) \n\u2022Sexually transmitted infections screening and counseling \n\u2022Tobacco use cessation counseling (counseling for people with no \nsign of tobacco-related disease) \n\u2022Vaccines, including flu shots, hepatitis Bshots, pneumococcal shots \n\u2022\"Welcome to Medicare\" preventive visit (one-time) \n\u2022Annual Wellness Visit \n\u2022Lung cancer screening \n\u2022Routine physical exam \n\u2022Medicare diabetes prevention program \nAny additional preventive services approved by Medicare during the \ncontract year will be covered.  \nEMERGENCY CARE \nEmergency room $125 copay \nIf you are admitted to the hospital within 24 hours, you do not have to \npay your share of the cost for the emergency care. \nUrgently needed services $30 copay at an urgent care center \nUrgently needed services are provided to treat anon-emergency, \nunforeseen medical illness, injury or condition that requires immediate \nmedical attention. ", "doc_id": "97d8ef1b-2cdb-4bbb-bb15-0b00107dee59", "embedding": null, "doc_hash": "4fd401c3be8f82d7177741f087197d26d9b3a9c7cbddc73931461cb01c19f477", "extra_info": {"page_label": "9", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1950, "_node_type": "1"}, "relationships": {"1": "10c3b9d1-171d-47f2-8fa3-91ed85d01645"}}, "__type__": "1"}, "d7d70d22-97a1-4573-9ecf-253d1d3bf1e0": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\n8 Summary of Benefits H0028014000SB23 H0028014000 \nCovered Medical and Hospital Benefits (cont.)  \nOUTPATIENT CARE AND SERVICES \nDiagnostic services, labs and \nimaging \nCost share may vary depending \non the service and where service \nis provided \u2022Diagnostic mammography:  $0 to  $25 copay \n\u2022Diagnostic colonoscopy  $0 copay \n\u2022Diagnostic radiology:  $180 to  $245 copay \n\u2022Lab services:  $0 to  $30 copay \n\u2022Diagnostic tests and procedures:  $0 to  $35 copay \n\u2022Outpatient X-rays:  $0 to  $35 copay \n\u2022Radiation therapy:  $25 to  $35 copay  \nHearing Medicare-covered hearing exam:  $25 copay  \nRoutine hearing:  \nIn-Network: \nHER955 \n\u2022$0 copay for routine hearing exams up to 1per year. \n\u2022$299 copay for each Advanced level hearing aid up to 1per ear per  \nyear. \n\u2022$599 copay for each Premium level hearing aid up to 1per ear per  \nyear. \nHearing aid purchase includes: \n\u2022Unlimited follow-up provider visits during first year following  \nTruHearing hearing aid purchase \n\u202260-day trial period \n\u20223-year extended warranty \n\u202280 batteries per aid for non-rechargeable models \nYou must see aTruHearing provider to use this benefit. Call  \n1-844-255-7144 to schedule an appointment (for TTY, dial 711). \nDental Medicare-covered dental services:  $25 copay  \nRoutine dental:  \nThe cost-share indicated below is what you pay for the covered service. \nIn-Network: \nDEN337 \n\u2022$0 copay for scaling and root planing (deep cleaning) up to 1per  \nquadrant every 3years. \n\u2022$0 copay for comprehensive oral evaluation or periodontal exam,  \nocclusal adjustment, scaling for moderate inflammation up to 1  \nevery 3years. \n\u2022$0 copay for bridges, complete dentures, crown recementation,  \ndenture recementation, panoramic film or diagnostic x-rays, partial  \ndentures up to 1every 5years. \n\u2022$0 copay for crown, root canal, root canal retreatment up to 1per  \ntooth per lifetime. \n\u2022$0 copay for bitewing x-rays, intraoral x-rays up to 1set(s) per year. ", "doc_id": "d7d70d22-97a1-4573-9ecf-253d1d3bf1e0", "embedding": null, "doc_hash": "8ce892e425222f50a1b4142887c9d9b6abd167131540ab70e7465a63aaf17daa", "extra_info": {"page_label": "10", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 2277, "_node_type": "1"}, "relationships": {"1": "544f69fa-b053-4b1c-9703-fa89c2a02c28"}}, "__type__": "1"}, "d1bbf49b-2281-451a-b7fc-e320974bf014": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\nH0028014000SB23 Summary of Benefits 9H0028014000 \nCovered Medical and Hospital Benefits (cont.)  \n\u2022$0 copay for adjustments to dentures, denture rebase, denture  \nreline, denture repair, emergency diagnostic exam, tissue  \nconditioning up to 1per year. \n\u2022$0 copay for emergency treatment for pain, fluoride treatment, oral  \nsurgery, periodic oral exam, prophylaxis (cleaning) up to 2per year. \n\u2022$0 copay for periodontal maintenance up to 4per year. \n\u2022$0 copay for amalgam and/or composite filling, necessary  \nanesthesia with covered service, simple or surgical extraction up to  \nunlimited per year. \n\u2022$2000 maximum benefit coverage amount per year for preventive  \nand comprehensive benefits. \nDental services are subject to our standard claims review procedures  \nwhich could include dental history to approve coverage. Dental benefits  \nunder this plan may not cover all American Dental Association  \nprocedure codes. Information regarding each plan is available at  \nHumana.com/sb .  \nNetwork dentists have agreed to provide services at contracted fees  \n(the in-network fee schedules, of INFS). If amember visits a  \nparticipating network dentist, the member will not receive abill for  \ncharges more than the negotiated fee schedule on covered services  \n(coinsurance payment still applies).  \nUse the HumanaDental Medicare network for the Mandatory  \nSupplemental Dental. The provider locator can be found at  \nHumana.com >Find aDoctor >from the Search Type drop down select  \nDental >under Coverage Type select All Dental Networks >enter zip  \ncode >from the network drop down select HumanaDental Medicare.  \nVision \u2022Medicare-covered vision services:  $25 copay  \n\u2022Medicare-covered diabetic eye exam:  $0 copay \n\u2022Medicare-covered glaucoma screening:  $0 copay \n\u2022Medicare-covered eyewear (post-cataract):  $0 copay  \nRoutine vision:  \nIn-Network: \nVIS735 \n\u2022$0 copay for routine exam up to 1per year. \n\u2022$200 maximum benefit coverage amount per year for contact  \nlenses or eyeglasses-lenses and frames, fitting for eyeglasses-lenses  \nand frames. \n\u2022Eyeglass lens options may be available with the maximum benefit  \ncoverage amount up to 1pair per year. \n\u2022Maximum benefit coverage amount is limited to one time use per  \nyear. ", "doc_id": "d1bbf49b-2281-451a-b7fc-e320974bf014", "embedding": null, "doc_hash": "41a7f48257e0a44880592ffb1279c8ab988658d9d1e976c4756ef28dd93d8b1a", "extra_info": {"page_label": "11", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 2586, "_node_type": "1"}, "relationships": {"1": "fd7499f4-2259-44b6-9b27-42746c425901"}}, "__type__": "1"}, "6218d87e-b417-4a6f-a01e-a0d228cdd9d4": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\n10 Summary of Benefits H0028014000SB23 H0028014000 \nCovered Medical and Hospital Benefits (cont.)  \nThe provider locator for routine vision can be found at  Humana.com >  \nFind aDoctor >select Vision care icon >Vision coverage through  \nMedicare Advantage plans. \nMental health services Inpatient: \n\u2022$245 copay per day for days 1-8 \n\u2022$0 copay per day for days 9-90 \n\u2022Your plan covers up to 190 days in alifetime for inpatient mental \nhealth care in apsychiatric hospital. \nOutpatient (group and individual therapy visits):  $35 to  $40 copay \nCost share may vary depending on where service is provided. \nSkilled nursing facility (SNF) \u2022$0 copay per day for days 1-20 \n\u2022$196 copay per day for days 21-100 \n\u2022Your plan covers up to 100 days in aSNF \nPhysical Therapy  \u2022$35 copay \nADDITIONAL BENEFITS \nAmbulance $290  copay per date of service \nTransportation $0 copay for plan approved location up to 24 one-way trip(s) per year. \nThis benefit is not to exceed 50 miles per trip. \nThe member  must  contact transportation vendor to arrange \ntransportation and should contact Customer Care to be directed to \ntheir plan's specific transportation provider. \nMedicare Part Bdrugs \u2022Chemotherapy drugs:  20% of the cost \n\u2022Other Part Bdrugs:  20% of the cost ", "doc_id": "6218d87e-b417-4a6f-a01e-a0d228cdd9d4", "embedding": null, "doc_hash": "f001f0122be965d1321f6124615ce81449f0a562f40f87bb741a3bc9acbeabfa", "extra_info": {"page_label": "12", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1602, "_node_type": "1"}, "relationships": {"1": "966bacbe-d9e7-4dda-b7ff-7e730254403e"}}, "__type__": "1"}, "c8c48b14-9549-469e-a855-d6ca729d02c4": {"__data__": {"text": "H0028014000SB23 Summary of Benefits 11 H0028014000 \nPrescription Drug Benefits \nPRESCRIPTION DRUGS \nImportant Message About What You Pay for Vaccines \nOur plan covers most Part Dvaccines at no cost to you, no matter what cost-sharing tier it\u2019s on .\nImportant Message About What You Pay for Insulin \nYou won\u2019t pay more than $35 for aone-month (up to 30-day) supply of each Part Dinsulin product \ncovered by our plan, no matter what cost-sharing tier it\u2019s on .This applies to all Part Dcovered insulins, \nincluding the Select Insulins covered under the Insulin Savings Program as described below. If you receive \n\"Extra Help\", you will still pay no more than $35 for aone-month supply for each Part Dcovered insulin. \nPlease see your Prescription Drug Guide to find all Part Dinsulins covered by your plan. \nIf you don't receive Extra Help for your drugs, you'll pay the following:  \nDeductible This plan does not have adeductible.   \nInitial coverage \nYou pay the following until your total yearly drug costs reach  $4,660 .Total yearly drug costs are the total \ndrug costs paid by both you and our plan. Once you reach this amount, you will enter the Coverage Gap. \nMail Order Cost-Sharing \nPharmacy options Standard  \nWalmart Mail ,PillPack \nOther pharmacies are \navailable in our network. To find \npharmacy mail order options go to  \nHumana.com/pharmacyfinder Preferred \nCenterWell Pharmacy \u2122\nN/A 30-day supply 90-day supply* 30-day supply 90-day supply* \nTier 1: Preferred Generic $10 $30 $0 $0 \nTier 2: Generic $20 $60 $0 $0 \nTier 3: Preferred Brand $47 $141 $47 $131 \nTier 4: Non-Preferred \nDrug $100 $300 $99 $287 \nTier 5: Specialty Tier 33% N/A 33% N/A ", "doc_id": "c8c48b14-9549-469e-a855-d6ca729d02c4", "embedding": null, "doc_hash": "9b6a5727a30781210ae21d76f9cfa2a20f47e9179a121a5959f8fb8b5f07d695", "extra_info": {"page_label": "13", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1660, "_node_type": "1"}, "relationships": {"1": "ef812af2-ba1c-4900-82b0-4ff292578afe"}}, "__type__": "1"}, "aaa35494-00df-482c-ae36-408b50eeba13": {"__data__": {"text": "12 Summary of Benefits H0028014000SB23 H0028014000 \nRetail Cost-Sharing \nPharmacy options Retail All network retail pharmacies. To find the retail pharmacies near \nyou, go to  Humana.com/pharmacyfinder \nN/A 30-day supply 90-day supply* \nTier 1: Preferred Generic $0 $0 \nTier 2: Generic $0 $0 \nTier 3: Preferred Brand $47 $141 \nTier 4: Non-Preferred \nDrug $99 $297 \nTier 5: Specialty Tier 33% N/A \nYour plan participates in the Insulin Savings Program. You will pay no more than $35 for aone-month (up \nto a30-day) supply for Select Insulins, no matter what cost-sharing tier it\u2019s on .To identify which Select \nInsulins are included within the Insulin Savings Program, look for the  ISP indicator in your Prescription \nDrug Guide. You are not eligible for this program if you receive \"Extra Help\". \nYour plan also provides enhanced insulin coverage which means you will pay no more than $35 for a \none-month (up to 30-day) supply for all Part Dinsulins covered by our plan, including Select Insulins, no \nmatter what cost-sharing tier it\u2019s on .The enhanced insulin coverage is available, even if you receive \"Extra \nHelp\". \nYour share of the cost for Select Insulins: \nMail Order Cost-Sharing for Select Insulins \nPharmacy \noptions  Standard  \nWalmart Mail ,PillPack \nOther pharmacies are available in \nour network. To find pharmacy mail \norder options, go to  \nHumana.com/pharmacyfinder Preferred \nCenterWell Pharmacy \u2122\n- 30-day supply  90-day supply* 30-day supply  90-day supply* \nTier 3: Preferred Brand  $35 $105 $35 $95 \nRetail Cost-Sharing for Select Insulins \nPharmacy \noptions  Retail  \nAll network retail pharmacies. To find the retail pharmacies near you, go \nto  Humana.com/pharmacyfinder \n- 30-day supply  90-day supply* \nTier 3: Preferred Brand  $35 $105 ", "doc_id": "aaa35494-00df-482c-ae36-408b50eeba13", "embedding": null, "doc_hash": "4dbf5601625e6dc239a227fb027e481ded7dbf0209cc2739c2dc8868cff51097", "extra_info": {"page_label": "14", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1768, "_node_type": "1"}, "relationships": {"1": "510c1dcf-5ff9-407d-a25b-6f6fce06cb11"}}, "__type__": "1"}, "c086ed68-dc79-4426-a026-ca1d4361b5c3": {"__data__": {"text": "H0028014000SB23 Summary of Benefits 13 H0028014000 \nIf you receive Extra Help for your drugs, you'll pay the following: \nDeductible  This plan does not have adeductible. \nPharmacy cost-sharing \nFor generic drugs \n(including  30-day supply 90-day supply* \nbrand drugs treated as \ngeneric), either: $0 copay; or  \n$1.45 copay; or  \n$4.15 copay ;or \n15% of the cost $0 copay; or  \n$1.45 copay; or  \n$4.15 copay ;or \n15% of the cost \nFor all other drugs, \neither: $0 copay; or  \n$4 .30 copay; or  \n$10.35 copay ;or \n15%  of the cost  $0 copay; or  \n$4 .30 copay; or  \n$10.35 copay ;or \n15% of the cost  \nOther pharmacies are available in our network. \n*Some drugs are limited to a30-day supply \nADDITIONAL DRUG COVERAGE \nErectile dysfunction (ED) \ndrugs Covered at Tier 1cost-share amount. \nAnti-Obesity drugs Covered at Tier 2cost-share amount.  \nCost sharing may change depending on the pharmacy you choose, when you enter another phase of the  \nPart Dbenefit and if you qualify for \"Extra Help.\" To find out if you qualify for \"Extra Help,\" please contact  \nthe Social Security Office at 1-800-772-1213 Monday \u2014Friday, 7a.m. \u20147p.m. TTY users should call  \n1-800-325-0778. For more information on your prescription drug benefit, please call us or access your  \n\"Evidence of Coverage\" online. \nIf you reside in along-term care facility, you pay the same as at aretail pharmacy. \nYou may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network  \npharmacy. \nCoverage Gap \nAfter you enter the coverage gap, you pay  25 percent of the plan's cost for covered brand name drugs \nand  25 percent of the plan's cost for covered generic drugs until your out-of-pocket costs total  $7,400 \u2014 \nwhich is the end of the coverage gap. Not everyone will enter the coverage gap. \nUnder this plan,  you may pay even less for the following: \nTier 1(Preferred Generic) - All Drugs \nTier 2(Generic) - All Drugs \nTier 3(Preferred Brand) - Select Insulin Drugs \nFor more information on cost sharing in the coverage gap, please call us or access your Evidence of \nCoverage online. ", "doc_id": "c086ed68-dc79-4426-a026-ca1d4361b5c3", "embedding": null, "doc_hash": "5b84f3ef8d61366cc33aa692693e1391296167e9ac1fd385de09b3f5fee2fc4a", "extra_info": {"page_label": "15", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 2087, "_node_type": "1"}, "relationships": {"1": "8a81d30a-fb05-46f2-b486-3923c7966585"}}, "__type__": "1"}, "f2ec1d4d-ef35-4f48-960e-14ff324b773b": {"__data__": {"text": "14 Summary of Benefits H0028014000SB23 H0028014000 \nCatastrophic Coverage \nAfter your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and \nthrough mail order) reach  $7,4 00 you pay the greater of: \n\u20225% of the cost, or \n\u2022$4.15 copay for generic (including brand drugs treated as generic) and a  $10.35 copay for all other \ndrugs \nAdditional Benefits \nMedicare-covered foot care \n(podiatry) $25 copay \nMedicare-covered chiropractic \nservices $20 copay \nMedical equipment/ supplies \nCost share may vary depending \non the service and where service \nis provided \u2022Durable medical equipment (like wheelchairs or oxygen):  20% of \nthe cost \n\u2022Medical supplies:  20% of the cost \n\u2022Prosthetics (artificial limbs or braces):  20% of the cost \n\u2022Diabetic monitoring supplies:  $0 copay or  10% to  20% of the cost \nRehabilitation services \u2022Occupational and speech therapy:  $35 copay \n\u2022Cardiac rehabilitation:  $0 copay \n\u2022Pulmonary rehabilitation:  $20 copay \nTelehealth services \n(in addition to Original \nMedicare) \u2022Primary care provider (PCP):  $0 copay \n\u2022Specialist:  $25 copay \n\u2022Urgent care services:  $0 copay \n\u2022Substance abuse and behavioral health services:  $0 copay ", "doc_id": "f2ec1d4d-ef35-4f48-960e-14ff324b773b", "embedding": null, "doc_hash": "fd7e2956e7ed9d2ecc1c3e590912b0a6f714edf5a54a02d6d42e8d6561cd825d", "extra_info": {"page_label": "16", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1203, "_node_type": "1"}, "relationships": {"1": "45bbce71-1d4f-4777-9b76-469978086d5f"}}, "__type__": "1"}, "a3651ada-701c-43c1-81c1-c68827a22ba9": {"__data__": {"text": "H0028014000SB23 Summary of Benefits 15 H0028014000 \nMore benefits with  your plan \nEnjoy some of these extra benefits included in your plan . \nThis is asummary of what we cover. It doesn't list every service that we cover or list \nevery limitation or exclusion. The Evidence of Coverage (EOC) provides acomplete list of \ncoverage and services. Visit  Humana.com/medicare to view acopy of the EOC or call  \n1-800-833-2364 .\nHumana Flex Allowance \n$500 annual allowance on aprepaid \ncard to use toward out of pocket costs \nfor the plan's preventive and \ncomprehensive dental, vision, or hearing \nservices including copays. \nMembers can use this benefit at \nparticipating providers where the \nprimary business is Dental Care, Vision \nServices, or Hearing Services and Visa\u00ae \nis accepted. \nCannot be used for procedures such as \ncosmetic dentistry and teeth whitening. \nUnused amount expires at the end of \nthe plan year. \nAllowance amounts cannot be \ncombined with other benefit allowances. \nLimitations and restrictions may apply.   \nOver-the-Counter (OTC) Allowance \n$75 maximum benefit coverage \namount per quarter (3 months) for \nover-the-counter (OTC) prepaid card to \npurchase eligible OTC health and \nwellness products at participating \nretailers. \nUnused amount expires at the end of \nthe quarter. \nAllowance amounts cannot be \ncombined with other benefit allowances. \nLimitations and restrictions may apply.  Humana Spending Account Card  \nThe allowances listed below will be \nloaded onto this prepaid card. Each \nallowance is separate from any other \nallowance listed. Allowances shown are \naccessed by using this card. Allowance \namounts cannot be combined with \nother benefit allowances. Limitations \nand restrictions may apply. \n*Humana Flex Allowance  \n*OTC Allowance \n \nHMO Travel Benefit \nMembers can receive in-network \nbenefits when services are received \nfrom aparticipating HMO National \nNetwork provider during their travels to \nother states and Puerto Rico. \nSpecial Supplemental Benefits for \nthe Chronically Ill (SSBCI) Humana \nFlexible Care Assistance \nHumana Flexible Care Assistance is \navailable to members with chronic \nhealth conditions, who are participating \nin care management services, and meet \nprogram criteria. Eligible members may \nreceive medical expense assistance and \nother additional benefits, either \nprimarily health related or non-primarily \nhealth related, to address the member's \nunique individual needs. Benefits are \nlimited up to  $1,000 per year and must \nbe coordinated and authorized by acare \nmanager. There is no cost to participate.   ", "doc_id": "a3651ada-701c-43c1-81c1-c68827a22ba9", "embedding": null, "doc_hash": "ead4f499a33a734c247991d7c77ba5702d16ba97033de2c478c2c61294ebe143", "extra_info": {"page_label": "17", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 2590, "_node_type": "1"}, "relationships": {"1": "31f37692-0992-49b9-8919-c24d914a667f"}}, "__type__": "1"}, "6524a92b-3aa7-4d49-aab4-b26473ecb489": {"__data__": {"text": "16 Summary of Benefits H0028014000SB23 H0028014000 \nHealth Education \nOasis Everywhere benefit offers adult \nlearning and healthy lifestyle courses \nboth virtually and in-person. All \nprograms are live, interactive and \nencourage participation. Learning \nclasses range from History, Music, \nTravel, Culture, Art, Science, Technology, \nExercise and more. $0 copay with an \n$80 allowance per year toward courses \navailable in the Oasis catalog. \nNumerous healthy living courses are at \nno cost and an additional 3,560 \nfee-based classes offered nationwide. \nMember is responsible for costs above \nand beyond the allowance value.  \nHumana Well Dine \u00aeMeal Program \nHumana's home delivered meal \nprogram for members following an \ninpatient stay in the hospital or nursing \nfacility.  \nSpecial Supplemental Benefits for \nthe Chronically Ill (SSBCI) Worry \nFree TM Meals \nMembers diagnosed with Chronic \nObstructive Pulmonary Disease (COPD), \nDiabetes, or Congestive Heart Failure \n(CHF) ,participating with care \nmanagement services, and who meet \nprogram criteria may receive 2meals \nper day for 12 weeks, 168 meals total. \nAn additional 12 weeks of meals may be \navailable as determined by the plan. \nMembers may qualify for the Worry \nFree TM Meals program up to two times \nper plan year. There is no cost to \nparticipate. Authorization may be \nrequired.  Rewards and Incentives  \nGo365 by Humana \u00aeaRewards and \nIncentive program for completing \ncertain preventive health screenings and \nhealth and wellness activities.  \nSilverSneakers \u00aefitness program \nBasic fitness center membership \nincluding fitness classes.  ", "doc_id": "6524a92b-3aa7-4d49-aab4-b26473ecb489", "embedding": null, "doc_hash": "b6192ed136b6ef82758c122a13acbb9af27592882e0cb09b637e327b3c231e2e", "extra_info": {"page_label": "18", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1613, "_node_type": "1"}, "relationships": {"1": "c6f9c487-c132-4e8f-9115-a0247c8a6bb0"}}, "__type__": "1"}, "e04a8cff-3fc4-49b4-ab5e-ae34962a56f7": {"__data__": {"text": "17 \nH0028_SB_MAPD_HMO_014000_2023_M Summary of Benefits H0028014000SB23 To find out more about the coverage and costs of Original Medicare, look in the current \u201cMedicare &You\u201d \nhandbook. View it online at  http://www.medicare.gov or get acopy by calling 1-800-MEDICARE (1-800-633-4227), \n24 hours aday, seven days aweek. TTY users should call 1-877-486-2048. \nTelehealth services shown are in addition to the Original Medicare covered telehealth. Your cost may be different \nfor Original Medicare telehealth.  \nLimitations on telehealth services, also referred to as virtual visits or telemedicine, vary by state. These services \nare not asubstitute for emergency care and are not intended to replace your primary care provider or other \nproviders in your network. Any descriptions of when to use telehealth services are for informational purposes only \nand should not be construed as medical advice. Please refer to your evidence of coverage for additional details \non what your plan may cover or other rules that may apply.  \nPlans 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  \nhumana.com/finder/search or call us at the number listed at the beginning of \nthis booklet and we will send you one. \nYou can see our plan's  drug  guide at our website at  \nhumana.com/medicaredruglist or call us at the number listed at the beginning \nof this booklet and we will send you one. Find out  more ", "doc_id": "e04a8cff-3fc4-49b4-ab5e-ae34962a56f7", "embedding": null, "doc_hash": "097026420b23ba02d98e084658a08d96a967691ecc35d22d5068cd65a523e533", "extra_info": {"page_label": "19", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1501, "_node_type": "1"}, "relationships": {"1": "6c73d408-bf30-454d-876c-020652c30d26"}}, "__type__": "1"}, "292ebe4d-026c-4028-9f7b-d8e70bf4dc26": {"__data__": {"text": "Notes ", "doc_id": "292ebe4d-026c-4028-9f7b-d8e70bf4dc26", "embedding": null, "doc_hash": "ea287858b9278418efc8af2182154aa5e3104eea01925d173957e581206ba19e", "extra_info": {"page_label": "20", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 6, "_node_type": "1"}, "relationships": {"1": "e5fdc819-83a7-4408-b9b3-d9603860111a"}}, "__type__": "1"}, "1875fec4-33f1-439b-8717-6d8abeaa6b35": {"__data__": {"text": "Notes ", "doc_id": "1875fec4-33f1-439b-8717-6d8abeaa6b35", "embedding": null, "doc_hash": "c8662a92810a1cb6d93e31873d3f11ae59eb4d0509afe5423da5d1b24a710e18", "extra_info": {"page_label": "21", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 6, "_node_type": "1"}, "relationships": {"1": "7c0e5279-d099-49a9-a1a5-c6bbc4de70dd"}}, "__type__": "1"}, "3def36cc-7ce6-4b6a-8073-a398a5ba7416": {"__data__": {"text": "20 Summary of Benefits H0028014000SB23 H0028014000 \nGHHLNNXEN 0522 Important________________________________________________ \nAt Humana, it is important you are treated fairly. \nHumana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color, national \norigin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity, marital status, \nreligion, or language. Discrimination is against the law. Humana and its subsidiaries comply with applicable \nfederal civil rights laws. If you believe that you have been discriminated against by Humana or its \nsubsidiaries, there are ways to get help. \n\u2022You may file acomplaint, also known as agrievance:  \nDiscrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618. \nIf you need help filing agrievance, call  1-877-320-1235 or if you use a  TTY ,call  711 .\n\u2022You can also file acivil rights complaint with the  U.S. Department of Health and Human Services ,Office \nfor Civil Rights electronically through their Complaint Portal, available at  \nhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf ,or at  U.S. Department of Health and Human Services , \n200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201,  1-800-368-1019, \n800-537-7697 (TDD) .Complaint forms are available at  https://www.hhs.gov/ocr/office/file/index.html .\n\u2022California residents: You may also call California Department of Insurance toll-free hotline number:  \n1-800-927-HELP (4357) ,to file agrievance. \nAuxiliary aids and services, free of charge, are available to you. \n1-877-320-1235 (TTY: 711) \nHumana provides free auxiliary aids and services, such as qualified sign language interpreters, video remote \ninterpretation, and written information in other formats to people with disabilities when such auxiliary aids \nand services are necessary to ensure an equal opportunity to participate. ", "doc_id": "3def36cc-7ce6-4b6a-8073-a398a5ba7416", "embedding": null, "doc_hash": "ef9a51f94bba0965ee6626e5577c83ea36f9dfadb34c6ae0d93f3a34eaa3cd4d", "extra_info": {"page_label": "22", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1895, "_node_type": "1"}, "relationships": {"1": "9b745e95-5f45-484e-a2cb-f1f51ec7d7c9"}}, "__type__": "1"}, "c865e206-e2c6-41bf-ad98-e9132218de45": {"__data__": {"text": "H0028014000SB23 Summary of Benefits 21 H0028014000 ", "doc_id": "c865e206-e2c6-41bf-ad98-e9132218de45", "embedding": null, "doc_hash": "2c32e2437f56aa557bc1aa06cd5058aacb02870dea26d99c7a92d3baa84db397", "extra_info": {"page_label": "23", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 51, "_node_type": "1"}, "relationships": {"1": "dacde70f-6303-498f-88c4-228258ad41d6"}}, "__type__": "1"}, "0aa5601a-76f6-4cba-8d45-a59a9c7487ce": {"__data__": {"text": "22 Summary of Benefits H0028014000SB23 H0028014000 ", "doc_id": "0aa5601a-76f6-4cba-8d45-a59a9c7487ce", "embedding": null, "doc_hash": "44757af8dcb0e447b17292a3911dcb9934c6921325101ad5cde007e92e86c0ca", "extra_info": {"page_label": "24", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 51, "_node_type": "1"}, "relationships": {"1": "c643571a-869b-41aa-b4b7-642c04a97188"}}, "__type__": "1"}, "266f9258-2e26-41bb-98b5-148e40dbddd2": {"__data__": {"text": "Humana Gold Plus H0028-014 (HMO) \nH0028014000 ENG \nSt. Louis Metro area \nHumana.com \nGNHH4HIEN_23_C Summary of Benefits H0028014000SB23 ", "doc_id": "266f9258-2e26-41bb-98b5-148e40dbddd2", "embedding": null, "doc_hash": "66aa0a89631c771972c0039c418c1bea3bb65a635a61d09b03358c993452783e", "extra_info": {"page_label": "28", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 136, "_node_type": "1"}, "relationships": {"1": "544b24e7-9c5b-4ad5-b763-a94d9c2f994c"}}, "__type__": "1"}, "c4662c05-8b90-4253-afa8-deb2f3bf7d04": {"__data__": {"text": "IMPORTANT INFORMATION: IMPORTANT INFORMATION: \n2023 Medicare Star Ratings 2023 Medicare Star Ratings\nHumana - H0028\nFor 2023, Humana - H0028 received the For 2023, Humana - H0028 received the following Star Ratings from Medicare: following Star Ratings from Medicare: \nOverall Star Rating: Overall Star Rating:\nHealth Services Rating: Health Services Rating:\nDrug Services Rating: Drug Services Rating:\nEvery year, Medicare evaluates plans based on a 5-star rating system. Every year, Medicare evaluates plans based on a 5-star rating system.\nThe number of stars show how The number of stars show how \nwell a plan performs. well a plan performs.\nEXCELLENT\nABOVE AVERAGE\nAVERAGE\nBELOW AVERAGE\nPOORWhy Star Ratings Are Important Why Star Ratings Are Important\nMedicare rates plans on their health and drug services.\nThis lets you easily compare plans based on quality and\nperformance. \n  Star Ratings are based on factors that include:\nFeedback from members about the plan\u2019s service and care\nThe number of members who left or stayed with the plan\nThe number of complaints Medicare got about the plan\nData from doctors and hospitals that work with the plan\nMore stars mean a better plan \u2013 for example, members may\nget better care and better, faster customer service.\nGet More Information on Star Ratings Online Get More Information on Star Ratings Online \nCompare Star Ratings for this and other plans online at medicare.gov/plan-compare medicare.gov/plan-compare.\nQuestions about this plan? Questions about this plan? \nContact Humana 7 days a week from 8:00 a.m. to 8:00 p.m. local time at 800-833-2364 (toll-free) or 711 (TTY), from\nOctober 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday from 8:00\na.m. to 8:00 p.m. local time. Current members please call 800-457-4708 (toll-free) or 711 (TTY).\n1/1H0028_PRDEN23_M", "doc_id": "c4662c05-8b90-4253-afa8-deb2f3bf7d04", "embedding": null, "doc_hash": "d5334e583caf2d9304f3e4f090a60c4b03de1687601356429f2e073d9b6bd4d1", "extra_info": {"page_label": "1", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - CMS Plan Rating.pdf"}, "node_info": {"start": 0, "end": 1858, "_node_type": "1"}, "relationships": {"1": "4ac916dc-319f-4d53-98fc-291a6745fcd1"}}, "__type__": "1"}, "cba63cd8-c1e7-4c53-9efc-ad0c6248575b": {"__data__": {"text": "  GHHLNNXEN 0522Important _____________________________________________________________________\nAt Humana, it is important you are treated fairly. \nHumana Inc. and its subsidiaries do not discriminate or exclude people because of their race, \ncolor, national origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, \nethnicity, marital status, religion, or language. Discrimination is against the law. Humana and \nits subsidiaries comply with applicable federal civil rights laws. If you believe that you have \nbeen discriminated against by Humana or its subsidiaries, there are ways to get help. \n\u2022   You may file a complaint, also known as a grievance:  \nDiscrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618 \nIf you need help filing a grievance, call 1-877-320-1235 or if you use a TTY, call 711.\n\u2022   You can also file a civil rights complaint with the U.S. Department of Health and Human \nServices, Office for Civil Rights electronically through their Complaint Portal, available at \nhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at U.S. Department of Health and Human \nServices, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, \n1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at  \nhttps://www.hhs.gov/ocr/office/file/index.html.\n\u2022   California residents: You may also call the California Department of Insurance toll-free \nhotline number: 1-800-927-HELP (4357), to file a grievance.\nAuxiliary aids and services, free of charge, are available to you.  \n1-877-320-1235 (TTY: 711)\nHumana provides free auxiliary aids and services, such as qualified sign language  \ninterpreters, video remote interpretation, and written information in other formats  \nto people with disabilities when such auxiliary aids and services are necessary to  \nensure an equal opportunity to participate. \nH0028_PRDEN23_M", "doc_id": "cba63cd8-c1e7-4c53-9efc-ad0c6248575b", "embedding": null, "doc_hash": "831e24743029b5c072af4e7ab98f8203e868f002b8a090f7c0191bab128e2373", "extra_info": {"page_label": "2", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - CMS Plan Rating.pdf"}, "node_info": {"start": 0, "end": 1891, "_node_type": "1"}, "relationships": {"1": "4b3cc256-c207-4841-aaf4-6aeb02f3594e"}}, "__type__": "1"}, "8e9a420c-457a-4ccc-8fef-a33a80b742ef": {"__data__": {"text": "  GHHLNNXEN 0522Multi-Language Insert \nMulti-language Interpreter Services\nEnglish: We have free interpreter services to answer any questions you may have \nabout our health or drug plan. To get an interpreter, just call us at 1-877-320-1235 \n(TTY: 711). Someone who speaks English can help you. This is a free service.\nSpanish: Tenemos servicios de int\u00e9rprete sin costo alguno para responder \ncualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. \nPara hablar con un int\u00e9rprete, por favor llame al 1-877-320-1235 (TTY: 711). Alguien \nque\u00a0hable espa\u00f1ol le podr\u00e1 ayudar. Este es un servicio gratuito.\nChinese Mandarin:\u202f \u6211\u4eec\u63d0\u4f9b\u514d\u8d39\u7684\u7ffb\u8bd1\u670d\u52a1\uff0c\u5e2e\u52a9\u60a8\u89e3\u7b54\u5173\u4e8e\u5065\u5eb7\u6216\u836f\u7269\u4fdd\u9669\u7684\u4efb\u4f55\u7591\u95ee\u3002\u5982\u679c\n\u60a8\u9700\u8981\u6b64\u7ffb\u8bd1\u670d\u52a1\uff0c\u8bf7\u81f4\u7535  1-877-320-1235 (TTY: 711) \u3002\u6211\u4eec\u7684\u4e2d\u6587\u5de5\u4f5c\u4eba\u5458\u5f88\u4e50\u610f\u5e2e\u52a9\u60a8\u3002\u8fd9\u662f\n\u4e00\u9879\u514d\u8d39\u670d\u52a1\u3002\nChinese Cantonese: \u202f\u60a8\u5c0d\u6211\u5011\u7684\u5065\u5eb7\u6216\u85e5\u7269\u4fdd\u96aa\u53ef\u80fd\u5b58\u6709\u7591\u554f \uff0c\u70ba\u6b64\u6211\u5011\u63d0\u4f9b\u514d\u8cbb\u7684\u7ffb\u8b6f\u670d\u52d9 \u3002  \n\u5982\u9700\u7ffb\u8b6f\u670d\u52d9 \uff0c\u8acb\u81f4\u96fb  1-877-320-1235 (TTY: 711) \u3002\u6211\u5011\u8b1b\u4e2d\u6587\u7684\u4eba\u54e1\u5c07\u6a02\u610f\u70ba\u60a8\u63d0\u4f9b\u5e6b\u52a9 \u3002\u9019\u662f\n\u4e00\u9805 \u514d \u8cbb \u670d \u52d9\u3002\nTagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot \nang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan \no panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa \n1-877-320-1235 (TTY: 711). Maaari kayong tulungan ng isang nakakapagsalita \nng\u00a0Tagalog. Ito ay libreng serbisyo.\nFrench: Nous proposons des services gratuits d\u2019interpr\u00e9tation pour r\u00e9pondre \u00e0 \ntoutes vos questions relatives \u00e0 notre r\u00e9gime de sant\u00e9 ou d\u2019assurance-m\u00e9dicaments. \nPour acc\u00e9der au service d\u2019interpr\u00e9tation, il vous suffit de nous appeler au \n1-877-320-1235 (TTY: 711). Un interlocuteur parlant Fran\u00e7ais pourra vous aider. \nCe\u00a0service est gratuit.\nVietnamese: Ch\u00fang t\u00f4i c\u00f3 d\u1ecbch v\u1ee5 th\u00f4ng d\u1ecbch mi\u1ec5n ph\u00ed \u0111\u1ec3 tr\u1ea3 l\u1eddi c\u00e1c c\u00e2u h\u1ecfi v\u1ec1 \nch\u01b0\u01a1ng s\u1ee9c kh\u1ecfe v\u00e0 ch\u01b0\u01a1ng tr\u00ecnh thu\u1ed1c men. N\u1ebfu qu\u00ed v\u1ecb c\u1ea7n th\u00f4ng d\u1ecbch vi\u00ean xin \ng\u1ecdi\u00a01-877-320-1235 (TTY: 711)", "doc_id": "8e9a420c-457a-4ccc-8fef-a33a80b742ef", "embedding": null, "doc_hash": "20a3da7a0835675a512325f80aaa1395b81c742ce39b829ae7fbef2aee730e08", "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - CMS Plan Rating.pdf"}, "node_info": {"start": 0, "end": 1745, "_node_type": "1"}, "relationships": {"1": "6510f538-9d4d-445f-8c3e-8beac6916d13", "3": "a4d96eca-a09e-4053-adf2-909de068a966"}}, "__type__": "1"}, "a4d96eca-a09e-4053-adf2-909de068a966": {"__data__": {"text": "(TTY: 711) s\u1ebd c\u00f3 nh\u00e2n vi\u00ean n\u00f3i ti\u1ebfng Vi\u1ec7t gi\u00fap \u0111\u1ee1 qu\u00ed v\u1ecb. \u0110\u00e2y l\u00e0 \nd\u1ecbch v\u1ee5 mi\u1ec5n ph\u00ed.\nGerman: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu \nunserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie \nunter 1-877-320-1235 (TTY: 711). Man wird Ihnen dort auf Deutsch weiterhelfen. \nDieser Service ist kostenlos.\nKorean:  \ub2f9\uc0ac\ub294 \uc758\ub8cc \ubcf4\ud5d8 \ub610\ub294 \uc57d\ud488 \ubcf4\ud5d8\uc5d0 \uad00\ud55c \uc9c8\ubb38\uc5d0 \ub2f5\ud574 \ub4dc\ub9ac\uace0\uc790 \ubb34\ub8cc \ud1b5\uc5ed \uc11c\ube44\uc2a4\ub97c \uc81c\uacf5\ud558\uace0 \n\uc788\uc2b5\ub2c8\ub2e4. \ud1b5\uc5ed \uc11c\ube44\uc2a4\ub97c \uc774\uc6a9\ud558\ub824\uba74 \uc804\ud654  1-877-320-1235 (TTY: 711) \ubc88\uc73c\ub85c \ubb38\uc758\ud574 \uc8fc\uc2ed\uc2dc\uc624 . \n\ud55c\uad6d\uc5b4\ub97c \ud558\ub294 \ub2f4\ub2f9\uc790\uac00 \ub3c4\uc640 \ub4dc\ub9b4 \uac83\uc785\ub2c8\ub2e4. \uc774 \uc11c\ube44\uc2a4\ub294 \ubb34\ub8cc\ub85c \uc6b4\uc601\ub429\ub2c8\ub2e4.  \nH0028_PRDEN23_M", "doc_id": "a4d96eca-a09e-4053-adf2-909de068a966", "embedding": null, "doc_hash": "a5023307fb8aa26e02d5c5d21209faebd6fc76b16ae2f4c534494457d4fd7e5f", "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - CMS Plan Rating.pdf"}, "node_info": {"start": 1735, "end": 2267, "_node_type": "1"}, "relationships": {"1": "6510f538-9d4d-445f-8c3e-8beac6916d13", "2": "8e9a420c-457a-4ccc-8fef-a33a80b742ef"}}, "__type__": "1"}, "0ce22cc3-d2f0-4f13-aaa7-a6499b2e5c66": {"__data__": {"text": "  GHHLNNXEN 0522Russian:  \u0415\u0441\u043b\u0438 \u0443 \u0432\u0430\u0441 \u0432\u043e\u0437\u043d\u0438\u043a\u043d\u0443\u0442 \u0432\u043e\u043f\u0440\u043e\u0441\u044b \u043e\u0442\u043d\u043e\u0441\u0438\u0442\u0435\u043b\u044c\u043d\u043e \u0441\u0442\u0440\u0430\u0445\u043e\u0432\u043e\u0433\u043e \u0438\u043b\u0438 \n\u043c\u0435\u0434\u0438\u043a\u0430\u043c\u0435\u043d\u0442\u043d\u043e\u0433\u043e \u043f\u043b\u0430\u043d\u0430, \u0432\u044b \u043c\u043e\u0436\u0435\u0442\u0435 \u0432\u043e\u0441\u043f\u043e\u043b\u044c\u0437\u043e\u0432\u0430\u0442\u044c\u0441\u044f \u043d\u0430\u0448\u0438\u043c\u0438 \u0431\u0435\u0441\u043f\u043b\u0430\u0442\u043d\u044b\u043c\u0438 \n\u0443\u0441\u043b\u0443\u0433\u0430\u043c\u0438 \u043f\u0435\u0440\u0435\u0432\u043e\u0434\u0447\u0438\u043a\u043e\u0432. \u0427\u0442\u043e\u0431\u044b \u0432\u043e\u0441\u043f\u043e\u043b\u044c\u0437\u043e\u0432\u0430\u0442\u044c\u0441\u044f \u0443\u0441\u043b\u0443\u0433\u0430\u043c\u0438 \u043f\u0435\u0440\u0435\u0432\u043e\u0434\u0447\u0438\u043a\u0430, \n\u043f\u043e\u0437\u0432\u043e\u043d\u0438\u0442\u0435 \u043d\u0430\u043c \u043f\u043e \u0442\u0435\u043b\u0435\u0444\u043e\u043d\u0443 1-877-320-1235 (TTY: 711). \u0412\u0430\u043c \u043e\u043a\u0430\u0436\u0435\u0442 \u043f\u043e\u043c\u043e\u0449\u044c \n\u0441\u043e\u0442\u0440\u0443\u0434\u043d\u0438\u043a, \u043a\u043e\u0442\u043e\u0440\u044b\u0439 \u0433\u043e\u0432\u043e\u0440\u0438\u0442 \u043f\u043e-p\u0443\u0441\u0441\u043a\u0438. \u0414\u0430\u043d\u043d\u0430\u044f\u00a0\u0443\u0441\u043b\u0443\u0433\u0430 \u0431\u0435\u0441\u043f\u043b\u0430\u0442\u043d\u0430\u044f.\n\u0625\u0646\u0646\u0627 \u0646\u0642\u062f\u0645 \u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0645\u062a\u0631\u062c\u0645 \u0627\u0644\u0641\u0648\u0631\u064a \u0627\u0644\u0645\u062c\u0627\u0646\u064a\u0629 \u0644\u0644\u0625\u062c\u0627\u0628\u0629 \u0639\u0646 \u0623\u064a \u0623\u0633\u0626\u0644\u0629 \u062a\u062a\u0639\u0644\u0642 \u0628\u0627\u0644\u0635\u062d\u0629  Arabic\n\u0623\u0648 \u062c\u062f\u0648\u0644 \u0627\u0644\u0623\u062f\u0648\u064a\u0629 \u0644\u062f\u064a\u0646\u0627. \u0644\u0644\u062d\u0635\u0648\u0644 \u0639\u0644\u0649 \u0645\u062a\u0631\u062c\u0645 \u0641\u0648\u0631\u064a\u060c \u0644\u064a\u0633 \u0639\u0644\u064a\u0643 \u0633\u0648\u0649 \u0627\u0644\u0627\u062a\u0635\u0627\u0644 \u0628\u0646\u0627\n\u0633\u064a\u0642\u0648\u0645 \u0634\u062e\u0635 \u0645\u0627 \u064a\u062a\u062d\u062f\u062b \u0627\u0644\u0639\u0631\u0628\u064a\u0629 \u0628\u0645\u0633\u0627\u0639\u062f\u062a\u0643. \u0647\u0630\u0647 1-877-320-1235 (TTY: 711)  \u0639\u0644\u0649\n\u062e\u062f\u0645\u0629 \u0645\u062c\u0627\u0646\u064a\u0629.\nHindi:  \u0939\u092e\u093e\u0930\u0947 \u0938\u094d\u093e \u0938\u094d\u0925\u094d\u092f \u0925\u094d\u092f \u093e \u0926\u094d\u093e \u0915\u0940 \u0925\u094d\u092f \u094b\u091c\u0928\u093e \u0915 \u0947  \u092c\u093e\u0930\u0947 \u092e\u0947\u0902 \u0906\u092a\u0915 \u0947  \u0915\u0915 \u0938\u0940 \u092d\u0940 \u092a\u094d\u0930\u0936\u094d\u0928 \u0915 \u0947  \u091c\u094d \u093e\u092c \u0926\u0947\u0928\u0947 \u0915 \u0947  \u0932\u093f\u090f \u0939\u092e\u093e\u0930\u0947 \u092a\u093e\u0938 \u092e\u0941\u092b\u094d\u0924 \n\u0926\u0941\u092d\u093e\u0915\u093f\u0925\u094d\u092f\u093e \u0938\u0947\u094d\u093e\u090f\u0901 \u0909\u092a\u093f \u092c\u094d\u0927 \u0939\u0948\u0902. \u090f\u0915 \u0926\u0941\u092d\u093e\u0915 \u093f\u0925\u094d\u092f\u093e \u092a\u094d\u0930\u093e\u092a\u094d\u0924 \u0915\u0930\u0928\u0947 \u0915 \u0947  \u0932\u093f\u090f, \u092c\u0938 \u0939\u092e\u0947\u0902 1-877-320-1235 (TTY: 711) \u092a\u0930 \n\u092b\u094b\u0928 \u0915\u0930\u0947\u0902. \u0915\u094b\u0908 \u0935\u094d\u092f\u0932 \u0924\u093f \u091c\u094b \u0915\u0939\u0928 \u0926\u0926\u0940 \u092c\u094b\u093f\u094d\u0924\u093e \u0939\u0948 \u0906\u092a\u0915\u0940 \u092e\u0926\u0926 \u0915\u0930 \u0938\u0915\u094d\u0924 \u093e \u0939\u0948. \u0925\u094d\u092f \u0939 \u090f\u0915 \u092e\u0941\u092b\u094d\u0924 \u0938\u0947\u094d \u093e \u0939\u0948.", "doc_id": "0ce22cc3-d2f0-4f13-aaa7-a6499b2e5c66", "embedding": null, "doc_hash": "dffec1862a444a867d9647853fdc8432b5ac833d9233d533ded1413ce8171879", "extra_info": {"page_label": "4", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - CMS Plan Rating.pdf"}, "node_info": {"start": 0, "end": 915, "_node_type": "1"}, "relationships": {"1": "482d3eae-6f93-424b-a9bd-f48f4f155571", "3": "83ca32df-ebb5-439e-9950-9d1b38d734e0"}}, "__type__": "1"}, "83ca32df-ebb5-439e-9950-9d1b38d734e0": {"__data__": {"text": "\u093e \u0939\u0948. \nItalian:  \u00c8 disponibile un servizio di interpretariato gratuito per rispondere a \neventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, \ncontattare il numero 1-877-320-1235 (TTY: 711). Un nostro incaricato che parla \nItalianovi fornir\u00e0 l\u2019assistenza necessaria. \u00c8\u00a0un servizio gratuito.\nPortugues:  Dispomos de servi\u00e7os de interpreta\u00e7\u00e3o gratuitos para responder \na\u00a0qualquer quest\u00e3o que tenha acerca do nosso plano de sa\u00fade ou de medica\u00e7\u00e3o. \nPara obter um int\u00e9rprete, contacte-nos atrav\u00e9s do n\u00famero 1-877-320-1235 \n(TTY:\u00a0711). Ir\u00e1 encontrar algu\u00e9m que fale\u00a0o idioma Portugu\u00eas para o ajudar. \nEste\u00a0servi\u00e7o \u00e9\u00a0gratuito.\nFrench Creole: Nou genyen s\u00e8vis ent\u00e8pr\u00e8t gratis pou reponn tout kesyon ou ta \ngenyen kons\u00e8nan plan medikal oswa dw\u00f2g nou an. Pou jwenn yon ent\u00e8pr\u00e8t, jis rele \nnou nan 1-877-320-1235 (TTY: 711). Yon moun ki pale Krey\u00f2l kapab ede w. Sa a se \nyon s\u00e8vis ki gratis.\nPolish:  Umo\u017cliwiamy bezp\u0142atne skorzystanie z us\u0142ug t\u0142umacza ustnego, kt\u00f3ry \npomo\u017ce w\u00a0uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania \nlek\u00f3w. Aby skorzysta\u0107 z pomocy t\u0142umacza znaj\u0105cego j\u0119zyk polski, nale\u017cy zadzwoni\u0107 \npod numer 1-877-320-1235 (TTY: 711). Ta\u00a0us\u0142uga jest bezp\u0142atna.\nJapanese  :\u00a0\u5f53\u793e\u306e\u5065\u5eb7\u5065\u5eb7\u4fdd\u967a\u3068\u85ac\u54c1\u51e6\u65b9\u85ac\u30d7\u30e9\u30f3\u306b\u95a2\u3059\u308b\u3054\u8cea\u554f\u306b\u304a\u7b54\u3048\u3059\u308b\u305f\u3081\u306b\u200c\u3001\u7121\u6599\u306e\u901a\u8a33\n\u30b5\u200c\u30fc\u30d3\u30b9\u304c\u3042\u308a\u307e\u3059\u3054\u3056\u3044\u307e\u3059\u200c\u3002\u901a\u8a33\u3092\u3054\u7528\u547d\u306b\u306a\u308b\u306b\u306f\u200c\u3001 1-877-320-1235 (TTY : 711 )\u306b\u304a\u96fb\u8a71\u304f\u3060\n\u3055\u3044\u200c\u3002\u65e5\u672c\u8a9e\u3092\u8a71\u3059\u4eba\u8005\u304c\u652f\u63f4\u3044\u305f\u3057\u307e\u3059\u200c\u3002\u3053\u308c\u306f\u7121\u6599\u306e\u30b5\u200c\u30fc\u30d3\u30b9\u3067\u3059\u200c\u3002\nH0028_PRDEN23_M", "doc_id": "83ca32df-ebb5-439e-9950-9d1b38d734e0", "embedding": null, "doc_hash": "1094bfde340a5c3fe9a840a1e1f06a8051cc981dffcd9f51e8ffdbf11853a9f6", "extra_info": {"page_label": "4", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - CMS Plan Rating.pdf"}, "node_info": {"start": 910, "end": 2285, "_node_type": "1"}, "relationships": {"1": "482d3eae-6f93-424b-a9bd-f48f4f155571", "2": "0ce22cc3-d2f0-4f13-aaa7-a6499b2e5c66"}}, "__type__": "1"}, "7c6df006-37c7-4905-b5e8-862cd798a946": {"__data__": {"text": "H0028_EOC_MAPD_HMOPOS_015000_2023_C H0028015000EOC23EOC076\nYour 2023 \nEvidence of Coverage", "doc_id": "7c6df006-37c7-4905-b5e8-862cd798a946", "embedding": null, "doc_hash": "c75187386f85bed0ddb9938eec3ad4bf2d9ae8d9a0eb06861881774950ac4705", "extra_info": {"page_label": "1", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 90, "_node_type": "1"}, "relationships": {"1": "3b3bae26-2679-4d69-b4ac-241fad854b4a"}}, "__type__": "1"}, "ed5c060f-3acd-4c08-b953-cfd0ffc4eb7f": {"__data__": {"text": "Thanks for being a Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) member. We  \nvalue your membership, and we're dedicated to helping you be the best you want to be. \nThis Evidence of Coverage contains important information about your plan. This book is a very  \ndetailed document with the full, legal description of your benefits and costs. You should keep  \nthis document for reference throughout the plan year.\nHumana cares about your well-being\nWe look forward to being your partner in health for many years to come. If you have any  \nquestions, we're here to help.", "doc_id": "ed5c060f-3acd-4c08-b953-cfd0ffc4eb7f", "embedding": null, "doc_hash": "17a6ac6bfbf4b70f46f4fd35e132136349680e01dc6fcc2f352eb89b6a35dad2", "extra_info": {"page_label": "2", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 571, "_node_type": "1"}, "relationships": {"1": "b96b03ce-619e-4b51-a791-a81aeedb0b2e"}}, "__type__": "1"}, "4f19a4dd-2c70-498a-8739-6f7347008a6d": {"__data__": {"text": "H0028_EOC_MAPD_HMOPOS_015000_2023_C H0028015000EOC232023\nHumana Gold Plus\nSNP-DE H0028-015 (HMO-POS  \nD-SNP)\nMissouri\nSelect Counties in MissouriEvidence of Coverage", "doc_id": "4f19a4dd-2c70-498a-8739-6f7347008a6d", "embedding": null, "doc_hash": "3afb3b4ea7c1757f5a9cdb3addd27e77d2ee08104dd55ea9489f8920c2cf8899", "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 165, "_node_type": "1"}, "relationships": {"1": "0f560b38-6656-42ea-9cac-25ac01665a69"}}, "__type__": "1"}, "1c4df0fc-d6c1-46a0-b2f0-b0048b80b31d": {"__data__": {"text": "OMB Approval 0938-1051 (Expires: February 29, 2024)January 1 - December 31, 2023\nEvidence of Coverage:\nYour Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Humana Gold \nPlus SNP-DE H0028-015 (HMO-POS D-SNP)\nThis document gives you the details about your Medicare health care and prescription drug coverage from January \n1 - December 31, 2023. This is an important legal document. Please keep it in a safe place.\nFor questions about this document, please contact Customer Care at 1-800-457-4708. (TTY users should \ncall 711). Hours are from 8 a.m. to 8 p.m. seven days a week from Oct. 1 \u2013 Mar. 31 and 8 a.m. to 8 p.m. \nMonday-Friday from Apr. 1 - Sept. 30.\nThis plan, Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP), is offered by CHA HMO, Inc., a Humana \ncompany. (When this Evidence of Coverage says \"we,\" \"us,\" or \"our,\" it means CHA HMO, Inc., a Humana company. \nWhen it says \"plan\" or \"our plan,\" it means Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP).)\nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) has been approved by the National Committee for Quality \nAssurance (NCQA) to operate as a Special Needs Plan (SNP) until December 31, 2025 based on a review of Humana \nGold Plus SNP-DE H0028-015 (HMO-POS D-SNP)'s Model of Care.\nThis document is available for free in Spanish.\nThis information is available in a different format, including Braille, large print, and audio. Please call Customer Care \nat the number listed above if you need plan information in another format.\nBenefits, premiums, deductibles, and/or copayments/coinsurance may change on January 1, 2024.\nThe formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when \nnecessary. We will notify affected enrollees about changes at least 30 days in advance.\nThis document explains your benefits and rights. Use this document to understand about: \n\u2022Your plan premium and cost sharing; \n\u2022Your medical and prescription drug benefits; \n\u2022How to file a complaint if you are not satisfied with a service or treatment; \n\u2022How to contact us if you need further assistance; and, \n\u2022Other protections required by Medicare law.\nH0028_EOC_MAPD_HMOPOS_015000_2023_C", "doc_id": "1c4df0fc-d6c1-46a0-b2f0-b0048b80b31d", "embedding": null, "doc_hash": "59e91432df746d6480b30cfee04f92add9ace6666f1c856c425b28074e6dc130", "extra_info": {"page_label": "5", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2209, "_node_type": "1"}, "relationships": {"1": "9219484d-514f-46a0-99fa-8a83302f3717"}}, "__type__": "1"}, "770b0281-0bc7-453c-bfde-45051bf615f4": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 6\nTable of Contents\n2023 Evidence of Coverage\nTable of Contents\nChapter 1.Getting started as a member.....................................................................9\nSECTION 1 Introduction..........................................................................................10\nSECTION 2 What makes you eligible to be a plan member?..............................................11\nSECTION 3 Important membership materials you will receive..........................................13\nSECTION 4 Your monthly costs for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP)...14\nSECTION 5 More information about your monthly premium.............................................17\nSECTION 6 Keeping your plan membership record up to date...........................................19\nSECTION 7 How other insurance works with our plan......................................................20\nChapter 2.Important phone numbers and resources..................................................21\nSECTION 1 Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) contacts (how to contact \nus, including how to reach Customer Care) ...................................................22\nSECTION 2 Medicare (how to get help and information directly from the Federal Medicare \nprogram)...............................................................................................24\nSECTION 3 State Health Insurance Assistance Program (free help, information, and answers \nto your questions about Medicare)..............................................................26\nSECTION 4 Quality Improvement Organization.............................................................26\nSECTION 5 Social Security........................................................................................27\nSECTION 6 Medicaid...............................................................................................27\nSECTION 7 Information about programs to help people pay for their prescription drugs..........29\nSECTION 8 How to contact the Railroad Retirement Board...............................................31\nSECTION 9 Do you have \"group insurance\" or other health insurance from an employer?.......31\nChapter 3.Using the plan for your medical services ...................................................32\nSECTION 1 Things to know about getting your medical care as a \nmember of our plan ................................................................................33\nSECTION 2 Use providers in the plan\u2019s network to get your medical care.............................34\nSECTION 3 How to get services when you have an emergency or urgent need for care or \nduring a disaster.....................................................................................37\nSECTION 4 What if you are billed directly for the full cost of your services?...........................39\nSECTION 5 How are your medical services covered when you are in a \"clinical research \nstudy\"?.................................................................................................40\nSECTION 6 Rules for getting care in a \"religious non-medical health care institution\".............41\nSECTION 7 Rules for ownership of durable medical equipment.........................................42\nChapter 4.Medical Benefits Chart (what is covered)...................................................44\nSECTION 1 Understanding your out-of-pocket costs for covered services ...........................45\nSECTION 2 Use the Medical Benefits Chart to find out what is covered and how much you \nwill pay.................................................................................................46\nSECTION 3 What services are covered outside of Humana Gold Plus SNP-DE H0028-015 \n(HMO-POS D-SNP)....................................................................................82\nSECTION 4 What services are not covered by the plan?...................................................82\nChapter 5.Using the plan\u2019s coverage for your Part D prescription drugs........................87", "doc_id": "770b0281-0bc7-453c-bfde-45051bf615f4", "embedding": null, "doc_hash": "467d287782ff818c4dd0810b609c0f241db543f19abd1f8d7ff65202e4678056", "extra_info": {"page_label": "6", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 4115, "_node_type": "1"}, "relationships": {"1": "03bbb391-4b4b-4d5d-a7fb-4563444c9d3c"}}, "__type__": "1"}, "e9f2d3c1-ea76-4ef5-9b7b-6a4dd16b1460": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 7\nTable of Contents\nSECTION 1 Introduction ..........................................................................................88\nSECTION 2 Fill your prescription at a network pharmacy or through the plan\u2019s mail-order \nservice..................................................................................................88\nSECTION 3 Your drugs need to be in the plan\u2019s \"Drug Guide\".............................................92\nSECTION 4 There are restrictions on coverage for some drugs...........................................93\nSECTION 5 What if one of your drugs is not covered in the way you\u2019d like it to be covered?......94\nSECTION 6 What if your coverage changes for one of your drugs?.....................................97\nSECTION 7 What types of drugs are not covered by the plan?...........................................99\nSECTION 8 Filling a prescription...............................................................................100\nSECTION 9 Part D drug coverage in special situations....................................................100\nSECTION 10Programs on drug safety and managing medications....................................101\nChapter 6.What you pay for your Part D prescription drugs.......................................104\nSECTION 1 Introduction ........................................................................................105\nSECTION 2 What you pay for a drug depends on which \"drug payment stage\" you are in \nwhen you get the drug............................................................................107\nSECTION 3 We send you reports that explain payments for your drugs and which payment \nstage you are in ....................................................................................107\nSECTION 4 During the Deductible Stage, you pay the full cost of your drugs.......................109\nSECTION 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and \nyou pay your share................................................................................109\nSECTION 6 Costs in the Coverage Gap Stage...............................................................112\nSECTION 7 During the Catastrophic Coverage Stage, the plan pays most of the cost for your \ndrugs..................................................................................................113\nSECTION 8 Additional benefits information................................................................113\nSECTION 9 Part D Vaccines. What you pay for depends on how and where you get them......113\nChapter 7.Asking us to pay a bill you have received for covered \nmedical services or drugs......................................................................115\nSECTION 1 Situations in which you should ask us to pay for your covered services or drugs ...116\nSECTION 2 How to ask us to pay you back or to pay a bill you have received.......................118\nSECTION 3 We will consider your request for payment and say yes or no...........................118\nChapter 8.Your rights and responsibilities..............................................................119\nSECTION 1 Our plan must honor your rights and cultural sensitivities as a member of the \nplan ...................................................................................................120\nSECTION 2 You have some responsibilities as a member of the plan.................................129\nChapter 9.What to do if you have a problem or complaint (coverage decisions, appeals, \ncomplaints).........................................................................................131\nSECTION 1 Introduction ........................................................................................132\nSECTION 2 Where to get more information and personalized assistance...........................132\nSECTION 3 To deal with your problem, which process should you use?..............................133\nSECTION 4 Handling problems about your Medicare benefits..........................................134\nSECTION 5 A guide to the basics of coverage decisions and appeals ................................134\nSECTION 6 Your medical care: How to ask for a coverage decision or make an appeal of a \ncoverage decision..................................................................................137\nSECTION 7 Your Part D prescription drugs: How to ask for a coverage decision or make an \nappeal ................................................................................................143", "doc_id": "e9f2d3c1-ea76-4ef5-9b7b-6a4dd16b1460", "embedding": null, "doc_hash": "29a6ff3e6f1b9aca8145af0a72487bc405f3578626deef43f26b5c2be88a92ce", "extra_info": {"page_label": "7", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 4605, "_node_type": "1"}, "relationships": {"1": "59d89076-9535-4e90-b0bd-1f17a9a40fd5"}}, "__type__": "1"}, "ef65b35f-6994-41d8-9b53-d42c9d901d82": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 8\nTable of Contents\nSECTION 8 How to ask us to cover a longer inpatient hospital stay if you think the doctor is \ndischarging you too soon........................................................................151\nSECTION 9 How to ask us to keep covering certain medical services if you think your coverage \nis ending too soon .................................................................................157\nSECTION 10Taking your appeal to Level 3 and beyond...................................................162\nSECTION 11How to make a complaint about quality of care, waiting times, customer service, or \nother concerns .....................................................................................164\nSECTION 12Handling problems about your Medicaid \nbenefits...............................................................................................167\nChapter 10.Ending your membership in the plan.......................................................168\nSECTION 1 Introduction to ending your membership in our plan .....................................169\nSECTION 2 When can you end your membership in our plan?.........................................169\nSECTION 3 How do you end your membership in our plan? ............................................173\nSECTION 4 Until your membership ends, you must keep getting your medical services and \ndrugs through our plan...........................................................................174\nSECTION 5 Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) must end your membership \nin the plan in certain situations.................................................................174\nChapter 11.Legal notices.......................................................................................176\nSECTION 1 Notice about governing law .....................................................................177\nSECTION 2 Notice about nondiscrimination................................................................177\nSECTION 3 Notice about Medicare Secondary Payer subrogation rights ............................177\nSECTION 4 Additional Notice about Subrogation (Recovery from a Third Party)...................177\nSECTION 5 Notice of coordination of benefits..............................................................178\nChapter 12.Definitions of important words...............................................................181\nExhibit A.\nLists the names, addresses, phone numbers, and other contact information for a  \nvariety of helpful resources in your state.State Agency Contact Information..........................................................192", "doc_id": "ef65b35f-6994-41d8-9b53-d42c9d901d82", "embedding": null, "doc_hash": "69d1f0ffa00980fe6300bd4c4e710a8e54394294579ad5a7cd6e4a654b25ade7", "extra_info": {"page_label": "8", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2711, "_node_type": "1"}, "relationships": {"1": "5ced7010-2d4c-47d3-a51f-4f9d3c421a23"}}, "__type__": "1"}, "9c14e2fa-59f4-4276-a693-040506d7a050": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 9\nChapter 1 Getting started as a memberEOC076\nCHAPTER 1:\nGetting started as a member", "doc_id": "9c14e2fa-59f4-4276-a693-040506d7a050", "embedding": null, "doc_hash": "2780fc54112f7b53791bba54acaa77faad986b2347ee6aab2d801398166baea8", "extra_info": {"page_label": "9", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 164, "_node_type": "1"}, "relationships": {"1": "a706f6f5-e5ee-4ff7-830a-4ee3707013f4"}}, "__type__": "1"}, "3917d8fb-1219-42f9-bfff-a8c4fd32de3a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 10\nChapter 1 Getting started as a member\nSECTION 1 Introduction\nSection 1.1 You are enrolled in Humana Gold Plus SNP-DE H0028-015 (HMO-POS  \nD-SNP), which is a specialized Medicare Advantage Plan (Special Needs  \nPlan)\nYou are covered by both Medicare and Medicaid:\n\u2022Medicare is the Federal health insurance program for people 65 years of age or older, some people under \nage 65 with certain disabilities, and people with end-stage renal disease (kidney failure).\n\u2022Medicaid is a joint Federal and state government program that helps with medical costs for certain people \nwith limited incomes and resources. Medicaid coverage varies depending on the state and the type of \nMedicaid you have. Some people with Medicaid get help paying for their Medicare premiums and other costs. \nOther people also get coverage for additional services and drugs that are not covered by Medicare.\nYou have chosen to get your Medicare health care and your prescription drug coverage through our plan, Humana \nGold Plus SNP-DE H0028-015 (HMO-POS D-SNP). We are required to cover all Part A and Part B services. However, \ncost sharing and provider access in this plan differ from Original Medicare.\nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) is a specialized Medicare Advantage Plan (a Medicare \n\"Special Needs Plan\"), which means its benefits are designed for people with special health care needs. Humana \nGold Plus SNP-DE H0028-015 (HMO-POS D-SNP) is designed for people who have Medicare and who are also \nentitled to assistance from MO HealthNet (Medicaid).\nBecause you get assistance from MO HealthNet (Medicaid) with your Medicare Part A and B cost-sharing \n(deductibles, copayments, and coinsurance) you may pay nothing for your Medicare health care services. MO \nHealthNet (Medicaid) may also provide other benefits to you by covering health care services and prescription \ndrugs that are not usually covered under Medicare. You will also receive \"Extra Help\" from Medicare to pay for the \ncosts of your Medicare prescription drugs.  Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) will help \nmanage all of these benefits for you, so that you get the health care services and payment assistance that you are \nentitled to.\nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) is run by a private company. Like all Medicare Advantage \nPlans, this Medicare Special Needs Plan is approved by Medicare. The plan also has a contract with the Missouri \nMedicaid program to coordinate your Medicaid benefits. We are pleased to be providing your Medicare health care \ncoverage, including your prescription drug coverage.\nCoverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient Protection \nand Affordable Care Act\u2019s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue \nService (IRS) website at: www.irs.gov/Affordable-Care-Act/Individuals-and-Families for more information.\nSection 1.2 What is the Evidence of Coverage document about?\nThis Evidence of Coverage document tells you how to get your Medicare medical care and prescription drugs. It \nexplains your rights and responsibilities, what is covered, what you pay as a member of the plan, and how to file a \ncomplaint if you are not satisfied with a decision or treatment.", "doc_id": "3917d8fb-1219-42f9-bfff-a8c4fd32de3a", "embedding": null, "doc_hash": "189988d8e26eff0e6be0d9ed55ff7421080bc95bf516bbfba9de228aa5f51fdf", "extra_info": {"page_label": "10", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3366, "_node_type": "1"}, "relationships": {"1": "4805c533-3b25-4edc-bf61-49a4bccb5ecb"}}, "__type__": "1"}, "1bd2f048-fa74-4899-afb8-6cf350ad8360": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 11\nChapter 1 Getting started as a member\nThe words \"coverage\" and \"covered services\" refer to the medical care and services and the prescription drugs \navailable to you as a member of Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP).\nIt's important for you to learn what the plan's rules are and what services are available to you. We encourage you \nto set aside some time to look through this Evidence of Coverage document.\nIf you are confused, concerned or just have a question, please contact Customer Care.\nSection 1.3 Legal information about the Evidence of Coverage\nThis Evidence of Coverage is part of our contract with you about how Humana Gold Plus SNP-DE H0028-015 \n(HMO-POS D-SNP) covers your care. Other parts of this contract include your enrollment form, the Prescription Drug \nGuide (Formulary), and any notices you receive from us about changes to your coverage or conditions that affect \nyour coverage. These notices are sometimes called \"riders\" or \"amendments.\"\nThe contract is in effect for months in which you are enrolled in Humana Gold Plus SNP-DE H0028-015 (HMO-POS \nD-SNP) between January 1, 2023, and December 31, 2023.\nEach calendar year, Medicare allows us to make changes to the plans that we offer. This means we can change the \ncosts and benefits of Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) after December 31, 2023. We can \nalso choose to stop offering the plan in your service area, or to offer it in a different service area, after December 31, \n2023.\nMedicare (the Centers for Medicare & Medicaid Services) must approve Humana Gold Plus SNP-DE H0028-015 \n(HMO-POS D-SNP) each year. You can continue each year to get Medicare coverage as a member of our plan as \nlong as we choose to continue to offer the plan and Medicare renews its approval of the plan.\nSECTION 2 What makes you eligible to be a plan member?\nSection 2.1 Your eligibility requirements\nYou are eligible for membership in our plan as long as:\n\u2022You have both Medicare Part A and Medicare Part B\n\u2022-- and -- You live in our geographic service area (Section 2.3 below describes our service area). Incarcerated \nindividuals are not considered living in the geographic service area even if they are physically located in it.\n\u2022-- and -- you are a United States citizen or are lawfully present in the United States\n\u2022-- and -- You meet the special eligibility requirements described below.\nSpecial eligibility requirements for our plan\nOur plan is designed to meet the needs of people who receive certain Medicaid benefits. (Medicaid is a joint Federal \nand state government program that helps with medical costs for certain people with limited incomes and \nresources.) To be eligible for our plan you must be eligible for both Medicare and certain levels of Medicaid: \nFBDE,QMB,QMB+,SLMB+. ", "doc_id": "1bd2f048-fa74-4899-afb8-6cf350ad8360", "embedding": null, "doc_hash": "86e1b2064438dce02a5015b5c3d4f878d193f73add2105ae26402df33bcf887e", "extra_info": {"page_label": "11", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2872, "_node_type": "1"}, "relationships": {"1": "e52e8c07-f7f5-48a8-ac35-02b9add8bd47"}}, "__type__": "1"}, "11552297-9775-4182-877c-cdd447200c6a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 12\nChapter 1 Getting started as a member\nPlease note: If you lose your eligibility but can reasonably be expected to regain eligibility within six-month(s), then \nyou are still eligible for membership in our plan (Chapter 4, Section 2.1 tells you about coverage and cost-sharing \nduring a period of deemed continued eligibility).\nSection 2.2 What is Medicaid?\nMedicaid is a joint Federal and state government program that helps with medical costs for certain people who \nhave limited incomes and resources. Each state decides what counts as income and resources, who is eligible, \nwhat services are covered, and the cost for services. States also can decide how to run their program as long as \nthey follow the Federal guidelines.\nFull Benefit Dual Eligible (FBDE): Financial assistance may be available to pay Medicare Part A Premiums, and/or \nMedicare Part B Premiums, and other cost-sharing (like deductibles, coinsurance, and copayments) and provides \nfull Medicaid benefits. \nIn addition, there are programs offered through Medicaid that help people with Medicare pay their Medicare costs, \nsuch as their Medicare premiums. These \"Medicare Savings Programs\" help people with limited income and \nresources save money each year: \n\u2022Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost-sharing \n(like deductibles, coinsurance, and copayments). (Some people with QMB are also eligible for full Medicaid \nbenefits (QMB+).)\n\u2022Specified Low-Income Medicare Beneficiary Plus (SLMB+): Helps pay Part B premiums and provides full \nMedicaid benefits for Medicaid services provided by Medicaid providers. \nSection 2.3 Here is the plan service area for Humana Gold Plus SNP-DE H0028-015  \n(HMO-POS D-SNP)\nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) is available only to individuals who live in our plan service \narea. To remain a member of our plan, you must continue to reside in the plan service area. The service area is \ndescribed below.\nOur service area includes the following county/counties in Missouri: Barry, Cass, Cedar, Christian, Clay, Crawford, \nDade, Dallas, Douglas, Greene, Howell, Iron, Jackson, Jasper, Jefferson, Johnson, Laclede, Lafayette, Lawrence, \nMadison, McDonald, Newton, Perry, Pike, Platte, Polk, Pulaski, St. Charles, St. Francois, St. Louis, St. Louis City, Stone, \nTaney, Warren, Washington, Webster, Wright Counties, MO.\nIf you plan to move to a new state, you should also contact your state's Medicaid office and ask how this move will \naffect your Medicaid benefits. Phone numbers for Medicaid are in Chapter 2, Section 6 of this document.\nIf you plan to move out of the service area, you cannot remain a member of this plan. Please contact Customer \nCare to see if we have a plan in your new area. When you move, you will have a Special Enrollment Period that will \nallow you to switch to Original Medicare or enroll in a Medicare health or drug plan that is available in your new \nlocation.\nIt is also important that you call Social Security if you move or change your mailing address. You can find phone \nnumbers and contact information for Social Security in Chapter 2, Section 5.", "doc_id": "11552297-9775-4182-877c-cdd447200c6a", "embedding": null, "doc_hash": "747b6129ec2fa788766be9c28e7a2561fec9aa9c4939ea8b7b608d3a447163f2", "extra_info": {"page_label": "12", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3242, "_node_type": "1"}, "relationships": {"1": "9c59b63c-fe5e-4b6f-9fd5-b1049d2baa06"}}, "__type__": "1"}, "5359b1df-7b03-4348-858d-0f38480af92b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 13\nChapter 1 Getting started as a member\nSection 2.4 U.S. Citizen or Lawful Presence\nA member of a Medicare health plan must be a U.S. citizen or lawfully present in the United States. Medicare (the \nCenters for Medicare & Medicaid Services) will notify Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) if you \nare not eligible to remain a member on this basis. Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) must \ndisenroll you if you do not meet this requirement.\nSECTION 3 Important membership materials you will receive\nSection 3.1 Your plan membership card\nWhile you are a member of our plan, you must use your membership card whenever you get services covered by \nthis plan and for prescription drugs you get at network pharmacies. You should also show the provider your MO \nHealthNet (Medicaid) card. Here's a sample membership card to show you what yours will look like:\nDo NOT use your red, white, and blue Medicare card for covered medical services while you are a member of this \nplan. If you use your Medicare card instead of your Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) \nmembership card, you may have to pay the full cost of medical services yourself. Keep your Medicare card in a safe \nplace. You may be asked to show it if you need hospital services, hospice services, or participate in Medicare \napproved clinical research studies also called clinical trials.\nIf your plan membership card is damaged, lost, or stolen, call Customer Care right away and we will send you a \nnew card.\nBe sure to show your MO HealthNet (Medicaid) ID card in addition to your Humana Gold Plus SNP-DE H0028-015 \n(HMO-POS D-SNP) membership card to make your provider aware that you may have additional coverage.\nSection 3.2 Provider Directory\nThe Provider Directory lists our network providers, durable medical equipment suppliers, and pharmacies. Network \nproviders are the doctors and other health care professionals, medical groups, durable medical equipment \nsuppliers, hospitals, and other health care facilities that have an agreement with us to accept our payment and \nany plan cost sharing as payment in full.", "doc_id": "5359b1df-7b03-4348-858d-0f38480af92b", "embedding": null, "doc_hash": "67921f0672bd12ac34abaad5d0a6882a9b037232014af24c9f44a7cefd690874", "extra_info": {"page_label": "13", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2204, "_node_type": "1"}, "relationships": {"1": "a7efc45e-2821-4e4e-993b-36224131874a"}}, "__type__": "1"}, "acec41fc-1d9c-4fa6-825a-f4af1b11cc95": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 14\nChapter 1 Getting started as a member\nYou must use network providers to get your medical care and services. If you go elsewhere without proper \nauthorization you will have to pay in full. The only exceptions are emergencies, urgently needed services when the \nnetwork is not available (that is, in situations when it is unreasonable or not possible to obtain services in-network), \nout-of-area dialysis services, and cases in which Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) \nauthorizes use of out-of-network providers.\nMany of the plan's network providers are also Medicaid certified. Refer to your Provider Directory to identify which \nplan network providers are also participating with MO HealthNet (Medicaid). You are not restricted to Medicaid \ncertified providers for your plan services.\nNetwork pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for our plan \nmembers. You can use the Provider Directory to find the network pharmacy you want to use. See Chapter 5, Section \n2.5 for information on when you can use pharmacies that are not in the plan\u2019s network.\nIf you don\u2019t have your copy of the Provider Directory, you can get a copy from Customer Care. You can also find this \ninformation on our website at Humana.com/PlanDocuments. The website can give you the most up-to-date \ninformation about changes in our network providers and pharmacies.\nSection 3.3 The plan's Prescription Drug Guide (Formulary)\nThe plan has a Prescription Drug Guide (Formulary). We call it the \"Drug Guide\" for short. It tells which Part D \nprescription drugs are covered under the Part D benefit included in Humana Gold Plus SNP-DE H0028-015 \n(HMO-POS D-SNP). The drugs on this list are selected by the plan with the help of a team of doctors and \npharmacists. The list must meet requirements set by Medicare. Medicare has approved the Humana Gold Plus \nSNP-DE H0028-015 (HMO-POS D-SNP) Drug Guide.\nThe Drug Guide also tells you if there are any rules that restrict coverage for your drugs.\nWe will provide you a copy of the Drug Guide. The Drug Guide we provide you includes information for the covered \ndrugs that are most commonly used by our members. However, we cover additional drugs that are not included in \nthe provided Drug Guide. If one of your drugs is not listed in the Drug Guide, you should visit our website or contact \nCustomer Care to find out if we cover it. To get the most complete and current information about which drugs are \ncovered, you can visit the plan\u2019s website (Humana.com/PlanDocuments) or call Customer Care.\nSECTION 4 Your monthly costs for Humana Gold Plus SNP-DE H0028-015  \n(HMO-POS D-SNP)\nYour costs may include the following:\n\u2022Plan Premium (Section 4.1)\n\u2022Monthly Medicare Part B Premium (Section 4.2)\n\u2022Part D Late Enrollment Penalty (Section 4.3)\n\u2022Income Related Monthly Adjusted Amount (Section 4.4)\nIn some situations, your plan premium could be less\nThere are programs to help people with limited resources pay for their drugs. These include \"Extra Help\" and State \nPharmaceutical Assistance Programs. Chapter 2, Section 7 tells more about these programs. If you qualify, \nenrolling in the program might lower your monthly plan premium.", "doc_id": "acec41fc-1d9c-4fa6-825a-f4af1b11cc95", "embedding": null, "doc_hash": "41b43cef4c70175a28cc5ae215e39e9322ca29812926f7a6bbaa197eccfa532c", "extra_info": {"page_label": "14", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3289, "_node_type": "1"}, "relationships": {"1": "8aef6527-0a81-4f37-bee1-eec9b48a2eb6"}}, "__type__": "1"}, "ba0ffb7b-ba0a-4742-b09e-29a347f58953": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 15\nChapter 1 Getting started as a member\nIf you are already enrolled and getting help from one of these programs, the information about premiums in this \nEvidence of Coverage may not apply to you. \nMedicare Part B and Part D premiums differ for people with different incomes. If you have questions about these \npremiums review your copy of Medicare & You 2023 handbook, the section called \"2023 Medicare Costs.\" If you \nneed a copy you can download it from the Medicare website (www.medicare.gov). Or, you can order a printed copy \nby phone at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.\nSection 4.1 Plan premium\nAs a member of our plan, you pay a monthly plan premium. For 2023, the monthly premium for Humana Gold Plus \nSNP-DE H0028-015 (HMO-POS D-SNP) is $0 or up to $36.30. \nSection 4.2 Monthly Medicare Part B Premium\nMany members are required to pay other Medicare premiums\nIn addition to paying the monthly plan premium, some members are required to pay other Medicare premiums. As \nexplained in Section 2 above, in order to be eligible for our plan, you must maintain your eligibility for MO HealthNet \n(Medicaid) as well as have both Medicare Part A and Medicare Part B. For most Humana Gold Plus SNP-DE \nH0028-015 (HMO-POS D-SNP) members, MO HealthNet (Medicaid) pays for your Part A premium (if you don\u2019t \nqualify for it automatically) and for your Part B premium.\nIf MO HealthNet (Medicaid) is not paying your Medicare premiums for you, you must continue to pay your \nMedicare premiums to remain a member of the plan. This includes your premium for Part B. It may also include \na premium for Part A which affects members who aren\u2019t eligible for premium free Part A.\nSection 4.3 Part D Late Enrollment Penalty\nBecause you are dual-eligible, the LEP doesn\u2019t apply as long as you maintain your dual-eligible status, but if you \nlose status you may incur LEP. Some members are required to pay a Part D late enrollment penalty. The Part D \nlate enrollment penalty is an additional premium that must be paid for Part D coverage if at any time after your \ninitial enrollment period is over, there is a period of 63 days or more in a row when you did not have Part D or other \ncreditable prescription drug coverage. \"Creditable prescription drug coverage\" is coverage that meets Medicare\u2019s \nminimum standards since it is expected to pay, on average, at least as much as Medicare\u2019s standard prescription \ndrug coverage. The cost of the late enrollment penalty depends on how long you went without Part D or other \ncreditable prescription drug coverage. You will have to pay this penalty for as long as you have Part D coverage.\nThe Part D late enrollment penalty is added to your monthly premium. When you first enroll in Humana Gold Plus \nSNP-DE H0028-015 (HMO-POS D-SNP), we let you know the amount of the penalty. \nYou will not have to pay it if:\n\u2022You receive \u201cExtra Help\u201d from Medicare to pay for your prescription drugs.\n\u2022You have gone less than 63 days in a row without creditable coverage. \n\u2022You have had creditable drug coverage through another source such as a former employer, union, TRICARE, \nor Department of Veterans Affairs. Your insurer or your human resources department will tell you each year if ", "doc_id": "ba0ffb7b-ba0a-4742-b09e-29a347f58953", "embedding": null, "doc_hash": "773dfc028838f8f61940dd3aa37106d1734b3570870da3b4c3d2f9bd302ce3b1", "extra_info": {"page_label": "15", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3348, "_node_type": "1"}, "relationships": {"1": "81eecd6b-b598-47bb-b934-87e50e9ec70d"}}, "__type__": "1"}, "bf856344-20bc-4910-8446-84ac2d0af108": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 16\nChapter 1 Getting started as a member\nyour drug coverage is creditable coverage. This information may be sent to you in a letter or included in a \nnewsletter from the plan. Keep this information, because you may need it if you join a Medicare drug plan \nlater.\n\u2013Note: Any notice must state that you had \"creditable\" prescription drug coverage that is expected to pay \nas much as Medicare\u2019s standard prescription drug plan pays.\n\u2013Note: The following are not creditable prescription drug coverage: prescription drug discount cards, free \nclinics, and drug discount websites.\nMedicare determines the amount of the penalty. Here is how it works:\n\u2022First, count the number of full months that you delayed enrolling in a Medicare drug plan, after you were \neligible to enroll. Or count the number of full months you did not have creditable prescription drug coverage, \nif the break in coverage was 63 days or more. The penalty is 1% for every month that you did not have \ncreditable coverage. For example, if you go 14 months without coverage, the penalty will be 14%.\n\u2022Then Medicare determines the amount of the average monthly premium for Medicare drug plans in the \nnation from the previous year. For 2023, this average premium amount is $32.74. \n\u2022To calculate your monthly penalty, you multiply the penalty percentage and the average monthly premium \nand then round it to the nearest 10 cents. In the example here it would be 14% times $32.74, which equals \n$4.58. This rounds to $4.60. This amount would be added to the monthly premium for someone with a Part \nD late enrollment penalty.\nThere are three important things to note about this monthly Part D late enrollment penalty:\n\u2022First, the penalty may change each year, because the average monthly premium can change each year.\n\u2022Second, you will continue to pay a penalty every month for as long as you are enrolled in a plan that has \nMedicare Part D drug benefits, even if you change plans.\n\u2022Third, if you are under 65 and currently receiving Medicare benefits, the Part D late enrollment penalty will \nreset when you turn 65. After age 65, your Part D late enrollment penalty will be based only on the months \nthat you don\u2019t have coverage after your initial enrollment period for aging into Medicare.\nIf you disagree about your Part D late enrollment penalty, you or your representative can ask for a review. \nGenerally, you must request this review within 60 days from the date on the first letter you receive stating you \nhave to pay a late enrollment penalty. However, if you were paying a penalty before joining our plan, you may not \nhave another chance to request a review of that late enrollment penalty.\nImportant: Do not stop paying your Part D late enrollment penalty while you\u2019re waiting for a review of the decision \nabout your late enrollment penalty. If you do, you could be disenrolled for failure to pay your premiums.\nSection 4.4 Income Related Monthly Adjustment Amount\nSome members may be required to pay an extra charge, known as the Part D Income Related Monthly Adjustment \nAmount, also known as IRMAA. The extra charge is figured out using your modified adjusted gross income as \nreported on your IRS tax return from 2 years ago. If this amount is above a certain amount, you\u2019ll pay the standard \npremium amount and the additional IRMAA. For more information on the extra amount you may have to pay \nbased on your income, visit \nhttps://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug\n-plans. ", "doc_id": "bf856344-20bc-4910-8446-84ac2d0af108", "embedding": null, "doc_hash": "b5c160cbd9c43af982f61d942fec453006c975d3fa846ad0f6f2d4841276fad9", "extra_info": {"page_label": "16", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3600, "_node_type": "1"}, "relationships": {"1": "84cb59ad-8699-4c1f-a8d3-5c769454edd0"}}, "__type__": "1"}, "16bea5c7-26b3-45f3-a36e-d40916854ca7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 17\nChapter 1 Getting started as a member\nIf you have to pay an extra amount, Social Security, not your Medicare plan, will send you a letter telling you what \nthat extra amount will be. The extra amount will be withheld from your Social Security, Railroad Retirement Board, \nor Office of Personnel Management benefit check, no matter how you usually pay your plan premium, unless your \nmonthly benefit isn\u2019t enough to cover the extra amount owed. If your benefit check isn\u2019t enough to cover the extra \namount, you will get a bill from Medicare. You must pay the extra amount to the government. It cannot be \npaid with your monthly plan premium. If you do not pay the extra amount you will be disenrolled from the \nplan and lose prescription drug coverage. \nIf you disagree about paying an extra amount, you can ask Social Security to review the decision. To find out more \nabout how to do this, contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778).\nSECTION 5 More information about your monthly premium\nSection 5.1 There are several ways you can pay your plan premium  \nThere are four ways you can pay your plan premium.\nYou were asked to choose one when you enrolled, but you can change your method of payment at any time. The \nfour options described below are:\n\u2022Pay by check\n\u2022Set up automatic payments from your bank account or credit card\n\u2022Set up automatic payments from your Railroad Retirement Board check\n\u2022Set up automatic payments from your Social Security check\nIf you'd like to change your payment option, call Customer Care at 1-800-457-4708, TTY 711. If you're selecting \nany of the options for automatic payments, you can also go to Humana.com/pay and sign in with your username \nand password. (If it's the first time you're signing in, click on Register for MyHumana and follow the instructions on \nthe screen.)\nIf you decide to change the way you pay your premium, it can take up to three months for your new payment \nmethod to take effect. While we are processing your request for a new payment method, you are responsible for \nmaking sure that your plan premium is paid on time.\nOption 1: Paying by check\nYou can pay by check using the Humana coupon book. It will be mailed to you before or near your plan effective \ndate. If you choose this option, your premium will always be due on the first day of the month.\nMake sure you follow these steps so there are no delays in processing your payments:\n\u2022Make your check out to Humana. You can also use a money order if you don't have a checking account.\n\u2022Always include the coupon along with your payment and send it to the address on the coupon.\n\u2022Write your Humana account number on your check. You can find your account number on the top left corner \nof your coupon.", "doc_id": "16bea5c7-26b3-45f3-a36e-d40916854ca7", "embedding": null, "doc_hash": "ed214848e7f4a4c78ad9b3412c56e2c792678a258d4ac25cc8abc8e3ba915292", "extra_info": {"page_label": "17", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2819, "_node_type": "1"}, "relationships": {"1": "fa4c7ccf-727f-401a-93e5-7211d33e0564"}}, "__type__": "1"}, "23627685-7dd3-422b-a345-ed6ce85f3dd1": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 18\nChapter 1 Getting started as a member\n\u2022If the payment is for multiple members or accounts, write all account numbers on your check, as well as the \npayment amount intended for each.\n\u2022If someone else makes a payment for you, be sure your name and Humana account number are written on \nthe check.\nIf you want to pay more than one month's premium, just send in all the coupons you want to pay at one time and \nmake your check out for the total amount.\nRemember\u2014don't make out or send checks to the Centers for Medicare & Medicaid Services or to the US \nDepartment of Health and Human Services because that would cause a delay and your premium might be late.\nIf you need to replace your coupon book, call Customer Care at 1-800-457-4708, TTY 711.\nOption 2: You can set up automatic payments from your checking or savings account, or through your credit \ncard or debit card\nYou can have your monthly premium automatically withdrawn from your checking or savings account, or \nautomatically charged to your credit card or debit card. You can contact Customer Care for more information on \nhow to pay your plan premium this way or you can visit Humana.com/pay and sign into MyHumana to set up your \nautomatic payments from your bank account or credit card.\nIf you choose this option, we'll withdraw the premium from your bank account, or charge it to your card, between \nthe 2nd -7th of each month.\nOption 3: Having your premium taken out of your monthly Railroad Retirement Board check\nYou can have the plan premium taken out of your monthly Railroad Retirement Board check. You can contact \nCustomer Care for more information on how to pay your plan premium this way. We will be happy to help you set \nthis up.\nIf you choose this option or Option 4 below, one to three benefit checks could elapse before the premium \ndeduction occurs, and the initial deduction includes the total premium amount during this time. You can also visit \nHumana.com/pay and sign in to MyHumana to set up your RRB or SSA payment option.\nOption 4: Having your premium taken out of your monthly Social Security check\nYou can have the plan premium taken out of your monthly Social Security check. Contact Customer Care for more \ninformation on how to pay your monthly plan premium this way or you can visit Humana.com/pay and sign into \nMyHumana to set up your SSA payment option. We will be happy to help you set this up.\nIf you choose this option, it can take up to three months for your new payment method to take effect.\nChanging the way you pay your premium. If you decide to change the way you pay your premium, it can take up \nto three months for your new payment method to take effect. While we are processing your request for a new \npayment method, you are responsible for making sure that your plan premium is paid on time. To change your \npayment method, if applicable, please contact Customer Care. If you\u2019re selecting any of the options for automatic \npayments, you can also go to Humana.com/pay and sign in with your username and password. (If it's the first \ntime you're signing in, click on Register for MyHumana and follow the instructions on the screen.) ", "doc_id": "23627685-7dd3-422b-a345-ed6ce85f3dd1", "embedding": null, "doc_hash": "8f6c63a0931b200fa4abffc09c45f70110c48f4c2875e2ce620a897d7e609d3a", "extra_info": {"page_label": "18", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3224, "_node_type": "1"}, "relationships": {"1": "4b842583-60ab-45f8-9251-7bcc388758a7"}}, "__type__": "1"}, "ebfad792-9703-435e-97a1-29407e16dcdd": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 19\nChapter 1 Getting started as a member\nWhat to do if you are having trouble paying your plan premium\nIf you are having trouble paying your premium on time, please contact Customer Care to see if we can direct you to \nprograms that will help with your plan premium. (Phone numbers for Customer Care are printed on the back cover \nof this booklet.)\nSection 5.2 Can we change your monthly plan premium during the year?\nNo. We are not allowed to change the amount we charge for the plan\u2019s monthly plan premium during the year. If \nthe monthly plan premium changes for next year, we will tell you in September and the change will take effect on \nJanuary 1.\nHowever, in some cases the part of the premium that you have to pay can change during the year. This happens if \nyou become eligible for the \"Extra Help\" program or if you lose your eligibility for the \"Extra Help\" program during \nthe year. If a member qualifies for \"Extra Help\" with their prescription drug costs, the \"Extra Help\" program will pay \npart of the member\u2019s monthly plan premium. A member who loses their eligibility during the year will need to start \npaying their full monthly premium. You can find out more about the \"Extra Help\" program in Chapter 2, Section 7.\nSECTION 6 Keeping your plan membership record up to date\nYour membership record has information from your enrollment form, including your address and telephone \nnumber. It shows your specific plan coverage including your Primary Care Provider.\nThe doctors, hospitals, pharmacists, and other providers in the plan's network need to have correct information \nabout you. These network providers use your membership record to know what services and drugs are \ncovered and the cost-sharing amounts for you. Because of this, it is very important that you help us keep your \ninformation up to date.\nLet us know about these changes:\n\u2022Changes to your name, your address, or your phone number\n\u2022Changes in any other health insurance coverage you have (such as from your employer, your spouse's \nemployer, workers' compensation, or Medicaid)\n\u2022If you have any liability claims, such as claims from an automobile accident\n\u2022If you have been admitted to a nursing home\n\u2022If you receive care in an out-of-area or out-of-network hospital or emergency room\n\u2022If your designated responsible party (such as a caregiver) changes\n\u2022If you are participating in a clinical research study (Note: You are not required to tell your plan about the \nclinical research studies you intend to participate in but we encourage you to do so)\nIf any of this information changes, please let us know by calling Customer Care.\nIt is also important to contact Social Security if you move or change your mailing address. You can find phone \nnumbers and contact information for Social Security in Chapter 2, Section 5.", "doc_id": "ebfad792-9703-435e-97a1-29407e16dcdd", "embedding": null, "doc_hash": "4897a87f48db6abf9551d70e6fac32ff7c80e68323c2683a39807a14b607b76d", "extra_info": {"page_label": "19", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2886, "_node_type": "1"}, "relationships": {"1": "b9346e9d-e13f-4afd-bdca-adeedfd3fc61"}}, "__type__": "1"}, "19cb383a-6e7d-45e7-9a77-5d34751699ec": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 20\nChapter 1 Getting started as a member\nSECTION 7 How other insurance works with our plan\nOther insurance \nMedicare requires that we collect information from you about any other medical or drug insurance coverage that \nyou have. That\u2019s because we must coordinate any other coverage you have with your benefits under our plan. This \nis called Coordination of Benefits.\nOnce each year, we will send you a letter that lists any other medical or drug insurance coverage that we know \nabout. Please read over this information carefully. If it is correct, you don\u2019t need to do anything. If the information \nis incorrect, or if you have other coverage that is not listed, please call Customer Care. You may need to give your \nplan member ID number to your other insurers (once you have confirmed their identity) so your bills are paid \ncorrectly and on time.\nWhen you have other insurance (like employer group health coverage), there are rules set by Medicare that decide \nwhether our plan or your other insurance pays first. The insurance that pays first is called the \"primary payer\" and \npays up to the limits of its coverage. The one that pays second, called the \"secondary payer,\" only pays if there are \ncosts left uncovered by the primary coverage. The secondary payer may not pay all of the uncovered costs. If you \nhave other insurance, tell your doctor, hospital, and pharmacy.\nThese rules apply for employer or union group health plan coverage:\n\u2022If you have retiree coverage, Medicare pays first.\n\u2022If your group health plan coverage is based on your or a family member's current employment, who pays \nfirst depends on your age, the number of people employed by your employer, and whether you have \nMedicare based on age, disability, or End-Stage Renal Disease (ESRD):\n\u2013If you're under 65 and disabled and you or your family member is still working, your group health plan \npays first if the employer has 100 or more employees or at least one employer in a multiple employer plan \nthat has more than 100 employees.\n\u2013If you're over 65 and you or your spouse is still working, your group health plan pays first if the employer \nhas 20 or more employees or at least one employer in a multiple employer plan that has more than 20 \nemployees.\n\u2022If you have Medicare because of ESRD, your group health plan will pay first for the first 30 months after you \nbecome eligible for Medicare.\nThese types of coverage usually pay first for services related to each type:\n\u2022No-fault insurance (including automobile insurance)\n\u2022Liability (including automobile insurance)\n\u2022Black lung benefits\n\u2022Workers' compensation\nMedicaid and TRICARE never pay first for Medicare-covered services. They only pay after Medicare and/or employer \ngroup health plans have paid.", "doc_id": "19cb383a-6e7d-45e7-9a77-5d34751699ec", "embedding": null, "doc_hash": "cabaa45e4c1ae4c8c40803a1bab13e5109dba82c60c794a5dbd4b93a7c18c82f", "extra_info": {"page_label": "20", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2825, "_node_type": "1"}, "relationships": {"1": "436fda78-8e7b-4ded-a029-eb6d6a121339"}}, "__type__": "1"}, "cf2802a1-d684-46d9-9c84-564caff4eaba": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 21\nChapter 2 Important phone numbers and resourcesEOC076\nCHAPTER 2:\nImportant phone numbers \n and resources", "doc_id": "cf2802a1-d684-46d9-9c84-564caff4eaba", "embedding": null, "doc_hash": "5dfa3ef804f7207d9ff6801c2651bae0c91a35d8809794d8359e7d4db15e5da5", "extra_info": {"page_label": "21", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 187, "_node_type": "1"}, "relationships": {"1": "a775a1dd-094f-4d00-8f39-f1cc79afe210"}}, "__type__": "1"}, "62594afb-fb73-48bf-a325-b47fe8340cfd": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 22\nChapter 2 Important phone numbers and resources\nSECTION 1 Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP)  \ncontacts\n(how to contact us, including how to reach Customer Care)\nHow to contact our plan's Customer Care\nFor assistance with claims, billing, or member card questions, please call or write to Humana Gold Plus SNP-DE \nH0028-015 (HMO-POS D-SNP) Customer Care. We will be happy to help you.\nMethod Customer Care \u2013 Contact Information\nCALL 1-800-457-4708 \nCalls to this number are free. You can call us seven days a week, from 8 a.m. to 8 p.m.  \nHowever, please note that our automated phone system may answer your call during  \nweekends and holidays from April 1 to September 30.  \nCustomer Care also has free language interpreter services available for non-English speakers.\nTTY 711 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free. Hours of operation are the same as above.\nFAX 1-877-837-7741\nWRITE Humana \nP.O. Box 14168 \nLexington, KY 40512-4168\nWEBSITE Humana.com/customer-support\nLive chat available through Humana.com, Monday through Friday, 8 a.m. to 8 p.m., Eastern  \nStandard Time.\nHow to contact us when you are asking for a coverage decision or appeal about your medical care\nA coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for \nyour medical services or Part D prescription drugs. An appeal is a formal way of asking us to review and change a \ncoverage decision we have made. For more information on asking for coverage decisions or appeals about your \nmedical care or Part D prescription drugs, see Chapter 9 (What to do if you have a problem or complaint (coverage \ndecisions, appeals, complaints)).", "doc_id": "62594afb-fb73-48bf-a325-b47fe8340cfd", "embedding": null, "doc_hash": "8420c1324a10ebc8e063029107b9ac4343a7cf65db494bb18ccf47a1a967d077", "extra_info": {"page_label": "22", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1869, "_node_type": "1"}, "relationships": {"1": "a383b9ee-818d-443b-aedc-6a61db937df1"}}, "__type__": "1"}, "968bea49-ccdf-437f-bd83-1ed8e24a6c35": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 23\nChapter 2 Important phone numbers and resources\nMethod Coverage Decisions and Appeals for Medical Care or Part D prescription drugs\u2013  \nContact Information\nCALL 1-800-457-4708, for fast (expedited) coverage decisions, call 1-866-737-5113 \nCalls to this number are free. You can call us seven days a week, from 8 a.m. to 8 p.m.  \nHowever, please note that our automated phone system may answer your call during  \nweekends and holidays from April 1 to September 30.\nTTY 711 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free. Hours of operation are the same as above.\nFAX 1-888-200-7440 for expedited coverage decisions only\nWRITE Humana \nP.O. Box 14168 \nLexington, KY 40512-4168\nWEBSITE Humana.com/medicare-support/member-guidelines/exceptions-and-appeals\nLive chat available through Humana.com, Monday through Friday, 8 a.m. to 8 p.m., Eastern  \nStandard Time.\nHow to contact us when you are making a complaint about your medical care\nYou can make a complaint about us or one of our network providers or pharmacies, including a complaint about \nthe quality of your care. This type of complaint does not involve coverage or payment disputes. For more \ninformation on making a complaint about your medical care, see Chapter 9 (What to do if you have a problem or \ncomplaint (coverage decisions, appeals, complaints)).\nMethod Complaints about Medical Care \u2013 Contact Information\nCALL 1-800-457-4708 \nCalls to this number are free. You can call us seven days a week, from 8 a.m. to 8 p.m. For  \nexpedited grievances please call 1-800-867-6601.\nTTY 711 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free. Hours of operation are the same as above.\nFAX 1-888-556-2128\nWRITE Humana Grievances and Appeals Dept. \nP.O. Box 14165 \nLexington, KY 40512-4165", "doc_id": "968bea49-ccdf-437f-bd83-1ed8e24a6c35", "embedding": null, "doc_hash": "1c8e406a417314cdf686bba2a806ada64d45295ce8fcfea41a297d62e6fe527e", "extra_info": {"page_label": "23", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2031, "_node_type": "1"}, "relationships": {"1": "6373c8a1-70fa-4cf0-8028-a46de1e70f13"}}, "__type__": "1"}, "d036c21c-9f61-4b53-8c16-36a7d3f915f1": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 24\nChapter 2 Important phone numbers and resources\nMethod Complaints about Medical Care \u2013 Contact Information\nMEDICARE  \nWEBSITEYou can submit a complaint about Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP)  \ndirectly to Medicare. To submit an online complaint to Medicare, go to \nwww.medicare.gov/MedicareComplaintForm/home.aspx.\nWhere to send a request asking us to pay the cost for medical care or a drug you have received\nIf you have received a bill or paid for services (such as a provider bill) that you think we should pay for, you may \nneed to ask us for reimbursement or to pay the provider bill. See Chapter 7 (Asking us to pay a bill you have received \nfor covered medical services or drugs).\nPlease note: If you send us a payment request and we deny any part of your request, you can appeal our decision. \nSee Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) for more \ninformation.\nMethod Payment Requests \u2013 Contact Information\nCALL 1-800-457-4708  \nCalls to this number are free. You can call us seven days a week, from 8 a.m. to 8 p.m.  \nHowever, please note that our automated phone system may answer your call during  \nweekends and holidays from April 1 to September 30.\nTTY 711 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free. Hours of operation are the same as above.\nWRITE Humana \nP.O. Box 14168 \nLexington, KY 40512-4168\nWEBSITE Humana.com\nLive chat available through Humana.com, Monday through Friday, 8 a.m. to 8 p.m., Eastern  \nStandard Time.\nSECTION 2 Medicare\n(how to get help and information directly from the Federal Medicare program)\nMedicare is the Federal health insurance program for people 65 years of age or older, some people under age 65 \nwith disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney \ntransplant).\nThe Federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services (sometimes called \n\"CMS\"). This agency contracts with Medicare Advantage organizations including us.", "doc_id": "d036c21c-9f61-4b53-8c16-36a7d3f915f1", "embedding": null, "doc_hash": "fac2cda3ff7a28d888a9dbb5e2fc54d43de4521ce200489ba13f219e88a51eba", "extra_info": {"page_label": "24", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2234, "_node_type": "1"}, "relationships": {"1": "11eaf81e-caac-43ec-817b-ff6cfc101f98"}}, "__type__": "1"}, "71bdcd9a-c8b2-44be-a385-de930f68a9b6": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 25\nChapter 2 Important phone numbers and resources\nMethod Medicare \u2013 Contact Information\nCALL 1-800-MEDICARE, or 1-800-633-4227 \nCalls to this number are free. \n24 hours a day, 7 days a week.\nTTY 1-877-486-2048 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free.\nWEBSITE www.medicare.gov\nThis is the official government website for Medicare. It gives you up-to-date information about \nMedicare and current Medicare issues. It also has information about hospitals, nursing homes, \nphysicians, home health agencies, and dialysis facilities. It includes documents you can print \ndirectly from your computer. You can also find Medicare contacts in your state.\nThe Medicare website also has detailed information about your Medicare eligibility and \nenrollment options with the following tools:\n\u2022Medicare Eligibility Tool: Provides Medicare eligibility status information.\n\u2022Medicare Plan Finder: Provides personalized information about available Medicare \nprescription drug plans, Medicare health plans, and Medigap (Medicare Supplement \nInsurance) policies in your area. These tools provide an estimate of what your \nout-of-pocket costs might be in different Medicare plans.\nYou can also use the website to tell Medicare about any complaints you have about Humana \nGold Plus SNP-DE H0028-015 (HMO-POS D-SNP):\n\u2022Tell Medicare about your complaint: You can submit a complaint about Humana Gold \nPlus SNP-DE H0028-015 (HMO-POS D-SNP) directly to Medicare. To submit a complaint to \nMedicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare \ntakes your complaints seriously and will use this information to help improve the quality \nof the Medicare program.\nIf you don't have a computer, your local library or senior center may be able to help you visit \nthis website using its computer. Or, you can call Medicare and tell them what information you \nare looking for. They will find the information on the website and review the information with \nyou. (You can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a \nweek. TTY users should call 1-877-486-2048.)", "doc_id": "71bdcd9a-c8b2-44be-a385-de930f68a9b6", "embedding": null, "doc_hash": "f954d810a7904ac11ede2dca42d3b67841cd6e74dfcc0a50591b5fcb2a9d2dcd", "extra_info": {"page_label": "25", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2270, "_node_type": "1"}, "relationships": {"1": "56282b31-05c6-4fad-b366-5c27e8e7705d"}}, "__type__": "1"}, "ef9029fd-114b-43c6-a537-77f1fec04d95": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 26\nChapter 2 Important phone numbers and resources\nSECTION 3 State Health Insurance Assistance Program\n(free help, information, and answers to your questions about Medicare)\nThe State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every \nstate. Contact information for your State Health Insurance Assistance Program (SHIP) can be found in \"Exhibit A\" in \nthe back of this document.\nThe State Health Insurance Assistance Program (SHIP) is an independent (not connected with any insurance \ncompany or health plan) state program that gets money from the Federal government to give free local health \ninsurance counseling to people with Medicare.\nState Health Insurance Assistance Program (SHIP) counselors can help you understand your Medicare rights, help \nyou make complaints about your medical care or treatment, and help you straighten out problems with your \nMedicare bills. State Health Insurance Assistance Program (SHIP) counselors can also help you with Medicare \nquestions or problems and help you understand your Medicare plan choices and answer questions about switching \nplans.\n METHOD TO ACCESS SHIP and OTHER RESOURCES:\n\u2022Visit www.medicare.gov \n\u2022Click on \"Talk to Someone\" in the middle of the homepage\n\u2022You now have the following options\n\u2013Option #1: You can have a live chat with a 1-800-MEDICARE representative\n\u2013Option #2: You can select your STATE from the dropdown menu and click GO. This will take you to a page \nwith phone numbers and resources specific to your state.\nSECTION 4 Quality Improvement Organization\nThere is a designated Quality Improvement Organization for serving Medicare beneficiaries in each state. Contact \ninformation for your state Quality Improvement Organization (QIO) can be found in \"Exhibit A\" in the back of this \ndocument.\nThe Quality Improvement Organization (QIO) has a group of doctors and other health care professionals who are \npaid by Medicare to check on and help improve the quality of care for people with Medicare. The Quality \nImprovement Organization (QIO) is an independent organization. It is not connected with our plan.\nYou should contact your Quality Improvement Organization (QIO) in any of these situations:\n\u2022You have a complaint about the quality of care you have received.\n\u2022You think coverage for your hospital stay is ending too soon.\n\u2022You think coverage for your home health care, skilled nursing facility care, or Comprehensive Outpatient \nRehabilitation Facility (CORF) services are ending too soon.", "doc_id": "ef9029fd-114b-43c6-a537-77f1fec04d95", "embedding": null, "doc_hash": "3a8b74caaadc81c650bb45159e240eeb53d7e70b1d617761b9f52cfa60bbcc83", "extra_info": {"page_label": "26", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2598, "_node_type": "1"}, "relationships": {"1": "40ffceba-1735-4058-881d-47ed34d9435d"}}, "__type__": "1"}, "62cdc4a0-c6ad-431f-8f82-cba2dcdc15bd": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 27\nChapter 2 Important phone numbers and resources\nSECTION 5 Social Security\nSocial Security is responsible for determining eligibility and handling enrollment for Medicare. U.S. citizens and \nlawful permanent residents who are 65 or older, or who have a disability or End-Stage Renal Disease and meet \ncertain conditions, are eligible for Medicare. If you are already getting Social Security checks, enrollment into \nMedicare is automatic. If you are not getting Social Security checks, you have to enroll in Medicare. To apply for \nMedicare, you can call Social Security or visit your local Social Security office.\nSocial Security is also responsible for determining who has to pay an extra amount for their Part D drug coverage \nbecause they have a higher income. If you got a letter from Social Security telling you that you have to pay the \nextra amount and have questions about the amount or if your income went down because of a life-changing \nevent, you can call Social Security to ask for reconsideration.\nIf you move or change your mailing address, it is important that you contact Social Security to let them know.\nMethod Social Security \u2013 Contact Information\nCALL 1-800-772-1213 \nCalls to this number are free. \nAvailable 8:00 am to 7:00 pm, Monday through Friday. \nYou can use Social Security's automated telephone services to get recorded information and  \nconduct some business 24 hours a day.\nTTY 1-800-325-0778 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are free. \nAvailable 8:00 am to 7:00 pm, Monday through Friday.\nWEBSITE www.ssa.gov\nSECTION 6 Medicaid\nTo be enrolled in this Dual Eligible Special Needs Plan, you must be enrolled in Medicare and also must receive \ncertain levels of assistance from MO HealthNet (Medicaid). (See Chapter 1, Section 2.1 \"Special eligibility \nrequirements for our plan\" for the specific requirements for this plan.)\nMedicaid is a joint Federal and state government program that helps with medical costs for certain people with \nlimited incomes and resources. \nFull Benefit Dual Eligible (FBDE): Financial assistance may be available to pay Medicare Part A Premiums, and/or \nMedicare Part B Premiums, and other cost-sharing (like deductibles, coinsurance, and copayments) and provides \nfull Medicaid benefits. ", "doc_id": "62cdc4a0-c6ad-431f-8f82-cba2dcdc15bd", "embedding": null, "doc_hash": "05d99acf7dcf1203aee4476b5632da9c04dbdde3fb863e572ff0a844799b300e", "extra_info": {"page_label": "27", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2444, "_node_type": "1"}, "relationships": {"1": "f7d2b211-732f-4d96-af71-8f3d76bcec6f"}}, "__type__": "1"}, "f82596c3-c19f-40f7-8828-b84ffe88b6fc": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 28\nChapter 2 Important phone numbers and resources\nIn addition, there are programs offered through Medicaid that help people with Medicare pay their Medicare costs, \nsuch as their Medicare premiums. These \"Medicare Savings Programs\" help people with limited income and \nresources save money each year:\n\u2022Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost-sharing \n(like deductibles, coinsurance, and copayments). (Some people with QMB are also eligible for full Medicaid \nbenefits (QMB+).)\n\u2022Specified Low-Income Medicare Beneficiary Plus (SLMB+): Helps pay Part B premiums and provides full \nMedicaid benefits for Medicaid services provided by Medicaid providers. \nIf you have questions about the assistance you get from Medicaid, contact MO HealthNet (Medicaid).\nContact information for MO HealthNet (Medicaid) can be found in \"Exhibit A\" in the back of this document.\nThe Missouri DIFP - Attention: Consumer Affairs helps people enrolled in Medicaid with service or billing problems. \nThey can help you file a grievance or appeal with our plan.\nMethod Missouri DIFP - Attention: Consumer Affairs - Contact Information\nCALL 1-800-726-7390\n8 a.m. - 5 p.m. local time, Monday - Friday\nTTY TTY 1-573-526-4536\nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nWRITE P.O. Box 690, \nJefferson City, MO 65102-0690\nWEBSITE https://insurance.mo.gov/consumers/complaints/index.php\nThe Missouri Department of Health & Senior Services helps people get information about nursing homes and \nresolve problems between nursing homes and residents or their families. \nMethod Missouri Department of Health & Senior Services - Contact Information\nCALL 1-800 309-3282\nTTY TTY: 711\nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nFAX (573) 751-6499\nWRITE PO Box 570\nJefferson City, MO 65102-0570\nEmail: LTCOmbudsman@health.mo.gov\nWEBSITE http://health.mo.gov/seniors/ombudsman/", "doc_id": "f82596c3-c19f-40f7-8828-b84ffe88b6fc", "embedding": null, "doc_hash": "6b930269ec89bcb1601d82a17a7c788df144a1a6dbb3055738e0205f363cc0e5", "extra_info": {"page_label": "28", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2132, "_node_type": "1"}, "relationships": {"1": "ccd87f54-0401-44d3-a6d9-4e7d0f15e92e"}}, "__type__": "1"}, "93596e62-e3be-4ed1-bfc4-94a314039bf6": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 29\nChapter 2 Important phone numbers and resources\nSECTION 7 Information about programs to help people pay for their  \nprescription drugs\nThe Medicare.gov website \n(https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/costs-in-the-coverag\ne-gap/5-ways-to-get-help-with-prescription-costs) provides information on how to lower your prescription \ndrug costs. For people with limited incomes, there are also other programs to assist, described below.\nMedicare's \"Extra Help\" Program\nBecause you are eligible for Medicaid, you qualify for and are getting \"Extra Help\" from Medicare to pay for your \nprescription drug plan costs. You do not need to do anything further to get this \"Extra Help.\"\nIf you have questions about \"Extra Help,\" call:\n\u20221-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048 (applications), 24 hours a day, 7 \ndays a week;\n\u2022The Social Security Office at 1-800-772-1213, between 8 am to 7 pm, Monday through Friday. TTY users \nshould call 1-800-325-0778; or\n\u2022Your State Medicaid Office (applications) (See Section 6 of this chapter for contact information).\nIf you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, \nour plan has a process for you to either request assistance in obtaining evidence of your proper copayment level, \nor, if you already have the evidence, to provide this evidence to us.\n\u2022If you already have a document that proves you have qualified for \"Extra Help,\" you can also show it the next \ntime you go to a pharmacy to have a prescription filled. You can use any one of the following documents to \nprovide evidence to us, or to show as proof at the pharmacy.\nProof that you already have \"Extra Help\" status\n\u2022A copy of your MO HealthNet (Medicaid) card showing your name and the date you became eligible for \"Extra \nHelp.\" The date has to be in the month of July or later of last year.\n\u2022A letter from the Social Security Administration showing your \"Extra Help\" status. This letter could be called \nImportant Information, Award Letter, Notice of Change, or Notice of Action.\n\u2022A letter from the Social Security Administration showing that you receive Supplemental Security Income. If \nthat\u2019s the case, you also qualify for \"Extra Help.\"\nProof that you have active MO HealthNet (Medicaid) status\n\u2022A copy of any state document or any printout from the state system showing your active Medicaid status. The \nactive date shown has to be in the month of July or later of last year.\nProof of a Medicaid payment for a stay at a medical facility", "doc_id": "93596e62-e3be-4ed1-bfc4-94a314039bf6", "embedding": null, "doc_hash": "64b279e562c0b796ae88857b5b2e768d08d62cfc129565a6d79ac9c9fb11c28a", "extra_info": {"page_label": "29", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2654, "_node_type": "1"}, "relationships": {"1": "bcfcbb84-3773-418d-b919-584da9309e02"}}, "__type__": "1"}, "3b357ffc-b856-4212-81b5-0609dabab13b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 30\nChapter 2 Important phone numbers and resources\nYour stay at the medical facility must be at least one full month long, and must be in the month of July or later of \nlast year.\n\u2022A billing statement from the facility showing the Medicaid payment\n\u2022A copy of any state document or any printout from the state system showing the Medicaid payment for you\nIf you first show one of the documents listed above as proof at the pharmacy, please also send us a copy. Mail the \ndocument to:\nHumana\nP.O. Box 14168\nLexington, KY 40512-4168\n\u2022When we receive the evidence showing your copayment level, we will update our system so that you can pay \nthe correct copayment when you get your next prescription at the pharmacy. If you overpay your \ncopayment, we will reimburse you. Either we will forward a check to you in the amount of your overpayment \nor we will offset future copayments. If the pharmacy hasn't collected a copayment from you and is carrying \nyour copayment as a debt owed by you, we may make the payment directly to the pharmacy. If a state paid \non your behalf, we may make payment directly to the state. Please contact Customer Care if you have \nquestions.\nWhat if you have coverage from a State Pharmaceutical Assistance Program (SPAP)?\nMany states and the U.S. Virgin Islands offer help paying for prescriptions, drug plan premiums and/or other drug \ncosts. If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program that provides \ncoverage for Part D drugs (other than \"Extra Help\"), you still get the 70% discount on covered brand name drugs. \nAlso, the plan pays 5% of the costs of brand drugs in the coverage gap. The 70% discount and the 5% paid by the \nplan are both applied to the price of the drug before any SPAP or other coverage.\nWhat if you have coverage from an AIDS Drug Assistance Program (ADAP)?\nWhat is the AIDS Drug Assistance Program (ADAP)?\nThe AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access to \nlife-saving HIV medications. Medicare Part D prescription drugs that are also on the ADAP formulary qualify for \nprescription cost-sharing assistance through the ADAP operating in your State. Note: To be eligible for the ADAP \noperating in your State, individuals must meet certain criteria, including proof of State residence and HIV status, \nlow income as defined by the State, and uninsured/under-insured status. If you change plans please notify your \nlocal ADAP enrollment worker so you can continue to receive assistance. For information on eligibility criteria, \ncovered drugs, or how to enroll in the program, please call the ADAP operating in your State. Contact information \nfor your AIDS Drug Assistance Program (ADAP) can be found in \"Exhibit A\" in the back of this document.\nState Pharmaceutical Assistance Programs\nMany states have State Pharmaceutical Assistance Programs that help some people pay for prescription drugs \nbased on financial need, age, medical condition, or disabilities. Each state has different rules to provide drug \ncoverage to its members.\nContact information for your State Pharmaceutical Assistance Program (SPAP) can be found in \"Exhibit A\" in the \nback of this document.", "doc_id": "3b357ffc-b856-4212-81b5-0609dabab13b", "embedding": null, "doc_hash": "c4c1058da54f592c144ca228fcf56c6d8026451b4be20bff9f30e8d17c983630", "extra_info": {"page_label": "30", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3304, "_node_type": "1"}, "relationships": {"1": "e961ed54-2513-4b47-8af9-3d930b6c4c2a"}}, "__type__": "1"}, "ae916781-e6be-4272-9c54-45db2b9a664a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 31\nChapter 2 Important phone numbers and resources\nSECTION 8 How to contact the Railroad Retirement Board\nThe Railroad Retirement Board is an independent Federal agency that administers comprehensive benefit \nprograms for the nation\u2019s railroad workers and their families. If you receive your Medicare through the Railroad \nRetirement Board, it is important that you let them know if you move or change your mailing address. If you have \nquestions regarding your benefits from the Railroad Retirement Board, contact the agency.\nMethod Railroad Retirement Board \u2013 Contact Information\nCALL 1-877-772-5772 \nCalls to this number are free.\nIf you press \u201c0,\u201d you may speak with an RRB representative from 9:00 am to 3:30 pm, Monday,  \nTuesday, Thursday, and Friday, and from 9:00 am to 12:00 pm on Wednesday.\nIf you press \u201c1\u201d, you may access the automated RRB HelpLine and recorded information 24  \nhours a day, including weekends and holidays.\nTTY 1-312-751-4701 \nThis number requires special telephone equipment and is only for people who have difficulties  \nwith hearing or speaking. \nCalls to this number are not free.\nWEBSITE rrb.gov/\nSECTION 9 Do you have \"group insurance\" or other health insurance from  \nan employer?\nIf you (or your spouse) get benefits from your (or your spouse's) employer or retiree group as part of this plan, you \nmay call the employer/union benefits administrator or Customer Care if you have any questions. You can ask about \nyour (or your spouse\u2019s) employer or retiree health benefits, premiums, or the enrollment period. (Phone numbers \nfor Customer Care are printed on the back cover of this document.) You may also call 1-800-MEDICARE \n(1-800-633-4227; TTY: 1-877-486-2048) with questions related to your Medicare coverage under this plan.\nIf you have other prescription drug coverage through your (or your spouse's) employer or retiree group, please \ncontact that group's benefits administrator. The benefits administrator can help you determine how your \ncurrent prescription drug coverage will work with our plan.", "doc_id": "ae916781-e6be-4272-9c54-45db2b9a664a", "embedding": null, "doc_hash": "90e9a1dff240ed611c15e06340324a2349929743a1c2a79e6bf325c23999004d", "extra_info": {"page_label": "31", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2126, "_node_type": "1"}, "relationships": {"1": "c88d1f96-f076-400d-b3f8-d2aa917ed864"}}, "__type__": "1"}, "c08db8e3-ab5a-4c10-a9ee-e2bb85709daa": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 32\nChapter 3 Using the plan for your medical servicesEOC076\nCHAPTER 3:\nUsing the plan \n for your medical services", "doc_id": "c08db8e3-ab5a-4c10-a9ee-e2bb85709daa", "embedding": null, "doc_hash": "517238f0138b2710c7882fb6e864e56800df34a70283a8b85803f42792c1c9a0", "extra_info": {"page_label": "32", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 193, "_node_type": "1"}, "relationships": {"1": "23bd0390-9873-4f79-b39d-7986091b95c9"}}, "__type__": "1"}, "9a36e625-f683-4a1b-bbec-697b992794f7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 33\nChapter 3 Using the plan for your medical services\nSECTION 1 Things to know about getting your medical care as a member of  \nour plan\nThis chapter explains what you need to know about using the plan to get your medical care and other services \ncovered. It gives definitions of terms and explains the rules you will need to follow to get the medical treatments, \nservices, equipment, prescription drugs, and other medical care that are covered by the plan.\nFor the details on what medical care is covered by our plan, use the benefits chart in the next chapter, Chapter 4 \n(Medical Benefits Chart, what is covered).\nSection 1.1 What are \"network providers\" and \"covered services\"?\n\u2022\"Providers\" are doctors and other health care professionals licensed by the state to provide medical services \nand care. The term \"providers\" also includes hospitals and other health care facilities.\n\u2022\"Network providers\" are the doctors and other health care professionals, medical groups, hospitals, and \nother health care facilities that have an agreement with us to accept our payment as payment in full. We \nhave arranged for these providers to deliver covered services to members in our plan. The providers in our \nnetwork bill us directly for care they give you. When you see a network provider, you pay nothing for covered \nservices. \nIf you are cost-share protected by MO HealthNet (Medicaid), see Chapter 4 Section 1.1 for more information \non Medicare cost-share protection from Medicaid.\n\u2022\"Covered services\" include all the medical care, health care services, supplies, equipment, and Prescription \nDrugs that are covered by our plan. Your covered services for medical care are listed in the benefits chart in \nChapter 4. Your covered services for prescription drugs are discussed in Chapter 5.\nSection 1.2 Basic rules for getting your medical care covered by the plan\nAs a Medicare health plan, Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) must cover all services covered \nby Original Medicare and may offer other services in addition to those covered under Original Medicare in the \nbenefits chart in Chapter 4.\nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) will generally cover your medical care as long as:\n\u2022The care you receive is included in the plan's Medical Benefits Chart (this chart is in Chapter 4 of this \ndocument).\n\u2022The care you receive is considered medically necessary. \"Medically necessary\" means that the services, \nsupplies, equipment, or drugs are needed for the prevention, diagnosis, or treatment of your medical \ncondition and meet accepted standards of medical practice.\n\u2022You have a network primary care provider (a PCP) who is providing and overseeing your care. As a  \nmember of our plan, you must choose a network PCP (for more information about this, see Section 2.1 in this  \nchapter).", "doc_id": "9a36e625-f683-4a1b-bbec-697b992794f7", "embedding": null, "doc_hash": "78f926e5f3d456624f31a91f598a29c511d9411b6a066308456fc33996207959", "extra_info": {"page_label": "33", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2899, "_node_type": "1"}, "relationships": {"1": "e4cb947a-e679-4dc4-8731-da11ef37cf79"}}, "__type__": "1"}, "33a25cd7-cf85-4263-a8f7-102d86cfdadd": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 34\nChapter 3 Using the plan for your medical services\n\u2013Your network PCP will coordinate the care you receive from other providers in the plan's network, such as \nspecialists, hospitals, skilled nursing facilities, or home health care agencies. However, referrals are not \nrequired to receive covered services from in-network providers. For more information about this, see \nSection 2.3 of this chapter.\n\u2022You must receive your care from a network provider (for more information about this, see Section 2 in this \nchapter). In most cases, care you receive from an out-of-network provider (a provider who is not part of our \nplan's network) will not be covered. This means that you will have to pay the provider in full for the services \nfurnished. Here are three exceptions:\n\u2013The plan covers emergency care or urgently needed services that you get from an out-of-network \nprovider. For more information about this, and to see what emergency or urgently needed services means, \nsee Section 3 in this chapter.\n\u2013If you need medical care that Medicare requires our plan to cover but there are no specialists in our \nnetwork that provide this care, you can get this care from an out-of-network provider at the same cost \nsharing you normally pay in-network. You must obtain authorization from the plan prior to seeking care \nfrom an out-of-network provider. In this situation, we will cover these services at no cost to you. For \ninformation about getting approval to see an out-of-network doctor, see Section 2.4 in this chapter.\n\u2013The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are \ntemporarily outside the plan's service area or when your provider for this service is temporarily unavailable \nor inaccessible. The cost sharing you pay the plan for dialysis can never exceed the cost sharing in Original \nMedicare. If you are outside the plan\u2019s service area and obtain the dialysis from a provider that is outside \nthe plan\u2019s network, your cost sharing cannot exceed the cost sharing you pay in-network. However, if your \nusual in-network provider for dialysis is temporarily unavailable and you choose to obtain services inside \nthe service area from a provider outside the plan\u2019s network the cost sharing for the dialysis may be higher.\nSECTION 2 Use providers in the plan's network to get your medical care      \nSection 2.1 You must choose a Primary Care Provider (PCP) to provide and oversee  \nyour care\nWhat is a \"PCP\" and what does the PCP do for you?\nA \"PCP\" is your Primary Care Provider. When you become a member of the plan, you must choose a network doctor \nto be your PCP. Your PCP is a provider who meets state license requirements and is trained to give you basic medical \ncare.\nHaving a PCP is an important step in managing your overall well-being. As the doctor who gets to know your \nmedical history best, your PCP can provide you with routine healthcare and ongoing preventive care to keep you as \nhealthy as possible. If you need to see specialists or get other services such as:\n\u2022X-Rays\n\u2022Lab Tests\n\u2022Physical Therapy \n\u2022Care from specialists\n\u2022Hospital admissions \n\u2022Follow-up care", "doc_id": "33a25cd7-cf85-4263-a8f7-102d86cfdadd", "embedding": null, "doc_hash": "6cadd9f345ab8472411f96b0e6c9c82c92610de99510fca13a4163cf62ae585f", "extra_info": {"page_label": "34", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3230, "_node_type": "1"}, "relationships": {"1": "ffd50294-da1f-49db-a69d-b11603a71f48"}}, "__type__": "1"}, "7fd25ab4-ea61-47f9-9033-ea67f0d49324": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 35\nChapter 3 Using the plan for your medical services\nYour PCP can help make sure all your care is coordinated, by checking with other network providers about your \ncare.\nYour plan requires you to have a PCP, but you don\u2019t need a referral from your PCP to see other network doctors or \nreceive the covered services listed in Chapter 3, Section 2.2 below. In some cases, your PCP will need to ask for prior \nauthorization (prior approval). Chapter 4 has more information on which services require prior authorization. \nJust call your PCP to make an appointment when you need one. To help your PCP understand your medical history \nand oversee all your care, you may want to have your previous doctors send your past medical records to your new \nPCP. \nHow do you get care from your PCP? \nYou will usually see your PCP first for most of your routine health care needs; however, there are a few types of \ncovered services you may get on your own, without first contacting your PCP. See Chapter 3, Section 2.2 for more \ninformation.\nIf it is after normal business hours and you have a need for routine care, please call your PCP back during normal \nbusiness hours. If you have an emergency or have an urgent need for care after normal business hours, see \nSections 3.1 or 3.2 in this chapter. \nHow do you choose your PCP?\nWhen you enrolled, you received a Provider Directory with a list of many PCPs in your area. If you need help finding \nor choosing one, call Customer Care or you can always see the most up-to-date list online at \nHumana.com/findadoctor.\nTo choose a PCP that's a good fit for you, call them to ask how long it usually takes to get an appointment and be \nsure the office hours are convenient for you. If there are particular network hospitals that you think you might \nwant to use, you should also ask if the PCP uses them.\nWhen you receive your Humana member ID card, the name and phone number of your PCP will be printed on it, so \nyou always have it handy.\nChanging your PCP\nYou may change your PCP for any reason, at any time. Also, it's possible that your PCP might leave our plan's \nnetwork of providers and you would have to find a new PCP.\nTo change your PCP call Customer Care. We'll make sure your new PCP is accepting new patients and then send you \nan updated member ID card. The change usually goes into effect on the first day of the month after you call.\nBe sure to tell Customer Care if you're currently seeing specialists or any other providers that required a referral \nfrom your old PCP. We'll make sure you can continue with any services that had already been approved. \nSection 2.2 What kinds of medical care can you get without a referral from your PCP?\nYou can get the services listed below without getting approval in advance from your PCP.\n\u2022Routine women's health care, which includes breast exams, screening mammograms (x-rays of the breast), \nPap tests, and pelvic exams as long as you get them from a network provider.\n\u2022Flu shots, COVID-19 vaccinations, Hepatitis B vaccinations, and pneumonia vaccinations.", "doc_id": "7fd25ab4-ea61-47f9-9033-ea67f0d49324", "embedding": null, "doc_hash": "3e235e1595abf124f2a7a63025a279f2e4e2436333b5f3bb66b3ff7e5aa4aedf", "extra_info": {"page_label": "35", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3128, "_node_type": "1"}, "relationships": {"1": "61965537-de19-451e-a2b8-9a50a00ea209"}}, "__type__": "1"}, "75a33a43-b930-4877-846f-c5d310c1c613": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 36\nChapter 3 Using the plan for your medical services\n\u2022Emergency services from network providers or from out-of-network providers\n\u2022Urgently needed services are covered services that are not emergency services, provided when the network \nproviders are temporarily unavailable or inaccessible or when the enrollee is out of the service area. For \nexample, you need immediate care during the weekend. Services must be immediately needed and \nmedically necessary.\n\u2022Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside \nthe plan's service area. (If possible, please call Customer Care before you leave the service area so we can \nhelp arrange for you to have maintenance dialysis while you are away.)\n\u2022All covered preventive services. These services are indicated in the Chapter 4 Medical Benefits Chart with an \n\u2022Supplemental Benefits covered by the plan. These services are indicated in the Chapter 4 Medical Benefits \nChart with an asterisk (*).\nSection 2.3 How to get care from specialists and other network providers\nA specialist is a doctor who provides health care services for a specific disease or part of the body. There are many \nkinds of specialists. Here are a few examples:\n\u2022Oncologists care for patients with cancer\n\u2022Cardiologists care for patients with heart conditions\n\u2022Orthopedists care for patients with certain bone, joint, or muscle conditions\nReferrals\nYou do not need a referral for covered services.\nFor some types of services, your PCP may need to get approval in advance from our plan (this is called getting \"prior \nauthorization\"). See Chapter 4, Section 2.1 for information about which services require prior authorization.\nWhat if a specialist or another network provider leaves our plan?\nWe may make changes to the hospitals, doctors, and specialists (providers) that are part of your plan during the \nyear. If your doctor or specialist leaves your plan you have certain rights and protections that are summarized \nbelow:\n\u2022Even though our network of providers may change during the year, Medicare requires that we furnish you \nwith uninterrupted access to qualified doctors and specialists. \n\u2022We will make a good faith effort to provide you with at least 30 days' notice that your provider is leaving our \nplan so that you have time to select a new provider.\n\u2022We will assist you in selecting a new qualified provider to continue managing your health care needs. \n\u2022If you are undergoing medical treatment you have the right to request, and we will work with you to ensure, \nthat the medically necessary treatment you are receiving is not interrupted.", "doc_id": "75a33a43-b930-4877-846f-c5d310c1c613", "embedding": null, "doc_hash": "881217efa3eb547a4d28dbdc0e2e7b3e33e8ea260b0d45263ca4a04977818297", "extra_info": {"page_label": "36", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2715, "_node_type": "1"}, "relationships": {"1": "3cfd0ae8-d695-43f3-b76d-e9aad7687d5f"}}, "__type__": "1"}, "7720db1a-981a-439b-910c-7610f516658c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 37\nChapter 3 Using the plan for your medical services\n\u2022If our network does not have a qualified specialist for a plan-covered service, we must cover that service at \nin-network cost sharing when the service is received from an out-of-network specialist. Prior authorization is \nrequired for service to be covered.\n\u2022If you find out your doctor or specialist is leaving your plan, please contact us so we can assist you in finding a \nnew provider to manage your care.\n\u2022If you believe we have not furnished you with a qualified provider to replace your previous provider or that \nyour care is not being appropriately managed, you have the right to file a quality of care complaint to the \nQIO, a quality of care grievance to the plan, or both. Please see Chapter 9.\nSection 2.4 How to get care from out-of-network providers \nYour network PCP or plan must give you approval in advance before you can use providers not in the plan's \nnetwork. This is called giving you a \"referral.\" For more information about this and situations when you can see an \nout-of-network provider without a referral (such as an emergency), see Sections 2.2 and 2.3 of this chapter. If you \ndon't have a referral (approval in advance) before you get services from an out-of-network provider, you may have \nto pay for these services yourself.\nFor some types of services, your doctor may need to get approval in advance from our plan (this is called getting \n\"prior authorization\"). See Chapter 4, Section 2.1 for more information about which services require prior \nauthorization.\nIt is best to ask an out-of-network provider to bill the plan first. But, if you have already paid for the covered \nservices, we will reimburse you for our share of the cost for covered services. Or if an out-of-network provider sends \nyou a bill that you think we should pay, you can send it to us for payment. See Chapter 7 (Asking us to pay our share \nof a bill you have received for covered medical services or drugs) for information about what to do if you receive a bill \nor if you need to ask for reimbursement.\nNote: Members are entitled to receive services from out-of-network providers for emergency or urgently needed \nservices. In addition, plans must cover dialysis services for ESRD members who have traveled outside the plans \nservice area and are not able to access contracted ESRD providers.\nSECTION 3 How to get services when you have an emergency or urgent  \nneed for care or during a disaster\nSection 3.1 Getting care if you have a medical emergency\nWhat is a \"medical emergency\" and what should you do if you have one?\nA \"medical emergency\" is when you, or any other prudent layperson with an average knowledge of health and \nmedicine, believe that you have medical symptoms that require immediate medical attention to prevent your loss \nof life (and, if you are a pregnant woman, loss of an unborn child), loss of a limb or function of a limb, or loss of or \nserious impairment to a bodily function. The medical symptoms may be an illness, injury, severe pain, or a medical \ncondition that is quickly getting worse. \nIf you have a medical emergency:", "doc_id": "7720db1a-981a-439b-910c-7610f516658c", "embedding": null, "doc_hash": "76e15a8af864512f6afcc77d8fec77c6f246ab9b7144ac3d919ac6bbc9e54c67", "extra_info": {"page_label": "37", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3203, "_node_type": "1"}, "relationships": {"1": "66b580d7-8fc7-4173-a9b0-017b9f33f715"}}, "__type__": "1"}, "67261a6f-041a-4255-ac1a-372398279eb4": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 38\nChapter 3 Using the plan for your medical services\n\u2022Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for \nan ambulance if you need it. You do not need to get approval or a referral first from your PCP. You do not need \nto use a network doctor. You may get covered emergency medical care whenever you need it, anywhere in \nthe United States or its territories, and from any provider with an appropriate state license even if they are not \npart of our network.\n\u2022As soon as possible, make sure that our plan has been told about your emergency. We need to follow up \non your emergency care. You or someone else should call to tell us about your emergency care, usually \nwithin 48 hours. Call Customer Care using the phone number printed on the back of this booklet.\nWhat is covered if you have a medical emergency?\nOur plan covers ambulance services in situations where getting to the emergency room in any other way could \nendanger your health. We also cover medical services during the emergency.\nThe doctors who are giving you emergency care will decide when your condition is stable and the medical \nemergency is over.\nAfter the emergency is over you are entitled to follow-up care to be sure your condition continues to be stable. Your \ndoctors will continue to treat you until your doctors contact us and make plans for additional care. Your follow-up \ncare will be covered by our plan. If your emergency care is provided by out-of-network providers, we will try to \narrange for network providers to take over your care as soon as your medical condition and the circumstances \nallow.\nWhat if it wasn't a medical emergency?\nSometimes it can be hard to know if you have a medical emergency. For example, you might go in for emergency \ncare \u2013 thinking that your health is in serious danger \u2013 and the doctor may say that it wasn't a medical emergency \nafter all. If it turns out that it was not an emergency, as long as you reasonably thought your health was in serious \ndanger, we will cover your care.\nHowever, after the doctor has said that it was not an emergency, we will cover additional care only if you get the \nadditional care in one of these two ways:\n\u2022You go to a network provider to get the additional care. \n\u2022 - or - The additional care you get is considered \"urgently needed services\" and you follow the rules for \ngetting this urgent care (for more information about this, see Section 3.2 below).\nSection 3.2 Getting care when you have an urgent need for services\nWhat are \"urgently needed services\"?\nAn urgently needed service is a non-emergency situation requiring immediate medical care but, given your \ncircumstances, it is not possible or not reasonable to obtain these services from a network provider. The plan must \ncover urgently needed services provided out of network. Some examples of urgently needed services are i) a severe \nsore throat that occurs over the weekend or ii) an unforeseen flare-up of a known condition when you are \ntemporarily outside the service area.\nWhat if you are in the plan's service area when you have an urgent need for care?", "doc_id": "67261a6f-041a-4255-ac1a-372398279eb4", "embedding": null, "doc_hash": "3b3039f127f219eb94ed89a369cebc38fc53fcad768a69b036e8ecedc78826ce", "extra_info": {"page_label": "38", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3216, "_node_type": "1"}, "relationships": {"1": "0d870915-aac8-4d37-b3a2-5d0d8e5684fa"}}, "__type__": "1"}, "057d0cc5-390c-42a0-9179-9aa280b54655": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 39\nChapter 3 Using the plan for your medical services\nYou should always try to obtain urgently needed services from network providers. However, if providers are \ntemporarily unavailable or inaccessible and it is not reasonable to wait to obtain care from your network provider \nwhen the network becomes available, we will cover urgently needed services that you get from an out-of-network \nprovider.\nThe plan's Provider Directory will tell you which urgent care facilities in your area are in-network. This information \ncan also be found online at Humana.com/findadoctor. For any other questions regarding urgently needed \nservices, please contact Customer Care (phone numbers are printed on the back cover of this booklet).\nWhat if you are outside the plan's service area when you have an urgent need for care?\nWhen you are outside the service area and cannot get care from a network provider, our plan will cover urgently \nneeded services that you get from any provider.\nOur plan covers worldwide emergency and urgent care services outside of the United States under the following \ncircumstances. If you have an emergency or an urgent need for care outside of the U.S. and its territories, you will \nbe responsible to pay for those services upfront and request appropriate reimbursement from us. We will \nreimburse you, for covered out-of-network emergency and urgent care services outside of the U.S. and its \nterritories, at rates no greater than the rates at which Original Medicare would pay for such services had the \nservices been performed in the United States in the locality where you reside. The amount we pay you, if any, will \nbe reduced by any applicable cost-sharing. Because we will reimburse at rates no greater than the rates at which \nOriginal Medicare would reimburse, and because foreign providers might charge more for services than the rates at \nwhich Original Medicare would pay, the total of our reimbursement plus the applicable cost-sharing may be less \nthan the amounts you pay the foreign provider. This is a supplemental benefit not generally covered by Medicare. \nYou must submit proof of payment to Humana for reimbursement. See Chapter 4 (Medical Benefits Chart, what is \ncovered) for more information. If you have already paid for the covered services, we will reimburse you for our \nshare of the cost for covered services. You can send the bill with medical records to us for payment consideration. \nSee Chapter 7 (Asking us to pay our share of a bill you have received for covered medical services or drugs) for \ninformation about what to do if you receive a bill or if you need to ask for reimbursement. \nSection 3.3 Getting care during a disaster\nIf the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States \ndeclares a state of disaster or emergency in your geographic area, you are still entitled to care from your plan.\nPlease visit the following website: Humana.com/alert for information on how to obtain needed care during a \ndisaster.\nIf you cannot use a network provider during a disaster, your plan will allow you to obtain care from out-of-network \nproviders at in-network cost-sharing. If you cannot use a network pharmacy during a disaster, you may be able to \nfill your prescription drugs at an out-of-network pharmacy. Please see Chapter 5, Section 2.5 for more information.\nSECTION 4 What if you are billed directly for the full cost of your services?\nSection 4.1 You can ask us to pay for covered services\nIf you have paid for your covered services, or if you have received a bill for covered medical services, go to Chapter \n7 (Asking us to pay a bill you have received for covered medical services or drugs) for information about what to do.", "doc_id": "057d0cc5-390c-42a0-9179-9aa280b54655", "embedding": null, "doc_hash": "5f30bdf8a10777b606f882721c29c62b20637689c00c58363766a4cce38d286d", "extra_info": {"page_label": "39", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3834, "_node_type": "1"}, "relationships": {"1": "250c7ab8-5d0d-4b6e-8f13-ddf200acb4de"}}, "__type__": "1"}, "b830e29f-0025-40bf-871f-5a248ee05e11": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 40\nChapter 3 Using the plan for your medical services\nSection 4.2 What should you do if services are not covered by our plan?\nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) covers all medically necessary services as listed in the \nMedical Benefits Chart in Chapter 4 of this document. If you receive services not covered by our plan or services \nobtained out-of-network and were not authorized, you are responsible for paying the full cost of services.\nFor covered services that have a benefit limitation, you also pay the full cost of any services you get after you have \nused up your benefit for that type of covered service. Paying for costs once a benefit limit has been reached will not \ncount toward your out-of-pocket maximum. You can call Customer Care when you want to know how much of \nyour benefit limit you have already used.\nSECTION 5 How are your medical services covered when you are in a  \n\"clinical research study\"?\nSection 5.1 What is a \"clinical research study\"?\nA clinical research study (also called a \"clinical trial\") is a way that doctors and scientists test new types of medical \ncare, like how well a new cancer drug works. Certain clinical research studies are approved by Medicare. Clinical \nresearch studies approved by Medicare typically request volunteers to participate in the study.\nOnce Medicare approves the study, and you express interest, someone who works on the study will contact you to \nexplain more about the study and see if you meet the requirements set by the scientists who are running the \nstudy. You can participate in the study as long as you meet the requirements for the study and you have a full \nunderstanding and acceptance of what is involved if you participate in the study.\nIf you participate in a Medicare-approved study, Original Medicare pays most of the costs for the covered services \nyou receive as part of the study. If you tell us that you are in a qualified clinical trial, then you are only responsible \nfor the in-network cost sharing for the services in that trial. If you paid more, for example, if you already paid the \nOriginal Medicare cost-sharing amount, we will reimburse the difference between what you paid and the \nin-network cost sharing. However, you will need to provide documentation to show us how much you paid. When \nyou are in a clinical research study, you may stay enrolled in our plan and continue to get the rest of your care (the \ncare that is not related to the study) through our plan.\nIf you want to participate in any Medicare-approved clinical research study, you do not need to tell us or to get \napproval from us or your PCP. The providers that deliver your care as part of the clinical research study do not need \nto be part of our plan\u2019s network of providers.\nAlthough you do not need to get our plan\u2019s permission to be in a clinical research study, we encourage you to \nnotify us in advance when you choose to participate in Medicare-qualified clinical trials.\nIf you participate in a study that Medicare or our plan has not approved, you will be responsible for paying all costs for \nyour participation in the study.\nSection 5.2 When you participate in a clinical research study, who pays for what?\nOnce you join a Medicare-approved clinical research study, Original Medicare covers the routine items and services \nyou receive as part of the study, including:", "doc_id": "b830e29f-0025-40bf-871f-5a248ee05e11", "embedding": null, "doc_hash": "30e3753ffabec366638a5cdf14ec37d174a9a57d632a21ae0fb204cfec3e0464", "extra_info": {"page_label": "40", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3445, "_node_type": "1"}, "relationships": {"1": "0b4c10e3-330e-4e9d-abb6-2270e73d033c"}}, "__type__": "1"}, "f82950aa-13a3-4d92-8581-3f337b8ca2b3": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 41\nChapter 3 Using the plan for your medical services\n\u2022Room and board for a hospital stay that Medicare would pay for even if you weren't in a study.\n\u2022An operation or other medical procedure if it is part of the research study.\n\u2022Treatment of side effects and complications of the new care.\nAfter Medicare has paid its share of the cost for these services, our plan will pay the rest. Like for all covered \nservices, you will pay nothing for the covered services you get in the clinical research study.\nWhen you are part of a clinical research study, neither Medicare nor our plan will pay for any of the following:\n\u2022Generally, Medicare will not pay for the new item or service that the study is testing unless Medicare would \ncover the item or service even if you were not in a study.\n\u2022Items or services provided only to collect data, and not used in your direct health care. For example, Medicare \nwould not pay for monthly CT scans done as part of the study if your medical condition would normally \nrequire only one CT scan.\nDo you want to know more?\nYou can get more information about joining a clinical research study by visiting the Medicare website to read or \ndownload the publication \"Medicare and Clinical Research Studies.\" (The publication is available at: \nwww.medicare.gov/Pubs/pdf/02226-Medicare-and-Clinical-Research-Studies.pdf.) You can also call \n1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.\nSECTION 6 Rules for getting care in a \"religious non-medical health care  \ninstitution\"\nSection 6.1 What is a religious non-medical health care institution?\nA religious non-medical health care institution is a facility that provides care for a condition that would ordinarily \nbe treated in a hospital or skilled nursing facility. If getting care in a hospital or a skilled nursing facility is against a \nmember's religious beliefs, we will instead provide coverage for care in a religious non-medical health care \ninstitution. This benefit is provided only for Part A inpatient services (non-medical health care services). \nSection 6.2 Receiving Care from a Religious Non-Medical Health Care Institution\nTo get care from a religious non-medical health care institution, you must sign a legal document that says you are \nconscientiously opposed to getting medical treatment that is \"non-excepted.\"\n\u2022\"Non-excepted\" medical care or treatment is any medical care or treatment that is voluntary and not required \nby any federal, state, or local law.\n\u2022\"Excepted\" medical treatment is medical care or treatment that you get that is not voluntary or is required \nunder federal, state, or local law.\nTo be covered by our plan, the care you get from a religious non-medical health care institution must meet the \nfollowing conditions:", "doc_id": "f82950aa-13a3-4d92-8581-3f337b8ca2b3", "embedding": null, "doc_hash": "0a0f4f8b1c417ea6e1486cd0b2547731a5d626826eb37d7a7f3709b2332002ac", "extra_info": {"page_label": "41", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2873, "_node_type": "1"}, "relationships": {"1": "218850bc-f4bb-4d34-9605-5e32f0eed11b"}}, "__type__": "1"}, "92714847-823d-4e9b-a692-ae772e3100ef": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 42\nChapter 3 Using the plan for your medical services\n\u2022The facility providing the care must be certified by Medicare.\n\u2022Our plan's coverage of services you receive is limited to non-religious aspects of care.\n\u2022If you get services from this institution that are provided to you in a facility, the following conditions apply:\n\u2013You must have a medical condition that would allow you to receive covered services for inpatient hospital \ncare or skilled nursing facility care.\n\u2013\u2013 and \u2013 You must get approval in advance from our plan before you are admitted to the facility or your stay \nwill not be covered.\nMedicare Inpatient Hospital coverage limits apply (please refer to the Medicare Benefits Chart in Chapter 4).\nSECTION 7 Rules for ownership of durable medical equipment\nSection 7.1 Will you own the durable medical equipment after making a certain  \nnumber of payments under our plan?\nDurable medical equipment (DME) includes items such as oxygen equipment and supplies, wheelchairs, walkers, \npowered mattress systems, crutches, diabetic supplies, speech generating devices, IV infusion pumps, nebulizers, \nand hospital beds ordered by a provider for use in the home. The member always owns certain items, such as \nprosthetics. In this section, we discuss other types of DME that you must rent.\nIn Original Medicare, people who rent certain types of DME own the equipment after paying copayments for the \nitem for 13 months. As a member of Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP), however, you \nusually will not acquire ownership of rented DME items no matter how many copayments you make for the item \nwhile a member of our plan, even if you made up to 12 consecutive payments for the DME item under Original \nMedicare before you joined our plan. Under certain limited circumstances, we will transfer ownership of the DME \nitem to you. Call Customer Care for more information.\nWhat happens to payments you made for durable medical equipment if you switch to Original Medicare?\nIf you did not acquire ownership of the DME item while in our plan, you will have to make 13 new consecutive \npayments after you switch to Original Medicare in order to own the item. The payments made while enrolled in \nyour plan do not count. \nExample 1: You made 12 or fewer consecutive payments for the item in Original Medicare and then joined our plan. \nThe payments you made in Original Medicare do not count. You will have to make 13 payments to our plan before \nowning the item.\nExample 2: You made 12 or fewer consecutive payments for the item in Original Medicare and then joined our plan. \nYou were in our plan but did not obtain ownership while in our plan. You then go back to Original Medicare. You will \nhave to make 13 consecutive new payments to own the item once you join Original Medicare again. All previous \npayments (whether to our plan or to Original Medicare) do not count.\nSection 7.2 Rules for oxygen equipment, supplies, and maintenance\nWhat oxygen benefits are you entitled to?", "doc_id": "92714847-823d-4e9b-a692-ae772e3100ef", "embedding": null, "doc_hash": "e10f213ca26eaf38a1a7df8c86eb68b53fece797b48acddb092f862ce7c7753c", "extra_info": {"page_label": "42", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3074, "_node_type": "1"}, "relationships": {"1": "3d966de5-0ad6-4fc5-afa8-d5fb5bea8dea"}}, "__type__": "1"}, "fe6acd69-aeca-49b2-8e58-abb529861667": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 43\nChapter 3 Using the plan for your medical services\nIf you qualify for Medicare oxygen equipment coverage Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) \nwill cover: \n\u2022Rental of oxygen equipment\n\u2022Delivery of oxygen and oxygen contents\n\u2022Tubing and related oxygen accessories for the delivery of oxygen and oxygen contents\n\u2022Maintenance and repairs of oxygen equipment\nIf you leave Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) or no longer medically require oxygen \nequipment, then the oxygen equipment must be returned.\nWhat happens if you leave your plan and return to Original Medicare?\nOriginal Medicare requires an oxygen supplier to provide you services for five years. During the first 36 months you \nrent the equipment. The remaining 24 months the supplier provides the equipment and maintenance (you are still \nresponsible for the copayment for oxygen). After five years you may choose to stay with the same company or go \nto another company. At this point, the five-year cycle begins again, even if you remain with the same company, \nrequiring you to pay copayments for the first 36 months. If you join or leave our plan, the five-year cycle starts \nover.", "doc_id": "fe6acd69-aeca-49b2-8e58-abb529861667", "embedding": null, "doc_hash": "29921aa7110658fb6edf1275971d2481883e26cafa793a89971de20f41670d24", "extra_info": {"page_label": "43", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1252, "_node_type": "1"}, "relationships": {"1": "d46063ca-d326-4e2e-8d41-3d1e45e3e916"}}, "__type__": "1"}, "ea08f880-5959-4f42-843a-759909ba4627": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 44\nChapter 4. Medical Benefits Chart (what is covered)EOC076\nCHAPTER 4:\nMedical Benefits Chart (what is  \ncovered)", "doc_id": "ea08f880-5959-4f42-843a-759909ba4627", "embedding": null, "doc_hash": "9d31a37839a91a8dde85830adb90164456793e42996a945dfa0f5002a155231c", "extra_info": {"page_label": "44", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 194, "_node_type": "1"}, "relationships": {"1": "618f0b0e-0280-4ebd-b425-573356244342"}}, "__type__": "1"}, "6bdce02d-1170-4c34-bccc-cb1ce2ee6e95": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 45\nChapter 4. Medical Benefits Chart (what is covered)\nSECTION 1 Understanding covered services\nThis chapter provides a Medical Benefits Chart that lists your covered services as a member of Humana Gold Plus \nSNP-DE H0028-015 (HMO-POS D-SNP). Later in this chapter, you can find information about medical services that \nare not covered. It also explains limits on certain services. Also, see exclusions and limitations pertaining to certain \nsupplemental benefits listed in the chart in this chapter.\nSection 1.1 You pay nothing for your covered services\nIf you get assistance from MO HealthNet (Medicaid), you pay nothing for your covered services as long as you \nfollow the plans\u2019 rules for getting your care. (See Chapter 3 for more information about the plans\u2019 rules for getting \nyour care.) \nYour provider may choose to submit to MO HealthNet (Medicaid) for consideration of additional secondary \npayment for an amount applied to deductibles, coinsurance, or copayments. If you are cost-share protected, \nproviders are required by federal regulation to accept Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) \nprimary payment and MO HealthNet (Medicaid) secondary payment as payment in full for covered Medicare Part A \nand Part B services - even when the Medicaid payment is zero or a provider chooses to not submit to Medicaid.\nIf you are cost-share protected by MO HealthNet (Medicaid), Humana Gold Plus SNP-DE H0028-015 (HMO-POS \nD-SNP) providers aren't allowed to collect or bill you for services and items covered under Medicare Part A and Part \nB, including deductibles, coinsurance, and copayments - even when Medicaid payment is zero or a provider \nchooses to not submit to Medicaid. If a provider asks you to pay, that's against the law. You may however be \nresponsible for a small Medicaid copayment. \nIf you are cost-share protected and you are billed or asked to pay the provider for deductibles, coinsurance, or \ncopayments on covered Medicare Part A and Part B services tell your provider you are cost-share protected and \ncan't be charged. If you have already made payment you have the right to a refund. If your provider will not stop \nbilling, you can call Customer Care or you can call Medicare at 1-800-Medicare (1-800-633-4227), (TTY \n1-877-486-2048). Customer Care or Medicare can ask your provider to stop billing you and refund any payment \nyou have made.\nSection 1.2 What is the most you will pay for Medicare Part A and Part B covered  \nmedical services?\nNote: Because our members also get assistance from MO HealthNet (Medicaid), very few members ever reach this \nout-of-pocket maximum. You are not responsible for paying any out-of-pocket costs toward the maximum \nout-of-pocket amount for covered Part A and Part B services. \nBecause you are enrolled in a Medicare Advantage Plan, there is a limit on the amount you have to pay \nout-of-pocket each year for medical services that are covered under Medicare Part A and Part B. This limit is called \nthe maximum out-of-pocket (MOOP) amount for medical services. For calendar year 2023 this amount is $8,300 \n(In-Network).\nThe amounts you pay for copayments and coinsurance for covered services count toward this maximum \nout-of-pocket amount. The amounts you pay for your plan premiums and your Part D prescription drugs do not \ncount toward your maximum out-of-pocket amount. In addition, amounts you pay for some services do not count ", "doc_id": "6bdce02d-1170-4c34-bccc-cb1ce2ee6e95", "embedding": null, "doc_hash": "eb0b3ebeed7359a55b6cb86afffcb1c06b599bea1faba2c00807a0a13b3d0b10", "extra_info": {"page_label": "45", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3499, "_node_type": "1"}, "relationships": {"1": "6b93020e-4ea3-4496-99e1-afbfeaa282c2"}}, "__type__": "1"}, "4af395e5-fbed-48ef-a802-384fc9e326b8": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 46\nChapter 4. Medical Benefits Chart (what is covered)\ntoward your maximum out-of-pocket amount. These services are marked with an asterisk in the Medical Benefits \nChart. If you reach the maximum out-of-pocket amount of $8,300, you will not have to pay any out-of-pocket \ncosts for the rest of the year for covered Part A and Part B services. However, you must continue to pay your plan \npremium and the Medicare Part B premium (unless your Part B premium is paid for you by MO HealthNet (Medicaid) \nor another third party).\nSECTION 2 Use the Medical Benefits Chart to find out what is covered\nSection 2.1 Your medical benefits as a member of the plan\nThe Medical Benefits Chart on the following pages lists the services Humana Gold Plus SNP-DE H0028-015 \n(HMO-POS D-SNP) covers. Part D prescription drug coverage is in Chapter 5. The services listed in the Medical \nBenefits Chart are covered only when the following coverage requirements are met:\n\u2022Your Medicare covered services must be provided according to the coverage guidelines established by Medicare.\n\u2022Your services (including medical care, services, supplies, equipment, and Part B prescription drugs) must be \nmedically necessary. \"Medically necessary\" means that the services, supplies, or drugs are needed for the \nprevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical \npractice.\n\u2022You receive your care from a network provider. In most cases, care you receive from an out-of-network provider \nwill not be covered unless it is emergent or urgent care or unless your plan or a network provider has given you a \nreferral. This means that you will have to pay the provider in full for the services furnished. \n\u2022You have a primary care provider (a PCP) who is providing and overseeing your care. In most situations, your PCP \nmust give you approval in advance before you can see other providers in the plan's network. This is called giving \nyou a \"referral\". However, referrals are not required for in-network services.\n\u2022Some of the services listed in the Medical Benefits Chart are covered only if your doctor or other network provider \ngets approval in advance (sometimes called \"prior authorization\") from us. Covered services that need approval \nin advance are marked in the Medical Benefits Chart by a footnote. In addition, the following services not listed \nin the Benefits Chart require prior authorization:\n>The preauthorization list can be found here: Humana.com/PAL\nOther important things to know about our coverage: \n\u2022You are covered by both Medicare and Medicaid. Medicare covers health care and prescription drugs. Medicaid \ncovers your cost-sharing for Medicare services, including plan medical deductibles and cost shares as well as \nMedicare Part A & Part B premiums, deductibles and cost-shares, for anyone who receives cost-share assistance \nfrom the MO HealthNet (Medicaid). MO HealthNet (Medicaid) may also cover services Medicare does not cover. \n\u2022Like all Medicare health plans, we cover everything that Original Medicare covers. (If you want to know more \nabout the coverage and costs of Original Medicare, look in your Medicare & You 2023 handbook. View it online at \nwww.medicare.gov or ask for a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a \nweek. TTY users should call 1-877-486-2048.)\n\u2022For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no \ncost to you.", "doc_id": "4af395e5-fbed-48ef-a802-384fc9e326b8", "embedding": null, "doc_hash": "d78a948fe25f197cca191968f0995717044438be12ce9bdcc4f1cb391b1c5b32", "extra_info": {"page_label": "46", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3556, "_node_type": "1"}, "relationships": {"1": "04411f5b-c85d-4e3a-afbb-8f8ca753af40"}}, "__type__": "1"}, "2354cce8-c467-4733-8f9b-7a8e46a8902c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 47\nChapter 4. Medical Benefits Chart (what is covered)\n\u2022If Medicare adds coverage for any new services during 2023, either Medicare or our plan will cover those \nservices.\n\u2022If you are within our plan's six-month period of deemed continued eligibility, we will continue to provide all \nMedicare Advantage plan-covered Medicare benefits. However, during this period, you may be subject to Part D \npremiums and Part D cost-shares based on your level of  \"Extra Help.\" Additionally, based on your level of MO \nHealthNet (Medicaid) eligibility, you may also be responsible for Medicare Part A and Part B premiums. We will \ncontinue to cover your Medicare Advantage plan covered cost-shares during this period. Medicare cost sharing \namounts for Medicare basic and supplemental benefits do not change during this period. \nYou do not pay anything for the services listed in the Benefits Chart, as long as you meet the coverage \nrequirements described above. Be sure to show your MO HealthNet (Medicaid) ID card in addition to your Humana \nmembership card to make your provider aware that you may have additional coverage. Your services are paid first \nby Humana and then by MO HealthNet (Medicaid).\nImportant Benefit Information for all Enrollees Participating in Wellness and Health Care Planning (WHP) Services\n\u2022You are eligible for the following WHP services, including advance care planning (ACP) services: \n\u2013Documenting what\u2019s important to you is essential to getting the care you want when you are too ill to speak \nfor yourself.\n\u2013As a Humana member, you have access to an online advance care planning resource called, MyDirectives\u00ae. \nThis resource helps you to create an advance directive where you can combine the elements of a:\n>Living will\n>Medical power of attorney\n>Do not attempt resuscitation form\n>Organ donation form\n\u2022You can create your own digital care plan on MyDirectives\u00ae and even include video and audio files. If you \nalready have these documents prepared you can store and share them here. MyDirectives\u00ae is available to you \nand your designated medical providers 24 hours a day, seven days a week. You can add new information at any \ntime as your health status or wishes change.\n\u2022To get started, visit Humana.com and log into MyHumana. Go to the MyHealth tab and select MyDirectives\u00ae in \nthe \"Health support for you\" section.\n\u2022Additionally, if you meet certain health conditions now or your health status changes in the future, Humana will \nreach out to you. A clinician or social worker will provide support to ensure you have an advance directive in \nplace and you are able to share it with your family and doctors. Participation in any programs that include \nWellness and Healthcare Planning or Advance Care Planning are voluntary and you are free to decline the \nservices at any time.\nImportant Benefit Information for Enrollees Who Qualify for \"Extra Help\":\n\u2022If you receive \"Extra Help\" to pay your Medicare prescription drug program costs, such as premiums, \ndeductibles, and coinsurance, you may be eligible for other targeted supplemental benefits and/or targeted \nreduced cost sharing.\n\u2022Please go to the Medical Benefits Chart in Chapter 4 for further detail.", "doc_id": "2354cce8-c467-4733-8f9b-7a8e46a8902c", "embedding": null, "doc_hash": "d98e087e661e84e2baf618fef8d92c24ebbb7063d402b30fd64031c54c443927", "extra_info": {"page_label": "47", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3265, "_node_type": "1"}, "relationships": {"1": "89279d59-07b1-459f-bed9-7601d10cf5ff"}}, "__type__": "1"}, "c8df2a36-4b2c-421d-8de4-58bc4ff3a7b0": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 48\nChapter 4. Medical Benefits Chart (what is covered)\nImportant Benefit Information for Enrollees with Chronic Conditions \n\u2022If you are diagnosed with the following chronic condition(s) identified below and meet certain criteria, you may \nbe eligible for special supplemental benefits for the chronically ill.\n\u2013Members diagnosed with Chronic Obstructive Pulmonary Disease (COPD), Diabetes, or Congestive Heart \nFailure (CHF) participating with care management services, who have had an inpatient hospital or skilled \nnursing facility stay within the last 30 days, and meet program criteria, may be eligible to receive meal \ndelivery through the Worry Free\u2122 Meals program.\n\u2013Members diagnosed with one or more of the following conditions, and who are eligible to participate with \ncare management services may receive additional benefits through Humana Flexible Care Assistance. \n>Chronic alcohol and other drug dependence\n>Certain autoimmune disorders\n>Cancer, excluding pre-cancer conditions or in-situ status\n>Certain cardiovascular disorders \n>Congestive heart failure\n>Dementia\n>Diabetes mellitus\n>End-stage liver disease\n>End-stage renal disease (ESRD) requiring dialysis\n>Certain severe hematologic (blood) disorders \n>HIV/AIDS\n>Certain chronic lung disorders \n>Certain chronic and disabling mental health conditions\n>Certain neurologic disorders \n>Stroke\n\u2022Please go to the \"Special Supplemental Benefits for the Chronically Ill\" row in the below Medical Benefits Chart \nfor further detail. \n\u2022Please contact us to find out exactly which benefits you may be eligible for.\n You will see this apple next to the preventive services in the benefits chart.\n* You will see this asterisk next to the supplemental benefits in the Medical Benefits Chart.\nSee Section 1.1 of this chapter for information on MO HealthNet (Medicaid) cost-share protection.\nMedical Benefits Chart  \nServices that are covered for you What you must pay when you get  \nthese services\n* $0 Rx Copay Benefit\n$0 copayment for all Medicare-covered Part D prescription drugs on your \nformulary, on all tiers, and through all drug stages, for members who \nreceive \u201cExtra Help\u201d for prescription drug costs. In-Network:\n$0 copayment\nMedicare-covered Part D \nprescription drugs\n Abdominal aortic aneurysm screening In-Network:\nThere is no coinsurance, ", "doc_id": "c8df2a36-4b2c-421d-8de4-58bc4ff3a7b0", "embedding": null, "doc_hash": "edd914c1f376d63acdc697dc6ef3665bcf3a6b191df7b211d6e5f96173751336", "extra_info": {"page_label": "48", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2394, "_node_type": "1"}, "relationships": {"1": "ef37630a-9d87-4041-8339-9d48ef7f8923"}}, "__type__": "1"}, "9dd70010-7db0-4566-875e-8974383537b8": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 49\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nA one-time screening ultrasound for people at risk. The plan only covers \nthis screening if you have certain risk factors and if you get a referral for it \nfrom your physician, physician assistant, nurse practitioner, or clinical \nnurse specialist.copayment, or deductible for \nmembers eligible for this preventive \nscreening.\nAcupuncture for chronic low back pain\nCovered services include:\nUp to 20 visits per year for Medicare beneficiaries under the following \ncircumstances:\nFor the purpose of this benefit, chronic low back pain is defined as:\n\u2022Lasting 12 weeks or longer;\n\u2022Nonspecific, in that it has no identifiable systemic cause (i.e., not \nassociated with metastatic, inflammatory, infectious, disease, etc.);\n\u2022Not associated with surgery; and\n\u2022Not associated with pregnancy.\nYour plan allows services to be received by a provider licensed to perform \nacupuncture or by providers meeting the Original Medicare provider \nrequirements.\nPrior authorization requirements may apply.In-Network:\nMedicare Covered Acupuncture \nServices\n$0 copayment\n\u2013Specialist's Office\nAllergy shots and serum\nYou are covered for allergy shots and serum when medically necessary.In-Network:\nAllergy Shots and Serum\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\nAmbulance services\n\u2022Covered ambulance services include fixed wing, rotary wing, and \nground ambulance services, to the nearest appropriate facility that can \nprovide care only if they are furnished to a member whose medical \ncondition is such that other means of transportation could endanger \nthe person's health or if authorized by the plan.\n\u2022Non-emergency transportation by ambulance is appropriate if it is \ndocumented that the member's condition is such that other means of \ntransportation could endanger the person's health and that \ntransportation by ambulance is medically required.\nPrior authorization requirements may apply.In-Network:\nEmergency Ambulance\n$0 copayment  regardless of the \nnumber of trips\n\u2013Ground Ambulance\n\u2013Air Ambulance\nNon-Emergency Ambulance\n$0 copayment  regardless of the \nnumber of trips\n\u2013Ground Ambulance\n\u2013Air Ambulance\n Annual wellness visit\nIf you've had Part B for longer than 12 months, you can get an annual \nwellness visit to develop or update a personalized prevention plan based \non your current health and risk factors. This is covered once every 12 \nmonths.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \nannual wellness visit.", "doc_id": "9dd70010-7db0-4566-875e-8974383537b8", "embedding": null, "doc_hash": "14e6638ab4582fab7afdc4e761342b8f05ceb2ab40072f73cbcc3f286bd03cbd", "extra_info": {"page_label": "49", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2661, "_node_type": "1"}, "relationships": {"1": "7fe7fa3e-23a2-4076-bdf8-e92d32af9bfe"}}, "__type__": "1"}, "b785d575-d7a2-472c-8328-30337dedc998": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 50\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nNote: Your first annual wellness visit can't take place within 12 months of \nyour \"Welcome to Medicare\" preventive visit. However, you don't need to \nhave had a \"Welcome to Medicare\" visit to be covered for annual wellness \nvisits after you've had Part B for 12 months.\n Bone mass measurement\nFor qualified individuals (generally, this means people at risk of losing bone \nmass or at risk of osteoporosis), the following services are covered every 24 \nmonths or more frequently if medically necessary: procedures to identify \nbone mass, detect bone loss, or determine bone quality, including a \nphysician's interpretation of the results.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for \nMedicare-covered bone mass \nmeasurement.\n Breast cancer screening (mammograms)\nCovered services include:\n\u2022One baseline mammogram between the ages of 35 and 39\n\u2022One screening mammogram every 12 months for women aged 40 and \nolder\n\u2022Clinical breast exams once every 24 monthsIn-Network:\nThere is no coinsurance, \ncopayment, or deductible for \ncovered screening mammograms.\nCardiac rehabilitation services\nComprehensive programs of cardiac rehabilitation services that include \nexercise, education, and counseling are covered for members who meet \ncertain conditions with a doctor\u2019s order. The plan also covers intensive \ncardiac rehabilitation programs that are typically more rigorous or more \nintense than cardiac rehabilitation programs.\nPrior authorization requirements may applyIn-Network:\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n Cardiovascular disease risk reduction visit (therapy for \ncardiovascular disease) \nWe cover one visit per year with your primary care doctor to help lower \nyour risk for cardiovascular disease. During this visit, your doctor may \ndiscuss aspirin use (if appropriate), check your blood pressure, and give you \ntips to make sure you're eating healthy.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \nintensive behavioral therapy \ncardiovascular disease preventive \nbenefit.\n Cardiovascular disease testing\nBlood tests for the detection of cardiovascular disease (or abnormalities \nassociated with an elevated risk of cardiovascular disease) once every 5 \nyears (60 months).In-Network:\nThere is no coinsurance, \ncopayment, or deductible for \ncardiovascular disease testing that \nis covered once every 5 years.\n Cervical and vaginal cancer screening\nCovered services include:\n\u2022For all women: Pap tests and pelvic exams are covered once every 24 \nmonthsIn-Network:\nThere is no coinsurance, \ncopayment, or deductible for \nMedicare-covered preventive Pap \nand pelvic exams.", "doc_id": "b785d575-d7a2-472c-8328-30337dedc998", "embedding": null, "doc_hash": "86c2dc426b3321c3ea0534076976f40311272a0ea3ca47cb966ec4135104ae52", "extra_info": {"page_label": "50", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2859, "_node_type": "1"}, "relationships": {"1": "26aad095-9fe3-487b-b7cd-233458e193e1"}}, "__type__": "1"}, "7459cb47-7189-47c2-a2e6-f9e8ad28f77c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 51\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\n\u2022If you are at high risk of cervical or vaginal cancer or you are of \nchildbearing age and have had an abnormal Pap test within the past 3 \nyears: one Pap test every 12 months\nChiropractic services\nCovered services include:\n\u2022We cover manual manipulation of the spine to correct subluxation\n*Additionally, you may self-refer to a network chiropractor for 12 visits per \ncalendar year for routine spinal adjustments. Covered supplemental \nservices include:\n\u2022New and established patient examinations\n\u2022Select x-ray procedures \n\u2022Non-spinal/extremity manipulation\n\u2022Select physical medicine modalities and procedures\nPrior authorization requirements may apply.In-Network:\nMedicare Covered Chiropractic \nServices\n$0 copayment\n\u2013Specialist's Office\nRoutine chiropractic \n$0 copayment\n\u2013Specialist's Office\n Colorectal cancer screening\nFor people 50 and older, the following are covered:\n\u2022Flexible sigmoidoscopy (or screening barium enema as an alternative) \nevery 48 months\nOne of the following every 12 months:\n\u2022Guaiac-based fecal occult blood test (gFOBT)\n\u2022Fecal immunochemical test (FIT)\nDNA based colorectal screening every 3 years\nFor people at high risk of colorectal cancer, we cover:\n\u2022Screening colonoscopy (or screening barium enema as an alternative) \nevery 24 months\nFor people not at high risk of colorectal cancer, we cover:\n\u2022Screening colonoscopy every 10 years (120 months), but not within 48 \nmonths of a screening sigmoidoscopyIn-Network:\nThere is no coinsurance, \ncopayment, or deductible for a \nMedicare-covered colorectal cancer \nscreening exam.\nDental services\nIn general, preventive dental services (such as cleaning, routine dental \nexams, and dental x-rays) are not covered by Original Medicare. We cover:\n\u2022Medically necessary dental services, as covered by Original Medicare\nPrior authorization requirements may apply.In-Network:\nMedicare Covered Dental Services\n$0 copayment\n\u2013Specialist's Office\nSupplemental dental benefits\n*You are covered for supplemental \ndental benefits. See the \nsupplemental dental benefit \ndescription at the end of this chart \nfor details.\n Depression screening In-Network:", "doc_id": "7459cb47-7189-47c2-a2e6-f9e8ad28f77c", "embedding": null, "doc_hash": "47f201014ce8bc867fb699ebca1cfaa4db2c2e7301ad2772cc4ee7febf6994bc", "extra_info": {"page_label": "51", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2331, "_node_type": "1"}, "relationships": {"1": "94cc97c7-300c-4ecd-a8a8-afd424e6fe58"}}, "__type__": "1"}, "3e0c3e02-8db7-4ea5-b8c3-05cec088f1e3": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 52\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nWe cover one screening for depression per year. The screening must be \ndone in a primary care setting that can provide follow-up treatment and/or \nreferrals.There is no coinsurance, \ncopayment, or deductible for an \nannual depression screening visit.\n Diabetes screening\nWe cover this screening (includes fasting glucose tests) if you have any of \nthe following risk factors: high blood pressure (hypertension), history of \nabnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a \nhistory of high blood sugar (glucose). Tests may also be covered if you \nmeet other requirements, like being overweight and having a family \nhistory of diabetes.\nBased on the results of these tests, you may be eligible for up to two \ndiabetes screenings every 12 months.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \nMedicare-covered diabetes \nscreening tests.\n Diabetes self-management training, diabetic services and supplies\nFor all people who have diabetes (insulin and non-insulin users). Covered \nservices include:\n\u2022Supplies to monitor your blood glucose: Blood glucose monitor, blood \nglucose test strips, lancet devices and lancets, and glucose-control \nsolutions for checking the accuracy of test strips and monitors.\n\u2013These are the only covered brands of blood glucose monitors and \ntest strips: ACCU-CHEK\u00ae manufactured by Roche, or Trividia products \nsometimes packaged under your pharmacy\u2019s name.\n\u2013Humana covers any blood glucose monitors and test strips specified \nwithin the preferred brand list above. In general, alternate \nnon-preferred brand products are not covered unless your doctor \nprovides adequate information that the use of an alternate brand is \nmedically necessary in your specific situation. If you are new to \nHumana and are using a brand of blood glucose monitor and test \nstrips that are not on the preferred brand list, you may contact us \nwithin the first 90 days of enrollment into the plan to request a \ntemporary supply of the alternate non-preferred brand. During this \ntime, you should talk with your doctor to decide whether any of the \npreferred product brands listed above are medically appropriate for \nyou. Non-preferred brand products will not be covered following the \ninitial 90 days of coverage without an approved prior authorization \nfor a coverage exception.\n\u2022For people with diabetes who have severe diabetic foot disease: One \npair per calendar year of therapeutic custom-molded shoes (including \ninserts provided with such shoes) and two additional pairs of inserts, or \none pair of depth shoes and three pairs of inserts (not including the \nnon-customized removable inserts provided with such shoes). Coverage \nincludes fitting.\n\u2022Diabetes self-management training is covered under certain conditionsIn-Network:\nDiabetes self-management training\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\n\u2013Outpatient Hospital\nDiabetic Monitoring Supplies\n$0 copayment\n\u2013Preferred Diabetic Supplier\n\u2013Diabetic Supplier\n\u2013Network Retail Pharmacy\nDiabetic Shoes and Inserts\n$0 copayment\n\u2013Durable Medical Equipment \nProvider\n\u2013Prosthetics Provider", "doc_id": "3e0c3e02-8db7-4ea5-b8c3-05cec088f1e3", "embedding": null, "doc_hash": "078f4cb35a460303abd218412dfb619efeba5ee45369387c7eb70127000e70cd", "extra_info": {"page_label": "52", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3325, "_node_type": "1"}, "relationships": {"1": "32e6b1a4-8f47-4d5e-ac52-0b5af7f73a06"}}, "__type__": "1"}, "da8fad0b-a3e2-43b1-b2db-0cc2680e9654": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 53\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\n\u2022For Continuous Glucose Monitors, see Durable medical equipment (DME) \nand related supplies.\nThe  (preventive service) only applies to Diabetes self-management \ntraining.\nPrior authorization requirements may apply.\nDurable medical equipment (DME) and related supplies\n(For a definition of \"durable medical equipment,\" see Chapter 12 as well as \nChapter 3, Section 7 of this document.)\nCovered items include, but are not limited to: wheelchairs, crutches, \npowered mattress systems, diabetic supplies, hospital beds ordered by a \nprovider for use in the home, IV infusion pumps, speech generating \ndevices, oxygen equipment, nebulizers, continuous glucose monitors**, \nand walkers.\nWe cover all medically necessary DME covered by Original Medicare. If our \nsupplier in your area does not carry a particular brand or manufacturer, \nyou may ask them if they can special order it for you. The most recent list \nof suppliers is available on our website Humana.com/findadoctor.\nPrior authorization requirements may apply.\n**Continuous glucose monitors available only through durable medical \nequipment provider.In-Network:\nDurable Medical Equipment\n$0 copayment\n\u2013Durable Medical Equipment \nProvider\n EKG screening\nThe screening EKG, when done as a referral from the \"Welcome to \nMedicare\" preventative visit, is only covered once during a beneficiary\u2019s \nlifetime.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for an \nEKG screening visit.\nEmergency care\nEmergency care refers to services that are:\n\u2022Furnished by a provider qualified to furnish emergency services, and\n\u2022Needed to evaluate or stabilize an emergency medical condition\nA medical emergency is when you, or any other prudent layperson with an \naverage knowledge of health and medicine, believe that you have medical \nsymptoms that require immediate medical attention to prevent loss of life \n(and, if you are a pregnant woman, loss of an unborn child), loss of a limb, \nor loss of function of a limb. The medical symptoms may be an illness, \ninjury, severe pain, or a medical condition that is quickly getting worse.\nCost-sharing for necessary emergency services furnished out-of-network is \nthe same as for such services furnished in-network.In-Network:\nEmergency Services\n$0 copayment\n\u2013Emergency Room\nProvider and Professional Services\n$0 copayment\n\u2013Emergency Room", "doc_id": "da8fad0b-a3e2-43b1-b2db-0cc2680e9654", "embedding": null, "doc_hash": "16ae14e423138b24cc9fb247f09326cc4fb281fee1e39d45b6aac8a4e60e1cc6", "extra_info": {"page_label": "53", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2554, "_node_type": "1"}, "relationships": {"1": "cf9febae-13d4-4a70-bcbd-b5b361261269"}}, "__type__": "1"}, "34f48f9b-b30a-40d4-8b21-d1df1f577275": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 54\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nYou are covered for emergency care world-wide. If you have an \nemergency outside of the U.S. and its territories, you will be responsible to \npay for the services rendered upfront. You must submit to Humana for \nreimbursement. For more information please see Chapter 7. We may not \nreimburse you for all out of pocket expenses. This is because our \ncontracted rates may be lower than provider rates outside of the U.S. and \nits territories. You are responsible for any costs exceeding our contracted \nrates as well as any applicable member cost-share.\n* Healthy Options Allowance\n$175 automatically loaded on a Humana Spending Account Card every \nmonth to use toward the purchase of items and services, such as:\n\u2022Food and produce\n\u2022Over-the-Counter (OTC) products\n\u2022Home supplies\n\u2022General supports for living (rent assistance, utilities, internet \npayments**)\n\u2022Meal delivery services\n\u2022Personal wellness products\n\u2022Bathroom safety devices\n\u2022Non-medical transportation**\n\u2022Pest control**\n\u2022Robotic pets\n\u2022Disaster-relief products\n\u2022Pet care and supplies**\nUnused funds will roll over to the next month and expire at the end of the \nplan year.\nFor instructions on how to use this card-based benefit, please refer to the \nHumana Spending Account Card explanation in Chapter 4 Medical Chart.\n**Refer to your card mailer for instructions on how to utilize for general \nsupports for living, non-medical transportation, pest control services, and \npet care and supplies.In-Network:\nThere is no coinsurance, \ncopayment, or deductible to \nparticipate.\nHearing services\nDiagnostic hearing and balance evaluations performed by your provider to \ndetermine if you need medical treatment are covered as outpatient care \nwhen furnished by a physician, audiologist, or other qualified provider.\nPrior authorization requirements may apply.In-Network:\nMedicare Covered Hearing Services\n$0 copayment\n\u2013Specialist's Office\nSupplemental hearing benefits\n*You are covered for supplemental \nhearing benefits. See the \nsupplemental hearing benefit \ndescription at the end of this chart \nfor details.\n HIV screening In-Network:", "doc_id": "34f48f9b-b30a-40d4-8b21-d1df1f577275", "embedding": null, "doc_hash": "26bd75d0501021e33e4cf13a3fbb1450acde76729ddd66372acf3a87c98ff1bb", "extra_info": {"page_label": "54", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2309, "_node_type": "1"}, "relationships": {"1": "f843f40c-ec1f-4f08-aae5-447eb2f53fd0"}}, "__type__": "1"}, "cf3addc8-8a38-442f-8b55-0a9bc128f7e7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 55\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nFor people who ask for an HIV screening test or who are at increased risk \nfor HIV infection, we cover:\n\u2022One screening exam every 12 months\nFor women who are pregnant, we cover:\n\u2022Up to three screening exams during a pregnancyThere is no coinsurance, \ncopayment, or deductible for \nmembers eligible for \nMedicare-covered preventive HIV \nscreening.\nHome health agency care\nPrior to receiving home health services, a doctor must certify that you need \nhome health services and will order home health services to be provided by \na home health agency. You must be homebound, which means leaving \nhome is a major effort.\nCovered services include, but are not limited to:\n\u2022Part-time or intermittent skilled nursing and home health aide services \n(To be covered under the home health care benefit, your skilled nursing \nand home health aide services combined must total fewer than 8 hours \nper day and 35 hours per week)\n\u2022Physical therapy, occupational therapy, and speech therapy\n\u2022Medical and social services\n\u2022Medical equipment and supplies\nPrior authorization requirements may apply. In-Network:\nHome Health Care\n$0 copayment\n\u2013Member's Home\nDurable Medical Equipment\n$0 copayment\n\u2013Durable Medical Equipment \nProvider\nHome infusion therapy\nHome infusion therapy involves the intravenous or subcutaneous \nadministration of drugs or biologicals to an individual at home. The \ncomponents needed to perform home infusion include the drug (for \nexample, antivirals, immune globulin), equipment (for example, a pump), \nand supplies (for example, tubing and catheters).\nCovered services include, but are not limited to:\n\u2022Professional services, including nursing services, furnished in \naccordance with the plan of care\n\u2022Patient training and education not otherwise covered under the durable \nmedical equipment benefit\n\u2022Remote monitoring\n\u2022Monitoring services for the provision of home infusion therapy and \nhome infusion drugs furnished by a qualified home infusion therapy \nsupplierIn-Network:\nMedical Supplies\n$0 copayment\n\u2013Medical Supply Provider\nMedicare Part B Covered Drugs\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\n\u2013Pharmacy\nProvider and Professional Services\n$0 copayment\n\u2013PCP's Office\nHospice care\nYou are eligible for the hospice benefit when your doctor and the hospice \nmedical director have given you a terminal prognosis certifying that you're \nterminally ill and have 6 months or less to live if your illness runs its normal \ncourse. You may receive care from any Medicare-certified hospice \nprogram. Your plan is obligated to help you find Medicare-certified hospice \nprograms in the plan\u2019s service area, including those the MA organization When you enroll in a \nMedicare-certified hospice \nprogram, your hospice services and \nyour Part A and Part B services \nrelated to your terminal prognosis \nare paid for by Original Medicare, \nnot Humana Gold Plus SNP-DE \nH0028-015 (HMO-POS D-SNP). ", "doc_id": "cf3addc8-8a38-442f-8b55-0a9bc128f7e7", "embedding": null, "doc_hash": "f6b285e3122baf16584a7fa59de47b8ce84324fe7a51b5e432a0222acacedfbd", "extra_info": {"page_label": "55", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3112, "_node_type": "1"}, "relationships": {"1": "afb7f9b4-0557-4b6c-abde-0615f548a017"}}, "__type__": "1"}, "d436f246-9f9a-4f36-a242-1dc088c921b4": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 56\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nowns, controls, or has a financial interest in. Your hospice doctor can be a \nnetwork provider or an out-of-network provider.\nCovered services include:\n\u2022Drugs for symptom control and pain relief \n\u2022Short-term respite care \n\u2022Home care\nFor hospice services and for services that are covered by Medicare Part A or \nB and are related to your terminal prognosis: Original Medicare (rather than \nour plan) will pay your hospice provider for your hospice services related to \nyour terminal prognosis. While you are in the hospice program, your \nhospice provider will bill Original Medicare for the services that Original \nMedicare pays for. You will be billed Original Medicare cost sharing.\nFor services that are covered by Medicare Part A or B and are not related to \nyour terminal prognosis: If you need non-emergency, non-urgently \nneeded services that are covered under Medicare Part A or B and that are \nnot related to your terminal prognosis, your cost for these services \ndepends on whether you use a provider in our plan's network and follow \nplan rules (such as if there is a requirement to obtain prior authorization).Hospice consultations are included \nas part of Inpatient hospital care. \nProvider cost sharing may apply for \noutpatient consultations.\nFor services that are covered by Humana Gold Plus SNP-DE H0028-015 \n(HMO-POS D-SNP) but are not covered by Medicare Part A or B: Humana \nGold Plus SNP-DE H0028-015 (HMO-POS D-SNP) will continue to cover \nplan-covered services that are not covered under Part A or B whether or not \nthey are related to your terminal prognosis. You pay your plan cost-sharing \namount for these services.\nFor drugs that may be covered by the plan's Part D benefit: If these drugs \nare unrelated to your terminal hospice condition you pay cost sharing. If \nthey are related to your terminal hospice condition then you pay Original \nMedicare cost sharing. Drugs are never covered by both hospice and our \nplan at the same time. For more information, please see Chapter 5, Section \n9.4 (What if you're in Medicare-certified hospice).\nNote: If you need non-hospice care (care that is not related to your \nterminal prognosis), you should contact us to arrange the services. \n* Hospital services in the home: Facility referred\nHospital services in the home allows for certain health care services to be \nprovided outside of a traditional hospital setting and within your home. \nCare begins after you\u2019re evaluated, determined to be eligible, and your \nprovider refers you. Your provider will consider your eligibility criteria \nincluding your medical conditions and your geographic location. You will \nreceive treatment and monitoring at home from a team of providers for up \nto 30 day episode of care. While under the acute phase of care you will be \nremotely monitored and visited in person twice daily by a provider.$0 copayment", "doc_id": "d436f246-9f9a-4f36-a242-1dc088c921b4", "embedding": null, "doc_hash": "c160c1118137058ebc65eb62b2142d7f0ba4888a5847d67b99f37c62574c2759", "extra_info": {"page_label": "56", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3078, "_node_type": "1"}, "relationships": {"1": "44cf9109-923b-4e43-a620-986b8a529727"}}, "__type__": "1"}, "69b170a8-a1f5-4ca8-aaf9-82fed26ce484": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 57\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nConditions which are eligible to be treated with this benefit include: \nasthma, congestive heart failure, pneumonia and chronic obstructive \npulmonary disease (COPD).\nPrior authorization requirements may apply.\n* Humana Spending Account Card \n\u2022Because you are enrolled in Humana Gold Plus SNP-DE H0028-015 \n(HMO-POS D-SNP) , you have card allowance benefits available for your \nuse. Your allowance benefit(s): \n\u2013* Healthy Options Allowance\nThese benefits are designed to help members meet their unique needs, \nand will be loaded onto a single Humana Spending Account Card that you \ncan use at specific locations and network retailers as determined by the \nplan. Allowance amounts cannot be combined with other benefit \nallowances. Limitations and restrictions may apply. Please note, this is not \na Medicaid benefit. Full details on each allowance benefit can be found in \nthis Chapter 4 Medical Benefits Chart.\nPlease activate your card as soon as you receive it in the mail. Funds will be \nadded to your card beginning January 2023. All funds expire as stated in \nthe benefit, at the end of the plan year, or when you leave the plan. \nAdditionally, Humana is not responsible for any lost or stolen cards. Please \nsee the back of your card for more information.$0 copayment\n* Humana Well Dine\u00ae meal program\nAfter your inpatient stay in either the hospital or a nursing facility, you are \neligible to receive 2 meals per day for 7 days at no extra cost to you. 14 \nnutritious meals will be delivered to your home. Meal program limited to 4 \ntimes per calendar year.  Meals have to be requested within 30 days of \ndischarge from inpatient stay.\nFor additional information, please contact the Customer Service number \non the back of your Humana Member ID card.In-Network:\nThere is no coinsurance, \ncopayment, or deductible to \nparticipate.\n Immunizations\nCovered Medicare Part B services include:\n\u2022Pneumonia vaccine\n\u2022Flu shots, once each flu season in the fall and winter, with additional flu \nshots if medically necessary\n\u2022Hepatitis B vaccine if you are at high or intermediate risk of getting \nHepatitis B\n\u2022COVID-19 vaccine\n\u2022Other vaccines if you are at risk and they meet Medicare Part B coverage \nrulesIn-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \npneumonia, influenza, Hepatitis B, \nand COVID-19 vaccines.", "doc_id": "69b170a8-a1f5-4ca8-aaf9-82fed26ce484", "embedding": null, "doc_hash": "2831c6be1f74d4ee5385420549df3feb1400067b89316b70fa7ac38b0d65027f", "extra_info": {"page_label": "57", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2551, "_node_type": "1"}, "relationships": {"1": "2017b307-5093-44d6-bcdd-85767ec7023e"}}, "__type__": "1"}, "b745cec2-2f12-41ec-8bb2-9369706c16e2": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 58\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nWe also cover some vaccines under our Part D prescription drug benefit. \nYou can find these vaccines listed in the plan\u2019s Drug Guide (Formulary).\nInpatient hospital care\nIncludes inpatient acute, inpatient rehabilitation, long-term care hospitals \nand other types of inpatient hospital services. Inpatient hospital care starts \nthe day you are formally admitted to the hospital with a doctor's order. The \nday before you are discharged is your last inpatient day.\nCovered services include but are not limited to:\n\u2022Semi-private room (or a private room if medically necessary)\n\u2022Meals including special diets\n\u2022Regular nursing services\n\u2022Costs of special care units (such as intensive care or coronary care units)\n\u2022Drugs and medications\n\u2022Lab tests\n\u2022X-rays and other radiology services\n\u2022Necessary surgical and medical supplies\n\u2022Use of appliances, such as wheelchairs\n\u2022Operating and recovery room costs\n\u2022Physical, occupational, and speech language therapy\n\u2022Inpatient substance abuse services\n\u2022Under certain conditions, the following types of transplants are covered: \ncorneal, kidney, kidney-pancreatic, heart, liver, lung, heart/lung, bone \nmarrow, stem cell, and intestinal/multivisceral. If you need a transplant, \nwe will arrange to have your case reviewed by a Medicare-approved \ntransplant center that will decide whether you are a candidate for a \ntransplant. Transplant providers may be local or outside of the service \narea. If our in-network transplant services are outside the community \npattern of care, you may choose to go locally as long as the local \ntransplant providers are willing to accept the Original Medicare rate. If \nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) provides \ntransplant services at a location outside the pattern of care for \ntransplants in your community and you choose to obtain transplants at \nthis distant location, we will arrange or pay for appropriate lodging and \ntransportation costs for you and a companion.\n\u2013If you are in need of a solid organ or bone marrow/stem cell \ntransplant, please contact our Transplant Department at \n1-866-421-5663, TTY 711 for important information about your \ntransplant care.\n\u2022Blood - including storage and administration. Coverage of whole blood \nand packed red cells begins with the first pint of blood that you need.\n\u2022Physician services\nNote: To be an inpatient, your provider must write an order to admit you \nformally as an inpatient of the hospital. Even if you stay in the hospital In-Network:\nInpatient Care\nInpatient Hospital\n\u2013$0 copayment per admission\nProvider and Professional Services\n$0 copayment\n\u2013Inpatient Hospital\nYou are covered for an unlimited \nnumber of medically necessary \ninpatient hospital days.", "doc_id": "b745cec2-2f12-41ec-8bb2-9369706c16e2", "embedding": null, "doc_hash": "3ec918b75c28b81615d33ffa9c2fac9a1e600c20ff2dff11f9e648cf92f269e1", "extra_info": {"page_label": "58", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2914, "_node_type": "1"}, "relationships": {"1": "a13f7229-c6d5-421c-b873-6f6ba0ea357f"}}, "__type__": "1"}, "0e3720f2-238e-4ad1-98df-2e3216f0877a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 59\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\novernight, you might still be considered an \"outpatient.\" If you are not sure \nif you are an inpatient or an outpatient, you should ask the hospital staff.\nYou can also find more information in a Medicare fact sheet called \"Are You \na Hospital Inpatient or Outpatient? If You Have Medicare \u2013 Ask!\" This fact \nsheet is available on the Web at \nhttps://www.medicare.gov/sites/default/files/2021-10/11435-Inpatient-o\nr-Outpatient.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY \nusers call 1-877-486-2048. You can call these numbers for free, 24 hours a \nday, 7 days a week.\nPrior authorization is required for inpatient hospital care.\nPrior authorization is required for transplant services.\nInpatient services in a psychiatric hospital\nCovered services include mental health care services that require a \nhospital stay.\n\u2022190-day lifetime limit for inpatient services in a psychiatric hospital\n\u2013The 190-day limit does not apply to Inpatient Mental Health services \nprovided in a psychiatric unit of a general hospital\n\u2022The benefit days used under the Original Medicare program will count \ntoward the 190-day lifetime reserve days when enrolling in a Medicare \nAdvantage plan\nPrior authorization is required for inpatient mental health care.In-Network:\nInpatient Mental Health Care\nInpatient Psychiatric Facility\n\u2013$0 copayment per admission\nInpatient Hospital\n\u2013$0 copayment per admission\nProvider and Professional Services\n$0 copayment\n\u2013Inpatient Hospital\n\u2013Inpatient Psychiatric Facility\nInpatient stay: Covered services received in a hospital or SNF during a \nnon-covered inpatient stay\nIf you have exhausted your inpatient benefits or if the inpatient stay is not \nreasonable and necessary, we will not cover your inpatient stay. However, \nin some cases, we will cover certain services you receive while you are in \nthe hospital or the skilled nursing facility (SNF). Covered services include, \nbut are not limited to:\n\u2022Physician services\n\u2022Diagnostic tests (like lab tests)\n\u2022X-ray, radium, and isotope therapy including technician materials and \nservices\n\u2022Surgical dressings\n\u2022Splints, casts and other devices used to reduce fractures and \ndislocations\n\u2022Prosthetics and orthotics devices (other than dental) that replace all or \npart of an internal body organ (including contiguous tissue), or all or \npart of the function of a permanently inoperative or malfunctioning \ninternal body organ, including replacement or repairs of such devices\n\u2022Leg, arm, back, and neck braces; trusses; and artificial legs, arms, and \neyes including adjustments, repairs, and replacements required When your inpatient stay is not \ncovered,  the approved services \nreceived will continue to be covered \nas described throughout this \nbenefit chart.", "doc_id": "0e3720f2-238e-4ad1-98df-2e3216f0877a", "embedding": null, "doc_hash": "7d7a9e45772108fcda597a6090a4998e939dd5201e6d8cb06f28ba6f7c1676d5", "extra_info": {"page_label": "59", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2949, "_node_type": "1"}, "relationships": {"1": "258369db-6c9c-40de-9132-6b93d5c87879"}}, "__type__": "1"}, "e9baef76-3520-4219-b948-3749a65f49ab": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 60\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nbecause of breakage, wear, loss, or a change in the patient's physical \ncondition\n\u2022Physical therapy, speech therapy, and occupational therapy\n Medical nutrition therapy\nThis benefit is for people with diabetes, renal (kidney) disease (but not on \ndialysis), or after a kidney transplant when ordered by your doctor.\nWe cover 3 hours of one-on-one counseling services during your first year \nthat you receive medical nutrition therapy services under Medicare (this \nincludes our plan, any other Medicare Advantage Plan, or Original \nMedicare), and 2 hours each year after that. If your condition, treatment, \nor diagnosis changes, you may be able to receive more hours of treatment \nwith a physician's order. A physician must prescribe these services and \nrenew their order yearly if your treatment is needed into the next calendar \nyear.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for \nmembers eligible for \nMedicare-covered medical nutrition \ntherapy services.\n Medicare Diabetes Prevention Program (MDPP)\nMDPP services will be covered for eligible Medicare beneficiaries under all \nMedicare health plans.\nMDPP is a structured health behavior change intervention that provides \npractical training in long-term dietary change, increased physical activity, \nand problem-solving strategies for overcoming challenges to sustaining \nweight loss and a healthy lifestyle.There is no coinsurance, \ncopayment, or deductible for the \nMDPP benefit.\nMedicare Part B prescription drugs\nThese drugs are covered under Part B of Original Medicare. Members of our \nplan receive coverage for these drugs through our plan. Covered drugs \ninclude:\n\u2022Drugs that usually aren't self-administered by the patient and are \ninjected or infused while you are getting physician, hospital outpatient, \nor ambulatory surgical center services\n\u2022Drugs you take using durable medical equipment (such as nebulizers) \nthat were authorized by the plan\n\u2022Clotting factors you give yourself by injection if you have hemophilia\n\u2022Immunosuppressive Drugs, if you were enrolled in Medicare Part A at \nthe time of the organ transplant\n\u2022Injectable osteoporosis drugs, if you are homebound, have a bone \nfracture that a doctor certifies was related to post-menopausal \nosteoporosis, and cannot self-administer the drug\n\u2022Antigens\n\u2022Certain oral anti-cancer drugs and anti-nausea drugs\n\u2022Certain drugs for home dialysis, including heparin, the antidote for \nheparin when medically necessary, topical anesthetics, and \nerythropoiesis-stimulating agents (such as Epogen\u00ae, Procrit\u00ae, Epoetin \nAlfa, Aranesp\u00ae, or Darbepoetin Alfa)In-Network:\nMedicare Part B Covered Drugs\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\n\u2013Pharmacy\nChemotherapy Drugs\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital", "doc_id": "e9baef76-3520-4219-b948-3749a65f49ab", "embedding": null, "doc_hash": "a57d6bf1f5fb500e8aaba2b5e05a6a1ccee2b5ce25f89e877da598fbc1f897b5", "extra_info": {"page_label": "60", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2983, "_node_type": "1"}, "relationships": {"1": "d60374bd-9b21-4e85-8ae9-70ec300ee0d4"}}, "__type__": "1"}, "771ec08a-ead4-4e8c-9fa2-d371b0c0747a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 61\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\n\u2022Intravenous Immune Globulin for the home treatment of primary \nimmune deficiency diseases\nThere is no additional cost for the administration of Part B drugs\nThe following link will take you to a list of Part B Drugs that may be subject \nto Step Therapy: Humana.com/PAL \nWe also cover some vaccines under our Part B and Part D prescription drug \nbenefit.\nChapter 5 explains the Part D prescription drug benefit, including the rules \nyou must follow to have prescriptions covered. What you pay for your Part \nD prescription drugs through our plan is explained in Chapter 6.\nPrior authorization may be required for in-network Part B drugs. You may \nalso have to try a different drug first before we will agree to cover the drug \nyou are requesting. This is called \"step therapy.\" Contact the plan for \ndetails.\n Obesity screening and therapy to promote sustained weight loss\nIf you have a body mass index of 30 or more, we cover intensive \ncounseling to help you lose weight. This counseling is covered if you get it \nin a primary care setting, where it can be coordinated with your \ncomprehensive prevention plan. Talk to your primary care doctor or \npractitioner to find out more.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for \npreventive obesity screening and \ntherapy.\nOpioid treatment program services\nMembers of our plan with opioid use disorder (OUD) can receive coverage \nof services to treat OUD through an Opioid Treatment Program (OTP) which \nincludes the following services:\n\u2022U.S. Food and Drug Administration (FDA)-approved opioid agonist and \nantagonist medication-assisted treatment (MAT) medications.\n\u2022Dispensing and administration of MAT medications (if applicable)\n\u2022Substance use counseling \n\u2022Individual and group therapy \n\u2022Toxicology testing\n\u2022Intake activities\n\u2022Periodic assessments\nPrior authorization requirements may apply.In-Network:\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Partial Hospitalization\nOutpatient diagnostic tests and therapeutic services and supplies\nCovered services include, but are not limited to:\n\u2022X-rays\n\u2022Radiation (radium and isotope) therapy including technician materials \nand supplies\n\u2022Surgical supplies, such as dressingsIn-Network:\nProvider and Professional Services\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office", "doc_id": "771ec08a-ead4-4e8c-9fa2-d371b0c0747a", "embedding": null, "doc_hash": "cb83526305190906bb74b35c8ae0f0ce06d26ca102aad9a6e3c6da81c2c80ccc", "extra_info": {"page_label": "61", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2512, "_node_type": "1"}, "relationships": {"1": "16e4c4dc-0fd1-41a0-a1de-8edcfbe03f0d"}}, "__type__": "1"}, "25291b76-c034-4202-b772-b21b04a00398": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 62\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\n\u2022Splints, casts and other devices used to reduce fractures and \ndislocations\n\u2022Laboratory tests\n\u2022Blood \u2013 including storage and administration. Coverage of whole blood \nand packed red cells begins with the first pint of blood that you need.\n\u2022Other outpatient diagnostic tests\nPrior authorization requirements may apply.Diagnostic Procedures and Tests\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\n\u2013Urgent Care Center\n\u2013Outpatient Hospital\nAdvanced Imaging Services\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Freestanding Radiological \nFacility\nBasic Radiological Services\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\n\u2013Urgent Care Center\n\u2013Outpatient Hospital\n\u2013Freestanding Radiological \nFacility\nDiagnostic Mammography\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Freestanding Radiological \nFacility\nRadiation Therapy\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Freestanding Radiological \nFacility\nNuclear Medicine Services\n$0 copayment\n\u2013Outpatient Hospital\n\u2013Freestanding Radiological \nFacility\nFacility Based Sleep Study\n$0 copayment\n\u2013Specialist's Office", "doc_id": "25291b76-c034-4202-b772-b21b04a00398", "embedding": null, "doc_hash": "660c80922a5b82aea47abdc9c05cf4719310572cc5a0f315409fb86136c34afe", "extra_info": {"page_label": "62", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1323, "_node_type": "1"}, "relationships": {"1": "0576b29b-5e00-4809-90de-a5d8d4ed643e"}}, "__type__": "1"}, "92ff0a4c-3152-4152-871d-2ce28215f8e7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 63\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\n\u2013Outpatient Hospital\nHome Based Sleep Study\n$0 copayment\n\u2013Member's Home\nMedical Supplies\n$0 copayment\n\u2013Medical Supply Provider\nDiagnostic Colonoscopy\n$0 copayment\n\u2013Ambulatory Surgical Center\n\u2013Outpatient Hospital\nLab Services\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\n\u2013Urgent Care Center\n\u2013Outpatient Hospital\n\u2013Freestanding Laboratory\nOutpatient hospital observation\nObservation services are hospital outpatient services given to determine if \nyou need to be admitted as an inpatient or can be discharged. \nFor outpatient hospital observation services to be covered, they must meet \nthe Medicare criteria and be considered reasonable and necessary. \nObservation services are covered only when provided by the order of a \nphysician or another individual authorized by state licensure law and \nhospital staff bylaws to admit patients to the hospital or order outpatient \ntests.\nNote: Unless the provider has written an order to admit you as an inpatient \nto the hospital, you are an outpatient and pay the cost-sharing amounts \nfor outpatient hospital services. Even if you stay in the hospital overnight, \nyou might still be considered an \"outpatient.\" If you are not sure if you are \nan outpatient, you should ask the hospital staff.\nYou can also find more information in a Medicare fact sheet called \"Are You \na Hospital Inpatient or Outpatient? If You Have Medicare - Ask!\" This fact \nsheet is available on the Web at \nhttps://www.medicare.gov/sites/default/files/2021-10/11435-Inpatient-o\nr-Outpatient.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY \nusers call 1-877-486-2048. You can call these numbers for free, 24 hours a \nday, 7 days a week.In-Network:\n$0 copayment\n\u2013Outpatient Hospital", "doc_id": "92ff0a4c-3152-4152-871d-2ce28215f8e7", "embedding": null, "doc_hash": "b047639c863fd93a59d41e00f2e941ba35a6d606f7f66ee70e7a97c8a863a244", "extra_info": {"page_label": "63", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1922, "_node_type": "1"}, "relationships": {"1": "62f5c672-f3bf-4871-9ba5-1fab45527137"}}, "__type__": "1"}, "2a657811-d7b6-4d58-8bfa-d2938b2a519b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 64\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nPrior authorization requirements may apply.\nOutpatient hospital services\nWe cover medically-necessary services you get in the outpatient \ndepartment of a hospital for diagnosis or treatment of an illness or injury.\nCovered services include, but are not limited to:\n\u2022Services in an emergency department or outpatient clinic, such as \nobservation services or outpatient surgery\n\u2022Laboratory and diagnostic tests billed by the hospital\n\u2022Mental health care, including care in a partial-hospitalization program, if \na doctor certifies that inpatient treatment would be required without it\n\u2022X-rays and other radiology services billed by the hospital\n\u2022Medical supplies such as splints and casts\n\u2022Certain drugs and biologicals that you can't give yourself\nNote: Unless the provider has written an order to admit you as an inpatient \nto the hospital, you are an outpatient and pay the cost-sharing amounts \nfor outpatient hospital services. Even if you stay in the hospital overnight, \nyou might still be considered an \"outpatient.\" If you are not sure if you are \nan outpatient, you should ask the hospital staff.\nYou can also find more information in a Medicare fact sheet called \"Are You \na Hospital Inpatient or Outpatient? If You Have Medicare - Ask!\" This fact \nsheet is available on the Web at \nhttps://www.medicare.gov/sites/default/files/2021-10/11435-Inpatient-o\nr-Outpatient.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY \nusers call 1-877-486-2048. You can call these numbers for free, 24 hours a \nday, 7 days a week.\nPrior authorization requirements may apply.In-Network:\nDiagnostic Procedures and Tests\n$0 copayment\n\u2013Outpatient Hospital\nAdvanced Imaging Services\n$0 copayment\n\u2013Outpatient Hospital\nNuclear Medicine Services\n$0 copayment\n\u2013Outpatient Hospital\nBasic Radiological Services\n$0 copayment\n\u2013Outpatient Hospital\nDiagnostic Mammography\n$0 copayment\n\u2013Outpatient Hospital\nRadiation Therapy\n$0 copayment\n\u2013Outpatient Hospital\nLab Services\n$0 copayment\n\u2013Outpatient Hospital\nSurgery Services\n$0 copayment\n\u2013Outpatient Hospital\nMental Health Services\n$0 copayment\n\u2013Outpatient Hospital\n\u2013Partial Hospitalization\nWound Care\n$0 copayment\n\u2013Outpatient Hospital\nFacility Based Sleep Study\n$0 copayment\n\u2013Outpatient Hospital", "doc_id": "2a657811-d7b6-4d58-8bfa-d2938b2a519b", "embedding": null, "doc_hash": "d8cca9289a427da243899699731d4fe09b90a42ff448fa58faadb9fb980ad6e6", "extra_info": {"page_label": "64", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2442, "_node_type": "1"}, "relationships": {"1": "59e085da-64aa-48e3-8376-04ff018abdcf"}}, "__type__": "1"}, "70345a82-0217-471c-9031-5119e047d3a1": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 65\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nEmergency Services\n$0 copayment\n\u2013Emergency Room\nDiagnostic Colonoscopy\n$0 copayment\n\u2013Outpatient Hospital\nOutpatient mental health care\nCovered services include:\nMental health services provided by a state-licensed psychiatrist or doctor, \nclinical psychologist, clinical social worker, clinical nurse specialist, nurse \npractitioner, physician assistant, or other Medicare-qualified mental health \ncare professional as allowed under applicable state laws.\nPrior authorization requirements may apply. In-Network:\nMental Health Services\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Partial Hospitalization\nOutpatient rehabilitation services\nCovered services include: physical therapy, occupational therapy, and \nspeech language therapy.\nOutpatient rehabilitation services are provided in various outpatient \nsettings, such as hospital outpatient departments, independent therapist \noffices, and Comprehensive Outpatient Rehabilitation Facilities (CORFs).\nPrior authorization requirements may apply.In-Network:\nPhysical Therapy\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Comprehensive Outpatient \nRehab Facility\nSpeech Therapy\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Comprehensive Outpatient \nRehab Facility\nOccupational Therapy\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Comprehensive Outpatient \nRehab Facility\nOutpatient substance abuse services\nYou are covered for treatment of substance abuse, as covered by Original \nMedicare.\nPrior authorization requirements may apply.In-Network:\nSubstance Abuse Services\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n\u2013Partial Hospitalization\nOutpatient surgery, including services provided at hospital \noutpatient facilities and ambulatory surgical centersIn-Network:\nSurgery Services", "doc_id": "70345a82-0217-471c-9031-5119e047d3a1", "embedding": null, "doc_hash": "87d2b16b1abedb61cfcbfd66f17594abb7bc3a100983259edbe3adaed126e33e", "extra_info": {"page_label": "65", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2001, "_node_type": "1"}, "relationships": {"1": "6c1b0711-7477-47a6-b17d-b611cc0e5ee7"}}, "__type__": "1"}, "b04974f1-8e5e-439b-9d24-f6ae9b26b059": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 66\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nNote: If you are having surgery in a hospital facility, you should check with \nyour provider about whether you will be an inpatient or outpatient. Unless \nthe provider writes an order to admit you as an inpatient to the hospital, \nyou are an outpatient and pay the cost-sharing amounts for outpatient \nsurgery. Even if you stay in the hospital overnight, you might still be \nconsidered an \"outpatient.\"\nPrior authorization requirements may apply.$0 copayment\n\u2013Outpatient Hospital\n\u2013Ambulatory Surgical Center\nDiagnostic Colonoscopy\n$0 copayment\n\u2013Ambulatory Surgical Center\n\u2013Outpatient Hospital\nPartial hospitalization services\n\"Partial hospitalization\" is a structured program of active psychiatric \ntreatment provided as a hospital outpatient service, or by a community \nmental health center, that is more intense than the care received in your \ndoctor\u2019s or therapist\u2019s office and is an alternative to inpatient \nhospitalization.\nPrior authorization requirements may apply.In-Network:\nMental Health Services\n$0 copayment\n\u2013Partial Hospitalization\n* Personal emergency response system\nThe personal emergency response system provides help in emergency \nsituations. The medical alert service comes with an installed in-home \ncommunication device and a wearable button. You have the choice \nbetween a push button unit (with or without AutoAlert fall detection) or a \nwrist unit (without AutoAlert).\nPlease contact Customer Care to take advantage of this benefit or to \nreceive more information.In-Network:\n$0 copayment per year for  \ninstallation and monitoring service\n* Physical exam (Routine)\nIn addition to the Annual Wellness Visit or the \"Welcome to Medicare\" \nphysical exam, you are covered for the following exam once per year:\n\u2022Comprehensive preventive medicine evaluation and management, \nincluding an age and gender appropriate history, examination, and \ncounseling/anticipatory guidance/risk factor reduction interventions\nNote: Any lab or diagnostic procedures that are ordered are not covered \nunder this benefit and you pay your plan cost-sharing amount for those \nservices separately.In-Network:\nRoutine Physical Exams\n$0 copayment\n\u2013PCP's Office\nPhysician/Practitioner services, including doctor's office visits\nCovered services include:\n\u2022Medically-necessary medical care or surgery services furnished in a \nphysician\u2019s office, certified ambulatory surgical center, hospital \noutpatient department, or any other location\n\u2022Consultation, diagnosis, and treatment by a specialist\n\u2022Basic hearing and balance exams performed by your specialist, if your In-Network:\nProvider and Professional Services\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\nTelehealth Services\n$0 copayment", "doc_id": "b04974f1-8e5e-439b-9d24-f6ae9b26b059", "embedding": null, "doc_hash": "14aca307d2ff2df28c9d8bbed44beb3be73dfe8009c2b7d7d3e4d724543fdca0", "extra_info": {"page_label": "66", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2903, "_node_type": "1"}, "relationships": {"1": "0ceaf771-8c0c-4a33-a6f5-f5456143c647"}}, "__type__": "1"}, "5b8b1ec9-54a3-4031-8944-f5c76a2b07ec": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 67\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\ndoctor orders it to see if you need medical treatment\n\u2022Certain telehealth services, including services by primary care providers \n(PCPs) and specialists; individual sessions for mental health specialty \nservices and psychiatric services; individual sessions for outpatient \nsubstance abuse; and urgently needed services.\n\u2013You have the option of getting these services through an in-person \nvisit or by telehealth. If you choose to get one of these services by \ntelehealth, you must use a network provider who offers the service \nvia telehealth.\n\u2013You may use a phone, computer, tablet, or other video technology.\n\u2022Some telehealth services including consultation, diagnosis, and \ntreatment by a physician or practitioner, for patients in certain rural \nareas or other places approved by Medicare.\n\u2022Telehealth services for monthly end-stage renal disease-related visits \nfor home dialysis members in a hospital-based or critical access \nhospital-based renal dialysis center, renal dialysis facility, or the \nmember\u2019s home.\n\u2022Telehealth services to diagnose, evaluate, or treat symptoms of a \nstroke, regardless of your location.\n\u2022Telehealth services for members with a substance use disorder or \nco-occurring mental health disorder, regardless of their location.\n\u2022Telehealth services for diagnosis, evaluation, and treatment of mental \nhealth disorders if:\n\u2013You have an in-person visit within 6 months prior to your first \ntelehealth visit\n\u2013You have an in-person visit every 12 months while receiving these \ntelehealth services\n\u2013Exceptions can be made to the above for certain circumstances\n\u2022Telehealth services for mental health visits provided by Rural Health \nClinics and Federally Qualified Health Centers\n\u2022Virtual check-ins (for example, by phone or video chat) with your doctor \nfor 5-10 minutes if:\n\u2013You\u2019re not a new patient and\n\u2013The check-in isn\u2019t related to an office visit in the past 7 days and\n\u2013The check-in doesn\u2019t lead to an office visit within 24 hours or the \nsoonest available appointment\n\u2022Evaluation of video and/or images you send to your doctor, and \ninterpretation and follow-up by your doctor within 24 hours if:\n\u2013You\u2019re not a new patient and\n\u2013The evaluation isn\u2019t related to an office visit in the past 7 days and\n\u2013The evaluation doesn\u2019t lead to an office visit within 24 hours or the \nsoonest available appointment\n\u2022Consultation your doctor has with other doctors by phone, internet, or \nelectronic health record\n\u2022Second opinion by another network provider prior to surgery\n\u2022Non-routine dental care (covered services are limited to surgery of the \njaw or related structures, setting fractures of the jaw or facial bones, \u2013PCP Virtual\n\u2013Specialist Virtual\n\u2013Mental Health Care and \nSubstance Abuse Treatment \nVirtual\n\u2013Urgent Care Virtual\nAdvanced Imaging Services\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\nSurgery Services\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\nRadiation Therapy\n$0 copayment\n\u2013Specialist's Office\nUrgently Needed Services\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office", "doc_id": "5b8b1ec9-54a3-4031-8944-f5c76a2b07ec", "embedding": null, "doc_hash": "d18151be03226e7822e9c73ce785d065289e77c301afb15ec4439179a8a8c7f6", "extra_info": {"page_label": "67", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3235, "_node_type": "1"}, "relationships": {"1": "e0b19272-5427-47cb-9bb9-95139ad8c3fc"}}, "__type__": "1"}, "e302e844-2ebe-433c-b00e-7b25cebe466d": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 68\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nextraction of teeth to prepare the jaw for radiation treatments of \nneoplastic cancer disease, or services that would be covered when \nprovided by a physician)\n\u2022Urgently needed services furnished in a physician\u2019s office\nPrior authorization requirements may apply. \nPodiatry services\nCovered services include:\n\u2022Diagnosis and the medical or surgical treatment of injuries and diseases \nof the feet (such as hammer toe or heel spurs)\n\u2022Routine foot care for members with certain medical conditions affecting \nthe lower limbs\n*You are also covered for supplemental routine foot care benefits:\n\u2022You may self-refer for 6 visits per year to a network specialist. Covered \nsupplemental services include:\n\u2013Paring or cutting of benign hyperkeratotic lesions (e.g., corn, wart, \ncallus)\n\u2013Trimming or debridement of nails\nPrior authorization requirements may apply.In-Network:\nMedicare Covered Podiatry Services\n$0 copayment\n\u2013Specialist's Office\nRoutine foot care \n$0 copayment\n\u2013Specialist's Office\n*Post-Discharge Personal Home Care\nWith the Post-Discharge benefit you will be eligible to receive services for \nshort term support at home to assist with transition of care after a \nqualifying inpatient hospital stay for a minimum of 4 hours per day up to a \nmaximum of 44 hours per year. Services must be initiated within 30 days \nof discharge event and utilized within 60 days of discharge for each \nqualifying event up to the maximum annual allowance.\nPrior authorization requirements may apply. Contact the plan for details.In-Network: \n$0 copayment\n Prostate cancer screening exams\nFor men aged 50 and older, covered services include the following - once \nevery 12 months:\n\u2022Digital rectal exam\n\u2022Prostate Specific Antigen (PSA) testIn-Network:\nThere is no coinsurance, \ncopayment, or deductible for an \nannual PSA test.\nProsthetic devices and related supplies\nDevices (other than dental) that replace all or part of a body part or \nfunction. These include, but are not limited to: colostomy bags and \nsupplies directly related to colostomy care, pacemakers, braces, prosthetic \nshoes, artificial limbs, and breast prostheses (including a surgical brassiere \nafter a mastectomy). Includes certain supplies related to prosthetic \ndevices, and repair and/or replacement of prosthetic devices. Also includes In-Network:\n$0 copayment\n\u2013Prosthetics Provider", "doc_id": "e302e844-2ebe-433c-b00e-7b25cebe466d", "embedding": null, "doc_hash": "4af63c3c8478cc1a6b8087c690e0aef01e6e8c2297fa745f3cf02cc9a3c7afb1", "extra_info": {"page_label": "68", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2558, "_node_type": "1"}, "relationships": {"1": "360f886a-27c3-40fe-83bf-2306d46050a1"}}, "__type__": "1"}, "a1f2a676-06df-4fc9-a467-6660c1abebed": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 69\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nsome coverage following cataract removal or cataract surgery \u2013 see \n\"Vision Care\" later in this section for more detail.\nPrior authorization requirements may apply.\nPulmonary rehabilitation services\nComprehensive programs of pulmonary rehabilitation are covered for \nmembers who have moderate to very severe chronic obstructive \npulmonary disease (COPD) and an order for pulmonary rehabilitation from \nthe doctor treating the chronic respiratory disease.\nPrior authorization requirements may apply. In-Network:\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\nYou will not be responsible for the \ncopayments, coinsurances, or \ndeductibles for the services listed in \nthis section.\n Screening and counseling to reduce alcohol misuse\nWe cover one alcohol misuse screening for adults with Medicare (including \npregnant women) who misuse alcohol, but aren't alcohol dependent.\nIf you screen positive for alcohol misuse, you can get up to 4 brief \nface-to-face counseling sessions per year (if you're competent and alert \nduring counseling) provided by a qualified primary care doctor or \npractitioner in a primary care setting.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \nMedicare-covered screening and \ncounseling to reduce alcohol \nmisuse preventive benefit.\n Screening for lung cancer with low dose computed tomography\n(LDCT) \nFor qualified individuals, a LDCT is covered every 12 months.\nEligible members are: people aged 50 \u2013 77 years who have no signs or \nsymptoms of lung cancer, but who have a history of tobacco smoking of at \nleast 20 pack-years and who currently smoke or have quit smoking within \nthe last 15 years, who receive a written order for LDCT during a lung cancer \nscreening counseling and shared decision-making visit that meets the \nMedicare criteria for such visits and be furnished by a physician or qualified \nnon-physician practitioner.\nFor LDCT lung cancer screenings after the initial LDCT screening: the member \nmust receive a written order for the LDCT lung cancer screening, which \nmay be furnished during any appropriate visit with a physician or qualified \nnon-physician practitioner. If a physician or qualified non-physician \npractitioner elects to provide a lung cancer screening counseling and \nshared decision making visit for subsequent lung cancer screenings with \nLDCT, the visit must meet the Medicare criteria for such visits.In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \nMedicare covered counseling and \nshared decision making visit or for \nthe LDCT.\n Screening for sexually transmitted infections (STIs) and counseling\nto prevent STIsIn-Network:\nThere is no coinsurance, \ncopayment, or deductible for the ", "doc_id": "a1f2a676-06df-4fc9-a467-6660c1abebed", "embedding": null, "doc_hash": "9c600eab7d281a7778c38a26aebcb370ad434ab346babd14b656dfca72f7b1cd", "extra_info": {"page_label": "69", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2924, "_node_type": "1"}, "relationships": {"1": "5c49e22a-64eb-48d5-8876-811a6a5d8da6"}}, "__type__": "1"}, "babd7430-5d88-48a5-ba0b-769f201af186": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 70\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nWe cover sexually transmitted infection (STI) screenings for chlamydia, \ngonorrhea, syphilis, and Hepatitis B. These screenings are covered for \npregnant women and for certain people who are at increased risk for an \nSTI when the tests are ordered by a primary care provider. We cover these \ntests once every 12 months or at certain times during pregnancy.\nWe also cover up to 2 individual 20 to 30 minute, face-to-face \nhigh-intensity behavioral counseling sessions each year for sexually active \nadults at increased risk for STIs. We will only cover these counseling \nsessions as a preventive service if they are provided by a primary care \nprovider and take place in a primary care setting, such as a doctor's office.Medicare-covered screening for \nSTIs and counseling for STIs \npreventive benefit.\nServices to treat kidney disease\nCovered services include:\n\u2022Kidney disease education services to teach kidney care and help \nmembers make informed decisions about their care. For members with \nstage IV chronic kidney disease when referred by their doctor, we cover \nup to six sessions of kidney disease education services per lifetime\n\u2022Outpatient dialysis treatments (including dialysis treatments when \ntemporarily out of the service area, as explained in Chapter 3, or when \nyour provider for this service is temporarily unavailable or inaccessible)\n\u2022Inpatient dialysis treatments (if you are admitted as an inpatient to a \nhospital for special care)\n\u2022Self-dialysis training (includes training for you and anyone helping you \nwith your home dialysis treatments)\n\u2022Home dialysis equipment and supplies\n\u2022Certain home support services (such as, when necessary, visits by \ntrained dialysis workers to check on your home dialysis, to help in \nemergencies, and check your dialysis equipment and water supply)\nCertain drugs for dialysis are covered under your Medicare Part B drug \nbenefit. For information about coverage for Part B Drugs, please go to the \nsection, \"Medicare Part B prescription drugs.\"\nPrior authorization requirements may apply.In-Network:\nKidney Disease Education Services\n$0 copayment\n\u2013PCP's Office\n\u2013Specialist's Office\nRenal Dialysis Services\n$0 copayment\n\u2013Dialysis Center\n\u2013Outpatient Hospital\nDurable Medical Equipment\n$0 copayment\n\u2013Durable Medical Equipment \nProvider\nHome Health Care\n$0 copayment\n\u2013Member's Home\n* SilverSneakers\u00ae Fitness program\nSilverSneakers\u00ae is a fitness program for seniors that is included at no \nadditional charge with qualifying Medicare health plans. Members have \naccess to 15,000+ fitness locations across the country that may include \nweights and machines plus group exercise classes led by trained \ninstructors at select locations. Access online education on \nSilverSneakers.com, watch workout videos on SilverSneakers \nOn-DemandTM or download the SilverSneakers GOTM fitness app, for \nadditional workout ideas.In-Network:\n$0 copayment", "doc_id": "babd7430-5d88-48a5-ba0b-769f201af186", "embedding": null, "doc_hash": "27f02cf3820032f458d4bcb9ba829df1dd56de9ebdf8172be8b41d0911ccd726", "extra_info": {"page_label": "70", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3103, "_node_type": "1"}, "relationships": {"1": "59813012-8b2e-4709-863d-a9216907ec7b"}}, "__type__": "1"}, "0de7fc24-190c-493e-ae68-fdba07b744d1": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 71\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nAny fitness center services that usually have an extra fee are not included \nin your membership.\nSkilled nursing facility (SNF) care\n(For a definition of \"skilled nursing facility care,\" see Chapter 12 of this \ndocument. Skilled nursing facilities are sometimes called \"SNFs.\")\nYou are covered for up to 100 medically necessary days per benefit period. \nPrior hospital stay is not required. Covered services include but are not \nlimited to:\n\u2022Semiprivate room (or a private room if medically necessary)\n\u2022Meals, including special diets\n\u2022Skilled nursing services\n\u2022Physical therapy, occupational therapy, and speech therapy\n\u2022Drugs administered to you as part of your plan of care (This includes \nsubstances that are naturally present in the body, such as blood clotting \nfactors.)\n\u2022Blood - including storage and administration. Coverage of whole blood \nand packed red cells begins with the first pint of blood you need.\n\u2022Medical and surgical supplies ordinarily provided by SNFs\n\u2022Laboratory tests ordinarily provided by SNFs\n\u2022X-rays and other radiology services ordinarily provided by SNFs\n\u2022Use of appliances such as wheelchairs ordinarily provided by SNFs\n\u2022Physician/Practitioner services\nGenerally, you will get your SNF care from network facilities. However, \nunder certain conditions listed below, you may be able to get your care \nfrom a facility that isn't a network provider, if the facility accepts our plan's \namounts for payment.\n\u2022A nursing home or continuing care retirement community where you \nwere living right before you went to the hospital (as long as it provides \nskilled nursing facility care)\n\u2022A SNF where your spouse is living at the time you leave the hospital\nPrior authorization requirements may apply.A new benefit period will begin on \nday one when you first enroll in a \nMedicare Advantage plan, or when \nyou have been discharged from \nskilled care in a skilled nursing \nfacility for 60 consecutive days.\nPer Benefit Period, you pay:\nIn-Network:\n$0 copayment per day, days 1 to 20 \n\u2013Skilled Nursing Facility\n$0 copayment per day, days 21 to \n100 \n\u2013Skilled Nursing Facility\n Smoking and tobacco use cessation (counseling to stop smoking or\ntobacco use)\nIf you use tobacco, but do not have signs or symptoms of tobacco-related \ndisease: We cover two counseling quit attempts within a 12-month period \nas a preventive service with no cost to you. Each counseling attempt \nincludes up to four face-to-face visits.\nIf you use tobacco and have been diagnosed with a tobacco-related \ndisease or are taking medicine that may be affected by tobacco: We cover \ncessation counseling services. We cover two counseling quit attempts In-Network:\nThere is no coinsurance, \ncopayment, or deductible for the \nMedicare-covered smoking and \ntobacco use cessation preventive \nbenefits.", "doc_id": "0de7fc24-190c-493e-ae68-fdba07b744d1", "embedding": null, "doc_hash": "3d1cac10e6e7aa4bb29b4723293a8d1774f2833fcd4f618c7a1cff454d20ce47", "extra_info": {"page_label": "71", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3005, "_node_type": "1"}, "relationships": {"1": "934b3f04-0fd5-415c-b746-ad733055737a"}}, "__type__": "1"}, "5ebc8cc2-b0c1-40be-b08c-f63e1bf12ee0": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 72\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nwithin a 12-month period, however, you will pay the applicable cost \nsharing. Each counseling attempt includes up to four face-to-face visits.\n* Smoking cessation program\nTo further assist in your effort to quit smoking or tobacco product use, we \ncover one additional counseling quit attempt within a 12-month period as \na service with no cost to you. This additional counseling attempt includes \nup to four face-to-face visits. This service can be used for either preventive \nmeasures or for diagnosis with a tobacco related disease.In-Network:\n$0 copayment\n* Special Supplemental Benefits for the Chronically Ill\nVital Support\u2122 Benefits\nTo help you achieve your best health, Humana offers members with \ncertain chronic conditions, who meet eligibility criteria, additional support \nthrough our Vital Support\u2122 Benefits. Please read, below, for benefits \navailable on this plan.\nWorry Free\u2122 Meals - The Worry Free\u2122 Meals program may be available to \nchronically ill members diagnosed with Chronic Obstructive Pulmonary \nDisease (COPD), Diabetes, or Congestive Heart Failure (CHF), who are \nparticipating in care management , have had an inpatient hospital or \nskilled nursing facility stay within the last 30 days, and meet program \ncriteria. Eligible members may receive 2 meals per day for 12 weeks, 168 \nmeals total. Members may receive an additional 12 weeks of meals if they \ncontinue to meet program criteria as determined by the plan. Members \nmay qualify for the Worry Free\u2122 Meals program up to 2 times per plan \nyear. Authorization may be required.\nHumana Flexible Care Assistance - Humana Flexible Care Assistance is \navailable to chronically ill members who are participating with care \nmanagement services and meet program criteria. Benefits are limited up \nto $1,000 per year and must be coordinated and authorized by a care \nmanager. Eligible members may receive primarily health related and \nnon-primarily health related additional benefits to address the individual's \nunique needs, including but not limited to:\n\u2022Medical expense assistance\n\u2022Meal delivery services\n\u2022Caregiver services\n\u2022Adult day care\n\u2022Utilities \n\u2022Non-medical transportation\n\u2022Medical supplies and prosthetics\n\u2022Pest control\n\u2022Alternative therapies\n\u2022Home and bathroom safety devicesIn-Network:\nThere is no coinsurance, \ncopayment, or deductible to \nparticipate.", "doc_id": "5ebc8cc2-b0c1-40be-b08c-f63e1bf12ee0", "embedding": null, "doc_hash": "fb2c39b4234dd7b02cabbae402c8aa26583e32252f085d7598f7d50dfa7b7275", "extra_info": {"page_label": "72", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2558, "_node_type": "1"}, "relationships": {"1": "749d9153-134e-40c8-8fe7-cd55fc8e56d9"}}, "__type__": "1"}, "8ba6fb9f-3903-4293-9514-9eb8adb0f1a0": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 73\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nMembers may discuss full list of items and services with their care \nmanager.\nSupervised Exercise Therapy (SET)\nSET is covered for members who have symptomatic peripheral artery \ndisease (PAD).\nUp to 36 sessions over a 12-week period are covered if the SET program \nrequirements are met.\nThe SET program must:\n\u2022Consist of sessions lasting 30-60 minutes, comprising a therapeutic \nexercise-training program for PAD in patients with claudication\n\u2022Be conducted in a hospital outpatient setting or a physician\u2019s office\n\u2022Be delivered by qualified auxiliary personnel necessary to ensure \nbenefits exceed harms, and who are trained in exercise therapy for PAD\n\u2022Be under the direct supervision of a physician, physician assistant, or \nnurse practitioner/clinical nurse specialist who must be trained in both \nbasic and advanced life support techniques\nSET may be covered beyond 36 sessions over 12 weeks for an additional 36 \nsessions over an extended period of time if deemed medically necessary \nby a health care provider.\nPrior authorization requirements may apply.In-Network:\n$0 copayment\n\u2013Specialist's Office\n\u2013Outpatient Hospital\n* Transportation\nYou are covered for 60 one-way, non-emergency trips to plan-approved \nlocations within the plan service area. There is a maximum allowed travel \ndistance of 75 miles per trip.\nPlease contact Customer Care for information on how to arrange \ntransportation. Customer Care will confirm your benefits and guide you to \nthe transportation provider to plan your trip.In-Network:\n$0 copayment\nUrgently needed services\nUrgently needed services are provided to treat a non-emergency, \nunforeseen medical illness, injury, or condition that requires immediate \nmedical care, but given your circumstances, it is not possible, or it is \nunreasonable, to obtain services from network providers. Examples of \nurgently needed services that the plan must cover out of network are i) you \nneed immediate care during the weekend, or ii) you are temporarily \noutside the service area of the plan. Services must be immediately needed \nand medically necessary. If it is unreasonable given your circumstances to \nimmediately obtain the medical care from the network provider then your In-Network:\nUrgently Needed Services\n$0 copayment\n\u2013Urgent Care Center", "doc_id": "8ba6fb9f-3903-4293-9514-9eb8adb0f1a0", "embedding": null, "doc_hash": "eb5fa0167e104a8b47b857d664fffe6ef5c4d999107c1619beee79a709ef28a4", "extra_info": {"page_label": "73", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2493, "_node_type": "1"}, "relationships": {"1": "84e62828-a4af-46e5-b397-637ebe5c1f77"}}, "__type__": "1"}, "cd9203a0-bbad-4dd4-97b1-7747acb75b4b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 74\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nplan will cover the urgently needed services from a provider \nout-of-network. \nYou are covered for urgently needed services world-wide. If you have an \nurgent need for care while outside of the U.S. and its territories, you will be \nresponsible to pay for the services rendered upfront. You must submit \nproof of payment to Humana for reimbursement. For more information \nplease see Chapter 7. We may not reimburse you for all out of pocket \nexpenses. This is because our contracted rates may be lower than provider \nrates outside of the U.S. and its territories. You are responsible for any costs \nexceeding our contracted rates as well as any applicable member \ncost-share.\nSee \"Physician/Practitioner services, including doctor\u2019s office visits\" for \nadditional information about urgently needed services provided in a \nphysician\u2019s office.\n Vision care\nCovered services include:\n\u2022Outpatient physician services for the diagnosis and treatment of \ndiseases and injuries of the eye, including treatment for age-related \nmacular degeneration. Original Medicare doesn't cover routine eye \nexams (eye refractions) for eyeglasses/contacts\n\u2022For people who are at high risk of glaucoma, we will cover one \nglaucoma screening each year. People at high risk of glaucoma include: \npeople with a family history of glaucoma, people with diabetes, \nAfrican-Americans who are age 50 and older, and Hispanic Americans \nwho are 65 or older\n\u2022For people with diabetes, screening for diabetic retinopathy is covered \nonce per year\n\u2022One pair of eyeglasses or contact lenses after each cataract surgery that \nincludes insertion of an intraocular lens. (If you have two separate \ncataract operations, you cannot reserve the benefit after the first \nsurgery and purchase two eyeglasses after the second surgery.)\n\u2022Covered eyeglasses after cataract surgery includes standard frames \nand lenses as defined by Medicare; any upgrades are not covered \n(including, but not limited to, deluxe frames, tinting, progressive lenses, \nor anti-reflective coating).\nThe  (preventive service) only applies to Glaucoma Screening.\nPrior authorization requirements may apply.In-Network:\nMedicare Covered Vision Services\n$0 copayment\n\u2013Specialist's Office\nGlaucoma Screening\n$0 copayment\n\u2013Specialist's Office\nDiabetic Eye Exam\n$0 copayment\n\u2013All Places of Treatment\nEyewear (Post Cataract Surgery)\n$0 copayment\n\u2013All Places of Treatment\nSupplemental vision benefits\n*You are covered for supplemental \nvision benefits. See the \nsupplemental vision benefit \ndescription at the end of this chart \nfor details.\nPlease note: the network of \nproviders for your supplemental \nvision benefits may be different \nthan the network of providers for \nthe Original Medicare vision \nbenefits listed above.\n \"Welcome to Medicare\" preventive visit In-Network:", "doc_id": "cd9203a0-bbad-4dd4-97b1-7747acb75b4b", "embedding": null, "doc_hash": "589b25398e1f1873df211b4f16be63441b957511457ae1c938f0531a718c04a5", "extra_info": {"page_label": "74", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3015, "_node_type": "1"}, "relationships": {"1": "d2b7d5a7-f229-44ec-bb73-a1f5acd69a3d"}}, "__type__": "1"}, "8cc2d788-d523-48d7-87ec-40546b6a86f0": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 75\nChapter 4. Medical Benefits Chart (what is covered)\nServices that are covered for you What you must pay when you get  \nthese services\nThe plan covers the one-time \"Welcome to Medicare\" preventive visit. The \nvisit includes a review of your health, as well as education and counseling \nabout the preventive services you need (including certain screenings and \nshots), and referrals for other care if needed.\nImportant: We cover the \"Welcome to Medicare\" preventive visit only \nwithin the first 12 months you have Medicare Part B. When you make your \nappointment, let your doctor's office know you would like to schedule your \n\"Welcome to Medicare\" preventive visit.There is no coinsurance, \ncopayment, or deductible for the \n\"Welcome to Medicare\" preventive \nvisit.\n* Wellness and Health Care Planning (WHP) Services\nAs a Humana member, you have access to an online advance care  \nplanning resource called, MyDirectives\u00ae on MyHumana. This resource helps  \nyou to create an advance directive where you can combine the elements  \nof a living will, medical power of attorney, do not attempt resuscitation,  \nand an organ donation form.There is no coinsurance,  \ncopayment, or deductible to  \nparticipate.\n* Wigs (related to chemotherapy treatment)\nYou are covered for up to $500 maximum benefit per calendar year for \nwigs related to chemotherapy treatment. The provider who prescribed \nchemotherapy must notify us to authorize your wig purchase. Once you \npurchase a wig, submit your receipt to us for reimbursement. (See Chapter \n7, Section 2 for instructions.) \nPrior authorization requirements may apply.In-Network:\n$0 copayment\nMandatory Supplemental Dental Benefit DEN144\nCoverage Description\nYou may receive the following non-Medicare covered routine dental-related services:\nDeductible $0\nAnnual Maximum $5,000\nDescription of BenefitIn-Network  \nYou Pay*Out-of- \nNetwork  \nYou Pay**\nPreventive Services\nExams \u2013 Frequency/Limitation - 2 procedure codes per calendar year\nPeriodic oral exam 0% 0%\nExams \u2013 Frequency/Limitations - 1 procedure code per calendar year\nEmergency diagnostic exam 0% 0%\nBitewing X-rays \u2013 Frequency/Limitations - 1 set per calendar year\nBitewing x-rays 0% 0%", "doc_id": "8cc2d788-d523-48d7-87ec-40546b6a86f0", "embedding": null, "doc_hash": "884c277d1b6973e41ad9fc5c30fd021a9ddfe287bf2e951379b45db467329187", "extra_info": {"page_label": "75", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2268, "_node_type": "1"}, "relationships": {"1": "97ea8c55-3378-42a5-8d9c-d8a90eb5bf38"}}, "__type__": "1"}, "1867fd7b-0296-4971-bfdc-a5288f55211b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 76\nChapter 4. Medical Benefits Chart (what is covered)\nDescription of BenefitIn-Network  \nYou Pay*Out-of- \nNetwork  \nYou Pay**\nIntraoral X-rays (inside the mouth)\u2013 Frequency/Limitations - 1 procedure code per calendar year\nPeriapical x-rays 0% 0%\nOcclusal x-rays 0% 0%\nFull Mouth or Panoramic X-rays \u2013 Frequency/Limitations - 1 procedure code every 5 calendar years\nComplete series 0% 0%\nPanoramic film 0% 0%\nProphylaxis (Cleaning) \u2013 Frequency/Limitations - 2 procedure codes per calendar year\nProphylaxis (cleaning) 0% 0%\nPeriodontal Maintenance \u2013 Frequency/Limitations - 4 procedure codes per calendar year\nPeriodontal maintenance following periodontal therapy 0% 0%\nFluoride \u2013 Frequency/Limitations - 2 procedure codes per calendar year\nTopical fluoride application 0% 0%\nComprehensive Services\nRestorations (Fillings) - Amalgam and/or Composite \u2013 Frequency/Limitations - Unlimited procedure codes  \nper calendar year\nAmalgam (silver) \u2013 primary or permanent 0% 0%\nResin-based composite (white) \u2013 anterior (front) or posterior (back) 0% 0%\nExtractions (Pulling Teeth) \u2013 Frequency/Limitations - Unlimited procedure codes per calendar year\nExtraction, erupted tooth, or exposed root 0% 0%\nSurgical removal of erupted tooth 0% 0%\nScaling- Generalized Inflammation- Frequency/Limitations - 1 procedure code every 3 calendar years\nScaling - moderate or severe gingival inflammation 0% 0%\nScaling and Root Planing \u2013 Frequency/Limitations - 1 procedure code every 3 calendar years, per quadrant\nPeriodontal scaling and root planing 0% 0%\nRoot Canal \u2013 Frequency/Limitations - 1 procedure code per tooth per lifetime\nRoot canal 0% 0%\nRoot Canal Retreatment \u2013 Frequency/Limitations - 1 procedure code per tooth per lifetime\nRetreatment of previous root canal therapy 0% 0%\nCrowns \u2013 Frequency/Limitations - 1 procedure code per tooth per lifetime\nCrowns 0% 0%\nOnlay 0% 0%\nInlay - alternate benefit only 0% 0%\nBridges - Frequency/Limitations - 1 procedure code every 5 calendar years\nPontic and retainer crown 0% 0%", "doc_id": "1867fd7b-0296-4971-bfdc-a5288f55211b", "embedding": null, "doc_hash": "d267ee623af3f2a0160c3615f7b302a5917dc6386f39a5b2ee9e302e5f77d55d", "extra_info": {"page_label": "76", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2085, "_node_type": "1"}, "relationships": {"1": "6bbb5786-d069-4820-8cfb-ef41df5ebaf5"}}, "__type__": "1"}, "f6dacc57-4ba9-460f-a22b-74d8d1aa919c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 77\nChapter 4. Medical Benefits Chart (what is covered)\nDescription of BenefitIn-Network  \nYou Pay*Out-of- \nNetwork  \nYou Pay**\nComplete Dentures \u2013 Frequency/Limitations - 1 upper complete and/or 1 lower complete denture every 5  \ncalendar years, including routine post-delivery care\nComplete denture \u2013 maxillary (upper) or mandibular (lower) 0% 0%\nImmediate denture \u2013 maxillary (upper) or mandibular (lower) 0% 0%\nRemovable Partial Dentures (including routine post-delivery care) \u2013 Frequency/Limitations - 1 upper and/or  \n1 lower partial denture every 5 calendar years\nPartial dentures \u2013 resin or metal, maxillary (upper) or mandibular (lower) 0% 0%\nUnilateral partial denture 0% 0%\nPartial denture - maxillary (upper) or mandibular (lower) 0% 0%\nRemovable unilateral partial denture 0% 0%\nOral Surgery \u2013 Frequency/Limitations - 2 procedure codes per calendar year\nOral surgery 0% 0%\nDenture Adjustments (not covered if within six months of initial placement) \u2013 Frequency/Limitations - 1  \nprocedure code per calendar year\nComplete denture adjustment\u2013 maxillary (upper) or mandibular (lower) 0% 0%\nPartial denture adjustment - maxillary (upper) or mandibular (lower) 0% 0%\nDenture Reline (not allowed on spare dentures or if within six months of initial placement) -  \nFrequency/Limitations - 1 procedure code per calendar year\nReline complete denture \u2013 maxillary (upper) or mandibular (lower) 0% 0%\nReline partial denture - maxillary (upper) or mandibular (lower) 0% 0%\nDenture Repairs \u2013 Frequency/Limitations - 1 procedure code per calendar year\nRepair complete denture base - maxillary (upper) or mandibular (lower) 0% 0%\nRepair partial denture base - maxillary (upper) or mandibular (lower) 0% 0%\nRepair partial denture framework - maxillary (upper) or mandibular (lower) 0% 0%\nReplace missing or broken tooth 0% 0%\nAdd tooth or clasp to partial denture 0% 0%\nReplace all teeth/acrylic \u2013 maxillary (upper) or mandibular (lower) 0% 0%\nDenture Rebase (not covered if within six months of initial placement) \u2013 Frequency/Limitations - 1  \nprocedure code per calendar year\nRebase complete denture \u2013 maxillary (upper) or mandibular (lower) 0% 0%\nRebase partial denture - maxillary (upper) or mandibular (lower) 0% 0%\nTissue Conditioning (not covered if within six months of initial placement) \u2013 Frequency/Limitations - 1  \nprocedure code per calendar year\nTissue conditioning - maxillary (upper) or mandibular (lower) 0% 0%\nOcclusal Adjustments (not covered if within six months of initial placement) \u2013 Frequency/Limitations - 1  \nprocedure code every 3 calendar years\nOcclusal adjustment - limited 0% 0%", "doc_id": "f6dacc57-4ba9-460f-a22b-74d8d1aa919c", "embedding": null, "doc_hash": "790bd546ef9b4e016db0874d08eb186b9f692a964a52baaf0e30d108017dbbde", "extra_info": {"page_label": "77", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2683, "_node_type": "1"}, "relationships": {"1": "bff0204d-9979-4181-9a8b-13f87a5515dc"}}, "__type__": "1"}, "37acf63e-e4ef-4feb-9786-bb13dc868781": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 78\nChapter 4. Medical Benefits Chart (what is covered)\nDescription of BenefitIn-Network  \nYou Pay*Out-of- \nNetwork  \nYou Pay**\nOcclusal adjustment - complete 0% 0%\nPain Management \u2013 Frequency/Limitations - 2 procedure codes per calendar year\nPalliative (emergency) treatment of dental pain 0% 0%\nAnesthesia \u2013 Frequency/Limitations - As needed with covered procedures\nAnalgesia, anxiolysis, inhalation of nitrous oxide 0% 0%\nDeep sedation/general anesthesia 0% 0%\nIntravenous moderate (conscious) sedation/analgesia 0% 0%\nApplication of desensitizing medicament 0% 0%\nRecementation of Crown \u2013 Frequency/Limitations - 1 procedure code every 5 calendar years\nRecement inlay, onlay or partial coverage restoration 0% 0%\nRecement indirectly fabricated or prefabricated post and core 0% 0%\nRecement crown 0% 0%\nRecementation of Bridge \u2013 Frequency/Limitations - 1 procedure code every 5 calendar years\nRecement fixed partial denture (bridge) 0% 0%\nDiagnostic Services \u2013 Frequency/Limitations - 1 procedure code every 3 calendar years\nPeriodontal exam 0% 0%\nComprehensive oral evaluation 0% 0%\nLimitations and exclusions may apply. Subject to the claims review process which may include a clinical review.\n**Out-of-network dentists have not agreed to provide services at contracted fees. Benefits received out-of-network \nare subject to any in-network benefit maximums, limitations, and/or exclusions. You may be billed by the \nout-of-network provider for any amount greater than the payment made by Humana to the provider. Please see \nbelow for provider locator instructions.\nNetwork providers agree to bill us directly. If a provider who is not in our network is not willing to bill us directly, you \nmay have to pay upfront and submit a request for reimbursement. See Chapter 2 Payment Requests-Contact \nInformation or visit Humana.com for information on requesting reimbursement. \nDental services are subject to our standard claims review procedures which could include dental history to approve \ncoverage. Dental benefits under this plan may not cover all American Dental Association procedure codes. \nInformation regarding each plan is available at Humana.com/sb.\nThe Mandatory Supplemental Dental benefits are provided through the Humana Dental Medicare Network. The \nprovider locator can be found at Humana.com > Find a doctor > Select the Dentist icon from the menu > From \nthe Distance drop down select preferred distance > Enter Zip code > From the look up method select All \nDental Networks > Then select HumanaDental Medicare.\nFor more information about Mandatory Supplemental Dental benefits contact HumanaDental for details \n(1-800-669-6614), TTY 711.", "doc_id": "37acf63e-e4ef-4feb-9786-bb13dc868781", "embedding": null, "doc_hash": "77b3f86221e616d234157ed9974e97255cedad9abd389b04f23b4f48ca8c4747", "extra_info": {"page_label": "78", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2738, "_node_type": "1"}, "relationships": {"1": "1849de7d-16ee-43e9-a046-b93ae74bd7c9"}}, "__type__": "1"}, "2e04d189-3a71-4b4d-9ae4-8d1c837f4d39": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 79\nChapter 4. Medical Benefits Chart (what is covered)\nHow Payments to You or Your Dentist Are Calculated\nFor covered dental services, we will pay as follows:\n\u2022We will determine the total covered expense.\n\u2022We will review the covered expense against the maximum benefits allowed.\n\u2022We will check to see if you have met your deductible, if applicable. If you have not, you will be required to pay \nthe covered expense up to the amount of the deductible.\n\u2022We will pay the remaining expense to you or your dentist, minus any coinsurance you owe (the procedure \nyou received may require you to pay a percentage of the cost).\nFor dental conditions that have two or more possible treatments, Humana will cover the lowest cost treatment, as \nlong as it is proven to provide satisfactory results. If you choose to receive a higher cost treatment, you will be \nresponsible to pay for the difference.\nSubmitting Pretreatment Plans\nIf the dental care you need is expected to exceed $300, we suggest you or your dentist send a dental treatment \nplan for us to review ahead of time so that we can provide you with an estimate for services. The pretreatment plan \nshould include:\n1. A list of services you will receive, using American Dental Association nomenclature and codes.\n2. Your dentist's written description of the proposed treatment.\n3. X-rays that show your dental needs.\n4. Itemized cost of the proposed treatment.\n5. Any other diagnostic materials we request.\nMandatory Supplemental Hearing Benefit HER945\nCoverage Description\nTo use your benefit, you must call TruHearing at 1-844-255-7144 to schedule an appointment.\nDescription of Benefit You Pay\nRoutine hearing exam (1 per year) $0\nUp to 2 TruHearing-branded hearing aids every 3 years (1 per ear every 3 \nyears). Benefit is limited to the TruHearing Advanced hearing aids, which \ncome in various styles and colors. You must see a TruHearing provider to \nuse this benefit. Call 1-844-255-7144 to schedule an appointment (for \nTTY, dial 711).\nHearing aid purchase includes:\n\u2013Unlimited follow-up provider visits during first year following \nTruHearing hearing aid purchase\n\u201360-day trial period\n\u20133-year extended warranty\n\u201380 batteries per aid \nBenefit does not include or cover any of the following:\n\u2013Ear molds\n\u2013Hearing aid accessories$0 per Advanced Aid", "doc_id": "2e04d189-3a71-4b4d-9ae4-8d1c837f4d39", "embedding": null, "doc_hash": "b785e16f889d5f3a9d6d01b1b0a2205c0a55bee47ec43c02ee6db98d279564e0", "extra_info": {"page_label": "79", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2382, "_node_type": "1"}, "relationships": {"1": "8f90fb16-e21e-420d-a1f1-2a1a328443e1"}}, "__type__": "1"}, "3eab93a1-37e0-42f4-b0bc-cbacb783683e": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 80\nChapter 4. Medical Benefits Chart (what is covered)\nDescription of Benefit You Pay\n\u2013Additional provider visits\n\u2013Additional batteries\n\u2013Hearing aids that are not TruHearing-branded Advanced hearing aids\n\u2013Costs associated with loss & damage warranty claims\nCosts associated with excluded items are the responsibility of the member \nand are not covered by the plan.\nMandatory Supplemental Vision Benefit VIS701\nCoverage Description\nVision benefit through EyeMed Vision Care \nYou may receive the following non-Medicare covered routine vision-related services:\nDescription of BenefitIn-Network \nYou Pay\n\u2022Routine Eye Exam (includes refraction) (1 per calendar year) by a \nHumana Medicare Insight Network optical provider$0*\nOR\n\u2022Refraction exam (1 per calendar year) when completed at the same  \nappointment as a Medicare covered comprehensive eye exam by a  \nHumana network medical optical provider.$0 for refraction exam in addition to  \nthe Medical Specialist cost-share for  \nthe medical exam\n\u2022Frames and Lens Package\nYou have a choice of:\n\u2013$400 Benefit toward the purchase and fitting of eyeglasses and pair \nof lenses or contact lenses at a network optical provider (1 per \ncalendar year)\nContact lenses will include conventional or disposable.\nUltraviolet protection and scratch resistant coating are included in the \neyeglass allowance benefit.\nThe benefit can only be used one time. Any remaining benefit dollars do \nnot \"roll over\" to a future purchase.Any amount over\n$400 retail price\nN/A\n*Your routine exam charge will not exceed $0 at a Humana Medicare Insight Network optical provider. Please \ninform the network provider that you are part of the Humana Medicare Insight Network. NOTE: The network of \nproviders for your supplemental vision benefits through EyeMed Vision Care may be different than the network of \nproviders for the Medicare-covered vision benefits.\nThe provider locator for routine vision can be found at Humana.com > Find a Doctor > Select Vision care icon > \nVision coverage through Medicare Advantage plans.", "doc_id": "3eab93a1-37e0-42f4-b0bc-cbacb783683e", "embedding": null, "doc_hash": "5bf15cd8080a698ec5ed33b6ac97aee90fe7fb3acbe4aa893b10785a9d03a580", "extra_info": {"page_label": "80", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2118, "_node_type": "1"}, "relationships": {"1": "45e3b0aa-015a-49fe-a240-fea8a328564b"}}, "__type__": "1"}, "3da22e1a-3ecd-44c8-8b67-c4f3fa32fbfd": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 81\nChapter 4. Medical Benefits Chart (what is covered)\n\u2022Copayments, coinsurances, and deductibles paid for supplemental benefits do not count toward your \nmaximum out-of-pocket amount.\n\u2022Note: Benefits are offered on a calendar year basis. If these benefits are changed or eliminated next year or the \nyear after and you have not used these benefits, you are no longer eligible for the benefits described above.", "doc_id": "3da22e1a-3ecd-44c8-8b67-c4f3fa32fbfd", "embedding": null, "doc_hash": "74da2da02223ecd6628feb7f12eb2b65aa2c7fa97f0f445a4309a51176a3ab62", "extra_info": {"page_label": "81", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 490, "_node_type": "1"}, "relationships": {"1": "b9b2128b-d471-41b7-8004-9fb4f8c646b4"}}, "__type__": "1"}, "c827e761-8ff6-4a77-8916-ff445c0ae97f": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 82\nChapter 4. Medical Benefits Chart (what is covered)\nSection 2.2 Getting care using our plan's optional visitor/traveler benefit\nThe HMO Travel Benefit is available to you as a member of Humana Gold Plus SNP-DE H0028-015 (HMO-POS  \nD-SNP). You can already access emergency and urgently needed care when outside the service area. However,  \nwhen traveling within the United States or Puerto Rico, the HMO Travel Benefit enables you to receive plan covered  \nservices, including preventive care. Covered services must be provided by providers within the National Medicare  \nHMO or SNP network. You may use \u201cFind a Doctor\u201d on Humana.com by using the \u201cJust Looking \u201cfeature or contact  \nCustomer Care for assistance in locating a network provider when using the HMO Travel Benefit. If you receive care  \nfrom a provider within the National Medicare HMO or SNP network, you will pay the same in-network copay or  \ncoinsurance you would pay if you received care within your home service area.\nIf you are planning to travel outside of your service area and anticipate needing to use the HMO Travel Benefit, it is  \nrecommended that you notify your primary care provider. It is also recommended that you check to see if the  \nprovider or providers you wish to see while traveling are in the National Medicare HMO or SNP network using the  \n\u201cFind a Doctor\u201d on Humana.com by using the \u201cJust Looking\u201d feature or contact Customer Care for assistance. \nSECTION 3 What services are covered outside Humana Gold Plus SNP-DE  \nH0028-015 (HMO-POS D-SNP)?\nSection 3.1 Services not covered by Humana Gold Plus SNP-DE H0028-015 (HMO-POS  \nD-SNP)\nAll services covered by Original Medicare are also covered by our plan. For services that are not covered by Humana \nGold Plus SNP-DE H0028-015 (HMO-POS D-SNP) but are available through MO HealthNet (Medicaid), please see \nyour Medicaid Member Handbook.\nSECTION 4 What services are not covered by the plan?\nSection 4.1 Services not covered by the plan (exclusions)\nThis section tells you what services are \"excluded\". For more information about MO HealthNet (Medicaid) benefits, \ncall Customer Care.\nThe chart below describes some services and items that aren't covered by the plan under any conditions or are \ncovered by the plan only under specific conditions. \nIf you get services that are excluded (not covered), you must pay for them yourself except under the specific \nconditions listed below. Even if you receive the excluded services at an emergency facility, the excluded services \nare still not covered and our plan will not pay for them. The only exception is if the service is appealed and decided: \nupon appeal to be a medical service that we should have paid for or covered because of your specific situation. (For \ninformation about appealing a decision we have made to not cover a medical service, go to Chapter 9, Section 6.3 \nin this booklet.)", "doc_id": "c827e761-8ff6-4a77-8916-ff445c0ae97f", "embedding": null, "doc_hash": "0d50a062b57eaffb56800acc42fe16ede0eb289b30038bc3c7024fac19dd4aa8", "extra_info": {"page_label": "82", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2968, "_node_type": "1"}, "relationships": {"1": "f9e923bd-c5c7-45b9-827c-077cebe35dac"}}, "__type__": "1"}, "65e3eab6-3a3f-4c9d-87fb-a8934fc64a02": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 83\nChapter 4. Medical Benefits Chart (what is covered)\nServices not covered by Medicare Not covered under any  \nconditionCovered only under specific conditions\nAcupuncture N/A Available for people with chronic low  \nback pain under certain circumstances.\nCharges for equipment which is primarily  \nand customarily used for a nonmedical  \npurpose, even though the item has some  \nremote medically related use.N/A Covered only when medically necessary.\nCosmetic surgery or procedures N/A \u2022Covered in cases of an accidental  \ninjury or for improvement of the  \nfunctioning of a malformed body  \nmember.\n\u2022Covered for all stages of  \nreconstruction for a breast after a  \nmastectomy, as well as for the  \nunaffected breast to produce a  \nsymmetrical appearance.\nExperimental medical and surgical  \nprocedures, equipment and  \nmedications. \nExperimental procedures and items are  \nthose items and procedures determined  \nby Original Medicare to not be generally  \naccepted by the medical community.N/A May be covered by Original Medicare  \nunder a Medicare-approved clinical  \nresearch study or by our plan \n(See Chapter 3, Section 5 for more  \ninformation on clinical research studies.)\nFees charged for care by your immediate  \nrelatives or members of your household.N/A                     \nFull-time nursing care in your home N/A                     \nNaturopath services (uses natural or  \nalternative treatments)\nNon-routine dental care Dental care required to treat illness or  \ninjury may be covered as inpatient or  \noutpatient care.\nOrthopedic shoes or supportive devices  \nfor the feetN/A Shoes that are part of a leg brace and are  \nincluded in the cost of the brace.  \nOrthopedic or therapeutic shoes for  \npeople with diabetic foot disease.\nPersonal items in your room at a hospital  \nor a skilled nursing facility, such as a  \ntelephone or a televisionN/A\nPrivate room in a hospital N/A Covered only when medically necessary", "doc_id": "65e3eab6-3a3f-4c9d-87fb-a8934fc64a02", "embedding": null, "doc_hash": "33c751f22c215be4613a039802344667120ee68218a5da1022298a5b4ecd4401", "extra_info": {"page_label": "83", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2012, "_node_type": "1"}, "relationships": {"1": "44d3251a-2d18-44bd-855d-d8cd31ac32c9"}}, "__type__": "1"}, "f9e86776-5bfe-4cde-b500-95eca73208e6": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 84\nChapter 4. Medical Benefits Chart (what is covered)\nServices not covered by Medicare Not covered under any  \nconditionCovered only under specific conditions\nReversal of sterilization procedures and  \nor non-prescription contraceptive  \nsupplies.N/                     A\nServices considered not reasonable and  \nnecessary, according to Original  \nMedicare standardsN/A\nIn addition to any exclusions or limitations described in the Medical Benefits Chart, or anywhere else in this \nEvidence of Coverage, the following items and services aren't covered under Original Medicare or by our plan:\n\u2022Radial keratotomy, LASIK surgery, and other low vision aids and services. \n\u2022Services provided to veterans in Veterans Affairs (VA) facilities. However, when emergency services are received \nat a VA hospital and the VA cost-sharing is more than the cost-sharing under our plan, we will reimburse \nveterans for the difference. Members are still responsible for our cost-sharing amounts.\nDental Mandatory Supplemental Benefit Exclusions include, but not limited to, the following:\n\u2022Network dentists have agreed to provide services at contracted fees (the in-network fee schedules, or INFS). If a \nmember visits a participating network dentist, the member will not receive a bill for charges more than the \nnegotiated fee schedule on covered services (coinsurance payment still applies).\n\u2022Initial placement or replacement of a prior denture that is unserviceable and cannot be made serviceable. Spare \ndentures are not covered. \n\u2022Dental reline may not be covered within six months of initial denture placement or on spare dentures.\n\u2022Dental adjustments may not be covered within six months of initial denture placement or on spare dentures. \n\u2022Expenses incurred while you qualify for any workers\u2019 compensation or occupational disease act or law, whether \nor not you applied for coverage.\n\u2022Services that are:\n\u2013Free or that you would not be required to pay for if you did not have this insurance, unless charges are \nreceived from and reimbursable to the U.S. government or any of its agencies as required by law.\n\u2013Furnished by, or payable under, any plan or law through any government or any political subdivision \u2013 this \ndoes not include Medicare or Medicaid.\n\u2013Furnished by any U.S. government-owned or operated hospital/institution/agency for any service connected \nwith sickness or bodily injury.\n\u2022Any loss caused or contributed by war or any act of war, whether declared or not; any act of international armed \nconflict; or any conflict involving armed forces of any international authority.\n\u2022Any expense arising from the completion of forms.\n\u2022Your failure to keep an appointment with the dentist.\n\u2022Any service we consider cosmetic dentistry unless it is necessary as a result of an accidental injury sustained \nwhile you are covered under this policy. We consider the following cosmetic dentistry procedures: \n\u2013Facings on crowns or pontics \u2013 the portion of a fixed bridge between the abutments \u2013 posterior to the second \nbicuspid.\n\u2013Any service to correct congenital malformation.\n\u2013Any service performed primarily to improve appearance; or characterization and personalization of prosthetic \ndevices.\n\u2022Charges for any type of implant and all related services, including crowns or the prosthetic device attached to it; \nprecision or semi-precision attachments; over-dentures and any endodontic treatment associated with \nover-dentures; other customized attachments.", "doc_id": "f9e86776-5bfe-4cde-b500-95eca73208e6", "embedding": null, "doc_hash": "2fc574012fb2be50d1d267c88a3250241ca579b37942650d6138b1895d76ac98", "extra_info": {"page_label": "84", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3535, "_node_type": "1"}, "relationships": {"1": "c4bb568f-006a-4adc-a56f-5ec5b54f3438"}}, "__type__": "1"}, "77ef3256-49b7-4f23-8640-a3a986a374bb": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 85\nChapter 4. Medical Benefits Chart (what is covered)\n\u2022Any service related to:\n\u2013Altering vertical dimension of teeth.\n\u2013Restoration or maintenance of occlusion.\n\u2013Splinting teeth, including multiple abutments, or any service to stabilize periodontally weakened teeth.\n\u2013Replacing tooth structures lost as a result of abrasion, attrition, erosion or abfraction.\n\u2013Bite registration or bite analysis.\n\u2022Infection control, including but not limited to sterilization techniques.\n\u2022Fees for treatment performed by someone other than a dentist, except for scaling, teeth cleaning and the \ntopical application of fluoride, which can be performed by a licensed dental hygienist. The treatment must be \nrendered under the supervision of the dentist in accordance with generally accepted dental standards.\n\u2022Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist.\n\u2022Prescription drugs or pre-medications, whether dispensed or prescribed.\n\u2022Any service not specifically listed in the Coverage Information.\n\u2022Any service that we determine is not a dental necessity; does not offer a favorable prognosis; does not have \nuniform professional endorsement; or is deemed to be experimental or investigational in nature.\n\u2022Orthodontic services.\n\u2022Any expense incurred before your effective date or after the date this supplemental benefit terminates.\n\u2022Services provided by someone who ordinarily lives in your home or who is a family member.\n\u2022Charges exceeding the reimbursement limit for the service.\n\u2022Treatment resulting from any intentionally self-inflicted injury or bodily illness.\n\u2022Local anesthetics, irrigation, bases, pulp caps, temporary dental services, study models, treatment plans, or \ntissue preparation associated with the impression or placement of a restoration when charged as a separate \nservice. These services are considered an integral part of the entire dental service.\n\u2022Repair and replacement of orthodontic appliances.\n\u2022Any surgical or nonsurgical treatment for any jaw joint problems, including any temporomandibular joint \ndisorder, craniomaxillary, craniomandibular disorder, or other conditions of the joint linking the jaw bone and \nskull; or treatment of the facial muscles used in expression and chewing functions, for symptoms including, but \nnot limited to, headaches.\nHearing Mandatory Supplemental Benefit Exclusions include, but not limited to, the following:\n\u2022Any fees for exams, tests, evaluations or any services in excess of the stated maximums.\n\u2022Any expenses which are covered by Medicare or any other government program or insurance plan, or for which \nyou are not legally required to pay.\n\u2022Services provided for clearance/consultation by a provider.\n\u2022Any refitting fees for lost or damaged hearing aids.\n\u2022Any fees for any services rendered by a non-network hearing aid provider. In-network hearing aid providers \nreserve the right to only service devices purchased from in-network providers.\n\u2022Hearing aids and provider visits to service hearing aids (except as specifically described in the Covered Benefits), \near molds, hearing aid accessories, warranty claim fees, and hearing aid batteries (beyond the covered limit).\nVision Mandatory Supplemental Benefit Exclusions include, but not limited to, the following:\n\u2022Any benefits received at a non-network optical provider.\n\u2022Refitting or change in lens design after initial fitting.\n\u2022Any expense arising from the completion of forms.\n\u2022Any service not specifically listed in your supplemental benefit.\n\u2022Orthoptic or vision training.\n\u2022Subnormal vision aids and associated testing.\n\u2022Aniseikonic lenses.\n\u2022Athletic or industrial lenses.         ", "doc_id": "77ef3256-49b7-4f23-8640-a3a986a374bb", "embedding": null, "doc_hash": "ca66566bf43500b501e64a30dd8a61066c79e7a2cac06c441eb33925f285607f", "extra_info": {"page_label": "85", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3729, "_node_type": "1"}, "relationships": {"1": "e31c649e-73b0-453e-8092-0f94482cd098"}}, "__type__": "1"}, "7cbe2f49-3d38-4f08-953a-54ff912c91d8": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 86\nChapter 4. Medical Benefits Chart (what is covered)\n\u2022Prisms (not covered with allowance, but may be available at a discounted rate off retail price; check with \nprovider for details)\n\u2022Any service we consider cosmetic.\n\u2022Any expense incurred before your effective date or after the date this supplemental benefit terminates.\n\u2022Services provided by someone who ordinarily lives in your home or who is a family member.\n\u2022Charges exceeding the allowance for the service.\n\u2022Treatment resulting from any intentionally self-inflicted injury or bodily illness.\n\u2022Plano lenses.\n\u2022Medical or surgical treatment of eye, eyes or supporting structures.\n\u2022Non-prescription sunglasses.\n\u2022Two pair of glasses in lieu of bifocals.\n\u2022Services or materials provided by any other group benefit plans providing vision care.\n\u2022Corrective vision treatment of an experimental nature.\n\u2022Solutions and/or cleaning products for glasses or contact lenses.\n\u2022Non-prescription items.\n\u2022Costs associated with securing materials.\n\u2022Pre- and post-operative services.\n\u2022Orthokeratology.\n\u2022Routine maintenance of materials.\n\u2022Artistically painted lenses.\n\u2022Any expenses incurred while you qualify for any workers' compensation or occupational disease act or law, \nwhether or not you applied for coverage.\n\u2022Services that are:\n\u2013Free or that you would not be required to pay for if you did not have this insurance, unless charges are \nreceived from and reimbursable to the U.S. government or any of its agencies as required by law.\n\u2013Furnished by, or payable under, any plan or law through any government or any political subdivision (this \ndoes not include Medicare or Medicaid).\n\u2013Furnished by any U.S. government-owned or operated hospital/institution/agency for any service connected \nwith sickness or bodily injury.\n\u2022Any loss caused or contributed by war or any act of war, whether declared or not; any act of international armed \nconflict; or any conflict involving armed forces of any international authority.\n\u2022Your failure to keep an appointment.\n\u2022Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist.\n\u2022Prescription drugs or pre-medications, whether dispensed or prescribed.\n\u2022Any service that we determine is not a visual necessity; does not offer a favorable prognosis; does not have \nuniform professional endorsement; or is deemed to be experimental or investigational in nature.\n\u2022Replacement of lenses or eyeglass frames furnished under this supplemental benefit that are lost or broken, \nunless otherwise available under the supplemental benefit.\n\u2022Any examination or material required by an employer as a condition of employment or safety eyewear.\n\u2022Pathological treatment.\nThe plan will not cover the excluded services listed above. Even if you receive the services at an emergency facility, \nthe excluded services are still not covered.", "doc_id": "7cbe2f49-3d38-4f08-953a-54ff912c91d8", "embedding": null, "doc_hash": "9310dee8c89fd829adc2129a518fd786316b719a73aabc11ea957a382c7a187f", "extra_info": {"page_label": "86", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2921, "_node_type": "1"}, "relationships": {"1": "b99d4fc7-9452-4a88-a056-e71f2e9c8bfd"}}, "__type__": "1"}, "8bcfff8e-b465-40a1-a6a5-77110cf7f91c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 87\nChapter 5 Using the plan's coverage for Part D prescription drugsEOC076\nCHAPTER 5: \nUsing the plan's coverage for Part D  \nprescription drugs", "doc_id": "8bcfff8e-b465-40a1-a6a5-77110cf7f91c", "embedding": null, "doc_hash": "64a1bc37e6801ded3419aee3bdf310e36d16e3b875b6682b46c4087d73116cd0", "extra_info": {"page_label": "87", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 224, "_node_type": "1"}, "relationships": {"1": "29a23499-5b04-4646-b1ec-73d6ea9241ca"}}, "__type__": "1"}, "f2ef8d67-7f54-4bdc-9e43-9ce946af1b6b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 88\nChapter 5 Using the plan's coverage for Part D prescription drugs\n How can you get information about your drug costs?\nBecause you are eligible for Medicaid, you qualify for and are getting \"Extra Help\" from Medicare to pay  \nfor your prescription drug plan costs. Because you are in the \"Extra Help\" program, some information in  \nthis Evidence of Coverage about the costs for Part D prescription drugs does not apply to you. \nSECTION 1 Introduction\nThis chapter explains rules for using your coverage for Part D drugs. Please see Chapter 4 for Medicare Part B \ndrug benefits and hospice drug benefits.\nIn addition to the drugs covered by Medicare, some prescription drugs may be covered for you under your Medicaid \nbenefits. For information about prescription drugs covered only by Medicaid, contact MO HealthNet (Medicaid) at \nthe phone number in Exhibit A of this booklet.\nSection 1.1 Basic rules for the plan's Part D drug coverage\nThe plan will generally cover your drugs as long as you follow these basic rules:\n\u2022You must have a provider (a doctor, dentist or other prescriber) write you a prescription which must be valid \nunder applicable state law.\n\u2022Your prescriber must not be on Medicare\u2019s Exclusion or Preclusion Lists.\n\u2022You generally must use a network pharmacy to fill your prescription. (See Section 2, Fill your prescriptions at a \nnetwork pharmacy or through the plan's mail-order service.)\n\u2022Your drug must be in the plan's Prescription Drug Guide (Formulary) (we call it the \"Drug Guide\" for short). (See \nSection 3, Your drugs need to be in the plan's \"Drug Guide.\")\n\u2022Your drug must be used for a medically accepted indication. A \"medically accepted indication\" is a use of the \ndrug that is either approved by the Food and Drug Administration or supported by certain reference books. \n(See Section 3 for more information about a medically accepted indication.)\nSECTION 2 Fill your prescription at a network pharmacy or through the  \nplan's mail-order service\nSection 2.1 Use a network pharmacy\nIn most cases, your prescriptions are covered only if they are filled at the plan's network pharmacies. (See Section \n2.5 for information about when we would cover prescriptions filled at out-of-network pharmacies.)\nA network pharmacy is a pharmacy that has a contract with the plan to provide your covered prescription drugs. \nThe term \"covered drugs\" means all of the Part D prescription drugs that are in the plan's Drug Guide.", "doc_id": "f2ef8d67-7f54-4bdc-9e43-9ce946af1b6b", "embedding": null, "doc_hash": "2539e927999852f33d95c32c8fc8f44a4f694ff3c1aacb571717169030337a44", "extra_info": {"page_label": "88", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2528, "_node_type": "1"}, "relationships": {"1": "416e82dd-6bc0-4ce3-97ef-ea6400ede39a"}}, "__type__": "1"}, "a3d30657-60cc-4250-be6a-7fba88f9dbe0": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 89\nChapter 5 Using the plan's coverage for Part D prescription drugs\nSection 2.2 Network pharmacies\nHow do you find a network pharmacy in your area?\nTo find a network pharmacy, you can look in your Provider Directory, visit our website \n(Humana.com/PlanDocuments), and/or call Customer Care.\nYou may go to any of our network pharmacies. Contact us to find out more about how your out-of-pocket costs \ncould vary for different drugs.\nWhat if the pharmacy you have been using leaves the network?\nIf the pharmacy you have been using leaves the plan's network, you will have to find a new pharmacy that is in the \nnetwork. To find another pharmacy in your area, you can get help from Customer Care or use the Provider Directory. \nYou can also find information on our website at Humana.com/PlanDocuments.\nWhat if you need a specialized pharmacy?\nSome prescriptions must be filled at a specialized pharmacy. Specialized pharmacies include:\n\u2022Pharmacies that supply drugs for home infusion therapy.\n\u2022Pharmacies that supply drugs for residents of a long-term care (LTC) facility. Usually, a LTC facility (such as a \nnursing home) has its own pharmacy. If you have any difficulty accessing your Part D benefits in an LTC \nfacility, please contact Customer Care.\n\u2022Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Program (not available in \nPuerto Rico). Except in emergencies, only Native Americans or Alaska Natives have access to these \npharmacies in our network.\n\u2022Pharmacies that dispense drugs that are restricted by the FDA to certain locations or that require special \nhandling, provider coordination, or education on their use. (Note: This scenario should happen rarely.)\nTo locate a specialized pharmacy, look in your Provider Directory or call Customer Care.\nSection 2.3 Using the plan's mail-order service\nFor certain kinds of drugs, you can use the plan's network mail-order service. Generally, the drugs provided through \nmail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. These drugs are \nmarked as \"mail-order\" drugs in our Drug Guide.\nOur plan's mail-order service allows you to order up to a 90-day supply.\nTo get order forms and information about filling your prescriptions by mail, please contact Customer Care.\nUsually a mail-order pharmacy order will be delivered to you in no more than 10 business days. When you plan to \nuse a mail-order pharmacy, it's a good precaution to ask your doctor to write two prescriptions for your drugs: one \nyou'll send for ordering by mail, and one you can fill in person at an in-network pharmacy if your mail-order doesn't \narrive on time. That way, you won't have a gap in your medication if your mail-order is delayed. If you have trouble \nfilling your drug while waiting for mail order, please call Customer Care.", "doc_id": "a3d30657-60cc-4250-be6a-7fba88f9dbe0", "embedding": null, "doc_hash": "14154bc6c9bd76663484d712134fb274cb91ba18e3cb86ec1cfafec6d13a5ed3", "extra_info": {"page_label": "89", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2920, "_node_type": "1"}, "relationships": {"1": "5b8f4140-266d-400b-8e44-0a1add4f54ce"}}, "__type__": "1"}, "b720dfda-1526-4c85-81e2-46b4aad1de7f": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 90\nChapter 5 Using the plan's coverage for Part D prescription drugs\nNew prescriptions the pharmacy receives directly from your doctor's office. \nThe pharmacy will automatically fill and deliver new prescriptions it receives from health care providers, without \nchecking with you first, if either:\n\u2022You used mail-order services with this plan in the past, or\n\u2022You sign up for automatic delivery of all new prescriptions received directly from health care providers. You \nmay request automatic delivery of all new prescriptions at any time by calling Customer Care.\nIf you receive a prescription automatically by mail that you do not want, and you were not contacted to see if \nyou wanted it before it shipped, you may be eligible for a refund.\nIf you used mail-order in the past and do not want the pharmacy to automatically fill and ship each new \nprescription, please contact us by calling Customer Care.\nIf you have never used our mail-order delivery and/or decide to stop automatic fills of new prescriptions, the \npharmacy will contact you each time it gets a new prescription from a health care provider to see if you want \nthe medication filled and shipped immediately. It is important that you respond each time you are contacted by \nthe pharmacy, to let them know whether to ship, delay, or cancel the new prescription.\nRefills on mail-order prescriptions. For refills of your drugs, you have the option to sign up for an automatic \nrefill program. Under this program we will start to process your next refill automatically when our records show \nyou should be close to running out of your drug. The pharmacy will contact you prior to shipping each refill to \nmake sure you need more medication, and you can cancel scheduled refills if you have enough of your \nmedication or if your medication has changed.\nIf you choose not to use our auto-refill program but still want the mail-order pharmacy to send you your \nprescription, please contact your pharmacy 14 business days before your current prescription will run out. This \nwill ensure your order is shipped to you in time.\nTo opt out of our program that automatically prepares mail-order refills, please contact us.\nIf you receive a refill automatically by mail that you do not want, you may be eligible for a refund.\nSection 2.4 How can you get a long-term supply of drugs?\nWhen you get a long-term supply of drugs, your cost sharing may be lower. The plan offers two ways to get a \nlong-term supply (also called an \"extended supply\") of \"maintenance\" drugs in our plan's Drug Guide. \n(Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.)\n1. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs. Your Provider \nDirectory tells you which pharmacies in our network can give you a long-term supply of maintenance drugs. You \ncan also call Customer Care for more information.\n2. You may also receive maintenance drugs through our mail-order program. Please see Section 2.3 for more \ninformation.\nSection 2.5 When can you use a pharmacy that is not in the plan's network?\nYour prescription may be covered in certain situations", "doc_id": "b720dfda-1526-4c85-81e2-46b4aad1de7f", "embedding": null, "doc_hash": "8f379dffc3a9b8395a5f3e9372c819f900a3d07d8262b0762241d97472236d7b", "extra_info": {"page_label": "90", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3262, "_node_type": "1"}, "relationships": {"1": "42bfff9b-9c25-4385-acf4-244125f691e8"}}, "__type__": "1"}, "8a4dd8a2-747a-404b-9513-4fe7830d30f4": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 91\nChapter 5 Using the plan's coverage for Part D prescription drugs\nGenerally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network \npharmacy. To help you, we have network pharmacies outside of our service area where you can get your \nprescriptions filled as a member of our plan. Please check first with Customer Care to see if there is a network \npharmacy nearby. You will most likely be required to pay the difference between what you pay for the drug at the \nout-of-network pharmacy and the cost that we would cover at an in-network pharmacy.\nHere are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:\n\u2022If you need a prescription because of a medical emergency\n\u2013We will cover prescriptions that are filled at an out-of-network pharmacy (up to a 30-day supply) if the \nprescriptions are related to care for a medical emergency. In this situation, you will have to pay the full \ncost (rather than paying just your copayment or coinsurance) when you fill your prescription. You can ask \nus to reimburse you for our share of the cost by submitting a paper claim form. If the prescription is \ncovered, it will be covered at an out-of-network rate. If you go to an out-of-network pharmacy, you may \nbe responsible for paying the difference between what we would pay for a prescription filled at an \nin-network pharmacy and what the out-of-network pharmacy charged for your prescription. (Chapter 7, \nSection 2.1 explains how to ask the plan to pay you back.)\n\u2022If you need coverage while you are traveling away from the plan's service area\n\u2013If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply \nof the drug before you leave. When possible, take along all the medication you will need. You may be able \nto order your prescription drugs ahead of time through our prescription mail-order service or through a \nnetwork retail pharmacy that offers an extended supply. If you are traveling outside of your plan's service \narea but within the United States and territories and become ill, or run out of your prescription drugs, call \nCustomer Care (phone numbers are printed on the back cover of this booklet) to find a network pharmacy \nin your area where you can fill your prescription. If a network pharmacy is not available, we will cover \nprescriptions that are filled at an out-of-network pharmacy (up to a 30-day supply) if you follow all other \ncoverage rules identified within this document. In this situation, you will have to pay the full cost (rather \nthan paying just your copayment or coinsurance) when you fill your prescription.\n\u2013If the prescription is covered, it will be covered at an out-of-network rate. You may be responsible for \npaying the difference between what we would pay for a prescription filled at an in-network pharmacy and \nwhat the out-of-network pharmacy charged for your prescription. You can ask us to reimburse you for our \nshare of the cost by submitting a paper claim form. (Chapter 7, Section 2.1 explains how to ask the plan to \npay you back.)\n\u2013Please recognize, however, that multiple non-emergency occurrences of out-of-network pharmacy \nclaims will result in claim denials. In addition, we cannot pay for any stolen medications or \nprescriptions that are filled by pharmacies outside the United States and territories, even for a \nmedical emergency, for example on a cruise ship when outside of the United States.\nOther times you can get your prescription covered if you go to an out-of-network pharmacy. These situations will \nbe covered at an out-of-network rate. In these situations, you will have to pay the full cost (rather than paying just \nyour copayment or coinsurance) when you fill your prescription. You can ask us to reimburse you for our share of", "doc_id": "8a4dd8a2-747a-404b-9513-4fe7830d30f4", "embedding": null, "doc_hash": "6e014e6925f31107c3c57c3e92b06da4f334e500a6a479c893abda47e8a7827e", "extra_info": {"page_label": "91", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3915, "_node_type": "1"}, "relationships": {"1": "2ccd8a58-b19c-4aa3-bcc2-c8b922fc1694", "3": "3abc471b-6f18-4eac-b6ea-c18b4ec1a19a"}}, "__type__": "1"}, "3abc471b-6f18-4eac-b6ea-c18b4ec1a19a": {"__data__": {"text": "when you fill your prescription. You can ask us to reimburse you for our share of \nthe cost by submitting a paper claim form. If you go to an out-of-network pharmacy or provider, you may be \nresponsible for paying the difference between what we would pay for a prescription filled at an in-network \npharmacy and what the out-of-network pharmacy charged for your prescription. (Chapter 7, Section 2.1 explains \nhow to ask the plan to pay you back.) We will cover your prescription at an out-of-network pharmacy if at least one \nof the following applies:", "doc_id": "3abc471b-6f18-4eac-b6ea-c18b4ec1a19a", "embedding": null, "doc_hash": "194d244cbe27d5a462ba9f6e92b24e755839407103a94713774975823793413b", "extra_info": {"page_label": "91", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 3834, "end": 4386, "_node_type": "1"}, "relationships": {"1": "2ccd8a58-b19c-4aa3-bcc2-c8b922fc1694", "2": "8a4dd8a2-747a-404b-9513-4fe7830d30f4"}}, "__type__": "1"}, "a4c9f06a-62d0-4080-aaf2-760c78cf0400": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 92\nChapter 5 Using the plan's coverage for Part D prescription drugs\n\u2022You can't get a covered drug that you need immediately because there are no open in-network pharmacies \nwithin a reasonable driving distance\n\u2022Your prescription is for a specialty drug in-network pharmacies don't usually keep in stock\n\u2022You were eligible for Medicaid at the time you got the prescription, even if you weren't enrolled yet. This is \ncalled retroactive enrollment\n\u2022You're evacuated from your home because of a state, federal, or public health emergency and don't have \naccess to an in-network pharmacy\n\u2022If you get a covered prescription drug from an institutional based pharmacy while a patient in an emergency \nroom, provider based clinic, outpatient surgery clinic, or other outpatient setting\nHow do you ask for reimbursement from the plan?\nIf you must use an out-of-network pharmacy, you will generally have to pay the full cost at the time you fill your \nprescription. You can ask us to reimburse you. (Chapter 7, Section 2.1 explains how to ask the plan to pay you \nback.)\nSECTION 3 Your drugs need to be in the plan's \"Drug Guide\"\nSection 3.1 The \"Drug Guide\" tells which Part D drugs are covered\nThe plan has a \"Prescription Drug Guide (Formulary).\" In this Evidence of Coverage, we call it the \"Drug Guide\" for \nshort.\nThe drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list meets \nMedicare\u2019s requirements and has been approved by Medicare.\nThe Drug Guide includes the drugs covered under Medicare Part D. In addition to the drugs covered by Medicare, \nsome prescription drugs may be covered for you under your Medicaid benefits. For information about prescription \ndrugs covered only by Medicaid, contact MO HealthNet (Medicaid) at the phone number in \"Exhibit A\" of this \nbooklet. \nWe will generally cover a drug in the plan's Drug Guide as long as you follow the other coverage rules explained in \nthis chapter and the use of the drug is a medically accepted indication. A \"medically accepted indication\" is a use \nof the drug that is either:\n\u2022Approved by the Food and Drug Administration for the diagnosis or condition for which it is being prescribed.\n\u2022-- or -- supported by certain references, such as the American Hospital Formulary Service Drug Information \nand the DRUGDEX Information System.\nThe Drug Guide includes brand name drugs, generic drugs, and biosimilars.\nA brand name drug is a prescription that is sold under a trademarked name owned by the drug manufacturer. \nBrand name drugs that are more complex than typical drugs (for example, drugs that are based on a protein) are \ncalled biological products. In the Drug Guide, when we refer to \"drugs,\" this could mean a drug or a biological \nproduct.", "doc_id": "a4c9f06a-62d0-4080-aaf2-760c78cf0400", "embedding": null, "doc_hash": "69cc2aa6479becf37cd5cf6d3d15370be7b1f6ea4e6bab7423234eef00537ff4", "extra_info": {"page_label": "92", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2841, "_node_type": "1"}, "relationships": {"1": "9d57e201-fe3c-46ba-85d6-f7559fbb1d0c"}}, "__type__": "1"}, "554aeb20-bd3b-4e16-b481-6498d189933f": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 93\nChapter 5 Using the plan's coverage for Part D prescription drugs\nA generic drug is a prescription drug that has the same active ingredients as the brand name drug. Since biological \nproducts are more complex than typical drugs, instead of having a generic form, they have alternatives that are \ncalled biosimilars. Generally, generics and biosimilars work just as well as the brand name drug or biological \nproduct and usually cost less. There are generic drug substitutes or biosimilar alternatives available for many \nbrand name drugs and some biological products.\nWhat is not in the Drug Guide?\nThe plan does not cover all prescription drugs.\n\u2022In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more \ninformation about this, see Section 7.1 in this chapter).\n\u2022In other cases, we have decided not to include a particular drug in the Drug Guide. In some cases you may be \nable to obtain a drug that is not in the drug guide. For more information, please see Chapter 9.\nFor information about prescription drugs covered by Medicaid, contact MO HealthNet (Medicaid) at the phone \nnumber in Exhibit A of this booklet.\nSection 3.2 How can you find out if a specific drug is in the Drug Guide?\nYou have three ways to find out:\n1. Check the most recent Drug Guide we provided electronically. (Please note: The Drug Guide we provide includes \ninformation for the covered drugs that are most commonly used by our members. However, we cover \nadditional drugs that are not included in the provided Drug Guide. If one of your drugs is not listed in the Drug \nGuide, you should visit our website or contact Customer Care to find out if we cover it.)\n2. Visit the plan's website (Humana.com/PlanDocuments). The Drug Guide on the website is always the most \ncurrent.\n3. Call Customer Care to find out if a particular drug is in the plan's Drug Guide or to ask for a copy of the list.\nSECTION 4 There are restrictions on coverage for some drugs\nSection 4.1 Why do some drugs have restrictions?\nFor certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and \npharmacists developed these rules to encourage you and your provider to use drugs in the most effective way. To \nfind out if any of these restrictions apply to a drug you take or want to take, check the Drug Guide. If a safe, \nlower-cost drug will work just as well medically as a higher-cost drug, the plan\u2019s rules are designed to encourage \nyou and your provider to use that lower-cost option.\nPlease note that sometimes a drug may appear more than once in our Drug Guide. This is because the same drugs \ncan differ based on the strength, amount, or form of the drug prescribed by your health care provider, and different \nrestrictions or cost sharing may apply to the different versions of the drug (for instance, 10 mg versus 100 mg; one \nper day versus two per day; tablet versus liquid).", "doc_id": "554aeb20-bd3b-4e16-b481-6498d189933f", "embedding": null, "doc_hash": "44f985a68452cb4c1508e84a296c44933a59d822c3c0dd64bbccc03a15814519", "extra_info": {"page_label": "93", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3011, "_node_type": "1"}, "relationships": {"1": "ebff97c3-a7e0-4422-a33d-ec441c202fc3"}}, "__type__": "1"}, "704aea51-1dac-4b3e-8f7d-e569d47bceb0": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 94\nChapter 5 Using the plan's coverage for Part D prescription drugs\nSection 4.2 What kinds of restrictions?\nThe sections below tell you more about the types of restrictions we use for certain drugs.\nIf there is a restriction for your drug, it usually means that you or your provider will have to take extra \nsteps in order for us to cover the drug. Contact Customer Care to learn what you or your provider would need to \ndo to get coverage for the drug. If you want us to waive the restriction for you, you will need to use the coverage \ndecision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See \nChapter 9)\nRestricting brand name drugs when a generic version is available\nGenerally, a \"generic\" drug works the same as a brand name drug and usually costs less. When a generic version \nof a brand name drug is available, our network pharmacies will provide you the generic version instead of \nthe brand name drug. However, if your provider has told us the medical reason that neither the generic drug nor \nother covered drugs that treat the same condition will work for you, then we will cover the brand name drug. (Your \nshare of the cost may be greater for the brand name drug than for the generic drug.)\nGetting plan approval in advance\nFor certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for \nyou. This is called \"prior authorization.\" This is put in place to ensure medication safety and help guide \nappropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.\nTrying a different drug first\nThis requirement encourages you to try less costly but usually just as effective drugs before the plan covers \nanother drug. For example, if Drug A and Drug B treat the same medical condition and Drug A is less costly, the plan \nmay require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This \nrequirement to try a different drug first is called \"step therapy.\"\nQuantity limits\nFor certain drugs, we limit how much of a drug you can get each time you fill your prescription. For example, if it is \nnormally considered safe to take only one pill per day for a certain drug, we may limit coverage for your \nprescription to no more than one pill per day.\nSECTION 5 What if one of your drugs is not covered in the way you\u2019d like it  \nto be covered?\nSection 5.1 There are things you can do if your drug is not covered in the way you\u2019d  \nlike it to be covered\nThere are situations where there is a prescription drug you are taking, or one that you and your provider think you \nshould be taking, that is not on our formulary or is on our formulary with restrictions. For example:\n\u2022The drug might not be covered at all. Or maybe a generic version of the drug is covered but the brand name \nversion you want to take is not covered.", "doc_id": "704aea51-1dac-4b3e-8f7d-e569d47bceb0", "embedding": null, "doc_hash": "9f24e9b8ce5d10c1152f29a6445725762a9810e640e4676bc9f0a329357b0aec", "extra_info": {"page_label": "94", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3009, "_node_type": "1"}, "relationships": {"1": "f7b53843-b7ad-494a-b357-28eda3ae9bc7"}}, "__type__": "1"}, "fbce9b0d-19e5-43b2-a508-d1880a608def": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 95\nChapter 5 Using the plan's coverage for Part D prescription drugs\n\u2022The drug is covered, but there are extra rules or restrictions on coverage for that drug, explained in Section 4.\n\u2022There are things you can do if your drug is not covered in the way that you\u2019d like it to be covered.\n\u2022If your drug is not in the Drug Guide or if your drug is restricted, go to Section 5.2 to learn what you can do.\nSection 5.2 What can you do if your drug is not in the Drug Guide or if the drug is  \nrestricted in some way?\nIf your drug is not in the Drug Guide or is restricted, here are options:\n\u2022You may be able to get a temporary supply of the drug.\n\u2022You can change to another drug.\n\u2022You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.\nYou may be able to get a temporary supply\nUnder certain circumstances, the plan must provide a temporary supply of a drug that you are already taking. The \ntemporary supply gives you time to talk with your provider about the change in coverage and decide what to do.\nTo be eligible for a temporary supply, the drug you have been taking must no longer be in the plan\u2019s Drug Guide \nOR is now restricted in some way.\n\u2022If you are a new member, we will cover a temporary supply of your drug during the first 90 days of your \nmembership in the plan.\n\u2022If you were in the plan last year, we will cover a temporary supply of your drug during the first 90 days of \nthe calendar year.\n\u2022This temporary supply will be for a maximum of 30 days. If your prescription is written for fewer days, we will \nallow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be \nfilled at a network pharmacy. (Please note that the long-term care pharmacy may provide the drug in \nsmaller amounts at a time to prevent waste.)\n\u2022For those members who have been in the plan for more than 90 days and reside in a long-term care \n(LTC) facility and need a supply right away:\nWe will cover one 31-day emergency supply of a particular drug, or less if your prescription is written for \nfewer days. This is in addition to the above temporary supply situation.\n\u2022Transition Supply for Current Members with changes in treatment setting:\nIf the setting where you receive treatment changes during the plan year, you may need a short-term supply \nof your drugs during the transition. For example:\n\u2013You're discharged from a hospital or skilled nursing facility (where your Medicare Part A payments include \ndrug costs) and need a prescription from a pharmacy to continue taking a drug at home (using your Part D \nplan benefit); or\n\u2013You transfer from one skilled nursing facility to another.", "doc_id": "fbce9b0d-19e5-43b2-a508-d1880a608def", "embedding": null, "doc_hash": "4a910ec3c8965cec6bdc94317532a9609d35f15d92cdd08d4df16128ca5fbc4b", "extra_info": {"page_label": "95", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2747, "_node_type": "1"}, "relationships": {"1": "cf8444cc-83bf-4fb5-824a-9311ba0090ab"}}, "__type__": "1"}, "437e32e8-aa13-4b29-9877-c683b522e84a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 96\nChapter 5 Using the plan's coverage for Part D prescription drugs\nIf you do change treatment settings and need to fill a prescription at a pharmacy, we'll cover up to a 31-day \nsupply of a drug covered by Medicare Part D, so your drug treatment won't be interrupted.\nIf you change treatment settings multiple times within the same month, you may have to request an \nexception or prior authorization for continued coverage of your drug.\nPolicies for Temporary Drug Supplies During the Transition Period\nWe consider the first 90 days of the 2023 plan year a transition period if you're a new member, you changed \nplans, or there were changes in your drug coverage. As described above, there are several ways we make \nsure you can get a temporary supply of your drugs, if needed, during the transition period.\nDuring the first 90 days, you can get a temporary supply if you have a current prescription for a drug that's \nnot in our Drug Guide or requires prior authorization because of restrictions. The conditions for getting a \ntemporary supply are described below.\nOne-Time Transition Supply at a Retail or Mail-Order Pharmacy\nWe'll cover up to a 30-day supply of a drug covered by Medicare Part D. While you have your temporary \nsupply, talk to your doctor about what to do after you use the temporary supply. You may be able to switch to \na covered drug that would work just as well for you. You and your doctor can request an exception if you \nbelieve it's medically necessary to continue the same drug.\nTransition Supply if you're in a Long-Term Care Facility\nWe'll cover up to a 31-day supply of a drug covered by Medicare Part D. This coverage is available anytime \nduring the 90 day transition period, as long as your current prescription is filled at a pharmacy in a long-term \ncare facility.\nIf you have a problem getting a prescribed drug later in the plan year (after the 90 day transition period), \nwe'll cover up to a 31-day emergency supply of a drug covered by Medicare Part D. The emergency supply \nwill let you continue your drug treatment while you and your doctor request an exception or prior \nauthorization to continue.\nTransition Period Extension\nIf you have requested an exception or made an appeal for drug coverage, it may be possible to extend the \ntemporary transition period while we're processing your request. Call Customer Care (phone numbers are \nprinted on the back cover of this booklet) if you believe we need to extend the transition period to make sure \nyou continue to receive your drugs as needed.\nCosts for Temporary Supplies\nYour copayment or coinsurance for a temporary drug supply will be based on your plan's approved drug \ncost-sharing tiers. If you're eligible for the low-income subsidy (LIS) in 2023, your copayment or coinsurance \nwon't exceed your LIS limit.\nTo ask for a temporary supply, call Customer Care.\nDuring the time when you are using a temporary supply of a drug, you should talk with your provider to decide \nwhat to do when your temporary supply runs out. You have two options:\n1. You can change to another drug", "doc_id": "437e32e8-aa13-4b29-9877-c683b522e84a", "embedding": null, "doc_hash": "5ff29e0eac0a878b28a5e509a11958a3412b32450f4f5e47b5310f7068dddeaa", "extra_info": {"page_label": "96", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3157, "_node_type": "1"}, "relationships": {"1": "6cc43358-0eec-49fd-b048-dbc55893946f"}}, "__type__": "1"}, "f244d19d-0a15-422a-9e61-3065b17cf690": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 97\nChapter 5 Using the plan's coverage for Part D prescription drugs\nTalk with your provider about whether there is a different drug covered by the plan that may work just as well for \nyou. You can call Customer Care to ask for a list of covered drugs that treat the same medical condition. This list \ncan help your provider find a covered drug that might work for you.\n2. You can ask for an exception\nYou and your provider can ask the plan to make an exception and cover the drug in the way you would like it \ncovered. If your provider says that you have medical reasons that justify asking us for an exception, your provider \ncan help you request an exception. For example, you can ask the plan to cover a drug even though it is not in the \nplan\u2019s Drug Guide. Or you can ask the plan to make an exception and cover the drug without restrictions.\nIf you are a current member and a drug you are taking will be removed from the formulary or restricted in some \nway for next year, we will tell you about any change prior to the new year. You can ask for an exception before next \nyear and we will give you an answer within 72 hours after we receive your request (or your prescriber\u2019s supporting \nstatement). If we approve your request, we will authorize the coverage before the change takes effect.\nIf you and your provider want to ask for an exception, Chapter 9, Section 7.4 tells you what to do. It explains the \nprocedures and deadlines that have been set by Medicare to make sure your request is handled promptly and \nfairly.\nSECTION 6 What if your coverage changes for one of your drugs?\nSection 6.1 The Drug Guide can change during the year\nMost of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, \nthe plan can make some changes to the Drug Guide. For example, the plan might:\n\u2022Add or remove drugs from the Drug Guide.\n\u2022Add or remove a restriction on coverage for a drug.\n\u2022Replace a brand name drug with a generic drug.\nWe must follow Medicare requirements before we change the plan\u2019s Drug Guide. \nSection 6.2 What happens if coverage changes for a drug you are taking?\nInformation on changes to drug coverage\nWhen changes to the Drug Guide occur, we post information on our website about those changes. We also update \nour online Drug Guide on a regularly scheduled basis. Below we point out the times that you would get direct notice \nif changes are made to a drug that you are taking.\nChanges to your drug coverage that affect you during the current plan year\n\u2022A new generic drug replaces a brand name drug in the Drug Guide (or we change the cost-sharing tier \nor add new restrictions to the brand name drug or both)\n\u2013We may immediately remove a brand name drug in our Drug Guide if we are replacing it with a newly \napproved generic version of the same drug. The generic drug will appear on the same or lower ", "doc_id": "f244d19d-0a15-422a-9e61-3065b17cf690", "embedding": null, "doc_hash": "fa20ce910b45496a72470223f78b187f80741b97bb1fba47a97939ed30cebb02", "extra_info": {"page_label": "97", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2956, "_node_type": "1"}, "relationships": {"1": "1918193b-cc28-4ce8-bf80-30cc3f5c6c6f"}}, "__type__": "1"}, "e31a00a8-2539-4b3a-9754-64267526b91b": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 98\nChapter 5 Using the plan's coverage for Part D prescription drugs\ncost-sharing tier and with the same or fewer restrictions. We may decide to keep the brand name drug in \nour Drug Guide, but immediately move it to a higher cost-sharing tier or add new restrictions or both when \nthe new generic is added.\n\u2013We may not tell you in advance before we make that change\u2014even if you are currently taking the brand \nname drug. If you are taking the brand name drug at the time we make the change, we will provide you \nwith information about the specific change(s). This will also include information on the steps you may \ntake to request an exception to cover the brand name drug. You may not get this notice before we make \nthe change.\n\u2013You or your prescriber can ask us to make an exception and continue to cover the brand name drug for \nyou. For information on how to ask for an exception, see Chapter 9.\n\u2022Unsafe drugs and other drugs in the Drug Guide that are withdrawn from the market\n\u2013Sometimes a drug may be deemed unsafe or taken off the market for another reason. If this happens, we \nmay immediately remove the drug from the Drug Guide. If you are taking that drug, we will tell you right \naway.\n\u2013Your prescriber will also know about this change, and can work with you to find another drug for your \ncondition.\n\u2022Other changes to drugs in the Drug Guide\n\u2013We may make other changes once the year has started that affect drugs you are taking. For example, we \nmight add a generic drug that is not new to the market to replace a brand name drug in the Drug Guide or \nchange the cost-sharing tier or add new restrictions to the brand name drug or both. We also might make \nchanges based on FDA boxed warnings or new clinical guidelines recognized by Medicare.\n\u2013For these changes, we must give you at least 30 days\u2019 advance notice of the change or give you notice of \nthe change and a 30-day refill of the drug you are taking at a network pharmacy.\n\u2013After you receive notice of the change, you should work with your prescriber to switch to a different drug \nthat we cover or to satisfy any new restrictions on the drug you are taking.\n\u2013You or your prescriber can ask us to make an exception and continue to cover the drug for you. For \ninformation on how to ask for an exception, see Chapter 9.\nChanges to the Drug Guide that do not affect you during the plan year\nWe may make certain changes to the Drug Guide that are not described above. In these cases, the changes will not \napply to you if you are taking the drug when the change is made; however, these changes will likely affect you \nstarting January 1 of the next plan year if you stay in the same plan.\nIn general, changes that will not affect you during the current plan year are:\n\u2022We move your drug into a higher cost-sharing tier\n\u2022We put a new restriction on the use of  your drug\n\u2022We remove your drug from the Drug Guide\nIf any of these changes happen for a drug you are taking (except for market withdrawal, a generic drug \nreplacing a brand name drug, or other change noted in the sections above), then the change won\u2019t affect your ", "doc_id": "e31a00a8-2539-4b3a-9754-64267526b91b", "embedding": null, "doc_hash": "0e5513fc0961c5536fbe491af36e92cc39a759cf583fa33164c9f4c8d6bd1056", "extra_info": {"page_label": "98", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3177, "_node_type": "1"}, "relationships": {"1": "837f3afc-a706-47d5-9f1d-10d0b84b427a"}}, "__type__": "1"}, "6225ff2c-d242-4f5b-a40b-e2217e03a1a7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 99\nChapter 5 Using the plan's coverage for Part D prescription drugs\nuse or what you pay as your share of the cost until January 1 of the next year. Until that date, you probably \nwon\u2019t see any increase in your payments or any added restriction to your use of the drug.\nWe will not tell you about these types of changes directly during the current plan year. You will need to check the \nDrug Guide for the next plan year (when the list is available during the open enrollment period) to see if there are \nany changes to the drugs you are taking that will impact you during the next plan year.\nSECTION 7 What types of drugs are not covered by the plan?\nSection 7.1 Types of drugs we do not cover\nThis section tells you what kinds of prescription drugs are \u201cexcluded.\u201d This means Medicare does not pay for these \ndrugs.  \nIf you appeal and the requested drug is found not to be excluded under Part D, we will pay for or cover it. (For \ninformation about appealing a decision, go to Chapter 9.) If the drug excluded by our plan is also excluded by \nMedicaid, you must pay for it yourself.\nHere are three general rules about drugs that Medicare drug plans will not cover under Part D:\n\u2022Our plan's Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B.\n\u2022Our plan cannot cover a drug purchased outside the United States or its territories.\n\u2022Our plan usually cannot cover off-label use. \"Off-label use\" is any use of the drug other than those indicated \non a drug's label as approved by the Food and Drug Administration.\n\u2013Coverage for \"off-label use\" is allowed only when the use is supported by certain references, such as the \nAmerican Hospital Formulary Service Drug Information and the DRUGDEX Information System.\nIn addition, by law, the following categories of drugs listed below are not covered by Medicare. However, some of \nthese drugs may be covered for you under your Medicaid drug coverage. Please contact MO HealthNet (Medicaid) \nfor more information. Contact information for MO HealthNet (Medicaid) can be found in \"Exhibit A\" in the back of \nthis document.\n\u2022Non-prescription drugs (also called over-the-counter drugs)\n\u2022Drugs used to promote fertility\n\u2022Drugs used for the relief of cough or cold symptoms\n\u2022Drugs used for cosmetic purposes or to promote hair growth\n\u2022Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations\n\u2022Drugs used for the treatment of sexual or erectile dysfunction\n\u2022Drugs used for treatment of anorexia, weight loss, or weight gain\n\u2022Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be \npurchased exclusively from the manufacturer as a condition of sale", "doc_id": "6225ff2c-d242-4f5b-a40b-e2217e03a1a7", "embedding": null, "doc_hash": "c10c09162acf9d6a2e0adb4e2271d931a26147bc606502a18c60571083c66d55", "extra_info": {"page_label": "99", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2797, "_node_type": "1"}, "relationships": {"1": "8461dade-a8c0-4999-8679-7110164daafc"}}, "__type__": "1"}, "2e76d6bc-049b-40d1-9ca3-f969631c63b0": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 100\nChapter 5 Using the plan's coverage for Part D prescription drugs\nSECTION 8 Filling a prescription\nSection 8.1 Provide your membership information\nTo fill your prescription, provide both your plan membership information and your MO HealthNet (Medicaid) \nmembership information, which can be found on your membership cards, at the network pharmacy you choose. \nThe network pharmacy will automatically bill the plan for your drug. You will need to pay the pharmacy your share \nof the cost when you pick up your prescription.\nBe sure to show your MO HealthNet (Medicaid) ID card in addition to your Humana Gold Plus SNP-DE H0028-015 \n(HMO-POS D-SNP) membership card to make your provider aware that you may have additional coverage.\nSection 8.2 What if you don't have your membership information with you?\nIf you don't have your plan membership information with you when you fill your prescription, you or the pharmacy \ncan call the plan to get the necessary information.\nIf the pharmacy is not able to get the necessary information, you may have to pay the full cost of the \nprescription when you pick it up. (You can then ask us to reimburse you for our share. See Chapter 7, Section 2 \nfor information about how to ask the plan for reimbursement.)\nSECTION 9 Part D drug coverage in special situations\nSection 9.1 What if you're in a hospital or a skilled nursing facility for a stay that is  \ncovered by the plan?\nIf you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we will generally cover \nthe cost of your prescription drugs during your stay. Once you leave the hospital or skilled nursing facility, the plan \nwill cover your prescription drugs as long as the drugs meet all of our rules for coverage described in this Chapter.\nSection 9.2 What if you're a resident in a long-term care (LTC) facility?\nUsually, a long-term care (LTC) facility (such as a nursing home) has its own pharmacy, or uses a pharmacy that \nsupplies drugs for all of its residents. If you are a resident of a LTC facility, you may get your prescription drugs \nthrough the facility\u2019s pharmacy or the one it uses, as long as it is part of our network.\nCheck your Provider Directory to find out if your LTC facility\u2019s pharmacy or the one that it uses is part of our network. \nIf it isn\u2019t, or if you need more information or assistance, please contact Customer Care. If you are in an LTC facility, \nwe must ensure that you are able to routinely receive your Part D benefits through our network of LTC pharmacies.\nWhat if you\u2019re a resident in a long-term care (LTC) facility and need a drug that is not in our Drug Guide or \nis restricted in some way?\nPlease refer to Section 5.2 about a temporary or emergency supply.", "doc_id": "2e76d6bc-049b-40d1-9ca3-f969631c63b0", "embedding": null, "doc_hash": "d917042dc9e8f193af92aac0d78601c965972a8ede1f23b35d1f7784a2f3539b", "extra_info": {"page_label": "100", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2820, "_node_type": "1"}, "relationships": {"1": "6f5e62fb-5ea4-4e2e-9826-12f28138f0ab"}}, "__type__": "1"}, "5942814d-cd56-47d3-8982-29bfe3186185": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 101\nChapter 5 Using the plan's coverage for Part D prescription drugs\nSection 9.3 What if you're also getting drug coverage from an employer or retiree  \ngroup plan?\nIf you currently have other prescription drug coverage through your (or your spouse\u2019s) employer or retiree group, \nplease contact that group\u2019s benefits administrator. He or she can help you determine how your current \nprescription drug coverage will work with our plan.\nIn general, if you have employee or retiree group coverage, the drug coverage you get from us will be secondary to \nyour group coverage. That means your group coverage would pay first.\nSpecial note about 'creditable coverage':\nEach year your employer or retiree group should send you a notice that tells if your prescription drug coverage for \nthe next calendar year is \"creditable\".\nIf the coverage from the group plan is \"creditable,\" it means that the plan has drug coverage that is expected to \npay, on average, at least as much as Medicare's standard prescription drug coverage.\nKeep this notice about creditable coverage, because you may need it later. If you enroll in a Medicare plan that \nincludes Part D drug coverage, you may need this notice to show that you have maintained creditable coverage. If \nyou didn\u2019t get the creditable coverage notice, request a copy from your employer or retiree plan\u2019s benefits \nadministrator or the employer or union.\nSection 9.4 What if you're in Medicare-certified hospice?\nHospice and our plan do not cover the same drug at the same time. If you are enrolled in Medicare hospice and \nrequire certain drugs (e.g.,anti-nausea, laxative, pain medication or anti-anxiety drugs) that are not covered by \nyour hospice because it is unrelated to your terminal illness and related conditions, our plan must receive \nnotification from either the prescriber or your hospice provider that the drug is unrelated before our plan can cover \nthe drug. To prevent delays in receiving these drugs that should be covered by our plan, ask your hospice provider \nor prescriber to provide notification before your prescription is filled.\nIn the event you either revoke your hospice election or are discharged from hospice, our plan should cover your \ndrugs as explained in this document. To prevent any delays at a pharmacy when your Medicare hospice benefit \nends, bring documentation to the pharmacy to verify your revocation or discharge.\nSECTION 10 Programs on drug safety and managing medications\nSection 10.1 Programs to help members use drugs safely\nWe conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care.\nWe do a review each time you fill a prescription. We also review our records on a regular basis. During these \nreviews, we look for potential problems such as:\n\u2022Possible medication errors\n\u2022Drugs that may not be necessary because you are taking another drug to treat the same condition", "doc_id": "5942814d-cd56-47d3-8982-29bfe3186185", "embedding": null, "doc_hash": "d7b289c71513bfc15a312666f9817024217bcef814d4657d4504c570ba26c200", "extra_info": {"page_label": "101", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2993, "_node_type": "1"}, "relationships": {"1": "56776356-42dc-468d-8fa1-bf8805380591"}}, "__type__": "1"}, "65415d54-9f43-43a6-85a1-48bf1e9d6212": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 102\nChapter 5 Using the plan's coverage for Part D prescription drugs\n\u2022Drugs that may not be safe or appropriate because of your age or gender\n\u2022Certain combinations of drugs that could harm you if taken at the same time\n\u2022Prescriptions for drugs that have ingredients you are allergic to\n\u2022Possible errors in the amount (dosage) of a drug you are taking\n\u2022Unsafe amounts of opioid pain medications\nIf we see a possible problem in your use of medications, we will work with your provider to correct the problem.\nSection 10.2 Drug Management Program (DMP) to help members safely use their opioid  \nmedications\nWe have a program that helps make sure our members safely use prescription, opioid and other frequently abused \nmedications. This program is called a Drug Management Program (DMP). If you use opioid medications that you \nget from several doctors or pharmacies, or if you had a recent opioid overdose, we may talk to your doctors to \nmake sure your use of opioid medications is appropriate and medically necessary. Working with your doctors, if we \ndecide your use of prescription opioid or benzodiazepine medications is not safe, we may limit how you can get \nthose medications. If we place you in our DMP, the limitations may be:\n\u2022Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain \npharmacy(ies)\n\u2022Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain doctor(s)\n\u2022Limiting the amount of opioid or benzodiazepine medications we will cover for you\nIf we plan on limiting how you may get these medications or how much you can get, we will send you a letter in \nadvance. The letter will explain the limitations we think should apply to you. You will have an opportunity to tell us \nwhich doctors or pharmacies you prefer to use, and about any other information you think is important for us to \nknow. After you\u2019ve had the opportunity to respond, if we decide to limit your coverage for these medications, we \nwill send you another letter confirming the limitation. If you think we made a mistake or you disagree with our \ndetermination or with the limitation, you and your prescriber have the right to ask us for an appeal. If you appeal, \nwe will review your case and give you a decision. If we continue to deny any part of your request related to the \nlimitations that apply to your access to medications, we will automatically send your case to an independent \nreviewer outside of our plan. See Chapter 9 for information about how to ask for an appeal.\nYou will not be placed in our DMP if you have certain medical conditions, such as active cancer-related pain or \nsickle cell disease, you are receiving hospice, palliative, or end-of-life care, or live in a long-term care facility.\nSection 10.3 Medication Therapy Management (MTM) and other programs to help  \nmembers manage their medications\nWe have programs that can help our members with complex health needs. One program is called Medication \nTherapy Management (MTM) program. These programs are voluntary and free. A team of pharmacists and doctors \ndeveloped the programs for us to help make sure that our members get the most benefit from the drugs they take.", "doc_id": "65415d54-9f43-43a6-85a1-48bf1e9d6212", "embedding": null, "doc_hash": "f2bdc5da2fcbe3733afbf964d030b7ce4e98b7ddb39e969f0321bce7cf5faaa9", "extra_info": {"page_label": "102", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3298, "_node_type": "1"}, "relationships": {"1": "47792a3d-13a2-4ab1-8dd2-137025fe3bfe"}}, "__type__": "1"}, "41599352-2737-4c08-84c4-e2bf85bccad4": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 103\nChapter 5 Using the plan's coverage for Part D prescription drugs\nSome members who take medications for different medical conditions and have high drug costs, or are in a DMP to \nhelp members use their opioids safely may be able to get services through an MTM program. A pharmacist or other \nhealth professional will give you a comprehensive review of all your medications. During the review, you can talk \nabout your medications, your costs, and any problems or questions you have about your prescription and \nover-the-counter medications. You\u2019ll get a written summary which has a recommended to-do list that includes \nsteps you should take to get the best results from your medications. You\u2019ll also get a medication list that will \ninclude all the medications you\u2019re taking, how much you take, and when and why you take them. In addition, \nmembers in the MTM program will receive information on the safe disposal of prescription medications that are \ncontrolled substances.\nIt\u2019s a good idea to talk to your doctor about your recommended to-do list and medication list. Bring the summary \nwith you to your visit or anytime you talk with your doctors, pharmacists, and other health care providers. Also, \nkeep your medication list up to date and with you (for example, with your ID) in case you go to the hospital or \nemergency room.\nIf we have a program that fits your needs, we will automatically enroll you in the program and send you \ninformation. If you decide not to participate, please notify us and we will withdraw you. If you have any questions \nabout these programs, please contact  Customer Care.", "doc_id": "41599352-2737-4c08-84c4-e2bf85bccad4", "embedding": null, "doc_hash": "df71db93871e1108faad7ed663f9fee1717c3fed061896ff192253692cc4c82a", "extra_info": {"page_label": "103", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1692, "_node_type": "1"}, "relationships": {"1": "e093c856-b912-422e-813e-50e2b05f092b"}}, "__type__": "1"}, "39c6f6f6-c75c-4b2a-9e20-401866e441ec": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 104\nChapter 6. What you pay for your Part D prescription drugsEOC076\nCHAPTER 6:\nWhat you pay for your Part D \nprescription drugs", "doc_id": "39c6f6f6-c75c-4b2a-9e20-401866e441ec", "embedding": null, "doc_hash": "c1e37aacfbb01e039ec5bcf6a5e909cf3258669c26e1a9a131dc25b0fb99e544", "extra_info": {"page_label": "104", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 208, "_node_type": "1"}, "relationships": {"1": "1411bed5-47b7-4ef0-8938-f750b1ce02cc"}}, "__type__": "1"}, "fed53ac8-ba52-4852-b451-2607b685d940": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 105\nChapter 6. What you pay for your Part D prescription drugs\nHow can you get information about your drug costs?\nBecause you are eligible for Medicaid, you qualify for and are getting \u201cExtra Help\u201d from Medicare to pay  \nfor your prescription drug plan costs. Because you are in the \u201cExtra Help\u201d program, some information in  \nthis Evidence of Coverage about the costs for Part D prescription drugs does not apply to you. \nSECTION 1 Introduction\nSection 1.1 Use this chapter together with other materials that explain your drug  \ncoverage\nThis chapter focuses on what you pay for Part D prescription drugs. To keep things simple, we use \"drug\" in this \nchapter to mean a Part D prescription drug. As explained in Chapter 5, not all drugs are Part D drugs \u2013 some drugs \nare excluded from Part D coverage by law. Some of the drugs excluded from Part D coverage are covered under \nMedicare Part A or Part B or under Medicaid. \nTo understand the payment information, you need to know what drugs are covered, where to fill your \nprescriptions, and what rules to follow when you get your covered drugs. Chapter 5, Sections 1 through 4 explain \nthese rules.\nSection 1.2 Types of out-of-pocket costs you may pay for covered drugs\nThere are different types of out-of-pocket costs for Part D drugs. The amount that you pay for a drug is called \"cost \nsharing,\" and there are three ways you may be asked to pay.\n\u2022The \"deductible\" is the amount you pay for drugs before our plan begins to pay its share.\n\u2022\"Copayment\" is a fixed amount you pay each time you fill a prescription.\n\u2022\"Coinsurance\" is a percentage of the total cost you pay each time you fill a prescription.\nSection 1.3 How Medicare calculates your out-of-pocket costs\nMedicare has rules about what counts and what does not count toward your out-of-pocket costs. Here are the \nrules we must follow to keep track of your out-of-pocket costs.\nThese payments are included in your out-of-pocket costs\nYour out-of-pocket costs include the payments listed below (as long as they are for Part D covered drugs and \nyou followed the rules for drug coverage that are explained in Chapter 5):\n\u2022The amount you pay for drugs when you are in any of the following drug payment stages:\n\u2013The Deductible Stage\n\u2013The Initial Coverage Stage", "doc_id": "fed53ac8-ba52-4852-b451-2607b685d940", "embedding": null, "doc_hash": "a657696a04d29fe680a1e958bd61f23eb6cf80c9d248bc0947062cc3115921e4", "extra_info": {"page_label": "105", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2349, "_node_type": "1"}, "relationships": {"1": "abf5a3d4-e5ee-40c4-8c58-acb5e30c45c0"}}, "__type__": "1"}, "3f8c937e-de43-4299-bb46-41244b9da479": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 106\nChapter 6. What you pay for your Part D prescription drugs\n\u2013The Coverage Gap Stage\n\u2022Any payments you made during this calendar year as a member of a different Medicare prescription drug \nplan before you joined our plan.\nIt matters who pays:\n\u2022If you make these payments yourself, they are included in your out-of-pocket costs.\n\u2022These payments are also included if they are made on your behalf by certain other individuals or \norganizations. This includes payments for your drugs made by a friend or relative, by most charities, by AIDS \ndrug assistance programs, by a State Pharmaceutical Assistance Program that is qualified by Medicare, or by \nthe Indian Health Service.\n\u2022Some payments made by the Medicare Coverage Gap Discount Program are included. The amount the \nmanufacturer pays for your brand name drugs is included. But the amount the plan pays for your generic \ndrugs is not included.\nMoving on to the Catastrophic Coverage Stage:\nIf you (or those paying on your behalf) have spent a total of $7,400 in out-of-pocket costs within the calendar \nyear, you will move from the Coverage Gap Stage to the Catastrophic Coverage Stage.\nThese payments are not included in your out-of-pocket costs\nYour out-of-pocket costs do not include any of these types of payments:\n\u2022Your monthly premium.\n\u2022Drugs you buy outside the United States and its territories.\n\u2022Drugs that are not covered by our plan.\n\u2022Drugs you get at an out-of-network pharmacy that do not meet the plan\u2019s requirements for out-of-network \ncoverage.\n\u2022Drugs covered by Medicaid only.\n\u2022Non-Part D drugs, including prescription drugs covered by Part A or Part B and other drugs excluded from \ncoverage by Medicare.\n\u2022Payments you make toward prescription drugs not normally covered in a Medicare Prescription Drug Plan.\n\u2022Payments made by the plan for your brand or generic drugs while in the Coverage Gap.\n\u2022Payments for your drugs that are made by group health plans including employer health plans.\n\u2022Payments for your drugs that are made by certain insurance plans and government-funded health programs \nsuch as TRICARE and the Veterans Affairs.\n\u2022Payments for your drugs made by a third-party with a legal obligation to pay for prescription costs (for \nexample, workers compensation).", "doc_id": "3f8c937e-de43-4299-bb46-41244b9da479", "embedding": null, "doc_hash": "24c1fa4b9b392f00a23482b2da291891523e363af52f3fc84820e5968c5cb9ad", "extra_info": {"page_label": "106", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2327, "_node_type": "1"}, "relationships": {"1": "2effd3c2-524f-445e-9ba4-82c6a58828b2"}}, "__type__": "1"}, "1159d90e-6316-4341-aabe-d1c0bae59e41": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 107\nChapter 6. What you pay for your Part D prescription drugs\nReminder: If any other organization such as the ones listed above pays part or all of your out-of-pocket costs for \ndrugs, you are required to tell our plan by calling Customer Care.\nHow can you keep track of your out-of-pocket total?\n\u2022We will help you. The SmartSummary you receive includes the current amount of your out-of-pocket costs. \nIf this amount reaches $7,400, this report will tell you that you have left the Coverage Gap Stage and have \nmoved on to the Catastrophic Coverage Stage.\n\u2022Make sure we have the information we need. Section 3.2 tells what you can do to help make sure that our \nrecords of what you have spent are complete and up to date.\nSECTION 2 What you pay for a drug depends on which \"drug payment  \nstage\" you are in when you get the drug\nSection 2.1 What are the drug payment stages for Humana Gold Plus SNP-DE  \nH0028-015 (HMO-POS D-SNP) members?\nThere are four \"drug payment stages\" for your Medicare Part D prescription drug coverage under Humana Gold Plus \nSNP-DE H0028-015 (HMO-POS D-SNP). How much you pay depends on what stage you are in when you get a \nprescription filled or refilled. Details of each stage are in Sections 4 through 7 of this chapter. The stages are:\nStage 1: Yearly Deductible Stage\nStage 2: Initial Coverage Stage\nStage 3: Coverage Gap Stage\nStage 4: Catastrophic Coverage Stage\nImportant Message About What You Pay for Insulin - You won\u2019t pay more than $35 for a one-month (up to \n30-day) supply of each Part D insulin product covered by our plan, no matter what cost-sharing tier it\u2019s on, even if \nyou haven\u2019t paid your deductible. Please see your Prescription Drug Guide to find all Part D insulins covered by your \nplan.\nImportant Note for the $0 Rx Copay Benefit: If you qualify for \"Extra Help\", you will pay nothing for all Medicare \ncovered Part D prescription drugs on all tiers and through all stages.\nSECTION 3 We send you reports that explain payments for your drugs and  \nwhich payment stage you are in\nSection 3.1 We send you a monthly summary called the SmartSummary\nOur plan keeps track of the costs of your prescription drugs and the payments you have made when you get your \nprescriptions filled or refilled at the pharmacy. This way, we can tell you when you have moved from one drug \npayment stage to the next. In particular, there are two types of costs we keep track of:", "doc_id": "1159d90e-6316-4341-aabe-d1c0bae59e41", "embedding": null, "doc_hash": "6ff58a5a0f7b5b63cec697fce0666d7b9f689b03794f1de00fae2dd0fc4cadb1", "extra_info": {"page_label": "107", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2493, "_node_type": "1"}, "relationships": {"1": "7104ddbd-03f5-4a85-9515-a888ea1d0515"}}, "__type__": "1"}, "84a4427c-5493-436b-84fb-3f058676a05e": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 108\nChapter 6. What you pay for your Part D prescription drugs\n\u2022We keep track of how much you have paid. This is called your \"out-of-pocket\" cost.\n\u2022We keep track of your \"total drug costs.\" This is the amount you pay out-of-pocket or others pay on your \nbehalf plus the amount paid by the plan.\nIf you have had one or more prescriptions filled through the plan during the previous month we will send you a \nSmartSummary. The SmartSummary includes:\n\u2022Information for that month. This report gives the payment details about the prescriptions you have filled \nduring the previous month. It shows the total drug costs, what the plan paid, and what you and others on \nyour behalf paid.\n\u2022Totals for the year since January 1. This is called \"year-to-date\" information. It shows the total drug costs \nand total payments for your drugs since the year began.\n\u2022Drug price information. This information will display the total drug price, and information about increases in \nprice from first fill for each prescription claim of the same quantity.\n\u2022Available lower cost alternative prescriptions. This will include information about other available drugs \nwith lower cost sharing for each prescription claim.\nSection 3.2 Help us keep our information about your drug payments up to date\nTo keep track of your drug costs and the payments you make for drugs, we use records we get from pharmacies. \nHere is how you can help us keep your information correct and up to date:\n\u2022Show your membership card every time you get a prescription filled. This helps us make sure we know \nabout the prescriptions you are filling and what you are paying.\n\u2022Make sure we have the information we need. There are times you may pay for the entire cost of a \nprescription drug. In these cases, we will not automatically get the information we need to keep track of your \nout-of-pocket costs. To help us keep track of your out-of-pocket costs, give us copies of your receipts. Here \nare examples of when you should give us copies of your drug receipts:\n\u2013When you purchase a covered drug at a network pharmacy at a special price or using a discount card that \nis not part of our plan's benefit\n\u2013When you made a copayment for drugs that are provided under a drug manufacturer patient assistance \nprogram\n\u2013Any time you have purchased covered drugs at out-of-network pharmacies or other times you have paid \nthe full price for a covered drug under special circumstances\nIf you are billed for a covered drug, you can ask our plan to pay our share of the cost. For instructions on how \nto do this, go to Chapter 7, Section 2.\n\u2022Send us information about the payments others have made for you. Payments made by certain other \nindividuals and organizations also count toward your out-of-pocket costs. For example, payments made by a \nState Pharmaceutical Assistance Program, an AIDS drug assistance program (ADAP), the Indian Health \nService, and most charities count toward your out-of-pocket costs. Keep a record of these payments and \nsend them to us so we can track your costs.", "doc_id": "84a4427c-5493-436b-84fb-3f058676a05e", "embedding": null, "doc_hash": "7c235946b54020e23a1de862209e7b250dbe965bb18ea11fc64a8b6c17883132", "extra_info": {"page_label": "108", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3112, "_node_type": "1"}, "relationships": {"1": "5ba809d3-89d1-41c0-9909-d1133f1bcfae"}}, "__type__": "1"}, "6745e4fc-928e-43cc-a218-ef44b8df1cf6": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 109\nChapter 6. What you pay for your Part D prescription drugs\n\u2022Check the written report we send you. When you receive the SmartSummary look it over to be sure the \ninformation is complete and correct. If you think something is missing, or you have any questions, please call \nus at Customer Care. Be sure to keep these reports. \nSECTION 4 During the Deductible Stage, you pay the full cost of your drugs\nMost of our members get \"Extra Help\" with their prescription drug costs, so the Deductible Stage does not apply to \nmany of them. If you receive \"Extra Help,\" you will:\n\u2022Not pay a deductible\nIf you do not receive \"Extra Help,\" the Deductible Stage is the first payment stage for your drug coverage. This \nstage begins when you fill your first prescription in the year. When you are in this payment stage, you must pay \nthe full cost of your drugs until you reach the plan\u2019s deductible amount, which is $505 for 2023. The \"full cost\" is \nusually lower than the normal full price of the drug, since our plan has negotiated lower costs for most drugs at \nnetwork pharmacies.\nOnce you have paid $505 for your drugs, you leave the Deductible Stage and move on to the Initial Coverage \nStage.\nImportant Message About What You Pay for Insulin - You won\u2019t pay more than $35 for a one-month (up to \n30-day) supply of each Part D insulin product covered by our plan, no matter what cost-sharing tier it\u2019s on, even if \nyou haven\u2019t paid your deductible. \nSECTION 5 During the Initial Coverage Stage, the plan pays its share of your  \ndrug costs and you pay your share\nSection 5.1 What you pay for a drug depends on the drug and where you fill your  \nprescription\nDuring the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription drugs, and you \npay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug \nand where you fill your prescription.\nYour pharmacy choices\nHow much you pay for a drug depends on whether you get the drug from:\n\u2022A network retail pharmacy\n\u2022A pharmacy that is not in the plan's network. We cover prescriptions filled at out-of-network pharmacies in \nonly limited situations. Please see Chapter 5, Section 2.5 to find out when we cover a prescription filled at an \nout-of-network pharmacy.\n\u2022The plan's mail-order pharmacy\nFor more information about these pharmacy choices and filling your prescriptions, see Chapter 5 and the plan's \nProvider Directory.", "doc_id": "6745e4fc-928e-43cc-a218-ef44b8df1cf6", "embedding": null, "doc_hash": "0da2ebad263ff5e9f8c2f022660572ffd8217d3c53cde8e4050462a7e2e4504a", "extra_info": {"page_label": "109", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2532, "_node_type": "1"}, "relationships": {"1": "2fe869cf-e6cc-4ddb-b046-c581b98dc151"}}, "__type__": "1"}, "8d69574d-6e2c-4683-b6f2-8c6988e9587e": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 110\nChapter 6. What you pay for your Part D prescription drugs\nSection 5.2 A table that shows your costs for a one-month supply of a drug\nImportant Note for the $0 Rx Copay Benefit: If you qualify for \"Extra Help\", you will pay nothing for all Medicare \ncovered Part D prescription drugs on all tiers and through all stages.\nDuring the Initial Coverage Stage, your share of the cost of a covered drug will be either a copayment or \ncoinsurance.\nAs shown in the table below, the amount of the copayment or coinsurance depends on the cost-sharing tier. \nSometimes the cost of the drug is lower than your copayment. In these cases, you pay the lower price for the drug \ninstead of the copayment.\nYour share of the cost when you get a one-month supply of a covered Part D prescription drug:\nImportant Note for the $0 Rx Copay Benefit: If you qualify for \u201cExtra Help\u201d, you will pay nothing for all Medicare  \ncovered Part D prescription drugs on all tiers and through all stages.\nTierRetail cost sharing  \n(in-network) \n(up to a 30-day  \nsupply)Mail-order cost  \nsharing (in-network) \n(up to a 30-day  \nsupply)Long-term care (LTC)  \ncost sharing  \n(in-network) \n(up to a 31-day  \nsupply)Out-of- network cost  \nsharing  \n(Coverage is limited  \nto certain situations;  \nsee Chapter 5 for  \ndetails.) (up to a  \n30-day supply)\nCost-Sharing \nAll Drug Tiers25% 25% 25% 25%\nN/A\nIn addition to the cost sharing listed above for your Part D prescription drugs, the table below tells you what you  \nwill pay for a one-month (up to a 30-day) supply of Part D covered insulin while in the Initial Coverage Stage.\nTierRetail cost sharing  \n(in-network) (up to  \na 30-day supply)Mail-order cost  \nsharing  \n(in-network) (up to  \na 30-day supply)Long-term care  \n(LTC) cost sharing  \n(in-network) (up to  \na 31-day supply)Out-of-network  \ncost sharing  \n(Coverage is limited  \nto certain  \nsituations; see  \nChapter 5 for  \ndetails.) (up to a  \n30-day supply)\nCost-Sharing All  \nTiers Insulin25% up to $35 25% up to $35 25% up to $35 25% up to $35\nN/A\nSection 5.3 If your doctor prescribes less than a full month's supply, you may not have  \nto pay the cost of the entire month's supply\nTypically, the amount you pay for a prescription drug covers a full month\u2019s supply. There may be times when you or \nyour doctor would like you to have less than a month\u2019s supply of a drug (for example, when you are trying a ", "doc_id": "8d69574d-6e2c-4683-b6f2-8c6988e9587e", "embedding": null, "doc_hash": "f5bfae21901bb04ba783ebfc710130da4ad3ba0b6014ccc992650a8d2ba91de3", "extra_info": {"page_label": "110", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2472, "_node_type": "1"}, "relationships": {"1": "c5fbd5a8-c1f1-4f2c-a045-cfcb044df77c"}}, "__type__": "1"}, "85ccc68a-0ab0-413d-8a3d-b2f911747cba": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 111\nChapter 6. What you pay for your Part D prescription drugs\nmedication for the first time). You can also ask your doctor to prescribe, and your pharmacist to dispense, less than \na full month\u2019s supply of your drugs, if this will help you better plan refill dates for different prescriptions.\nIf you receive less than a full month\u2019s supply of certain drugs, you will not have to pay for the full month\u2019s supply.\n\u2022If you are responsible for coinsurance, you pay a percentage of the total cost of the drug. Since the \ncoinsurance is based on the total cost of the drug, your cost will be lower since the total cost for the drug will \nbe lower.\n\u2022If you are responsible for a copayment for the drug, you will only pay for the number of days of the drug that \nyou receive instead of the whole month. We will calculate the amount you pay per day for your drug (the \n\"daily cost-sharing rate\") and multiply it by the number of days of the drug you receive.\nSection 5.4 A table that shows your costs for a long-term (up to a 90-day) supply of a  \ndrug\nImportant Note for the $0 Rx Copay Benefit: If you qualify for \"Extra Help\", you will pay nothing for all Medicare \ncovered Part D prescription drugs on all tiers and through all stages.\nFor some drugs, you can get a long-term supply (also called an \"extended supply\"). A long-term supply is up to a \n90-day supply.\nThe table below shows what you pay when you get a long-term supply of a drug.\nSpecialty drugs or other drugs deemed ineligible by the plan do not qualify for an extended supply. Please see your \nPrescription Drug Guide to find out what drugs are restricted.\nYour share of the cost when you get a long-term supply of a covered Part D prescription drug:\nImportant Note for the $0 Rx Copay Benefit: If you qualify for \u201cExtra Help\u201d, you will pay nothing for all Medicare \ncovered Part D prescription drugs on all tiers and through all stages.\nTierRetail cost sharing (in-network) \n(up to a 90-day supply)Mail-order cost sharing (in-network) \n(up to a 90-day supply)\nCost-Sharing \nAll Drug Tiers25% 25%\nN/A\nIn addition to the cost sharing listed above for your Part D prescription drugs, the table below tells you what you  \nwill pay for a long-term (up to a 90-day) supply of Part D covered insulin while in the Initial Coverage Stage.\nTierRetail cost sharing (in-network) (up to a  \n90-day supply)Mail-order cost sharing (in-network) (up  \nto a 90-day supply)\nCost-Sharing All  \nTiers Insulin25% up to $105 25% up to $105\nN/A", "doc_id": "85ccc68a-0ab0-413d-8a3d-b2f911747cba", "embedding": null, "doc_hash": "c92a285dd9e91fe005d2f3f3f7755d35b3024c517d5dc829cbf99508f5766058", "extra_info": {"page_label": "111", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2564, "_node_type": "1"}, "relationships": {"1": "e6007b0b-793f-433e-a0fa-f93addf09297"}}, "__type__": "1"}, "4f344f1a-0f87-4601-a5bc-ff5dddee4ad6": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 112\nChapter 6. What you pay for your Part D prescription drugs\nSection 5.5 You stay in the Initial Coverage Stage until your total drug costs for the  \nyear reach $4,660\nYou stay in the Initial Coverage Stage until the total amount for the prescription drugs you have filled reaches the \n$4,660 limit for the Initial Coverage Stage.\nThe SmartSummary that you receive will help you keep track of how much you, the plan, and any third parties, have \nspent on your behalf during the year. Many people do not reach the $4,660 limit in a year.\nWe will let you know if you reach this amount. If you do reach this amount, you will leave the Initial Coverage \nStage and move on to the Coverage Gap Stage. See Section 1.3 on how Medicare calculates your out-of-pocket \ncosts.\nSECTION 6 Costs in the Coverage Gap Stage  \nImportant Note for the $0 Rx Copay Benefit: If you qualify for \"Extra Help\", you will pay nothing for all Medicare  \ncovered Part D prescription drugs on all tiers and through all stages.\nWhen you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program provides manufacturer \ndiscounts on brand name drugs. You pay 25% of the negotiated price and a portion of the dispensing fee for brand \nname drugs. Both the amount you pay and the amount discounted by the manufacturer count toward your \nout-of-pocket costs as if you had paid them and moves you through the coverage gap.\nYou also receive some coverage for generic drugs. You pay no more than 25% of the cost for generic drugs and the \nplan pays the rest. Only the amount you pay counts and moves you through the coverage gap.\nYou continue paying these costs until your yearly out-of-pocket payments reach a maximum amount that \nMedicare has set. Once you reach this amount, $7,400, you leave the Coverage Gap Stage and move to the \nCatastrophic Coverage Stage. \nMedicare has rules about what counts and what does not count towards your out-of-pocket costs (Section 1.3). \nYou won\u2019t pay more than $35 for a one-month (up to 30-day) supply of each Part D insulin product covered by our \nplan, no matter what cost-sharing tier it\u2019s on while you are in the Coverage Gap Stage. ", "doc_id": "4f344f1a-0f87-4601-a5bc-ff5dddee4ad6", "embedding": null, "doc_hash": "ed79265abc5e8e20cd2a7eff11b84d814f1237bdf293d469ee6b48e9c40c53dd", "extra_info": {"page_label": "112", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2236, "_node_type": "1"}, "relationships": {"1": "641ee814-2572-41d2-b321-e25ad41c3bc6"}}, "__type__": "1"}, "3549f939-c86b-48a7-bb0f-f31ce6a19f3a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 113\nChapter 6. What you pay for your Part D prescription drugs\nSECTION 7 During the Catastrophic Coverage Stage, the plan pays most of  \nthe costs for your drugs\nImportant Note for the $0 Rx Copay Benefit: If you qualify for \u201cExtra Help\u201d, you will pay nothing for all Medicare \ncovered Part D prescription drugs on all tiers and through all stages.\nYou enter the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $7,400 limit for the \ncalendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of \nthe calendar year.\nDuring this stage, the plan will pay all of the costs for your drugs.\nThe $0 Rx Copay Benefit does not apply to Medicare excluded drugs.\nSECTION 8 Additional benefits information\nImportant Note: These are not Medicare covered prescription drugs and therefore, will not be covered under the \n$0 Rx Copay Benefit, for members who qualify for \"Extra Help\". Please see Chapter 4 \u2013 Medical Benefits Chart for \nadditional details.\nThere are no additional prescription drug benefits available with this plan.\nSECTION 9 Part D Vaccines. What you pay for depends on how and where  \nyou get them\nImportant Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you, \neven if you haven\u2019t paid your deductible. Call Customer Care for more information. \nThere are two parts to our coverage of Part D vaccinations:\n\u2022The first part of coverage is the cost of the vaccine itself.\n\u2022The second part of coverage is for the cost of giving you the vaccine. (This is sometimes called the \n\"administration\" of the vaccine.)\nYour costs for a Part D vaccination depends on three things:\n1. The type of vaccine (what you are being vaccinated for).\n\u2022Some vaccines are considered medical benefits. (See the Medical Benefits Chart, (what is covered in Chapter \n4).\n\u2022Other vaccines are considered Part D drugs. You can find these vaccines listed in the plan's Drug Guide \n(Formulary).\n2. Where you get the vaccine.\n\u2022The vaccine itself may be dispensed by a pharmacy or provided by the doctor\u2019s office.", "doc_id": "3549f939-c86b-48a7-bb0f-f31ce6a19f3a", "embedding": null, "doc_hash": "18441cdbdceb83869437072fdcf60e9a6b91a25a3d3ae305151e7b28273bb28d", "extra_info": {"page_label": "113", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2186, "_node_type": "1"}, "relationships": {"1": "d004f951-b0b3-4224-91c4-bf85499b7d94"}}, "__type__": "1"}, "2d77d51f-5986-4466-b65f-528d8fdf5342": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 114\nChapter 6. What you pay for your Part D prescription drugs\n3. Who gives you the vaccine.\n\u2022A pharmacist may give the vaccine in the pharmacy or another provider may give it in the doctor\u2019s office.\nWhat you pay at the time you get the Part D vaccination can vary depending on the circumstances and what Drug \nStage you are in.\n\u2022Sometimes when you get a vaccination, you will have to pay for the entire cost for both the vaccine itself and \nthe cost for the provider to give you the vaccine. You can ask our plan to pay you back.\n\u2022Other times, when you get a vaccination, you will pay only your share of the cost under your Part D benefit.\nBelow are three examples of ways you might get a Part D vaccine.\nYou get your vaccination at the network pharmacy. (Whether you have this choice depends on \nwhere you live. Some states do not allow pharmacies to give vaccines.)\n\u2022You will pay the pharmacy your coinsurance or copayment for the vaccine itself which \nincludes the cost of giving you the vaccine.\n\u2022Our plan will pay the remainder of the costs.Situation 1:\nYou get the Part D vaccination at your doctor's office.\n\u2022When you get the vaccine, you will pay for the entire cost of the vaccine itself and the cost \nfor the provider to give it to you.\n\u2022You can then ask our plan to pay our share of the cost by using the procedures that are \ndescribed in Chapter 7.\n\u2022You will be reimbursed the amount you paid less your normal coinsurance or copayment for \nthe vaccine (including administration) less any difference between the amount the doctor \ncharges and what we normally pay. (If you get \"Extra Help,\" we will reimburse you for this \ndifference.)Situation 2:\nYou buy the Part D vaccine itself at your pharmacy, and then take it to your doctor's office where \nthey give you the vaccine.\n\u2022You will have to pay the pharmacy your coinsurance or copayment for the vaccine itself.\n\u2022When your doctor gives you the vaccine, you will pay the entire cost for this service. You can \nthen ask our plan to pay our share of the cost by using the procedures described in Chapter \n7.\n\u2022You will be reimbursed the amount charged by the doctor for administering the vaccine less \nany difference between the amount the doctor charges and what we normally pay. (If you \nget \"Extra Help,\" we will reimburse you for this difference.)Situation 3:", "doc_id": "2d77d51f-5986-4466-b65f-528d8fdf5342", "embedding": null, "doc_hash": "370907b48abb353e4694da6eda2a56c432defb6539548424fb76cb8bbc3558b8", "extra_info": {"page_label": "114", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2403, "_node_type": "1"}, "relationships": {"1": "4f833ec8-0fae-4892-ba47-eeca1f1902d4"}}, "__type__": "1"}, "d0e5f6a4-ed7e-4391-8565-725b90229ab7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 115\nChapter 7 Asking us to pay a bill you have received for covered medical services or drugsEOC076\nCHAPTER 7: \nAsking us to pay a bill you have  \nreceived for covered medical  \nservices or drugs", "doc_id": "d0e5f6a4-ed7e-4391-8565-725b90229ab7", "embedding": null, "doc_hash": "e4c7e27e693bf9a619a3bb3c00cbb2cbcf2deff88d981a14506cac02febc35e6", "extra_info": {"page_label": "115", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 275, "_node_type": "1"}, "relationships": {"1": "9f5de443-543b-4b9d-b700-59fad19d7868"}}, "__type__": "1"}, "b79cc9c9-5c3b-479d-9562-4f02faaa730f": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 116\nChapter 7 Asking us to pay a bill you have received for covered medical services or drugs\nSECTION 1 Situations in which you should ask us to pay for your covered  \nservices or drugs\nOur network providers bill the plan directly for your covered services and drugs - you should not receive a bill for \ncovered services or drugs. If you get a bill for medical care or drugs you have received, you should send this bill to \nus so that we can pay it. When you send us the bill, we will look at the bill and decide whether the services should \nbe covered. If we decide they should be covered, we will pay the provider directly.\nIf you have already paid for services or drugs covered by the plan, you can ask our plan to pay you back \n(paying you back is often called \"reimbursing\" you). It is your right to be paid back by our plan whenever you've \npaid for medical services or drugs that are covered by our plan.There may be deadlines that you must meet to get \npaid back. Please see Section 2 of this chapter. When you send us a bill you have already paid, we will look at the \nbill and decide whether the services or drugs should be covered. If we decide they should be covered, we will pay \nyou back for the services or drugs.\nIf you are cost-share protected by MO HealthNet (Medicaid), see Chapter 4 Section 1.1 for more information on \nMedicare cost-share protection from Medicaid.\nThere may also be times when you get a bill from a provider for the full cost of medical care you have received or \npossibly for more than your share of cost sharing as discussed in the document. First try to resolve the bill with the \nprovider. If that does not work, send the bill to us instead of paying it. We will look at the bill and decide whether \nthe services should be covered. If we decide they should be covered, we will pay the provider directly. If we decide \nnot to pay it, we will notify the provider. You should never pay more than plan-allowed cost-sharing. If this provider \nis contracted, you still have the right to treatment.\nHere are examples of situations in which you may need to ask our plan to pay you back or to pay a bill you have \nreceived.\n1. When you've received emergency or urgently needed medical care from a provider who is not in our \nplan's network\nYou can receive emergency or urgently needed services from any provider, whether or not the provider is a part \nof our network. In these cases, ask the provider to bill the plan.\n\u2022If you pay the entire amount yourself at the time you receive the care, ask us to pay you back. Send us the \nbill, along with documentation of any payments you have made.\n\u2022You may get a bill from the provider asking for payment that you think you do not owe. Send us this bill, along \nwith documentation of any payments you have already made.\n\u2013If the provider is owed anything, we will pay the provider directly.\n\u2013If you have already paid for the service, we will pay you back.\n2. When a network provider sends you a bill you think you should not pay\nNetwork providers should always bill the plan directly. But sometimes they make mistakes, and ask you to pay \nfor your services.  ", "doc_id": "b79cc9c9-5c3b-479d-9562-4f02faaa730f", "embedding": null, "doc_hash": "0ab224f192c425b5c2eae2d68289ed3485090e2a443094433d375b67635a2bb6", "extra_info": {"page_label": "116", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3214, "_node_type": "1"}, "relationships": {"1": "d9f8bddd-72e3-46b7-b52a-77642dffc75d"}}, "__type__": "1"}, "d9be35e0-ab5b-4242-8b16-49179da3d0e1": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 117\nChapter 7 Asking us to pay a bill you have received for covered medical services or drugs\n\u2022We do not allow providers to bill you for covered services. We pay our providers directly, and we protect you \nfrom any charges. This is true even if we pay the provider less than the provider charges for a service.\n\u2022Whenever you get a bill from a network provider, send us the bill. We will contact the provider directly and \nresolve the billing problem.\n\u2022If you have already paid a bill to a network provider, send us the bill along with documentation of any \npayment you have made. You should ask us to pay you back for your covered services.\n3. If you are retroactively enrolled in our plan\nSometimes a person's enrollment in the plan is retroactive. (This means that the first day of their enrollment has \nalready passed. The enrollment date may even have occurred last year.)\nIf you were retroactively enrolled in our plan and you paid out-of-pocket for any of your covered services or \ndrugs after your enrollment date, you can ask us to pay you back. You will need to submit paperwork such as \nreceipts and bills for us to handle the reimbursement.\n4. When you use an out-of-network pharmacy to get a prescription filled\nIf you go to an out-of-network pharmacy, the pharmacy may not be able to submit the claim directly to us. \nWhen that happens, you will have to pay the full cost of your prescription. Save your receipt and send a copy to \nus when you ask us to pay you back. Remember that we only cover out-of-network pharmacies in limited \ncircumstances. See Chapter 5, Section 2.5 for a discussion of these circumstances.\n5. When you pay the full cost for a prescription because you don't have your plan membership card with you\nIf you do not have your plan membership card with you, you can ask the pharmacy to call the plan or to look up \nyour plan enrollment information. However, if the pharmacy cannot get the enrollment information they need \nright away, you may need to pay the full cost of the prescription yourself. Save your receipt and send a copy to \nus when you ask us to pay you back.\n6. When you pay the full cost for a prescription in other situations\nYou may pay the full cost of the prescription because you find that the drug is not covered for some reason.\n\u2022For example, the drug may not be on the plan's Prescription Drug Guide (Formulary); or it could have a \nrequirement or restriction that you didn't know about or don't think should apply to you. If you decide to get \nthe drug immediately, you may need to pay the full cost for it.\n\u2022Save your receipt and send a copy to us when you ask us to pay you back. In some situations, we may need \nto get more information from your doctor in order to pay you back for the drug.\nWhen you send us a request for payment, we will review your request and decide whether the service or drug \nshould be covered. This is called making a \"coverage decision.\" If we decide it should be covered, we will pay for \nthe service or drug. If we deny your request for payment, you can appeal our decision. Chapter 9 of this document \nhas information about how to make an appeal.", "doc_id": "d9be35e0-ab5b-4242-8b16-49179da3d0e1", "embedding": null, "doc_hash": "0efbb4eb0ab8abf9ec7817f6548b30176e594c884c8af146fd8d438d16405053", "extra_info": {"page_label": "117", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3216, "_node_type": "1"}, "relationships": {"1": "080cfcdc-cdca-4926-82e5-f8cd1f79dc37"}}, "__type__": "1"}, "09a606ca-d949-4811-b9ad-b9dd8c113d01": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 118\nChapter 7 Asking us to pay a bill you have received for covered medical services or drugs\nSECTION 2 How to ask us to pay you back or to pay a bill you have received\nYou may request us to pay you back by sending us a request in writing. If you send a request in writing, send your \nbill and documentation of any payment you have made. It\u2019s a good idea to make a copy of your bill and receipts \nfor your records.\nMail your request for payment together with any bills or paid receipts to us at this address:\nRequests for payment for Medical Services: \nHumana, P.O. Box 14601, Lexington, KY 40512-4601\nYou must submit your Part C (medical) claim to us within 12 months of the date you received the service, item, \nor Part B drug.\nRequests for payment for Part D drugs: \nHumana\nP.O. Box 14140\nLexington, KY 40512-4140\nYou must submit your Part D (prescription drug) claim to us within 36 months of the date you received the \ndrug.\nSECTION 3 We will consider your request for payment and say yes or no\nSection 3.1 We check to see whether we should cover the service or drug\nWhen we receive your request for payment, we will let you know if we need any additional information from you. \nOtherwise, we will consider your request and make a coverage decision.\n\u2022If we decide that the medical care or drug is covered and you followed all the rules, we will pay for the \nservice. If you have already paid for the service or drug, we will mail your reimbursement to you. If you have \nnot paid for the service or drug yet, we will mail the payment directly to the provider.\n\u2022If we decide that the medical care or drug is not covered, or you did not follow all the rules, we will not pay for \nthe care or drug. We will send you a letter explaining the reasons why we are not sending the payment and \nyour rights to appeal that decision.\nSection 3.2 If we tell you that we will not pay for the medical care or drug, you can  \nmake an appeal\nIf you think we have made a mistake in turning down your request for payment or the amount we are paying, you \ncan make an appeal. If you make an appeal, it means you are asking us to change the decision we made when we \nturned down your request for payment. The appeals process is a formal process with detailed procedures and \nimportant deadlines. For the details on how to make this appeal, go to Chapter 9 of this document.", "doc_id": "09a606ca-d949-4811-b9ad-b9dd8c113d01", "embedding": null, "doc_hash": "bc9277bebfadf21c60faf1b9efb78e1ef7e2ff1794a5b2f5abdd79c4f05568e2", "extra_info": {"page_label": "118", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2436, "_node_type": "1"}, "relationships": {"1": "32288a3b-aae2-4dc0-a4a3-b98e9bce57a0"}}, "__type__": "1"}, "220b96c2-9a76-488c-8457-6f25391d39a4": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 119\nChapter 8. Your rights and responsibilitiesEOC076\nCHAPTER 8:\nYour rights and responsibilities", "doc_id": "220b96c2-9a76-488c-8457-6f25391d39a4", "embedding": null, "doc_hash": "9848a1543f13a2c5f9c833de0a058827f0347cb2de1c641a33c520afe2809cf1", "extra_info": {"page_label": "119", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 177, "_node_type": "1"}, "relationships": {"1": "8ef8f965-8653-401f-9fa8-637eb4fe33e9"}}, "__type__": "1"}, "9dc15862-6691-4c7a-8219-11a627df5bd2": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 120\nChapter 8. Your rights and responsibilities\nSECTION 1 Our plan must honor your rights and cultural sensitivities as a  \nmember of the plan\nSection 1.1 We must provide information in a way that works for you and consistent  \nwith your cultural sensitivities (in languages other than English, in braille,  \nin large print, or other alternate formats, etc.)\nYour plan is required to ensure that all services, both clinical and non-clinical, are provided in a culturally \ncompetent manner and are accessible to all enrollees, including those with limited English proficiency, limited \nreading skills, hearing incapacity, or those with diverse cultural and ethnic backgrounds. Examples of how a plan \nmay meet these accessibility requirements include, but are not limited to provision of translator services, \ninterpreter services, teletypewriters, or TTY (text telephone or teletypewriter phone) connection.\nOur plan has free interpreter services available to answer questions from non-English speaking members. We can \nalso give you information in braille, in large print, or other alternate formats at no cost if you need it. We are \nrequired to give you information about the plan\u2019s benefits in a format that is accessible and appropriate for you. To \nget information from us in a way that works for you, please call Customer Care.\nOur plan is required to give female enrollees the option of direct access to a women\u2019s health specialist within the \nnetwork for women\u2019s routine and preventive health care services.\nIf providers in the plan\u2019s network for a specialty are not available, it is the plan\u2019s responsibility to locate specialty \nproviders outside the network who will provide you with the necessary care. In this case, you will only pay \nin-network cost sharing. If you find yourself in a situation where there are no specialists in the plan\u2019s network that \ncover a service you need, call the plan for information on where to go to obtain this service at in-network cost \nsharing.\nIf you have any trouble getting information from our plan in a format that is accessible and appropriate for you, \nplease call to file a grievance with Humana Grievances and Appeals Dept.  at 1-800-457-4708, TTY 711. You may \nalso file a complaint with Medicare by calling 1-800-MEDICARE (1-800-633-4227) or directly with the Office for \nCivil Rights 1-800-368-1019 or TTY 1-800-537-7697.\nSu plan debe garantizar que todos los servicios, tanto cl\u00ednicos como no cl\u00ednicos, se brinden de manera competente \ndesde el punto de vista cultural y sean accesibles para todos los afiliados, incluidos aquellos con dominio limitado \ndel ingl\u00e9s, habilidades de lectura limitadas, incapacidad auditiva o aquellos con or\u00edgenes culturales y \u00e9tnicos \ndiversos. Algunos ejemplos de c\u00f3mo un plan puede cumplir con estos requisitos de accesibilidad incluyen, entre \notros, la prestaci\u00f3n de servicios de traducci\u00f3n, servicios de interpretaci\u00f3n, telem\u00e1quinas de escribir o conexi\u00f3n TTY \n(tel\u00e9fono de texto o tel\u00e9fono de telem\u00e1quina).\nNuestro plan cuenta con servicios gratuitos de int\u00e9rpretes disponibles para responder preguntas de afiliados que \nno hablan ingl\u00e9s. Tambi\u00e9n podemos darle informaci\u00f3n en braille, en letra grande o en otros formatos alternativos \nsin costo en caso de ser necesario. Se nos exige darle informaci\u00f3n sobre los beneficios del plan en un formato que \nsea accesible y apropiado para usted. Para obtener", "doc_id": "9dc15862-6691-4c7a-8219-11a627df5bd2", "embedding": null, "doc_hash": "c66281b8579682fdd79b0d57cd0f0707c4be463a4ca98ea909debb67971818cf", "extra_info": {"page_label": "120", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3479, "_node_type": "1"}, "relationships": {"1": "71407cce-75d1-4a79-8154-a6b18d91f9da", "3": "34034b7d-2c67-4d2e-9c4e-eb7624f5f729"}}, "__type__": "1"}, "34034b7d-2c67-4d2e-9c4e-eb7624f5f729": {"__data__": {"text": "que \nsea accesible y apropiado para usted. Para obtener informaci\u00f3n de parte de nosotros de una forma que se ajuste a \nsus necesidades, llame a Atenci\u00f3n al cliente.\nNuestro plan debe brindarles a las mujeres inscritas la opci\u00f3n de acceso directo a un especialista en salud \nfemenina dentro de la red para servicios de cuidado de la salud preventivos y de rutina para mujeres.", "doc_id": "34034b7d-2c67-4d2e-9c4e-eb7624f5f729", "embedding": null, "doc_hash": "890a5a9a0d81e9d7ba60585e6c31dfc41c22ba958c36353fd09c60716a6307f4", "extra_info": {"page_label": "120", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 3424, "end": 3799, "_node_type": "1"}, "relationships": {"1": "71407cce-75d1-4a79-8154-a6b18d91f9da", "2": "9dc15862-6691-4c7a-8219-11a627df5bd2"}}, "__type__": "1"}, "cdd23294-2f78-49a7-9a07-4fc8f9424ce6": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 121\nChapter 8. Your rights and responsibilities\nSi no hay disponibles proveedores de la red del plan para una especialidad, es responsabilidad del plan localizar \nproveedores especializados fuera de la red que le proporcionen el cuidado necesario. En este caso, solo pagar\u00e1 el \ncosto compartido dentro de la red. Si se encuentra en una situaci\u00f3n en la cual no hay especialistas en la red del \nplan que cubran un servicio que usted necesita, llame al plan para obtener informaci\u00f3n sobre d\u00f3nde ir para \nobtener este servicio al costo compartido dentro de la red.\nSi tiene alguna dificultad para obtener informaci\u00f3n de nuestro plan en un formato que sea accesible y apropiado, \nllame para presentar una queja formal ante el Departamento de quejas formales y apelaciones de Humana al \n1-800-457-4708, TTY 711. Tambi\u00e9n puede presentar una queja ante Medicare llamando al 1-800-MEDICARE \n(1-800-633-4227) o directamente ante la Oficina de Derechos Civiles al 1-800-368-1019 o TTY 1-800-537-7697.\nSection 1.2 We must ensure that you get timely access to your covered services and  \ndrugs\nYou have the right to choose a primary care provider (PCP) in the plan's network to provide and arrange for your \ncovered services. We do not require you to get referrals to go to network providers.\nYou have the right to get appointments and covered services from the plan's network of providers within a \nreasonable amount of time. This includes the right to get timely services from specialists when you need that care. \nYou also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long \ndelays.\nIf you think that you are not getting your medical care or Part D drugs within a reasonable amount of time, Chapter \n9 tells what you can do.\nSection 1.3 We must protect the privacy of your personal health information\nFederal and state laws protect the privacy of your medical records and personal health information. We protect \nyour personal health information as required by these laws.\n\u2022Your \"personal health information\" includes the personal information you gave us when you enrolled in this \nplan as well as your medical records and other medical and health information.\n\u2022You have rights related to your information and controlling how your health information is used. We give you a \nwritten notice, called a \"Notice of Privacy Practice,\" that tells about these rights and explains how we protect the \nprivacy of your health information.\nHow do we protect the privacy of your health information?\n\u2022We make sure that unauthorized people don't see or change your records.\n\u2022Except for the circumstances noted below, if we intend to give your health information to anyone who isn\u2019t \nproviding your care or paying for your care, we are required to get written permission from you or someone you \nhave given legal power to make decisions for you first.\n\u2022There are certain exceptions that do not require us to get your written permission first. These exceptions are \nallowed or required by law.\n\u2013We are required to release health information to government agencies that are checking on quality of care.", "doc_id": "cdd23294-2f78-49a7-9a07-4fc8f9424ce6", "embedding": null, "doc_hash": "ca22856cda255429d0d1342242ed11260ef818fd76ce341261724fa597e1aaf1", "extra_info": {"page_label": "121", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3209, "_node_type": "1"}, "relationships": {"1": "955870ca-cea4-4b08-80cd-025aca2b84f4"}}, "__type__": "1"}, "bb4bc1d2-d443-4ce5-9645-9c0b84e37509": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 122\nChapter 8. Your rights and responsibilities\n\u2013Because you are a member of our plan through Medicare, we are required to give Medicare your health \ninformation including information about your Part D prescription drugs. If Medicare releases your information \nfor research or other uses, this will be done according to Federal statutes and regulations; typically, this \nrequires that information that uniquely identifies you not be shared.\nYou can see the information in your records and know how it has been shared with others\nYou have the right to look at your medical records held at the plan, and to get a copy of your records. We are \nallowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to \nyour medical records. If you ask us to do this, we will work with your health care provider to decide whether the \nchanges should be made.\nYou have the right to know how your health information has been shared with others for any purposes that are not \nroutine.\nIf you have questions or concerns about the privacy of your personal health information, please call Customer \nCare.\nNotice of Privacy Practices\nFor your personal health information\nTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW \nYOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.\nThe privacy of your personal and health information is important. You don't need to do anything unless you have a \nrequest or complaint.\nWe may change our privacy practices and the terms of this notice at any time, as allowed by law. Including \ninformation we created or received before we made the changes. When we make a significant change in our \nprivacy practices, we will change this notice and send the notice to our health plan subscribers.\nWhat is personal and health information?\nPersonal and health information includes both medical information and personal information, like your name, \naddress, telephone number, or Social Security number. The term \u201cinformation\u201d in this notice includes any personal \nand health information. This includes information created or received by a healthcare provider or health plan. The \ninformation relates to your physical or mental health or condition, providing healthcare to you, or the payment for \nsuch healthcare. \nHow do we protect your information?\nWe have a responsibility to protect the privacy of your information in all formats including electronic, written and \noral information. We have safeguards in place to protect your information in various ways including: \n\u2022Limiting who may see your information \n\u2022Limiting how we use or disclose your information\n\u2022Informing you of our legal duties about your information\n\u2022Training our employees about our privacy programs and procedures\nHow do we use and disclose your information?\nWe use and disclose your information:\n\u2022To you or someone who has the legal right to act on your behalf\n\u2022To the Secretary of the Department of Health and Human Services\nWe have the right to use and disclose your information:\n\u2022To a doctor, a hospital, or other healthcare provider so you can receive medical care", "doc_id": "bb4bc1d2-d443-4ce5-9645-9c0b84e37509", "embedding": null, "doc_hash": "58e91091e32bcbf1f62e8c66d739915458d45eb87be6c7addf594cb9a4fb3f31", "extra_info": {"page_label": "122", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3231, "_node_type": "1"}, "relationships": {"1": "0d3f70c7-c292-423d-8064-a7053216c696"}}, "__type__": "1"}, "39e9e6f2-3334-4914-99d7-cf6c5e0bc4a5": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 123\nChapter 8. Your rights and responsibilities\n\u2022For payment activities, including claims payment for covered services provided to you by healthcare providers \nand for health plan premium payments\n\u2022For healthcare operation activities. Including processing your enrollment, responding to your inquiries, \ncoordinating your care, improving quality, and determining premiums.\n\u2022For performing underwriting activities. However, we will not use any results of genetic testing or ask questions \nregarding family history.\n\u2022To your plan sponsor to permit them to perform, plan administration functions such as eligibility, enrollment \nand disenrollment activities. We may share summary level health information about you with your plan sponsor \nin certain situations. For example, to allow your plan sponsor to obtain bids from other health plans. Your \ndetailed health information will not be shared with your plan sponsor. We will ask your permission or your plan \nsponsor has to certify they agree to maintain the privacy of your information.\n\u2022To contact you with information about health-related benefits and services, appointment reminders, or \ntreatment alternatives that may be of interest to you. If you have opted out as described below, we will not \ncontact you. \n\u2022To your family and friends if you are unavailable to communicate, such as in an emergency. To your family and \nfriends or any other person you identify. This applies if the information is directly relevant to their involvement \nwith your health care or payment for that care. For example, if a family member or a caregiver calls us with prior \nknowledge of a claim, we may confirm if the claim has been received and paid.\n\u2022To provide payment information to the subscriber for Internal Revenue Service substantiation.\n\u2022To public health agencies, if we believe that there is a serious health or safety threat.\n\u2022To appropriate authorities when there are issues about abuse, neglect, or domestic violence.\n\u2022In response to a court or administrative order, subpoena, discovery request, or other lawful process.\n\u2022For law enforcement purposes, to military authorities, and as otherwise required by law.\n\u2022To help with disaster relief efforts.\n\u2022For compliance programs and health oversight activities.\n\u2022To fulfill our obligations under any workers\u2019 compensation law or contract.\n\u2022To avert a serious and imminent threat to your health or safety or the health or safety of others.\n\u2022For research purposes in limited circumstances.\n\u2022For procurement, banking, or transplantation of organs, eyes, or tissue.\n\u2022To a coroner, medical examiner, or funeral director.\nWill we use your information for purposes not described in this notice?\nWe will not use or disclose your information for any reason that is not described in this notice, without your written \npermission. You may cancel your permission at any time by notifying us in writing.\nThe following uses and disclosures will require your written permission:\n\u2022Most uses and disclosures of psychotherapy notes\n\u2022Marketing purposes\n\u2022Sale of protected health information\nWhat do we do with your information when you are no longer a member?\nYour information may continue to be used for purposes described in this notice. This includes when you do not \nobtain coverage through us. After the required legal retention period, we destroy the information following strict \nprocedures to maintain the confidentiality. \nWhat are my rights concerning my information?\nWe are committed to responding to your rights request in a timely manner\n\u2022Access - You have the right to review and obtain a copy of your information that may be used to make decisions \nabout you. You also may receive a summary of this health information. If you request copies, we may charge \nyou a fee for the labor for copying, supplies for creating the copy (paper or electronic) and postage.\n\u2022Adverse Underwriting Decision - If we decline your application for insurance, you have the right to be provided a \nreason for the denial. *", "doc_id": "39e9e6f2-3334-4914-99d7-cf6c5e0bc4a5", "embedding": null, "doc_hash": "80c70bb5fe2389bab95a31093cb0fde7120e9f766155db5cf63e322d0445c915", "extra_info": {"page_label": "123", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 4072, "_node_type": "1"}, "relationships": {"1": "35cb2e3e-6a10-47a9-8ab8-ab061f10a990"}}, "__type__": "1"}, "4904b475-fa7b-4706-8738-f464032dca15": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 124\nChapter 8. Your rights and responsibilities\n\u2022Alternate Communications - To avoid a life- threatening situation, you have the right to receive your information \nin a different manner or at a different place. We will accommodate your request if it is reasonable.\n\u2022Amendment - You have the right to request correction of any of this personal information through amendment \nor deletion. Within 30 business days of receipt of your written request, we will notify you of our amendment or \ndeletion of the information in dispute, or of our refusal to make such correction after further investigation. In the \nevent that we refuse to amend or delete the information in dispute, you have the right to submit to us a written \nstatement of the reasons for your disagreement with our assessment of the information in dispute and what \nyou consider to be the correct information. We shall make such a statement accessible to any and all parties \nreviewing the information in dispute.*\n\u2022Disclosure - You have the right to receive a listing of instances in which we or our business associates have \ndisclosed your information. This does not apply to treatment, payment, health plan operations, and certain \nother activities. We maintain this information and make it available to you for six years. If you request this list \nmore than once in a 12-month period, we may charge you a reasonable, cost-based fee.\n\u2022Notice - You have the right to request and receive a written copy of this notice any time.\n\u2022Restriction - You have the right to ask to limit how your information is used or disclosed. We are not required to \nagree to the limit, but if we do, we will abide by our agreement. You also have the right to agree to or terminate \na previously submitted limitation.\n* This right applies only to our Massachusetts residents in accordance with state regulations.\nWhat types of communications can I opt out of that are made to me?\n\u2022Appointment reminders\n\u2022Treatment alternatives or other health-related benefits or services\n\u2022Fundraising activities\nHow do I exercise my rights or obtain a copy of this notice?\nAll of your privacy rights can be exercised by obtaining the applicable forms. You may obtain any of the forms by:\n\u2022Contacting us at 1-866-861-2762 \n\u2022Accessing our Website at Humana.com and going to the Privacy Practices link\n\u2022Send completed request form to:\nHumana Inc.\nPrivacy Office 003/10911\n101 E. Main Street\nLouisville, KY 40202\nIf I believe my privacy has been violated, what should I do?\nIf you believe that your privacy has been violated, you may file a complaint with us by calling us at: \n1-866-861-2762 any time.\nYou may also submit a written complaint to the U.S. Department of Health and Human Services, Office for Civil \nRights (OCR). We will give you the appropriate OCR regional address on request. You can also e-mail your complaint \nto OCRComplaint@hhs.gov. If you elect to file a complaint, your benefits will not be affected and we will not punish \nor retaliate against you in any way.\nWe support your right to protect the privacy of your personal and health information.\nWe follow all federal and state laws, rules, and regulations addressing the protection of personal and health \ninformation. In situations when federal and state laws, rules, and regulations conflict, we follow the law, rule, or \nregulation which provides greater protection.\nWe are required by law to abide by the terms of this notice currently in effect.", "doc_id": "4904b475-fa7b-4706-8738-f464032dca15", "embedding": null, "doc_hash": "d53471a8d572baca0b01e49a636d1afeaa01c93f33fc3d3416653e8ac518cd01", "extra_info": {"page_label": "124", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3526, "_node_type": "1"}, "relationships": {"1": "ca1a4570-f7ed-46e7-8254-4c674ec8a5cf"}}, "__type__": "1"}, "29662bd4-7ed3-47ba-8534-8ce0bec03f77": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 125\nChapter 8. Your rights and responsibilities\nWhat will happen if my information is used or disclosed inappropriately?\nWe are required by law to provide individuals with notice of our legal duties and privacy practices regarding \npersonal and health information. If a breach of unsecured personal and health information occurs, we will notify \nyou in a timely manner.\nThe following affiliates and subsidiaries also adhere to our privacy programs and procedures:\nArcadian Health Plan, Inc.\nCarePlus Health Plans, Inc.\nCariten Health Plan, Inc.\nCHA HMO, Inc.\nCompBenefits Company\nCompBenefits Dental, Inc.\nCompBenefits Insurance Company\nDentiCare, Inc.\nEmphesys Insurance Company\nHumanaDental Insurance Company\nHumana Benefit Plan of Illinois, Inc.\nHumana Benefit Plan of South Carolina, Inc. \nHumana Benefit Plan of Texas, Inc.\nHumana Employers Health Plan of Georgia, Inc.\nHumana Health Benefit Plan of Louisiana, Inc.\nHumana Health Company of New York, Inc.\nHumana Health Insurance Company of Florida, Inc.\nHumana Health Plan of California, Inc.\nHumana Health Plan of Ohio, Inc.\nHumana Health Plan of Texas, Inc.\nHumana Health Plan, Inc.\nHumana Health Plans of Puerto Rico, Inc.\nHumana Insurance Company\nHumana Insurance Company of Kentucky\nHumana Insurance Company of New York\nHumana Insurance of Puerto Rico, Inc.\nHumana Medical Plan, Inc.\nHumana Medical Plan of Michigan, Inc.\nHumana Medical Plan of Pennsylvania, Inc.\nHumana Medical Plan of Utah, Inc.\nHumana Regional Health Plan, Inc.\nHumana Wisconsin Health Organization Insurance Corporation\nGo365 by Humana for Healthy Horizons \nManaged Care Indemnity, Inc.\nThe Dental Concern, Inc.\nEffective 9/2013\nA more complete picture of your health \nHumana has developed programs that have the ability to deliver your electronic healthcare history to authorized \nhealthcare providers. These healthcare providers can view your medical claims, pharmacy claims, laboratory \nclaims and results and radiology claims and results via various information exchange programs. In addition, some \nof the medical information systems used by your healthcare providers may download your information to provide ", "doc_id": "29662bd4-7ed3-47ba-8534-8ce0bec03f77", "embedding": null, "doc_hash": "98c3ff635f0d4f9fc867efe037924cbab0ff7689b91a197d775d2e5ba553b135", "extra_info": {"page_label": "125", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2226, "_node_type": "1"}, "relationships": {"1": "4afc3a2d-9cf7-49d8-a199-49157562715c"}}, "__type__": "1"}, "f26681f5-fc07-4a13-a5f4-59af4ac8a224": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 126\nChapter 8. Your rights and responsibilities\na more complete view of your health condition. For privacy reasons, records from psychiatric, substance abuse, or \nHIV-related treatment will not be shared.\nThe benefit of this information exchange is that healthcare providers receive a complete view of the healthcare \nservices you have received. This information is available to a broad range of healthcare providers, including but not \nlimited to:\n\u2022Primary Care Providers\n\u2022Medical Specialists\n\u2022Hospitals\n\u2022Urgent Care Centers\n\u2022Dental Providers\n\u2022Emergency Medical Service (EMS) Providers\n\u2022Selected Alternative and Complementary Medical Practices\nYou may use any of the methods listed below to decline your participation in the information sharing program *.\n1. Log in to MyHumana - the secure section of Humana.com\n\u2022Select \"My Profile\" option located in the upper right-hand corner of the webpage\n\u2022Select the \"Communications Preferences\" option within the dropdown list.\n\u2022Within the \"Privacy and Sharing\" section, select \"No\" to \"Primary Care Physician (PCP) and Treating \nHealthcare Providers.\"\n\u2022Click the \"Save Changes\" button at the bottom of the webpage.\n2. Call the automated response line at 1-800-733-9203.\n3. For TTY service, call 711. Our hours are Monday - Friday, 8 a.m. - 8 p.m. and Saturday, 8 a.m. - 3 p.m., Eastern \ntime.\n* There may be cases where Humana must exchange your health information to comply with regulatory requests \nand/or contractual agreements executed between Humana and a treating healthcare provider.\nWe may share information with affiliated companies as permitted by law. A list of our affiliates can be found in the \nback of our Notice of Privacy Practices found above. We may share information with third parties that Humana \ncontracts with to perform services on our behalf. As part of the work we do together, we may reach out to your \ndoctors and other healthcare providers. This helps us have the most up-to-date information about your treatment \nplans and health information to best support your doctors\u2019 plan of care. The disclosure of sensitive health \ninformation is strictly prohibited to any party other than the subject of the information or the provider who \noriginated the treatment or claims activity unless the member/patient is given an opportunity to provide \ninformed, written consent permitting Humana to release the information to a third party.\nIf you have any questions about how Humana protects your privacy, please access \nHumana.com/about/legal/privacy. If you do not have computer access, you can receive a copy of your Notice of \nPrivacy Practices by calling the customer service phone number located on the back of your Humana ID card.\nSection 1.4 We must give you information about the plan, its network of providers,  \nand your covered services\nAs a member of Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP), you have the right to get several kinds of \ninformation from us.\nIf you want any of the following kinds of information, please call Customer Care:\n\u2022Information about our plan. This includes, for example, information about the plan's financial condition.", "doc_id": "f26681f5-fc07-4a13-a5f4-59af4ac8a224", "embedding": null, "doc_hash": "a77166cba1441476b82508fefa3fbb32872a7edae6a458b490b127a6c06205ba", "extra_info": {"page_label": "126", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3210, "_node_type": "1"}, "relationships": {"1": "b0e5d0dd-0cb4-4ad4-a216-7b6fc7dd9993"}}, "__type__": "1"}, "1ecdef50-d72e-4f5b-baf6-7ca6efe32c48": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 127\nChapter 8. Your rights and responsibilities\n\u2022Information about our network providers and pharmacies. You have the right to get information about the \nqualifications of the providers and pharmacies in our network and how we pay the providers in our network.\n\u2022Information about your coverage and the rules you must follow when using your coverage. Chapters 3 and \n4 provide information regarding medical services. Chapter 5 and 6 provide information about Part D prescription \ndrug coverage.\n\u2022Information about why something is not covered and what you can do about it. Chapter 9 provides \ninformation on asking for a written explanation on why a medical service or Part D drug is not covered or if your \ncoverage is restricted. Chapter 9 also provides information on asking us to change a decision, also called an \nappeal.\nSection 1.5 We must support your right to make decisions about your care\nYou have the right to know your treatment options and participate in decisions about your health care\nYou have the right to get full information from your doctors and other health care providers. Your providers must \nexplain your medical condition and your treatment choices in a way that you can understand.\nYou also have the right to participate fully in decisions about your health care. To help you make decisions with \nyour doctors about what treatment is best for you, your rights include the following:\n\u2022To know about all of your choices. You have the right to be told about all of the treatment options that are \nrecommended for your condition, no matter what they cost or whether they are covered by our plan. It also \nincludes being told about programs our plan offers to help members manage their medications and use drugs \nsafely.\n\u2022To know about the risks. You have the right to be told about any risks involved in your care. You must be told in \nadvance if any proposed medical care or treatment is part of a research experiment. You always have the choice \nto refuse any experimental treatments.\n\u2022The right to say \"no.\" You have the right to refuse any recommended treatment. This includes the right to \nleave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to \nstop taking your medication. Of course, if you refuse treatment or stop taking medication, you accept full \nresponsibility for what happens to your body as a result.\nYou have the right to give instructions about what is to be done if you are not able to make medical \ndecisions for yourself\nSometimes people become unable to make health care decisions for themselves due to accidents or serious \nillness. You have the right to say what you want to happen if you are in this situation. This means that, if you want \nto, you can:\n\u2022Fill out a written form to give someone the legal authority to make medical decisions for you if you ever \nbecome unable to make decisions for yourself.\n\u2022Give your doctors written instructions about how you want them to handle your medical care if you become \nunable to make decisions for yourself.", "doc_id": "1ecdef50-d72e-4f5b-baf6-7ca6efe32c48", "embedding": null, "doc_hash": "15d19aedc7ee9e18543ef34715bb566164a9d54775869863bc0891fad575a66e", "extra_info": {"page_label": "127", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3142, "_node_type": "1"}, "relationships": {"1": "f0854f3a-1b23-410e-bbee-8bbcb3a95b43"}}, "__type__": "1"}, "00ed1be2-3370-4ac1-b265-8a1f2d26609e": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 128\nChapter 8. Your rights and responsibilities\nThe legal documents that you can use to give your directions in advance in these situations are called \"advance \ndirectives.\" There are different types of advance directives and different names for them. Documents called \n\"living will\" and \"power of attorney for health care\" are examples of advance directives.\nIf you want to use an \"advance directive\" to give your instructions, here is what to do:\n\u2022Get the form. You can get an advance directive form from your lawyer, from a social worker, or from some \noffice supply stores. You can sometimes get advance directive forms from organizations that give people \ninformation about Medicare.\n\u2022Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You \nshould consider having a lawyer help you prepare it.\n\u2022Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you \nname on the form who can make decisions for you if you can\u2019t. You may want to give copies to close friends or \nfamily members. Keep a copy at home.\nIf you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a \ncopy with you to the hospital.\n\u2022The hospital will ask you whether you have signed an advance directive form and whether you have it with you.\n\u2022If you have not signed an advance directive form, the hospital has forms available and will ask if you want to \nsign one.\nRemember, it is your choice whether you want to fill out an advance directive (including whether you want to \nsign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based \non whether or not you have signed an advance directive.\nWhat if your instructions are not followed?\nIf you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in \nit, you may file a complaint with your state's Quality Improvement Organization (QIO). Contact information can be \nfound in \"Exhibit A\" in the back of this book.\nSection 1.6 You have the right to make complaints and to ask us to reconsider  \ndecisions we have made\nAt Humana, a process called Utilization Management (UM) is used to determine whether a service or treatment is \ncovered and appropriate for payment under your benefit plan. Humana does not reward or provide financial \nincentives to doctors, other individuals or Humana employees for denying coverage or encouraging under use of \nservices. In fact, Humana works with your doctors and other providers to help you get the most appropriate care \nfor your medical condition. If you have questions or concerns related to Utilization Management, staff are available \nat least eight hours a day during normal business hours. Humana has free language interpreter services available \nto answer questions related to Utilization Management from non-English speaking members. Members may call \n1-800-457-4708 (TTY:711).\nHumana decides about coverage of new medical procedures and devices on an ongoing basis. This is done by \nchecking peer-reviewed medical literature and consulting with medical experts to see if the new technology is \neffective and safe. Humana also relies on guidance from the Centers for Medicare & Medicaid Services (CMS), which \noften makes national coverage decisions for new medical procedures or devices.", "doc_id": "00ed1be2-3370-4ac1-b265-8a1f2d26609e", "embedding": null, "doc_hash": "600af43e8fb941efadd542160833ca41801caa3d2ad9952250e41e6a86f21a27", "extra_info": {"page_label": "128", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3498, "_node_type": "1"}, "relationships": {"1": "56a34ccb-1230-4398-a1be-4047b59759f4"}}, "__type__": "1"}, "b6145b9a-7f0c-460a-82b9-4e90dc6fe9f9": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 129\nChapter 8. Your rights and responsibilities\nIf you have any problems, concerns, or complaints and need to request coverage, or make an appeal, Chapter 9 of \nthis document tells what you can do. Whatever you do \u2013 ask for a coverage decision, make an appeal, or make a \ncomplaint \u2013 we are required to treat you fairly.\nSection 1.7 What can you do if you believe you are being treated unfairly or your  \nrights are not being respected?\nIf it is about discrimination, call the Office for Civil Rights\nIf you believe you have been treated unfairly or your rights have not been respected due to your race, disability, \nreligion, sex, health, ethnicity, creed (beliefs), age, sexual orientation, or national origin, you should call the \nDepartment of Health and Human Services' Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or \ncall your local Office for Civil Rights.\nIs it about something else?\nIf you believe you have been treated unfairly or your rights have not been respected, and it's not about \ndiscrimination, you can get help dealing with the problem you are having:\n\u2022You can call Customer Care.\n\u2022You can call the SHIP. For details, go to Chapter 2, Section 3.\n\u2022Or, you can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. (TTY \n1-877-486-2048).\nSection 1.8 How to get more information about your rights\nThere are several places where you can get more information about your rights:\n\u2022You can call Customer Care.\n\u2022You can call the SHIP. For details, go to Chapter 2, Section 3.\n\u2022You can contact Medicare.\n\u2013You can visit the Medicare website to read or download the publication \"Medicare Rights & Protections.\" (The \npublication is available at: www.medicare.gov/Pubs/pdf/11534-Medicare-Rights-and-Protections.pdf.)\n\u2013Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY users should call \n1-877-486-2048).\nSECTION 2 You have some responsibilities as a member of the plan\nThings you need to do as a member of the plan are listed below. If you have any questions, please call Customer \nCare.", "doc_id": "b6145b9a-7f0c-460a-82b9-4e90dc6fe9f9", "embedding": null, "doc_hash": "fc9cf1806f7fd8dc8941d90093f86cc450c798fee2a0693421507b7e55b369b4", "extra_info": {"page_label": "129", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2157, "_node_type": "1"}, "relationships": {"1": "118f0783-de88-4784-88d5-e6569a952627"}}, "__type__": "1"}, "e74199be-f8be-4647-8dc9-663184b01061": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 130\nChapter 8. Your rights and responsibilities\n\u2022Get familiar with your covered services and the rules you must follow to get these covered services. Use \nthis Evidence of Coverage to learn what is covered for you and the rules you need to follow to get your covered \nservices.\n\u2013Chapters 3 and 4 give the details about your medical services.\n\u2013Chapters 5 and 6 give the details about your Part D prescription drug coverage.\n\u2022If you have any other health insurance coverage or prescription drug coverage in addition to our plan, \nyou are required to tell us. Chapter 1 tells you about coordinating these benefits.\n\u2022Tell your doctor and other health care providers that you are enrolled in our plan.\nShow your plan membership card and your MO HealthNet (Medicaid) card whenever you get your medical care \nor Part D prescription drugs.\n\u2022Help your doctors and other providers help you by giving them information, asking questions, and \nfollowing through on your care.\n\u2013To help get the best care, tell your doctors and other health providers about your health problems. Follow the \ntreatment plans and instructions that you and your doctors agree upon.\n\u2013Make sure your doctors know all of the drugs you are taking, including over-the-counter drugs, vitamins, and \nsupplements.\n\u2013If you have any questions, be sure to ask and get an answer you can understand.\n\u2022Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in \na way that helps the smooth running of your doctor's office, hospitals, and other offices.\n\u2022Pay what you owe. As a plan member, you are responsible for these payments: \n\u2013You must continue to pay your Medicare premiums to remain a member of our plan.\n\u2013For most of your drugs covered by the plan, you must pay your share of the cost when you get the drug.\n\u2013If you are required to pay the extra amount for Part D because of your higher income (as reported on your last \ntax return), you must continue to pay the extra amount directly to the government to remain a member of \nthe plan.\n\u2013If you move within our service area, we need to know so we can keep your membership record up to date \nand know how to contact you.\n\u2013If you move outside of our plan service area, you cannot remain a member of our plan.\n\u2013If you move, it is also important to tell Social Security (or the Railroad Retirement Board).", "doc_id": "e74199be-f8be-4647-8dc9-663184b01061", "embedding": null, "doc_hash": "b06951c0cb20a5d0a439c7a8cf1cc6da9aa3f541ebb6e855ae1d974763e9e72a", "extra_info": {"page_label": "130", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2442, "_node_type": "1"}, "relationships": {"1": "588789f3-a7a3-4a83-a060-9cbd07ea0570"}}, "__type__": "1"}, "fd29379e-dffc-4ab1-9368-624ccf9e0459": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 131\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)EOC076\nCHAPTER 9:\nWhat to do if you have a problem  \nor complaint (coverage decisions, \nappeals, complaints)", "doc_id": "fd29379e-dffc-4ab1-9368-624ccf9e0459", "embedding": null, "doc_hash": "41726b4f3fc4c137112f4677a5b24611ab4ba92c3a3965522f8fae36a3aa74f8", "extra_info": {"page_label": "131", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 290, "_node_type": "1"}, "relationships": {"1": "84a4b8c7-feb1-405b-ae25-381c480e5879"}}, "__type__": "1"}, "5cf7a6c1-c544-47c5-bbe0-3718b56d3b05": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 132\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSECTION 1 Introduction\nSection 1.1 What to do if you have a problem or concern\nThis chapter explains the processes for handling problems and concerns. The process you use to handle your \nproblem depends on two things:\n1. Whether your problem is about benefits covered by Medicare or Medicaid. If you would like help deciding \nwhether to use the Medicare process or the Medicaid process, or both, please contact Customer Care.\n2. The type of problem you are having:\n\u2022For some problems, you need to use the process for coverage decisions and appeals. \n\u2022For other problems, you need to use the process for making complaints; also called grievances.\nThese processes have been approved by Medicare. Each process has a set of rules, procedures, and deadlines that \nmust be followed by us and by you.\nThe guide in Section 3 will help you identify the right process to use and what you should do.\nSection 1.2 What about the legal terms?\nThere are legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. Many of \nthese terms are unfamiliar to most people and can be hard to understand. To make things easier, this chapter:\n\u2022Uses simpler words in place of certain legal terms. For example, this chapter generally says \"making a \ncomplaint\" rather than \"filing a grievance,\" \"coverage decision\" rather than \"organization determination\" or \n\"coverage determination\" or \"at-risk determination,\" and \"independent review organization\" instead of \n\"Independent Review Entity.\" \n\u2022It also uses abbreviations as little as possible. \nHowever, it can be helpful - and sometimes quite important - for you to know the correct legal terms. Knowing \nwhich terms to use will help you communicate more accurately to get the right help or information for your \nsituation. To help you know which terms to use, we include legal terms when we give the details for handling \nspecific types of situations.\nSECTION 2 Where to get more information and personalized assistance \nWe are always available to help you. Even if you have a complaint about our treatment of you, we are obligated to \nhonor your right to complain. Therefore, you should always reach out to Customer Care for help. But in some \nsituations, you may also want help or guidance from someone who is not connected with us. Below are two \nentities that can assist you.  \nState Health Insurance Assistance Program (SHIP). \nEach state has a government program with trained counselors. The program is not connected with us or with any \ninsurance company or health plan. The counselors at this program can help you understand which process you ", "doc_id": "5cf7a6c1-c544-47c5-bbe0-3718b56d3b05", "embedding": null, "doc_hash": "1cd642e3482d9bc9299831e981aa64879f198f80318ae9fd91c32273205ca945", "extra_info": {"page_label": "132", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2796, "_node_type": "1"}, "relationships": {"1": "e3b0d3e7-f660-4b82-9078-d74ebcd64c49"}}, "__type__": "1"}, "4d128bce-5e7a-423b-9cef-30322a6a5317": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 133\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nshould use to handle a problem you are having. They can also answer your questions, give you more information, \nand offer guidance on what to do.\nThe services of SHIP counselors are free. You will find phone numbers in \"Exhibit A\" at the end of this document.\nMedicare\nYou can also contact Medicare to get help. To contact Medicare:\n\u2022You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call \n1-877-486-2048.\n\u2022You can also visit the Medicare website (www.medicare.gov). \nYou can get help and information from MO HealthNet (Medicaid)\nYou will find contact information for MO HealthNet (Medicaid) in \"Exhibit A\" at the end of this booklet.\nSECTION 3 To deal with your problem, which process should you use?\nBecause you have Medicare and get assistance from MO HealthNet (Medicaid), you have different processes that \nyou can use to handle your problem or complaint. Which process you use depends on whether the problem is \nabout Medicare benefits or MO HealthNet (Medicaid) benefits. If your problem is about a benefit covered by \nMedicare, then you should use the Medicare process. If your problem is about a benefit covered by MO HealthNet \n(Medicaid), then you should use the Medicaid process. If you would like help deciding whether to use the Medicare \nprocess or the Medicaid process, please contact Customer Care.\nThe Medicare process and Medicaid process are described in different parts of this chapter. To find out which part \nyou should read, use the chart below.\nIs your problem about Medicare benefits or Medicaid benefits?\nIf you would like help deciding whether your problem is about Medicare benefits or Medicaid benefits, please  \ncontact Customer Care. \nMy problem is about \nMedicare benefits. \nGo to the next section of this chapter, Section 4, \n\"Handling problems about your Medicare benefits.\"My problem is about \nMedicaid coverage. \nSkip ahead to Section 12 of this chapter, \"Handling  \nproblems about your Medicaid benefits.\"", "doc_id": "4d128bce-5e7a-423b-9cef-30322a6a5317", "embedding": null, "doc_hash": "4abe7d922822836571f522d3eeb295d4595a1324cde06a39763d5722a5a3e1af", "extra_info": {"page_label": "133", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2170, "_node_type": "1"}, "relationships": {"1": "a961b99b-1ffc-4136-9c88-d0210f832534"}}, "__type__": "1"}, "a2010ea5-3d5c-4356-bbb8-f529d87eb631": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 134\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nPROBLEMS ABOUT YOUR MEDICARE BENEFITS\nSECTION 4 Handling problems about your Medicare benefits\nSection 4.1 Should you use the process for coverage decisions and appeals? Or should  \nyou use the process for making complaints?\nIf you have a problem or concern, you only need to read the parts of this chapter that apply to your situation. The \nchart below will help you find the right section of this chapter for problems or complaints about benefits covered \nby Medicare.\nTo figure out which part of this chapter will help with your problem or concern about your Medicare benefits, use \nthis chart: \nIs your problem or concern about your benefits or coverage?\nThis includes problems about whether medical care or prescription drugs are covered or not, the way they are  \ncovered, and problems related to payment for medical care or prescription drugs.\nYes. \nGo on to the next section of this chapter, Section 5, \"A  \nguide to the basics of coverage decisions and  \nappeals.\"No. \nSkip ahead to Section 11 at the end of this chapter: \n\"How to make a complaint about quality of care,  \nwaiting times, customer service, or other concerns.\"\nSECTION 5 A guide to the basics of coverage decisions and appeals\nSection 5.1 Asking for coverage decisions and making appeals: the big picture\nCoverage decisions and appeals deal with problems related to your benefits and coverage, including payment. This \nis the process you use for issues such as whether something is covered or not and the way in which something is \ncovered.\nAsking for coverage decisions prior to receiving services\nA coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for \nyour medical services or drugs. We are making a coverage decision whenever we decide what is covered for you \nand how much we pay. For example, your plan network doctor makes a (favorable) coverage decision for you \nwhenever you receive medical care from him or her or if your network doctor refers you to a medical specialist. You \nor your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a \nparticular medical service or refuses to provide medical care you think that you need. In other words, if you want to \nknow if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. In \nlimited circumstances a request for a coverage decision will be dismissed, which means we won\u2019t review the \nrequest. Examples of when a request will be dismissed include if the request is incomplete, if someone makes the \nrequest on your behalf but isn\u2019t legally authorized to do so or if you ask for your request to be withdrawn. If we ", "doc_id": "a2010ea5-3d5c-4356-bbb8-f529d87eb631", "embedding": null, "doc_hash": "ec6e4619b4ab14f3756b5e433ab58f52aeb69716ac10b90595296b770398975e", "extra_info": {"page_label": "134", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2893, "_node_type": "1"}, "relationships": {"1": "d15252dd-f92c-4529-9570-fb05f318160a"}}, "__type__": "1"}, "7c6a516f-c027-4dcb-9535-f51590333168": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 135\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\ndismiss a request for a coverage decision, we will send a notice explaining why the request was dismissed and how \nto ask for a review of the dismissal.\nIn some cases, we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you \ndisagree with this coverage decision, you can make an appeal. \nMaking an appeal\nIf we make a coverage decision and you are not satisfied, you can \"appeal\" the decision. An appeal is a formal way \nof asking us to review and change a coverage decision we have made. Under certain circumstances, which we \ndiscuss later, you can request an expedited or \"fast appeal\" of a coverage decision. Your appeal is handled by \ndifferent reviewers than those who made the original decision.\nWhen you appeal a decision for the first time, this is called a Level 1 appeal. In this appeal, we review the coverage \ndecision we made to check to see if we were properly following the rules. When we have completed the review, we \ngive you our decision.\nIn limited circumstances, a request for a Level 1 appeal will be dismissed, which means we won\u2019t review the \nrequest. Examples of when a request will be dismissed include if the request is incomplete, if someone makes the \nrequest on your behalf but isn\u2019t legally authorized to do so or if you ask for your request to be withdrawn. If we \ndismiss a request for a Level 1 appeal, we will send a notice explaining why the request was dismissed and how to \nask for a review of the dismissal.\nIf we say no to all or part of your Level 1 appeal, your appeal will automatically go on to Level 2. The Level 2 appeal \nis conducted by an independent review organization that is not connected to us. \n\u2022You do not need to do anything to start a Level 2 appeal. Medicare rules require we automatically send your \nappeal to Level 2 if we do not fully agree with your Level 1 appeal.\n\u2022See Section 6.4 of this chapter for more information about Level 2 appeals.\nIf you are not satisfied with the decision at the Level 2 appeal, you may be able to continue through additional \nlevels of appeal. (Section 10 in this chapter explains the Level 3, 4, and 5 appeals processes). \nSection 5.2 How to get help when you are asking for a coverage decision or making an  \nappeal\nHere are resources if you decide to ask for any kind of coverage decision or appeal a decision:\n\u2022You can call us at Customer Care.\n\u2022You can get free help from your State Health Insurance Assistance Program.\n\u2022Your doctor can make a request for you. If your doctor helps with an appeal past Level 2, they will need to \nbe appointed as your representative. Please call Customer Care and ask for the \"Appointment of \nRepresentative\" form. (The form is also available on Medicare\u2019s website at \nwww.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf)\n\u2013For medical care, your doctor can request a coverage decision or a Level 1 appeal on your behalf. If your \nappeal is denied at Level 1, it will be automatically forwarded to Level 2. ", "doc_id": "7c6a516f-c027-4dcb-9535-f51590333168", "embedding": null, "doc_hash": "ab1ff147b348670025e683cd35a5358cd412c96292ea1948de94677dd01109f0", "extra_info": {"page_label": "135", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3177, "_node_type": "1"}, "relationships": {"1": "cb3ceb9a-38a3-4639-8970-f43b4b0531b1"}}, "__type__": "1"}, "42f88e03-98d5-4c8b-8408-b1da23346926": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 136\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2013For Part D prescription drugs, your doctor or other prescriber can request a coverage decision or a Level 1 \nappeal on your behalf. If your Level 1 appeal is denied your doctor or prescriber can request a Level 2 \nappeal.\n\u2022You can ask someone to act on your behalf. If you want to, you can name another person to act for you as \nyour \"representative\" to ask for a coverage decision or make an appeal.\n\u2013If you want a friend, relative, or other person to be your representative, call Customer Care and ask for the \n\"Appointment of Representative\" form. (The form is also available on Medicare's website at \nwww.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf.) The form gives that person \npermission to act on your behalf. It must be signed by you and by the person who you would like to act on \nyour behalf. You must give us a copy of the signed form.\n\u2013While we can accept an appeal request without the form, we cannot begin or complete our review until \nwe receive it. If we do not receive the form within 44 calendar days after receiving your appeal request \n(our deadline for making a decision on your appeal), your appeal request will be dismissed. If this happens, \nwe will send you a written notice explaining your right to ask the independent review organization to \nreview our decision to dismiss your appeal.\n\u2022You also have the right to hire a lawyer. You may contact your own lawyer, or get the name of a lawyer \nfrom your local bar association or other referral service. There are also groups that will give you free legal \nservices if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage \ndecision or appeal a decision.\nSection 5.3 Which section of this chapter gives the details for your situation?\nThere are four different situations that involve coverage decisions and appeals. Since each situation has different \nrules and deadlines, we give the details for each one in a separate section:\n\u2022Section 6 of this chapter: \"Your medical care: How to ask for a coverage decision or make an appeal\"\n\u2022Section 7 of this chapter: \"Your Part D prescription drugs: How to ask for a coverage decision or make an \nappeal\"\n\u2022Section 8 of this chapter: \"How to ask us to cover a longer inpatient hospital stay if you think the doctor is \ndischarging you too soon\"\n\u2022Section 9 of this chapter: \"How to ask us to keep covering certain medical services if you think your coverage \nis ending too soon\" (Applies only to these services: home health care, skilled nursing facility care, and \nComprehensive Outpatient Rehabilitation Facility (CORF) services)\nIf you're not sure which section you should be using, please call Customer Care. You can also get help or \ninformation from government organizations such as your State Health Insurance Assistance Program.", "doc_id": "42f88e03-98d5-4c8b-8408-b1da23346926", "embedding": null, "doc_hash": "820410c714a5399b329c91d1e20c8507c535b9fc6ee1b68491131ab26f638688", "extra_info": {"page_label": "136", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2986, "_node_type": "1"}, "relationships": {"1": "19e41f82-7ad5-46e5-8be5-0bca1d7dc047"}}, "__type__": "1"}, "cd32f49e-5ea2-473f-baac-516dd5474591": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 137\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSECTION 6 Your medical care: How to ask for a coverage decision or make  \nan appeal of a coverage decision\nSection 6.1 This section tells what to do if you have problems getting coverage for  \nmedical care or if you want us to pay you back for your care\nThis section is about your benefits for medical care and services. These benefits are described in Chapter 4 of this \ndocument: Medical Benefits Chart (what is covered). To keep things simple, we generally refer to \"medical care \ncoverage\" or \"medical care\" which includes medical items and services as well as Medicare Part B prescription \ndrugs. In some cases, different rules apply to a request for a Part B prescription drug. In those cases, we will explain \nhow the rules for Part B prescription drugs are different from the rules for medical items and services.\nThis section tells what you can do if you are in any of the five following situations:\n1. You are not getting certain medical care you want, and you believe that this care is covered by our plan. Ask \nfor a coverage decision. Section 6.2.\n2. Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you \nbelieve that this care is covered by the plan. Ask for a coverage decision. Section 6.2.\n3. You have received medical care that you believe should be covered by the plan, but we have said we will not \npay for this care. Make an appeal. Section 6.3.\n4. You have received and paid for medical care that you believe should be covered by the plan, and you want to \nask our plan to reimburse you for this care. Send us the bill. Section 6.5.\n5. You are being told that coverage for certain medical care you have been getting that we previously approved \nwill be reduced or stopped, and you believe that reducing or stopping this care could harm your health. Make \nan appeal. Section 6.3.\n\u2022Note: If the coverage that will be stopped is for hospital care, home health care, skilled nursing \nfacility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services, you need to read \nSections 7 and 8 of this Chapter. Special rules apply to these types of care. \nSection 6.2 Step-by-step: How to ask for a coverage decision \nLegal Terms\nWhen a coverage decision involves your medical care, it is called an \"organization determination.\"\nA \"fast coverage decision\" is called an \"expedited determination.\"\nStep 1: Decide if you need a \"standard coverage decision\" or a \"fast coverage decision.\" ", "doc_id": "cd32f49e-5ea2-473f-baac-516dd5474591", "embedding": null, "doc_hash": "740bd019ff29adfc6a837bc408ce9fdc1a5fb2a3f8458093f1152e313e8c2efb", "extra_info": {"page_label": "137", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2650, "_node_type": "1"}, "relationships": {"1": "b41f90d9-db7a-4d0e-b68f-9ba91b67d8a9"}}, "__type__": "1"}, "c3aeee3b-f4f7-4446-8936-0a81647cf243": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 138\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nA \"standard coverage decision\" is usually made within 14 days or 72 hours for Part B drugs. A \"fast coverage \ndecision\" is generally made within 72 hours, for medical services, or 24 hours for Part B drugs. In order to \nget a fast coverage decision, you must meet two requirements: \n\u2022You may only ask for coverage for medical care you have not yet received.\n\u2022You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your \nhealth or hurt your ability to function.\n\u2022If your doctor tells us that your health requires a \"fast coverage decision,\" we will automatically \nagree to give you a fast coverage decision. \n\u2022If you ask for a fast coverage decision on your own, without your doctor\u2019s support, we will decide \nwhether your health requires that we give you a fast coverage decision. If we do not approve a fast \ncoverage decision, we will send you a letter that:\n\u2013Explains that we will use the standard deadlines\n\u2013Explains if your doctor asks for the fast coverage decision, we will automatically give you a fast coverage \ndecision\n\u2013Explains that you can file a \"fast complaint\" about our decision to give you a standard coverage decision \ninstead of the fast coverage decision you requested.\nStep 2: Ask our plan to make a coverage decision or fast coverage decision. \n\u2022Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for \nthe medical care you want. You, your doctor, or your representative can do this. Chapter 2 has contact \ninformation. \nStep 3: We consider your request for medical care coverage and give you our answer.\nFor standard coverage decisions we use the standard deadlines.\nThis means we will give you an answer within 14 calendar days after we receive your request for a medical \nitem or service. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 \nhours after we receive your request.\n\u2022However, if you ask for more time, or if we need more information that may benefit you we can take up to \n14 more days if your request is for a medical item or service. If we take extra days, we will tell you in writing. \nWe can\u2019t take extra time to make a decision if your request is for a Medicare Part B prescription drug.\n\u2022If you believe we should not take extra days, you can file a \"fast complaint\". We will give you an answer to \nyour complaint as soon as we make the decision. (The process for making a complaint is different from the \nprocess for coverage decisions and appeals. See Section 11 of this chapter for information on complaints.)\nFor fast coverage decisions we use an expedited timeframe. \nA fast coverage decision means we will answer within 72 hours if your request is for a medical item or \nservice. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours.", "doc_id": "c3aeee3b-f4f7-4446-8936-0a81647cf243", "embedding": null, "doc_hash": "28d6a41d8a9376e690fe77d8512c585bc70430a348c82b778f4dd4a3d77159ad", "extra_info": {"page_label": "138", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3051, "_node_type": "1"}, "relationships": {"1": "af45d2f4-a6cd-4e50-87b3-6dde7094047e"}}, "__type__": "1"}, "84216000-3711-4ffe-b8cb-13db9ec15e03": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 139\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022However, if you ask for more time, or if we need more that may benefit you we can take up to 14 more \ndays. If we take extra days, we will tell you in writing. We can\u2019t take extra time to make a decision if your \nrequest is for a Medicare Part B prescription drug.\n\u2022If you believe we should not take extra days, you can file a \"fast complaint\". (See Section 11 of this chapter \nfor information on complaints.) We will call you as soon as we make the decision.\n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no.\nStep 4: If we say no to your request for coverage for medical care, you can appeal.\n\u2022If we say no, you have the right to ask us to reconsider this decision by making an appeal. This means asking \nagain to get the medical care coverage you want. If you make an appeal, it means you are going on to Level \n1 of the appeals process. \nSection 6.3 Step-by-step: How to make a Level 1 appeal\nLegal Terms\nAn appeal to the plan about a medical care coverage decision is called a plan \"reconsideration.\"\nA \"fast appeal\" is also called an \"expedited reconsideration.\"\nStep 1: Decide if you need a \"standard appeal\" or a \"fast appeal.\"\nA \"standard appeal\" is usually made within 30 days. A \"fast appeal\" is generally made within 72 hours.\n\u2022If you are appealing a decision we made about coverage for care that you have not yet received, you and/or \nyour doctor will need to decide if you need a \"fast appeal.\" If your doctor tells us that your health requires a \n\"fast appeal,\" we will give you a fast appeal.\n\u2022The requirements for getting a \"fast appeal\" are the same as those for getting a \"fast coverage decision\" in \nSection 6.2 of this chapter.\nStep 2: Ask our plan for an appeal or a fast appeal\n\u2022If you are asking for a standard appeal, submit your standard appeal in writing. \n\u2022If you are asking for a fast appeal, make your appeal in writing or call us. \nChapter 2 has contact information.\n\u2022You must make your appeal request within 60 calendar days from the date on the written notice we sent \nto tell you our answer on the coverage decision. If you miss this deadline and have a good reason for missing \nit, explain the reason your appeal is late when you make your appeal. We may give you more time to make \nyour appeal. Examples of good cause may include a serious illness that prevented you from contacting us or \nif we provided you with incorrect or incomplete information about the deadline for requesting an appeal. ", "doc_id": "84216000-3711-4ffe-b8cb-13db9ec15e03", "embedding": null, "doc_hash": "8467033889fbe5c69011d9857664d6e9f6a34e53a470d7740eb38de8ed2c8a5e", "extra_info": {"page_label": "139", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2691, "_node_type": "1"}, "relationships": {"1": "5eca12dc-cab1-4271-bbe9-d6e0d19058f1"}}, "__type__": "1"}, "bc7533d6-01e1-4728-bb88-a45a5155dd1d": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 140\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022You can ask for a copy of the information regarding your medical decision. You and your doctor may \nadd more information to support your appeal. We are allowed to charge a fee for copying and sending \nthis information to you. \nStep 3: We consider your appeal and we give you our answer.\n\u2022When we are reviewing your appeal, we take a careful look at all of the information. We check to see if we \nwere following all the rules when we said no to your request.\n\u2022We will gather more information if needed, possibly contacting you or your doctor.\nDeadlines for a \"fast\" appeal\n\u2022For fast appeals, we must give you our answer within 72 hours after we receive your appeal. We will give \nyou our answer sooner if your health requires us to do so.\n\u2013If you ask for more time, or if we need more information that may benefit you, we can take up to 14 \nmore calendar days if your request is for a medical item or service. If we take extra days, we will tell you \nin writing. We can\u2019t take extra time if your request is for a Medicare Part B prescription drug.\n\u2013If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra \ndays), we are required to automatically send your request on to Level 2 of the appeals process, where it \nwill be reviewed by an independent review organization. Section 6.4 explains the Level 2 appeal process.\n\u2022If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we \nhave agreed to provide within 72 hours after we receive your appeal. \n\u2022If our answer is no to part or all of what you requested, we will send you our decision in writing and \nautomatically forward your appeal to the independent review organization for a Level 2 appeal. The \nindependent review organization will notify you in writing when it receives your appeal. \nDeadlines for a \"standard\" appeal\n\u2022For standard appeals, we must give you our answer within 30 calendar days after we receive your appeal. If \nyour request is for a Medicare Part B prescription drug you have not yet received, we will give you our answer \nwithin 7 calendar days after we receive your appeal. We will give you our decision sooner if your health \ncondition requires us to. \n\u2013However, if you ask for more time, or if we need more information that may benefit you, we can take up \nto 14 more calendar days if your request is for a medical item or service. If we take extra days, we will tell \nyou in writing. We can\u2019t take extra time to make a decision if your request is for a Medicare Part B \nprescription drug.\n\u2013If you believe we should not take extra days, you can file a \"fast complaint.\" When you file a fast \ncomplaint, we will give you an answer to your complaint within 24 hours. (For more information about the \nprocess for making complaints, including fast complaints, see Section 11 of this chapter.)\n\u2013If we do not give you an answer by the deadline (or by the end of the extended time period), we will send \nyour request to a Level 2 appeal where an independent review organization will review the appeal. Section \n6.4 explains the Level 2 appeal process.", "doc_id": "bc7533d6-01e1-4728-bb88-a45a5155dd1d", "embedding": null, "doc_hash": "7b62ed9040e1291f2dd509f3f45b0acc19f4b5b76c29dc225fbfcb4d9411bf09", "extra_info": {"page_label": "140", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3303, "_node_type": "1"}, "relationships": {"1": "31453792-fe49-4abe-a39e-fabc3df8f5de"}}, "__type__": "1"}, "0d47bc0c-e5d8-465e-8e47-100e25880498": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 141\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we \nhave agreed to provide within 30 calendar days if your request is for a medical item or service, or within 7 \ncalendar days if your request is for a Medicare Part B prescription drug.\n\u2022If our plan says no to part or all of your appeal, we will automatically send your appeal to the \nindependent review organization for a Level 2 appeal. \nSection 6.4 Step-by-step: How a Level 2 appeal is done\nLegal Terms\nThe formal name for the \"independent review organization\" is the \"Independent Review Entity.\" It is  \nsometimes called the \"IRE.\"\nThe independent review organization is an independent organization hired by Medicare. It is not connected \nwith us and is not a government agency. This organization decides whether the decision we made is correct or if it \nshould be changed. Medicare oversees its work.\nStep 1: The independent review organization reviews your appeal.\n\u2022We will send the information about your appeal to this organization. This information is called your \"case \nfile.\" You have the right to ask us for a copy of your case file. We are allowed to charge you a fee for \ncopying and sending this information to you.\n\u2022You have a right to give the independent review organization additional information to support your appeal.\n\u2022Reviewers at the independent review organization will take a careful look at all of the information related to \nyour appeal.\nIf you had a \"fast\" appeal at Level 1, you will also have a \"fast\" appeal at Level 2\n\u2022For the \"fast appeal\" the review organization must give you an answer to your Level 2 appeal within 72 \nhours of when it receives your appeal.\n\u2022If your request is for a medical item or service and the independent review organization needs to gather \nmore information that may benefit you, it can take up to 14 more calendar days. The independent review \norganization can\u2019t take extra time to make a decision if your request is for a Medicare Part B prescription drug.\nIf you had a \"standard\" appeal at Level 1, you will also have a \"standard\" appeal at Level 2\n\u2022For the \"standard appeal\" if your request is for a medical item or service, the review organization must give \nyou an answer to your Level 2 appeal within 30 calendar days of when it receives your appeal. \n\u2022If your request is for a Medicare Part B prescription drug, the review organization must give you an answer to \nyour Level 2 appeal within 7 calendar days of when it receives your appeal.\n\u2022If your request is for a medical item or service and the independent review organization needs to gather \nmore information that may benefit you, it can take up to 14 more calendar days. The independent review \norganization can\u2019t take extra time to make a decision if your request is for a Medicare Part B prescription drug.", "doc_id": "0d47bc0c-e5d8-465e-8e47-100e25880498", "embedding": null, "doc_hash": "9fb138bda2399413a6e7c2eaec04edbd5697a7dea5fe57143024cc8c09cfdcdb", "extra_info": {"page_label": "141", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3021, "_node_type": "1"}, "relationships": {"1": "cd6e6069-8236-4141-b1d9-e425e4df6260"}}, "__type__": "1"}, "38255058-e2c7-4956-bf79-a65765fa792c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 142\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nStep 2: The independent review organization gives you their answer.\nThe independent review organization will tell you its decision in writing and explain the reasons for it.\n\u2022If the independent review organization says yes to part or all of a request for a medical item or \nservice, we must authorize the medical care coverage within 72 hours or provide the service within 14 \ncalendar days after we receive the independent review organization's decision for standard requests or \nprovide the service within 72 hours from the date the plan receives the independent review organization's \ndecision for expedited requests.\n\u2022If the independent review organization says yes to part or all of a request for a Medicare Part B \nprescription drug, we must authorize or provide the Medicare Part B prescription drug within 72 hours after \nwe receive the independent review organization\u2019s decision for standard requests or within 24 hours from \nthe date we receive the independent review organization\u2019s decision for expedited requests.\n\u2022If this organization says no to part or all of your appeal, it means they agree with our plan that your \nrequest (or part of your request) for coverage for medical care should not be approved. (This is called \n\"upholding the decision.\" or \"turning down your appeal.\") In this case, the independent review organization \nwill send you a letter:\n\u2013Explaining its decision. \n\u2013Notifying you of the right to a Level 3 appeal if the dollar value of the medical care coverage you are \nrequesting meets a certain minimum. The written notice you get from the independent review \norganization will tell you the dollar amount you must meet to continue the appeals process. \n\u2013Telling you how to file a Level 3 appeal. \nStep 3: If your case meets the requirements, you choose whether you want to take your appeal further.\n\u2022There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If you \nwant to go to a Level 3 appeal the details on how to do this are in the written notice you get after your Level 2 \nappeal.\n\u2022The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 10 in this \nchapter tells more about Levels 3, 4, and 5 of the appeals process.\nSection 6.5 What if you are asking us to pay you back for a bill you have received for  \nmedical care?\nWe can\u2019t reimburse you directly for a Medicaid service or item. If you get a bill for Medicaid-covered services \nand items, send the bill to us. You should not pay the bill yourself. We will contact the provider directly and take \ncare of the problem. But if you do pay the bill, you can get a refund from that health care provider if you followed \nthe rules for getting the service or item.\nAsking for reimbursement is asking for a coverage decision from us\nIf you send us the paperwork that asks for reimbursement, you are asking for a coverage decision. To make this \ndecision, we will check to see if the medical care you paid for is a covered service. We will also check to see if you \nfollowed all the rules for using your coverage for medical care. ", "doc_id": "38255058-e2c7-4956-bf79-a65765fa792c", "embedding": null, "doc_hash": "47a395fb61ea0c5fc8f8098ddacb7a847c485e6255687f39c686bdd462f2f493", "extra_info": {"page_label": "142", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3294, "_node_type": "1"}, "relationships": {"1": "0cd937f5-7c18-459f-8ecb-2f7a0e6d68a7"}}, "__type__": "1"}, "9b00abd3-5df0-4641-9803-38e3f4e805d9": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 143\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022If we say yes to your request: If the medical care is covered and you followed all the rules, we will send you \nthe payment for within 60 calendar days after we receive your request. If you haven\u2019t paid for the services, \nwe will send the payment directly to the provider.\n\u2022If we say no to your request: If the medical care is not covered, or you did not follow all the rules, we will not \nsend payment. Instead, we will send you a letter that says we will not pay for the services and the reasons \nwhy. \nIf you do not agree with our decision to turn you down, you can make an appeal. If you make an appeal, it means \nyou are asking us to change the coverage decision we made when we turned down your request for payment.\nTo make this appeal, follow the process for appeals that we describe in Section 5.3. For appeals concerning \nreimbursement, please note:\n\u2022We must give you our answer within 60 calendar days after we receive your appeal. If you are asking us to \npay you back for medical care you have already received and paid for, you are not allowed to ask for a fast \nappeal. \n\u2022If the independent review organization decides we should pay, we must send the payment you have \nrequested to you or to the provider within 30 calendar days. If the answer to your appeal is yes at any stage \nof the appeals process after Level 2, we must send the payment you requested to you or to the provider \nwithin 60 calendar days.\nSECTION 7 Your Part D prescription drugs: How to ask for a coverage  \ndecision or make an appeal\nSection 7.1 This section tells you what to do if you have problems getting a Part D  \ndrug or you want us to pay you back for a Part D drug\nYour benefits include coverage for many prescription drugs. To be covered, the drug must be used for a \nmedically accepted indication. (See Chapter 5 for more information about a medically accepted indication.) For \ndetails about Part D drugs, rules, restrictions, and costs please see Chapters 5 and 6.\n\u2022This section is about your Part D drugs only. To keep things simple, we generally say \"drug\" in the rest of \nthis section, instead of repeating \"covered outpatient prescription drug\" or \"Part D drug\" every time. We also \nuse the term \"drug guide\" instead of \"List of Covered Drugs\" or \"Formulary.\"\n\u2022If you do not know if a drug is covered or if you meet the rules, you can ask us. Some drugs require that you \nget approval from us before we will cover it.\n\u2022If your pharmacy tells you that your prescription cannot be filled as written, the pharmacy will give you a \nwritten notice explaining how to contact us to ask for a coverage decision.", "doc_id": "9b00abd3-5df0-4641-9803-38e3f4e805d9", "embedding": null, "doc_hash": "cef8fc9ac4866e8ccbf4064a1c826e4ad075a164f02b0667e6556e3cf3ef47cd", "extra_info": {"page_label": "143", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2790, "_node_type": "1"}, "relationships": {"1": "36e6279b-6442-4137-ae8a-3811045f78d7"}}, "__type__": "1"}, "7e39ea01-fa49-4469-b181-8f768118c04a": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 144\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nPart D coverage decisions and appeals\nLegal Term\nAn initial coverage decision about your Part D drugs is called a \"coverage determination.\"\nA coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for \nyour drugs. This section tells what you can do if you are in any of the following situations:\n\u2022Asking to cover a Part D drug that is not in the plan\u2019s Prescription Drug Guide (Formulary). Ask for an \nexception. Section 7.2 \n\u2022Asking to waive a restriction on the plan\u2019s coverage for a drug (such as limits on the amount of the drug you \ncan get) Ask for an exception. Section 7.2 \n\u2022Asking to get pre-approval for a drug. Ask for a coverage decision. Section 7.4 \n\u2022Pay for a prescription drug you already bought. Ask us to pay you back. Section 7.4 \nIf you disagree with a coverage decision we have made, you can appeal our decision. \nThis section tells you both how to ask for coverage decisions and how to request an appeal. \nSection 7.2 What is an exception?\nLegal Terms\nAsking for coverage of a drug that is not in the Drug Guide is sometimes called asking for a \"formulary  \nexception.\"\nAsking for removal of a restriction on coverage for a drug is sometimes called asking for a \"formulary  \nexception.\"\nAsking to pay a lower price for a covered non-preferred drug is sometimes called asking for a \"tiering exception.\"\nIf a drug is not covered in the way you would like it to be covered, you can ask us to make an \"exception.\" An \nexception is a type of coverage decision. \nFor us to consider your exception request, your doctor or other prescriber will need to explain the medical reasons \nwhy you need the exception approved. Here are two examples of exceptions that you or your doctor or other \nprescriber can ask us to make:\n1. Covering a Part D drug for you that is not in our Prescription Drug Guide. If we agree to cover a drug that is \nnot in the Drug Guide, you will need to pay the cost-sharing amount that applies to all of our drugs. You cannot \nask for an exception to the cost-sharing amount we require you to pay for the drug. \n2. Removing a restriction for a covered drug. Chapter 5 describes the extra rules or restrictions that apply to \ncertain drugs in our Prescription Drug Guide. If we agree to make an exception and waive a restriction for you, \nyou can ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.", "doc_id": "7e39ea01-fa49-4469-b181-8f768118c04a", "embedding": null, "doc_hash": "1718b452449d9979b045e31fa6589799fa3608fd8f16ce263585ee418a3e9dd0", "extra_info": {"page_label": "144", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2610, "_node_type": "1"}, "relationships": {"1": "d886fb8f-e41c-4d5e-932c-b34d342149d4"}}, "__type__": "1"}, "b72fa594-82ae-4802-83cd-93fd89b9e746": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 145\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSection 7.3 Important things to know about asking for exceptions\nYour doctor must tell us the medical reasons\nYour doctor or other prescriber must give us a statement that explains the medical reasons for requesting an \nexception. For a faster decision, include this medical information from your doctor or other prescriber when you ask \nfor the exception.\nTypically, our Drug Guide includes more than one drug for treating a particular condition. These different \npossibilities are called \"alternative\" drugs. If an alternative drug would be just as effective as the drug you are \nrequesting and would not cause more side effects or other health problems, we will generally not approve your \nrequest for an exception.\nWe can say yes or no to your request\n\u2022If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is \ntrue as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and \neffective for treating your condition.\n\u2022If we say no to your request, you can ask for another review of our decision by making an appeal.\nSection 7.4 Step-by-step: How to ask for a coverage decision, including an exception\nLegal Term\nA \"fast coverage decision\" is called an \"expedited coverage determination.\"\nStep 1: Decide if you need a \"standard coverage decision\" or a \"fast coverage decision.\"\n\"Standard coverage decisions\" are made within 72 hours after we receive your doctor\u2019s statement. \"Fast \ncoverage decisions\" are made within 24 hours after we receive your doctor\u2019s statement. \nIf your health requires it, ask us to give you a \"fast coverage decision.\" To get a fast coverage decision, you must \nmeet two requirements:\n\u2022You must be asking for a drug you have not yet received. (You cannot ask for fast coverage decision to be paid \nback for a drug you have already bought.)\n\u2022Using the standard deadlines could cause serious harm to your health or hurt your ability to function.\n\u2022If your doctor or other prescriber tells us that your health requires a \"fast coverage decision,\" we will \nautomatically give you a fast coverage decision.\n\u2022If you ask for a fast coverage decision on your own, without your doctor or prescriber\u2019s support, we \nwill decide whether your health requires that we give you a fast coverage decision. If we do not \napprove a fast coverage decision, we will send you a letter that:\n\u2013Explains that we will use the standard deadlines.", "doc_id": "b72fa594-82ae-4802-83cd-93fd89b9e746", "embedding": null, "doc_hash": "3c36cd89bf581a4cbdf15a1af3cc27ad185d8dd55b180a5096388881e2e049e1", "extra_info": {"page_label": "145", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2629, "_node_type": "1"}, "relationships": {"1": "cf6c7754-2bf2-4c11-b784-bb3cb24be9ca"}}, "__type__": "1"}, "d0c0e1b0-a723-4421-ab83-87e870ce6cd5": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 146\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2013Explains if your doctor or other prescriber asks for the fast coverage decision, we will automatically give \nyou a fast coverage decision.\n\u2013Tells you how you can file a \"fast complaint\" about our decision to give you a standard coverage decision \ninstead of the fast coverage decision you requested. We will answer your complaint within 24 hours of \nreceipt.\nStep 2: Request a \"standard coverage decision\" or a \"fast coverage decision.\"\nStart by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the \nmedical care you want. You can also access the coverage decision process through our website. We must accept \nany written request, including a request submitted on the CMS Model Coverage Determination Request Form or on \nour plan\u2019s form, which is available on our website. Chapter 2 has contact information.  To submit a coverage \ndetermination request online, please go to: Humana.com/member/member-rights/pharmacy-authorizations. \nFill out the Coverage Determination Request Form. You'll need to send us supporting documentation from the \nprescribing doctor to show medical need. Your information will be sent to us securely. To assist us in processing \nyour request, please be sure to include your name, contact information, and information identifying which denied \nclaim is being appealed.\nYou, your doctor, (or other prescriber) or your representative can do this. You can also have a lawyer act on your \nbehalf. Section 4 of this chapter tells how you can give written permission to someone else to act as your \nrepresentative.\n\u2022If you are requesting an exception, provide the \"supporting statement,\" which is the medical reasons for \nthe exception. Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other \nprescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary.\nStep 3: We consider your request and give you our answer.\nDeadlines for a \"fast\" coverage decision\n\u2022We must generally give you our answer within 24 hours after we receive your request. \n\u2013For exceptions, we will give you our answer within 24 hours after we receive your doctor\u2019s supporting \nstatement. We will give you our answer sooner if your health requires us to. \n\u2013If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, \nwhere it will be reviewed by an independent review organization.\n\u2022If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed \nto provide within 24 hours after we receive your request or doctor's statement supporting your request.\n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no. We will also tell you how you can appeal.\nDeadlines for a \"standard\" coverage decision about a drug you have not yet received\n\u2022We must generally give you our answer within 72 hours after we receive your request.\n\u2013For exceptions, we will give you our answer within 72 hours after we receive your doctor\u2019s supporting \nstatement. We will give you our answer sooner if your health requires us to. ", "doc_id": "d0c0e1b0-a723-4421-ab83-87e870ce6cd5", "embedding": null, "doc_hash": "9d2d05aed5111e65a50c894a20cb1fa817a44fc742c1934dc12fa13736f1bc96", "extra_info": {"page_label": "146", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3365, "_node_type": "1"}, "relationships": {"1": "2f4b08a4-94c9-4b13-85c1-af90c0027bb6"}}, "__type__": "1"}, "c0c8d48a-575d-40f1-920c-8d380e89ca45": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 147\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2013If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, \nwhere it will be reviewed by an independent review organization. \n\u2022If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed \nto provide within 72 hours after we receive your request or doctor's statement supporting your request. \n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no. We will also tell you how you can appeal.\nDeadlines for a \"standard\" coverage decision about payment for a drug you have already bought\n\u2022We must give you our answer within 14 calendar days after we receive your request.\n\u2013If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, \nwhere it will be reviewed by an independent review organization. \n\u2022If our answer is yes to part or all of what you requested, we are also required to make payment to you \nwithin 14 calendar days after we receive your request.\n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no. We will also tell you how you can appeal.\nStep 4: If we say no to your coverage request, you can make an appeal.\n\u2022If we say no, you have the right to ask us to reconsider this decision by making an appeal. This means asking \nagain to get the drug coverage you want. If you make an appeal, it means you are going on to Level 1 of the \nappeals process.\nSection 7.5 Step-by-step: How to make a Level 1 appeal\nLegal Terms\nAn appeal to the plan about a Part D drug coverage decision is called a plan \"redetermination.\"\nA \"fast appeal\" is also called an \"expedited redetermination.\"\nStep 1: Decide if you need a \"standard appeal\" or a \"fast appeal.\"\nA \"standard appeal\" is usually made within 7 days. A \"fast appeal\" is generally made within 72 hours. If your \nhealth requires it, ask for a \"fast appeal\".\n\u2022If you are appealing a decision we made about a drug you have not yet received, you and your doctor or \nother prescriber will need to decide if you need a \"fast appeal.\"\n\u2022The requirements for getting a \"fast appeal\" are the same as those for getting a \"fast coverage decision\" in \nSection 6.4 of this chapter.\nStep 2: You, your representative, doctor or other prescriber must contact us and make your Level 1 appeal. \nIf your health requires a quick response, you must ask for a \"fast appeal.\"", "doc_id": "c0c8d48a-575d-40f1-920c-8d380e89ca45", "embedding": null, "doc_hash": "e21aee9f313559089826b382d2a38925873fdd01f56db3b43cdab043873a33df", "extra_info": {"page_label": "147", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2673, "_node_type": "1"}, "relationships": {"1": "f77a0e64-a9f2-44f0-b89f-cedfbef10fe2"}}, "__type__": "1"}, "3a39838b-7d47-4c33-988f-9d8f4aa99a4e": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 148\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022For standard appeals, submit a written request. Chapter 2 has contact information.\n\u2022For fast appeals, either submit your appeal in writing or call us at (1-800-867-6601). Chapter 2 has \ncontact information.\n\u2022We must accept any written request, including a request submitted on the CMS Model Coverage \nDetermination Request Form, which is available on our website. Please be sure to include your name, contact \ninformation, and information regarding your claim to assist us in processing your request. \n\u2022You must make your appeal request within 60 calendar days from the date on the written notice we sent \nto tell you our answer on the coverage decision. If you miss this deadline and have a good reason for missing \nit, explain the reason your appeal is late when you make your appeal. We may give you more time to make \nyour appeal. Examples of good cause may include a serious illness that prevented you from contacting us or \nif we provided you with incorrect or incomplete information about the deadline for requesting an appeal.\n\u2022You can ask for a copy of the information in your appeal and add more information. You and your doctor \nmay add more information to support your appeal. We are allowed to charge a fee for copying and sending \nthis information to you. \nStep 3: We consider your appeal and we give you our answer.\n\u2022When we are reviewing your appeal, we take another careful look at all of the information about your \ncoverage request. We check to see if we were following all the rules when we said no to your request. We \nmay contact you or your doctor or other prescriber to get more information.\nDeadlines for a \"fast\" appeal\n\u2022For fast appeals, we must give you our answer within 72 hours after we receive your appeal. We will give \nyou our answer sooner if your health requires us to. \n\u2013If we do not give you an answer within 72 hours, we are required to send your request on to Level 2 of the \nappeals process, where it will be reviewed by an independent review organization. Section 7.6 explains the \nLevel 2 appeal process.\n\u2022If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed \nto provide within 72 hours after we receive your appeal. \n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no and how you can appeal our decision.\nDeadlines for a \"standard\" appeal for a drug you have not yet received\n\u2022For standard appeals, we must give you our answer within 7 calendar days after we receive your appeal. \nWe will give you our decision sooner if you have not received the drug yet and your health condition requires \nus to do so. \n\u2013If we do not give you a decision within 7 calendar days, we are required to send your request on to Level 2 \nof the appeals process, where it will be reviewed by an independent review organization. Section 7.6 \nexplains the Level 2 appeal process.", "doc_id": "3a39838b-7d47-4c33-988f-9d8f4aa99a4e", "embedding": null, "doc_hash": "0f75ad95946f376386e23fe7919b8e92e0e4c0d9ee177a07f5a5966e782967c2", "extra_info": {"page_label": "148", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3107, "_node_type": "1"}, "relationships": {"1": "0bba286e-cb34-4520-98f9-10da3bfd851e"}}, "__type__": "1"}, "19670c68-a810-4000-839b-4140f28e6bcc": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 149\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022If our answer is yes to part or all of what you requested, we must provide the coverage as quickly as your \nhealth requires, but no later than 7 calendar days after we receive your appeal. \n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no and how you can appeal our decision. \nDeadlines for a \"standard appeal\" about payment for a drug you have already bought \n\u2022We must give you our answer within 14 calendar days after we receive your request.\n\u2013If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, \nwhere it will be reviewed by an independent review organization. \n\u2022If our answer is yes to part or all of what you requested, we are also required to make payment to you \nwithin 30 calendar days after we receive your request.\n\u2022If our answer is no to part or all of what you requested, we will send you a written statement that \nexplains why we said no. We will also tell you how you can appeal.\nStep 4: If we say no to your appeal, you decide if you want to continue with the appeals process and make \nanother appeal.\n\u2022If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process. \nSection 7.6 Step-by-step: How to make a Level 2 appeal\nLegal Term\nThe formal name for the \"independent review organization\" is the \"Independent Review Entity.\" It is  \nsometimes called the \"IRE.\"\nThe independent review organization is an independent organization hired by Medicare. It is not connected \nwith us and is not a government agency. This organization decides whether the decision we made is correct or if it \nshould be changed. Medicare oversees its work.\nStep 1: You (or your representative or your doctor or other prescriber) must contact the independent review \norganization and ask for a review of your case.\n\u2022If we say no to your Level 1 appeal, the written notice we send you will include instructions on how to make \na Level 2 appeal with the independent review organization. These instructions will tell who can make this \nLevel 2 appeal, what deadlines you must follow, and how to reach the review organization. If, however, we \ndid not complete our review within the applicable timeframe, or make an unfavorable decision regarding \n\"at-risk\" determination under our drug management program, we will automatically forward your claim to \nthe IRE.\n\u2022We will send the information about your appeal to this organization. This information is called your \"case \nfile.\" You have the right to ask us for a copy of your case file. We are allowed to charge you a fee for \ncopying and sending this information to you. \n\u2022You have a right to give the independent review organization additional information to support your appeal.", "doc_id": "19670c68-a810-4000-839b-4140f28e6bcc", "embedding": null, "doc_hash": "c101680db3d1370ce510e4ee3a2e2f25b4ad766eb68f07e076670b958d8de770", "extra_info": {"page_label": "149", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2976, "_node_type": "1"}, "relationships": {"1": "a99c9c94-831e-43ca-99ad-2215ae11f7ad"}}, "__type__": "1"}, "09b23eb6-db52-4b2b-b416-35c480ed479c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 150\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nStep 2: The independent review organization reviews your appeal.\nReviewers at the independent review organization will take a careful look at all of the information related to your \nappeal. \nDeadlines for \"fast\" appeal \n\u2022If your health requires it, ask the independent review organization for a \"fast appeal.\" \n\u2022If the organization agrees to give you a \"fast appeal,\" the organization must give you an answer to your Level \n2 appeal within 72 hours after it receives your appeal request.\nDeadlines for \"standard\" appeal \n\u2022For standard appeals, the review organization must give you an answer to your Level 2 appeal within 7 \ncalendar days after it receives your appeal if it is for a drug you have not yet received. If you are requesting \nthat we pay you back for a drug you have already bought, the review organization must give you an answer \nto your level 2 appeal within 14 calendar days after it receives your request.\nStep 3: The independent review organization gives you their answer. \nFor \"fast appeals\": \n\u2022If the independent review organization says yes to part or all of what you requested, we must provide \nthe drug coverage that was approved by the review organization within 24 hours after we receive the \ndecision from the review organization.\nFor \"standard appeals\": \n\u2022If the independent review organization says yes to part or all of your request for coverage, we must \nprovide the drug coverage that was approved by the review organization within 72 hours after we receive \nthe decision from the review organization. \n\u2022If the independent review organization says yes to part or all of your request to pay you back for a \ndrug you already bought, we are required to send payment to you within 30 calendar days after we \nreceive the decision from the review organization. \nWhat if the review organization says no to your appeal?\nIf this organization says no to part or all of your appeal, it means they agree with our decision not to approve \nyour request (or part of your request). (This is called \"upholding the decision.\" It is also called \"turning down your \nappeal.\") In this case, the independent review organization will send you a letter:\n\u2022Explaining its decision.\n\u2022Notifying you of the right to a Level 3 appeal if the dollar value of the drug coverage you are requesting meets \na certain minimum. If the dollar value of the drug coverage you are requesting is too low, you cannot make \nanother appeal and the decision at Level 2 is final.\n\u2022Telling you the dollar value that must be in dispute to continue with the appeals process.\nStep 4: If your case meets the requirements, you choose whether you want to take your appeal further.", "doc_id": "09b23eb6-db52-4b2b-b416-35c480ed479c", "embedding": null, "doc_hash": "71e76d368eb707a1559bef189c7395821dd5d2f41d13a84cc164a800a9fc8e22", "extra_info": {"page_label": "150", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2840, "_node_type": "1"}, "relationships": {"1": "bcff4d9f-5fe1-4fee-be8b-dc7f31c150df"}}, "__type__": "1"}, "92ea0eab-6000-43c9-84af-69b9d0df0334": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 151\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal).\n\u2022If you want to go on to a Level 3 appeal, the details on how to do this are in the written notice you get after \nyour Level 2 appeal decision. \n\u2022The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 10 in this \nchapter tells more about Levels 3, 4, and 5 of the appeals process.\nSECTION 8 How to ask us to cover a longer inpatient hospital stay if you  \nthink the doctor is discharging you too soon\nWhen you are admitted to a hospital, you have the right to get all of your covered hospital services that are \nnecessary to diagnose and treat your illness or injury. \nDuring your covered hospital stay, your doctor and the hospital staff will be working with you to prepare for the day \nwhen you will leave the hospital. They will help arrange for care you may need after you leave.\n\u2022The day you leave the hospital is called your \"discharge date.\"\n\u2022When your discharge date is decided, your doctor or the hospital staff will tell you. \n\u2022If you think you are being asked to leave the hospital too soon, you can ask for a longer hospital stay and \nyour request will be considered. \nSection 8.1 During your inpatient hospital stay, you will get a written notice from  \nMedicare that tells about your rights\nWithin two days of being admitted to the hospital, you will be given a written notice called An Important Message \nfrom Medicare about Your Rights. Everyone with Medicare gets a copy of this notice. If you do not get the notice \nfrom someone at the hospital (for example, a caseworker or nurse), ask any hospital employee for it. If you need \nhelp, please call Customer Care or 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. (TTY \n1-877-486-2048).\n1. Read this notice carefully and ask questions if you don't understand it. It tells you:\n\u2022Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your \ndoctor. This includes the right to know what these services are, who will pay for them, and where you can \nget them.\n\u2022Your right to be involved in any decisions about your hospital stay.\n\u2022Where to report any concerns you have about quality of your hospital care.\n\u2022Your right to request an immediate review of the decision to discharge you if you think you are being \ndischarged from the hospital too soon. This is a formal, legal way to ask for a delay in your discharge date \nso that we will cover your hospital care for a longer time.\n2. You will be asked to sign the written notice to show that you received it and understand your rights. ", "doc_id": "92ea0eab-6000-43c9-84af-69b9d0df0334", "embedding": null, "doc_hash": "7abd168466553766b6b3b91a573f475778e935c4936c415d2b3507a9fef2f1de", "extra_info": {"page_label": "151", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2842, "_node_type": "1"}, "relationships": {"1": "15010ef0-c017-44da-9b50-b2a34972e3b0"}}, "__type__": "1"}, "0f26c1c1-a7f2-412a-9944-d649961b9f6e": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 152\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022You or someone who is acting on your behalf will be asked to sign the notice. \n\u2022Signing the notice shows only that you have received the information about your rights. The notice does \nnot give your discharge date. Signing the notice does not mean you are agreeing on a discharge date.\n3. Keep your copy of the notice handy so you will have the information about making an appeal (or reporting a \nconcern about quality of care) if you need it.\n\u2022If you sign the notice more than two days before your discharge date, you will get another copy before \nyou are scheduled to be discharged.\n\u2022To look at a copy of this notice in advance, you can call Customer Care or 1-800 MEDICARE \n(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also \nsee the notice online at \nwww.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.\nSection 8.2 Step-by-step: How to make a Level 1 appeal to change your hospital  \ndischarge date\nIf you want to ask for your inpatient hospital services to be covered by us for a longer time, you will need to use the \nappeals process to make this request. Before you start, understand what you need to do and what the deadlines \nare.\n\u2022Follow the process. \n\u2022Meet the deadlines.  \n\u2022Ask for help if you need it. If you have questions or need help at any time, please call Customer Care. Or call \nyour State Health Insurance Assistance Program, a government organization that provides personalized \nassistance.\nDuring a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It checks to see if your \nplanned discharge date is medically appropriate for you.\nThe Quality Improvement Organization is a group of doctors and other health care professionals paid by the \nFederal government to check on and help improve the quality of care for people with Medicare. This includes \nreviewing hospital discharge dates for people with Medicare. These experts are not part of our plan.\nStep 1: Contact the Quality Improvement Organization for your state and ask for an immediate review of \nyour hospital discharge. You must act quickly.\nHow can you contact this organization?\n\u2022The written notice you received (An Important Message from Medicare About Your Rights) tells you how to \nreach this organization. Or find the name, address, and phone number of the Quality Improvement \nOrganization for your state in Chapter 2.\nAct quickly:", "doc_id": "0f26c1c1-a7f2-412a-9944-d649961b9f6e", "embedding": null, "doc_hash": "a15f0d680522c761ccd922749629829178f699c176132195c7f0037a2c6e55f5", "extra_info": {"page_label": "152", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2611, "_node_type": "1"}, "relationships": {"1": "d79e78f9-6978-4ab8-8a86-d729d345e751"}}, "__type__": "1"}, "dd95c1a9-f26a-4793-acd8-a1f771ad1f29": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 153\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022To make your appeal, you must contact the Quality Improvement Organization before you leave the hospital \nand no later than midnight the day of your discharge. \n\u2013If you meet this deadline, you may stay in the hospital after your discharge date without paying for it \nwhile you wait to get the decision from the Quality Improvement Organization.\n\u2013If you do not meet this deadline, and you decide to stay in the hospital after your planned discharge \ndate, you may have to pay all of the costs for hospital care you receive after your planned discharge date.\n\u2022If you miss the deadline for contacting the Quality Improvement Organization, and you still wish to appeal, \nyou must make an appeal directly to our plan instead. For details about this other way to make your appeal, \nsee Section 8.4 of this chapter.\nOnce you request an immediate review of your hospital discharge the Quality Improvement Organization will \ncontact us. By noon of the day after we are contacted we will give you a Detailed Notice of Discharge. This notice \ngives your planned discharge date and explains in detail the reasons why your doctor, the hospital, and we think it \nis right (medically appropriate) for you to be discharged on that date. \nYou can get a sample of the Detailed Notice of Discharge by calling Customer Care or 1-800-MEDICARE \n(1-800-633-4227), 24 hours a day, 7 days a week. (TTY users should call 1-877-486-2048.) Or you can see a \nsample notice online at \nwww.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeappealNotices.\nStep 2: The Quality Improvement Organization conducts an independent review of your case.\n\u2022Health professionals at the Quality Improvement Organization (\"the reviewers\") will ask you (or your \nrepresentative) why you believe coverage for the services should continue. You don't have to prepare \nanything in writing, but you may do so if you wish. \n\u2022The reviewers will also look at your medical information, talk with your doctor, and review information that \nthe hospital and we have given to them.\n\u2022By noon of the day after the reviewers told us of your appeal, you will also get a written notice from us that \ngives your planned discharge date.  This notice also explains in detail the reasons why your doctor, the \nhospital, and we think it is right (medically appropriate) for you to be discharged on that date.\nStep 3: Within one full day after it has all the needed information, the Quality Improvement Organization \nwill give you its answer to your appeal.\nWhat happens if the answer is yes?\n\u2022If the review organization says yes, we must keep providing your covered inpatient hospital services for \nas long as these services are medically necessary. \n\u2022You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In \naddition, there may be limitations on your covered hospital services. \nWhat happens if the answer is no?", "doc_id": "dd95c1a9-f26a-4793-acd8-a1f771ad1f29", "embedding": null, "doc_hash": "1783e38a53ed64d0d7ca8a8b311364dee4647d0345b1bd2cae50d7b2e2e49648", "extra_info": {"page_label": "153", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3098, "_node_type": "1"}, "relationships": {"1": "4bfc82ca-f567-42d4-95e5-b3c63ecfed6c"}}, "__type__": "1"}, "5b823ed9-a08a-40b5-8f18-c1c1d6fc2cca": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 154\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022If the review organization says no, they are saying that your planned discharge date is medically appropriate. \nIf this happens, our coverage for your inpatient hospital services will end at noon on the day after the \nQuality Improvement Organization gives you its answer to your appeal. \n\u2022If the review organization says no to your appeal and you decide to stay in the hospital, then you may have \nto pay the full cost of hospital care you receive after noon on the day after the Quality Improvement \nOrganization gives you its answer to your appeal.\nStep 4: If the answer to your Level 1 appeal is no, you decide if you want to make another appeal.\n\u2022If the Quality Improvement Organization has said no to your appeal, and you stay in the hospital after your \nplanned discharge date, then you can make another appeal. Making another appeal means you are going on \nto \"Level 2\" of the appeals process.\nSection 8.3 Step-by-step: How to make a Level 2 appeal to change your hospital  \ndischarge date\nDuring a Level 2 appeal, you ask the Quality Improvement Organization to take another look at their decision on \nyour first appeal. If the Quality Improvement Organization turns down your Level 2 appeal, you may have to pay \nthe full cost for your stay after your planned discharge date.\nStep 1: Contact the Quality Improvement Organization again and ask for another review.\n\u2022You must ask for this review within 60 calendar days after the day the Quality Improvement Organization \nsaid no to your Level 1 appeal. You can ask for this review only if you stay in the hospital after the date that \nyour coverage for the care ended.\nStep 2: The Quality Improvement Organization does a second review of your situation.\n\u2022Reviewers at the Quality Improvement Organization will take another careful look at all of the information \nrelated to your appeal.\nStep 3: Within 14 calendar days of receipt of your request for a Level 2 appeal, the reviewers will decide on \nyour appeal and tell you their decision.\nIf the review organization says yes:\n\u2022We must reimburse you for our share of the costs of hospital care you have received since noon on the day \nafter the date your first appeal was turned down by the Quality Improvement Organization. We must \ncontinue providing coverage for your inpatient hospital care for as long as it is medically necessary. \n\u2022You must continue to pay your share of the costs and coverage limitations may apply.\nIf the review organization says no:\n\u2022It means they agree with the decision they made on your Level 1 appeal.\n\u2022The notice you get will tell you in writing what you can do if you wish to continue with the review process.", "doc_id": "5b823ed9-a08a-40b5-8f18-c1c1d6fc2cca", "embedding": null, "doc_hash": "1e35c6dc16e8a6b8d3957c2cf3db1a2bfc664f784ea3b72c3b033b395bdec0cf", "extra_info": {"page_label": "154", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2833, "_node_type": "1"}, "relationships": {"1": "17358d04-2a13-450d-8d23-17f1e0fcc891"}}, "__type__": "1"}, "087dfdac-5912-4754-8220-85c06326c33e": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 155\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nStep 4: If the answer is no, you will need to decide whether you want to take your appeal further by going \non to Level 3.\n\u2022There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If you \nwant to go to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level \n2 appeal decision. \n\u2022The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 10 in this \nchapter tells more about Levels 3, 4, and 5 of the appeals process.\nSection 8.4 What if you miss the deadline for making your Level 1 appeal?\nLegal Term\nA \"fast\" review (or \"fast appeal\") is also called an \"expedited appeal.\"\nYou can appeal to us instead\nAs explained above, you must act quickly to start your Level 1 appeal of your hospital discharge. If you miss the \ndeadline for contacting the Quality Improvement Organization, there is another way to make your appeal.\nIf you use this other way of making your appeal, the first two levels of appeal are different.\nStep-by-Step: How to make a Level 1 Alternate Appeal \nStep 1: Contact us and ask for a \"fast review.\"\n\u2022Ask for a \"fast review.\" This means you are asking us to give you an answer using the \"fast\" deadlines rather \nthan the \"standard\" deadlines. Chapter 2 has contact information.\nStep 2: We do a \"fast\" review of your planned discharge date, checking to see if it was medically \nappropriate.\n\u2022During this review, we take a look at all of the information about your hospital stay. We check to see if your \nplanned discharge date was medically appropriate. We see if the decision about when you should leave the \nhospital was fair and followed all the rules.\nStep 3: We give you our decision within 72 hours after you ask for a \"fast review\".\n\u2022If we say yes to your appeal, it means we have agreed with you that you still need to be in the hospital after \nthe discharge date. We will keep providing your covered inpatient hospital services for as long as they are \nmedically necessary. It also means that we have agreed to reimburse you for our share of the costs of care \nyou have received since the date when we said your coverage would end. (You must pay your share of the \ncosts and there may be coverage limitations that apply.) \n\u2022If we say no to your appeal, we are saying that your planned discharge date was medically appropriate. Our \ncoverage for your inpatient hospital services ends as of the day we said coverage would end. \n\u2013If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of \nhospital care you received after the planned discharge date.", "doc_id": "087dfdac-5912-4754-8220-85c06326c33e", "embedding": null, "doc_hash": "1a94fb2877342f889fc66a098ab0170ae7d00f72985ad89acdc65249d98e1691", "extra_info": {"page_label": "155", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2841, "_node_type": "1"}, "relationships": {"1": "590250cd-1555-4994-8c35-cb304b1c97d6"}}, "__type__": "1"}, "35dbbaec-1000-4614-962e-1693ce8a5617": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 156\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nStep 4: If we say no to your appeal, your case will automatically be sent on to the next level of the appeals \nprocess.\nStep-by-Step: Level 2 Alternate Appeal Process\nLegal Term\nThe formal name for the \"independent review organization\" is the \"Independent Review Entity.\" It is  \nsometimes called the \"IRE.\"\nThe independent review organization is an independent organization hired by Medicare. It is not connected \nwith us and is not a government agency. This organization decides whether the decision we made is correct or if it \nshould be changed. Medicare oversees its work. \nStep 1: We will automatically forward your case to the independent review organization.\n\u2022We are required to send the information for your Level 2 appeal to the independent review organization \nwithin 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not \nmeeting this deadline or other deadlines, you can make a complaint. Section 11 of this chapter tells how to \nmake a complaint.)\nStep 2: The independent review organization does a \"fast review\" of your appeal. The reviewers give you an \nanswer within 72 hours.\n\u2022Reviewers at the independent review organization will take a careful look at all of the information related to \nyour appeal of your hospital discharge. \n\u2022If this organization says yes to your appeal, then we must pay you back for our share of the costs of \nhospital care you received since the date of your planned discharge. We must also continue the plan's \ncoverage of your inpatient hospital services for as long as it is medically necessary. You must continue to pay \nyour share of the costs. If there are coverage limitations, these could limit how much we would reimburse or \nhow long we would continue to cover your services. \n\u2022If this organization says no to your appeal, it means they agree that your planned hospital discharge date \nwas medically appropriate. \n\u2013The written notice you get from the independent review organization will tell you how to start a Level 3 \nappeal, which is handled by an Administrative Law Judge or attorney adjudicator.\nStep 3: If the independent review organization turns down your appeal, you choose whether you want to \ntake your appeal further.\n\u2022There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If \nreviewers say no to your Level 2 appeal, you decide whether to accept their decision or go on to Level 3 \nappeal. \n\u2022Section 10 in this chapter tells more about Levels 3, 4, and 5 of the appeals process.", "doc_id": "35dbbaec-1000-4614-962e-1693ce8a5617", "embedding": null, "doc_hash": "2a3b1bcd331f1c18675424c86b0771f373adc4b2504c4c263bd901b11f46e8e1", "extra_info": {"page_label": "156", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2729, "_node_type": "1"}, "relationships": {"1": "a7eb9891-3e6f-45f6-8ffd-6a7eba663823"}}, "__type__": "1"}, "ff45f6f4-c140-4a3c-b3f2-976f68362bc6": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 157\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSECTION 9 How to ask us to keep covering certain medical services if you  \nthink your coverage is ending too soon\nSection 9.1 This section is about three services only:  \nHome health care, skilled nursing facility care, and Comprehensive  \nOutpatient Rehabilitation Facility (CORF) services\nWhen you are getting home health services, skilled nursing care, or rehabilitation care (Comprehensive \nOutpatient Rehabilitation Facility), you have the right to keep getting your covered services for that type of care \nfor as long as the care is needed to diagnose and treat your illness or injury.\nWhen we decide it is time to stop covering any of the three types of care for you, we are required to tell you in \nadvance. When your coverage for that care ends, we will stop paying for your care.\nIf you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you \nhow to ask for an appeal.\nSection 9.2 We will tell you in advance when your coverage will be ending\nLegal Terms\n\"Notice of Medicare Non-Coverage.\" It tells you how you can request a \"fast-track appeal.\" Requesting a  \nfast-track appeal is a formal, legal way to request a change to our coverage decision about when to stop your  \ncare.\n1. You receive a notice in writing at least two days before our plan is going to stop covering your care. The \nnotice tells you:\n\u2022The date when we will stop covering the care for you. \n\u2022How to request a \"fast track appeal\" to request us to keep covering your care for a longer period of time.\n2. You, or someone who is acting on your behalf, will be asked to sign the written notice to show that you \nreceived it. Signing the notice shows only that you have received the information about when your coverage \nwill stop. Signing it does not mean you agree with the plan\u2019s decision to stop care.\nSection 9.3 Step-by-step: How to make a Level 1 appeal to have our plan cover your  \ncare for a longer time\nIf you want to ask us to cover your care for a longer period of time, you will need to use the appeals process to \nmake this request. Before you start, understand what you need to do and what the deadlines are.\n\u2022Follow the process. \n\u2022Meet the deadlines. ", "doc_id": "ff45f6f4-c140-4a3c-b3f2-976f68362bc6", "embedding": null, "doc_hash": "6808d95e97c2c496d573f44abe8f40fe6d869e79f952e4a081a54c6d586eb8db", "extra_info": {"page_label": "157", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2381, "_node_type": "1"}, "relationships": {"1": "290bf3d4-2eac-43c0-8719-0913776aeb58"}}, "__type__": "1"}, "21fe6da2-3ffa-41c4-ab0a-c6ba0758eb95": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 158\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022Ask for help if you need it. If you have questions or need help at any time, please call Customer Care. Or call \nyour State Health Insurance Assistance Program, a government organization that provides personalized \nassistance. \nDuring a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It decides if the end \ndate for your care is medically appropriate. \nStep 1: Make your Level 1 appeal: contact the Quality Improvement Organization and ask for a fast-track \nappeal. You must act quickly.\nHow can you contact this organization?\n\u2022The written notice you received (Notice of Medicare Non-Coverage) tells you how to reach this organization. (Or \nfind the name, address, and phone number of the Quality Improvement Organization for your state in \nChapter 2.)\nAct quickly:\n\u2022You must contact the Quality Improvement Organization to start your appeal by noon of the day before the \neffective date on the Notice of Medicare Non-Coverage.\nYour deadline for contacting this organization.\n\u2022If you miss the deadline for contacting the Quality Improvement Organization, and you still wish to file an \nappeal, you must make an appeal directly to us instead. For details about this other way to make your \nappeal, see Section 9.5 of this chapter.\nStep 2: The Quality Improvement Organization conducts an independent review of your case.\nLegal Terms\n\"Detailed Explanation of Non-Coverage.\" Notice that provides details on reasons for ending coverage.\nWhat happens during this review?\n\u2022Health professionals at the Quality Improvement Organization (\"the reviewers\") will ask you (or your \nrepresentative) why you believe coverage for the services should continue. You don't have to prepare \nanything in writing, but you may do so if you wish. \n\u2022The review organization will also look at your medical information, talk with your doctor, and review \ninformation that our plan has given to them.\n\u2022By the end of the day the reviewers tell us of your appeal,  you will get the Detailed Explanation of \nNon-Coverage from us that explains in detail our reasons for ending our coverage for your services.\nStep 3: Within one full day after they have all the information they need, the reviewers will tell you their \ndecision.\nWhat happens if the reviewers say yes?", "doc_id": "21fe6da2-3ffa-41c4-ab0a-c6ba0758eb95", "embedding": null, "doc_hash": "558c5ab6ec61dddd49d08223bbafd1b81730cb644f2c30f5c7c7a888bd8577af", "extra_info": {"page_label": "158", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2446, "_node_type": "1"}, "relationships": {"1": "f2979cca-f3f1-4c85-9dc7-6b71909e5c11"}}, "__type__": "1"}, "5db1624f-4c2e-4def-85e6-cd469831783f": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 159\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022If the reviewers say yes to your appeal, then we must keep providing your covered services for as long as \nit is medically necessary. \n\u2022You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). \nThere may be limitations on your covered services. \nWhat happens if the reviewers say no?\n\u2022If the reviewers say no, then your coverage will end on the date we have told you. \n\u2022If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive \nOutpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, then you will have \nto pay the full cost of this care yourself.\nStep 4: If the answer to your Level 1 appeal is no, you decide if you want to make another appeal.\n\u2022If reviewers say no to your Level 1 appeal \u2013 and you choose to continue getting care after your coverage for \nthe care has ended \u2013 then you can make a Level 2 appeal.\nSection 9.4 Step-by-step: How to make a Level 2 appeal to have our plan cover your  \ncare for a longer time\nDuring a Level 2 appeal, you ask the Quality Improvement Organization to take another look at the decision on \nyour first appeal. If the Quality Improvement Organization turns down your Level 2 appeal, you may have to pay \nthe full cost for your home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation \nFacility (CORF) services after the date when we said your coverage would end.\nStep 1: Contact the Quality Improvement Organization again and ask for another review.\n\u2022You must ask for this review within 60 days after the day when the Quality Improvement Organization said \nno to your Level 1 appeal. You can ask for this review only if you continued getting care after the date that \nyour coverage for the care ended.\nStep 2: The Quality Improvement Organization does a second review of your situation.\n\u2022Reviewers at the Quality Improvement Organization will take another careful look at all of the information \nrelated to your appeal. \nStep 3: Within 14 days of receipt of your appeal request, reviewers will decide on your appeal and tell you \ntheir decision.\nWhat happens if the review organization says yes?\n\u2022We must reimburse you for our share of the costs of care you have received since the date when we said \nyour coverage would end. We must continue providing coverage for the care for as long as it is medically \nnecessary.\n\u2022You must continue to pay your share of the costs and there may be coverage limitations that apply. \nWhat happens if the review organization says no?", "doc_id": "5db1624f-4c2e-4def-85e6-cd469831783f", "embedding": null, "doc_hash": "ee381026017f012cf0ec2d7552bc7d2e1d08e96cb945e7fb4ac602782f71e368", "extra_info": {"page_label": "159", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2762, "_node_type": "1"}, "relationships": {"1": "2f7566b9-b47d-4f73-b863-f0675de59f27"}}, "__type__": "1"}, "5cef2e1c-3a6b-46b4-ae02-8f3c2b8f3f03": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 160\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022It means they agree with the decision we made to your Level 1 appeal. \n\u2022The notice you get will tell you in writing what you can do if you wish to continue with the review process. It \nwill give you the details about how to go on to the next level of appeal, which is handled by an Administrative \nLaw Judge or attorney adjudicator. \nStep 4: If the answer is no, you will need to decide whether you want to take your appeal further.\n\u2022There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If you want to go \non to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal \ndecision. \n\u2022The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 10 in this \nchapter tells more about Levels 3, 4, and 5 of the appeals process.\nSection 9.5 What if you miss the deadline for making your Level 1 appeal?\nYou can appeal to us instead\nAs explained above, you must act quickly to contact the Quality Improvement Organization to start your first \nappeal (within a day or two, at the most). If you miss the deadline for contacting this organization, there is another \nway to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different.\nStep-by-Step: How to make a Level 1 Alternate appeal \nLegal Terms\nA \"fast\" review (or \"fast appeal\") is also called an \"expedited appeal.\"\nStep 1: Contact us and ask for a \"fast review.\"\n\u2022Ask for a \"fast review.\" This means you are asking us to give you an answer using the \"fast\" deadlines rather \nthan the \"standard\" deadlines. Chapter 2 has contact information.\nStep 2: We do a \"fast\" review of the decision we made about when to end coverage for your services.\n\u2022During this review, we take another look at all of the information about your case. We check to see if we were \nfollowing all the rules when we set the date for ending the plan's coverage for services you were receiving.\nStep 3: We give you our decision within 72 hours after you ask for a \"fast review\".\n\u2022If we say yes to your appeal, it means we have agreed with you that you need services longer, and will keep \nproviding your covered services for as long as it is medically necessary. It also means that we have agreed to \nreimburse you for our share of the costs of care you have received since the date when we said your \ncoverage would end. (You must pay your share of the costs and there may be coverage limitations that \napply.) \n\u2022If we say no to your appeal, then your coverage will end on the date we told you and we will not pay any \nshare of the costs after this date. ", "doc_id": "5cef2e1c-3a6b-46b4-ae02-8f3c2b8f3f03", "embedding": null, "doc_hash": "fdca7a491ba81e272596dda71b0c54d24b3f2f0cc9f04ab3e252a81ee3af1187", "extra_info": {"page_label": "160", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2836, "_node_type": "1"}, "relationships": {"1": "93fda818-e244-4274-8a21-6eac4fc8af1a"}}, "__type__": "1"}, "c1c88df8-94e5-46b0-970d-fec734b6a456": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 161\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022If you continued to get home health care, or skilled nursing facility care, or Comprehensive Outpatient \nRehabilitation Facility (CORF) services after the date when we said your coverage would end, then you will \nhave to pay the full cost of this care.\nStep 4: If we say no to your fast appeal, your case will automatically go on to the next level of the appeals \nprocess.\nLegal Terms\nThe formal name for the \"independent review organization\" is the \"Independent Review Entity.\" It is  \nsometimes called the \"IRE.\"\nStep-by-Step: Level 2 Alternate Appeal Process\nDuring the Level 2 appeal, the independent review organization reviews the decision we made to your \"fast \nappeal.\" This organization decides whether the decision should be changed. The independent review \norganization is an independent organization that is hired by Medicare. This organization is not connected with \nour plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job \nof being the independent review organization. Medicare oversees its work.\nStep 1: We automatically forward your case to the independent review organization.\n\u2022We are required to send the information for your Level 2 appeal to the independent review organization \nwithin 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not \nmeeting this deadline or other deadlines, you can make a complaint. Section 11 of this chapter tells how to \nmake a complaint.) \nStep 2: The independent review organization does a \"fast review\" of your appeal. The reviewers give you an \nanswer within 72 hours.\n\u2022Reviewers at the independent review organization will take a careful look at all of the information related to \nyour appeal. \n\u2022If this organization says yes to your appeal, then we must pay you back for our share of the costs of care \nyou have received since the date when we said your coverage would end. We must also continue to cover \nthe care for as long as it is medically necessary. You must continue to pay your share of the costs. If there are \ncoverage limitations, these could limit how much we would reimburse or how long we would continue to \ncover your services. \n\u2022If this organization says no to your appeal, it means they agree with the decision our plan made to your \nfirst appeal and will not change it. \n\u2022The notice you get from the independent review organization will tell you in writing what you can do if you \nwish to go on to a Level 3 appeal.\nStep 3: If the independent review organization says no to your appeal, you choose whether you want to take \nyour appeal further.\n\u2022There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If you want to go \non to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal \ndecision.", "doc_id": "c1c88df8-94e5-46b0-970d-fec734b6a456", "embedding": null, "doc_hash": "5887ac2dbfaac2fb4e779196844bc5d798a972ec2f40a1b4286dbc1361b65128", "extra_info": {"page_label": "161", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3044, "_node_type": "1"}, "relationships": {"1": "d08e6245-3ca4-43c1-9ea1-1d826c39ab76"}}, "__type__": "1"}, "037ff7cd-faf9-4039-b272-002847098c25": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 162\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2022A Level 3 appeal is reviewed by an Administrative Law Judge or attorney adjudicator. Section 10 in this \nchapter tells more about Levels 3, 4, and 5 of the appeals process.\nSECTION 10 Taking your appeal to Level 3 and beyond\nSection 10.1 Appeal Levels 3, 4 and 5 for Medical Service Requests\nThis section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal, and both of your \nappeals have been turned down.\nIf the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be \nable to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal \nany further. The written response you receive to your Level 2 appeal will explain how to make a Level 3 appeal. \nFor most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who \nhandles the review of your appeal at each of these levels. \nLevel 3 appeal An Administrative Law Judge or an attorney adjudicator who works for the Federal  \ngovernment will review your appeal and give you an answer.\n\u2022If the Administrative Law Judge or attorney adjudicator says yes to your appeal, the appeals process \nmay or may not be over. Unlike a decision at Level 2 appeal, we have the right to appeal a Level 3 decision \nthat is favorable to you. If we decide to appeal it will go to a Level 4 appeal.\n\u2013If we decide not to appeal the decision, we must authorize or provide you with the service within 60 \ncalendar days after receiving the Administrative Law Judge\u2019s or attorney adjudicator\u2019s decision.\n\u2013If we decide to appeal the decision, we will send you a copy of the Level 4 appeal request with any \naccompanying documents. We may wait for the Level 4 appeal decision before authorizing or providing \nthe service in dispute.\n\u2022If the Administrative Law Judge or attorney adjudicator says no to your appeal, the appeals process \nmay or may not be over. \n\u2013If you decide to accept this decision that turns down your appeal, the appeals process is over. \n\u2013If you do not want to accept the decision, you can continue to the next level of the review process. The \nnotice you get will tell you what to do for a Level 4 appeal. \nLevel 4 appeal The Medicare Appeals Council (Council) will review your appeal and give you an answer. The  \nCouncil is part of the Federal government.\n\u2022If the answer is yes, or if the Council denies our request to review a favorable Level 3 appeal decision, \nthe appeals process may or may not be over. Unlike a decision at Level 2, we have the right to appeal a \nLevel 4 decision that is favorable to you. We will decide whether to appeal this decision to Level 5. \n\u2013If we decide not to appeal the decision, we must authorize or provide you with the service within 60 \ncalendar days after receiving the Council's decision.", "doc_id": "037ff7cd-faf9-4039-b272-002847098c25", "embedding": null, "doc_hash": "5016c8d70276df60ec45d1d3ad7209dc4d6d9e92604adb67f91f7f5d503b6801", "extra_info": {"page_label": "162", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3031, "_node_type": "1"}, "relationships": {"1": "c287ac8e-5547-4afc-85a2-55c18929302e"}}, "__type__": "1"}, "2e29f716-3177-4d18-81fe-b32ff6cd0d42": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 163\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2013If we decide to appeal the decision, we will let you know in writing. \n\u2022If the answer is no or if the Council denies the review request, the appeals process may or may not be \nover. \n\u2013If you decide to accept this decision that turns down your appeal, the appeals process is over. \n\u2013If you do not want to accept the decision, you may be able to continue to the next level of the review \nprocess. If the Council says no to your appeal, the notice you get will tell you whether the rules allow you \nto go on to a Level 5 appeal and how to continue with a Level 5 appeal. \nLevel 5 appeal A judge at the Federal District Court will review your appeal. \n\u2022A judge will review all of the information and decide yes or no to your request. This is a final answer. There are \nno more appeal levels after the Federal District Court.\nSection 10.2 Appeal Levels 3, 4 and 5 for Part D Drug Requests\nThis section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal, and both of your \nappeals have been turned down.\nIf the value of the drug you have appealed meets a certain dollar amount, you may be able to go on to additional \nlevels of appeal. If the dollar amount is less, you cannot appeal any further. The written response you receive to \nyour Level 2 appeal will explain who to contact and what to do to ask for a Level 3 appeal.\nFor most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who \nhandles the review of your appeal at each of these levels.\nLevel 3 appeal An Administrative Law Judge or attorney adjudicator who works for the Federal  \ngovernment will review your appeal and give you an answer.\n\u2022If the answer is yes, the appeals process is over. We must authorize or provide the drug coverage that \nwas approved by the Administrative Law Judge or attorney adjudicator within 72 hours (24 hours for \nexpedited appeals) or make payment no later than 30 calendar days after we receive the decision.\n\u2022If the answer is no, the appeals process may or may not be over. \n\u2013If you decide to accept this decision that turns down your appeal, the appeals process is over. \n\u2013If you do not want to accept the decision, you can continue to the next level of the review process. The \nnotice you get will tell you what to do for a Level 4 appeal.\nLevel 4 appeal The Medicare Appeals Council (Council) will review your appeal and give you an answer. The  \nCouncil is part of the Federal government.\n\u2022If the answer is yes, the appeals process is over. We must authorize or provide the drug coverage that \nwas approved by the Council within 72 hours (24 hours for expedited appeals) or make payment no later \nthan 30 calendar days after we receive the decision.\n\u2022If the answer is no, the appeals process may or may not be over. ", "doc_id": "2e29f716-3177-4d18-81fe-b32ff6cd0d42", "embedding": null, "doc_hash": "4447657a44b6c3b39320d75a4cf753dcf1390388ee3218863bc52f8eae008adf", "extra_info": {"page_label": "163", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2976, "_node_type": "1"}, "relationships": {"1": "0295e345-ddfa-4a1b-8eff-425927b618e9"}}, "__type__": "1"}, "1ef58c11-1c14-482b-8b62-370669a9a15c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 164\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\n\u2013If you decide to accept this decision that turns down your appeal, the appeals process is over. \n\u2013If you do not want to accept the decision, you may be able to continue to the next level of the review \nprocess. If the Council says no to your appeal or denies your request to review the appeal, the notice you \nget will tell you whether the rules allow you to go on to a Level 5 appeal. It will also tell you who to contact \nand what to do next if you choose to continue with your appeal.\nLevel 5 appeal A judge at the Federal District Court will review your appeal. \n\u2022A judge will review all of the information and decide yes or no to your request. This is a final answer. There are \nno more appeal levels after the Federal District Court.\nSECTION 11 How to make a complaint about quality of care, waiting times,  \ncustomer service, or other concerns\nSection 11.1 What kinds of problems are handled by the complaint process?\nThe complaint process is only used for certain types of problems. This includes problems related to quality of care, \nwaiting times, and the customer service. Here are examples of the kinds of problems handled by the complaint \nprocess.\nComplaint Example\nQuality of your  \nmedical care\u2022Are you unhappy with the quality of the care you have received (including care in the  \nhospital)?\nRespecting your  \nprivacy\u2022Did someone not respect your right to privacy or share confidential information?\nDisrespect, poor  \ncustomer service,  \nor other negative  \nbehaviors\u2022Has someone been rude or disrespectful to you?\n\u2022Are you unhappy with our Customer Care?\n\u2022Do you feel you are being encouraged to leave the plan?\nWaiting times \u2022Are you having trouble getting an appointment, or waiting too long to get it?\n\u2022Have you been kept waiting too long by doctors, pharmacists, or other health  \nprofessionals? Or by our Customer Care or other staff at the plan?\n\u2013Examples include waiting too long on the phone, in the waiting or exam room, or  \ngetting a prescription.\nCleanliness \u2022Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor's  \noffice?\nInformation you  \nget from us\u2022Did we fail to give you a required notice?\n\u2022Is our written information hard to understand?", "doc_id": "1ef58c11-1c14-482b-8b62-370669a9a15c", "embedding": null, "doc_hash": "16f5675fd602b38e3deb3244406b4730bd2dbf72c7ba2d2b4932beb6a378c52e", "extra_info": {"page_label": "164", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2390, "_node_type": "1"}, "relationships": {"1": "5ae8a322-d326-4a55-8302-b1faff5a537a"}}, "__type__": "1"}, "3840c9a8-bb2f-435a-bce4-f2518e2298be": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 165\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nComplaint Example\nTimeliness \n(These types of  \ncomplaints are all  \nrelated to the \ntimeliness of our  \nactions related to  \ncoverage decisions  \nand appeals)If you have asked for a coverage decision or made an appeal, and you think that we are  \nnot responding quickly enough, you can make a complaint about our slowness. Here are  \nexamples:\n\u2022You asked us for a \"fast coverage decision\" or a \"fast appeal\", and we have said no;  \nyou can make a complaint.\n\u2022You believe we are not meeting the deadlines for coverage decisions or appeals; you  \ncan make a complaint.\n\u2022You believe we are not meeting deadlines for covering or reimbursing you for certain  \nmedical services or drugs that were approved; you can make a complaint. \n\u2022You believe we failed to meet required deadlines for forwarding your case to the  \nindependent review organization; you can make a complaint. \nSection 11.2 How to make a complaint\nLegal Terms\n\u2022A \"Complaint\" is also called a \"grievance.\" \n\u2022\"Making a complaint\" is also called \"filing a grievance.\"\n\u2022\"Using the process for complaints\" is also called \"using the process for filing a grievance.\"\n\u2022A \"fast complaint\" is also called an \"expedited grievance.\"\nSection 11.3 Step-by-step: Making a complaint\nStep 1: Contact us promptly \u2013 either by phone or in writing.\n\u2022Usually, calling Customer Care is the first step. If there is anything else you need to do, Customer Care will \nlet you know. \n\u2022If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing \nand send it to us. If you put your complaint in writing, we will respond to your complaint in writing.\n\u2022Grievance Filing Instructions\nFile a verbal grievance by calling Customer Care at 1-800-457-4708 TTY 711\nSend a written grievance to:\nHumana Grievances and Appeals Dept. \nP.O. Box 14165 \nLexington, KY 40512\u20134165", "doc_id": "3840c9a8-bb2f-435a-bce4-f2518e2298be", "embedding": null, "doc_hash": "6463f9978544664c41c7785d2378e5502f8be66081a3501558a055d4f63fe8ad", "extra_info": {"page_label": "165", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2023, "_node_type": "1"}, "relationships": {"1": "8582b286-0da6-4138-ad08-3107ffd7f79a"}}, "__type__": "1"}, "e110b059-13fd-4311-bd10-e0f6a7cead5d": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 166\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nWhen filing a grievance, please provide:\n  Name\n  Address\n  Telephone number\n  Member identification number\n  A summary of the complaint and any previous contact with us related to the complaint\n The action you are requesting from us\n A signature from you or your authorized representative and the date. If you want a friend, relative, your \ndoctor or other provider, or other person to be your representative, call Customer Care (phone numbers are \nprinted on the back cover of this booklet) and ask for the \"Appointment of Representative\" form. (The form \nis also available on Medicare's website at \nwww.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf). The form gives that person \npermission to act on your behalf. It must be signed by you and by the person who you would like to act on \nyour behalf. You must give us a copy of the signed form.\n\u2022Option for Fast Review of your Grievance\nYou may request a fast review, and we will respond within  24 hours upon receipt, if your grievance concerns \none of the following circumstances:\n\u2013We\u2019ve extended the timeframe for making an organization determination/reconsiderations, and you \nbelieve you need a decision faster. \n\u2013We denied your request for a fast review of a 72-hour organization/coverage decision.\n\u2013We denied your request for a fast review of a 72-hour appeal.\nIt's best to call Customer Care if you want to request fast review of your grievance. If you mail your request, \nwe'll call you to let you know we received it.\n\u2022The deadline for making a complaint is 60 calendar days from the time you had the problem you want to \ncomplain about.  \nStep 2: We look into your complaint and give you our answer.\n\u2022If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an \nanswer on the same phone call.  \n\u2022Most complaints are answered within 30 calendar days. If we need more information and the delay is in \nyour best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days \ntotal) to answer your complaint. If we decide to take extra days, we will tell you in writing.\n\u2022If you are making a complaint because we denied your request for a \"fast coverage decision\" or a \"fast \nappeal,\" we will automatically give you a \"fast complaint.\" If you have a \"fast complaint,\" it means we \nwill give you an answer within 24 hours.\n\u2022If we do not agree with some or all of your complaint or don't take responsibility for the problem you are \ncomplaining about, we will include our reasons in our response to you.", "doc_id": "e110b059-13fd-4311-bd10-e0f6a7cead5d", "embedding": null, "doc_hash": "a4a5e135dc4988853fefacebf6d42d51489eb5666c8823ce79db905791621a6b", "extra_info": {"page_label": "166", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2736, "_node_type": "1"}, "relationships": {"1": "95099e15-a51c-4805-b7b5-a42074066edf"}}, "__type__": "1"}, "2d4e8f86-d9f8-428b-81b2-507a024bc577": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 167\nChapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints)\nSection 11.4 You can also make complaints about quality of care to the Quality  \nImprovement Organization\nWhen your complaint is about quality of care, you also have two extra options: \n\u2022You can make your complaint directly to the Quality Improvement Organization. The Quality \nImprovement Organization is a group of practicing doctors and other health care experts paid by the Federal \ngovernment to check and improve the care given to Medicare patients. Chapter 2 has contact information.\nOr\n\u2022You can make your complaint to both the Quality Improvement Organization and us at the same time. \nSection 11.5 You can also tell Medicare about your complaint\nYou can submit a complaint about Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) directly to Medicare. \nTo submit a complaint to Medicare, go to www.medicare.gov/MedicareComplaintForm/home.aspx. You may also \ncall 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048.\nPROBLEMS ABOUT YOUR MEDICAID BENEFITS\nSECTION 12 Handling problems about your Medicaid benefits\nContact information for MO HealthNet (Medicaid) can be found in \"Exhibit A\" in the back of this document. ", "doc_id": "2d4e8f86-d9f8-428b-81b2-507a024bc577", "embedding": null, "doc_hash": "af591d0e62f5c86969f2957df3ef8d1e6800c4077fc7142051e897006cd57063", "extra_info": {"page_label": "167", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1328, "_node_type": "1"}, "relationships": {"1": "6b777d8d-aef8-4d8e-bebe-a087999fbd2f"}}, "__type__": "1"}, "ff5edc85-32f4-408e-89b9-0fa7f16c65d7": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 168\nChapter 10 Ending your membership in the planEOC076\nCHAPTER 10:\nEnding your membership in the plan", "doc_id": "ff5edc85-32f4-408e-89b9-0fa7f16c65d7", "embedding": null, "doc_hash": "435d919f5461eaf160d13d02a82b2f8ed142484083d183ed90b48bc6cf5e4cfa", "extra_info": {"page_label": "168", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 182, "_node_type": "1"}, "relationships": {"1": "fe58eac7-671d-41e3-a5a1-fc342d177fe8"}}, "__type__": "1"}, "bb068039-d703-4177-bcd7-cfaf2ba87af6": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 169\nChapter 10 Ending your membership in the plan\nSECTION 1 Introduction to ending your membership in our plan\nEnding your membership in Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) may be voluntary (your own \nchoice) or involuntary (not your own choice):\n\u2022You might leave our plan because you have decided that you want to leave. Sections 2 and 3 provide \ninformation on ending your membership voluntarily.\n\u2022There are also limited situations where you do not choose to leave, but we are required to end your \nmembership. Section 5 tells you about situations when we must end your membership.\nIf you are leaving our plan, our plan must continue to provide your medical care and prescription drugs and you will \ncontinue to pay your cost share until your membership ends.\nSECTION 2 When can you end your membership in our plan?\nSection 2.1 You may be able to end your membership because you have Medicare and  \nMedicaid\nMost people with Medicare can end their membership only during certain times of the year. Because you have \nMedicaid, you may be able to end your membership in our plan or switch to a different plan one time during each \nof the following Special Enrollment Periods:\n\u2022January to March\n\u2022April to June\n\u2022July to September\nIf you joined our plan during one of these periods, you\u2019ll have to wait for the next period to end your membership or \nswitch to a different plan. You can\u2019t use this Special Enrollment Period to end your membership in our plan \nbetween October and December. However, all people with Medicare can make changes from October 15 - \nDecember 7 during the Annual Enrollment Period. Section 2.2 tells you more about the Annual Enrollment Period.\n\u2022Choose any of the following types of Medicare plans:\n\u2013Another Medicare health plan, with or without prescription drug coverage\n\u2013Original Medicare with a separate Medicare prescription drug plan\n\u2013Original Medicare without a separate Medicare prescription drug plan\n>If you choose this option, Medicare may enroll you in a drug plan, unless you have opted out of automatic \nenrollment.\nNote: If you disenroll from Medicare prescription drug coverage and go without \u201ccreditable\u201d prescription drug \ncoverage for a continuous period of 63 days or more, you may have to pay a Part D late enrollment penalty if \nyou join a Medicare drug plan later. ", "doc_id": "bb068039-d703-4177-bcd7-cfaf2ba87af6", "embedding": null, "doc_hash": "6bcc609e612d7af771ecb402f8fb339d1f818462a65b94d753ace6d3c67cdd4e", "extra_info": {"page_label": "169", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2404, "_node_type": "1"}, "relationships": {"1": "9ece048d-fe7a-4e23-89c9-3aa0e609a4d9"}}, "__type__": "1"}, "bafd7fe2-9f21-481d-9e6d-0421a103b230": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 170\nChapter 10 Ending your membership in the plan\nContact MO HealthNet (Medicaid) to learn about your Medicaid plan options (telephone numbers are in \nChapter 2, Section 6 of this document).\n\u2022When will your membership end? Your membership will usually end on the first day of the month after we \nreceive your request to change your plans. Your enrollment in your new plan will also begin on this day.\nSection 2.2 You can end your membership during the Annual Enrollment Period\nYou can end your membership during the Annual Enrollment Period (also known as the \u201cAnnual Open Enrollment \nPeriod\u201d). During this time, review your health and drug coverage and decide about coverage for the upcoming \nyear.\n\u2022The Annual Enrollment Period is from October 15 to December 7.\n\u2022Choose to keep your current coverage or make changes to your coverage for the upcoming year. If you \ndecide to change to a new plan, you can choose any of the following types of plans:\n\u2013Another Medicare health plan, with or without prescription drug coverage.\n\u2013Original Medicare with a separate Medicare prescription drug plan\n                                                                       OR\n\u2013Original Medicare without a separate Medicare prescription drug plan.\n\u2022Your membership will end in our plan when your new plan\u2019s coverage begins on January 1. \nIf you receive \u201cExtra Help\u201d from Medicare to pay for your prescription drugs: If you switch to Original \nMedicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug \nplan, unless you have opted out of automatic enrollment.\nNote: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug \ncoverage for 63 days or more in a row, you may have to pay a Part D late enrollment penalty if you join a \nMedicare drug plan later.\nSection 2.3You can end your membership during the Medicare Advantage Open  \nEnrollment Period\nYou have the opportunity to make one change to your health coverage during the Medicare Advantage Open \nEnrollment Period.\n\u2022The annual Medicare Advantage Open Enrollment Period is from January 1 to March 31.\n\u2022During the annual Medicare Advantage Open Enrollment Period you can:\n\u2013Switch to another Medicare Advantage Plan with or without prescription drug coverage. \n\u2013Disenroll from our plan and obtain coverage through Original Medicare. If you choose to switch to Original \nMedicare during this period, you can also join a separate Medicare prescription drug plan at that time.\n\u2022Your membership will end on the first day of the month after you enroll in a different Medicare Advantage \nplan or we get your request to switch to Original Medicare. If you also choose to enroll in a Medicare ", "doc_id": "bafd7fe2-9f21-481d-9e6d-0421a103b230", "embedding": null, "doc_hash": "b9300da1de6d4ef6fc36e451ce10dab9b8829a1869c37936d658781978949186", "extra_info": {"page_label": "170", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2804, "_node_type": "1"}, "relationships": {"1": "d6a934ec-1504-4a8e-b92d-a15167b22b64"}}, "__type__": "1"}, "2e10f53b-680d-4721-b124-8a90470bf9e1": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 171\nChapter 10 Ending your membership in the plan\nprescription drug plan, your membership in the drug plan will begin the first day of the month after the drug \nplan gets your enrollment request.\nSection 2.4 In certain situations, you can end your membership during a Special  \nEnrollment Period\nIn certain situations, you may be eligible to end your membership at other times of the year. This is known as a \nSpecial Enrollment Period.\n\u2022You may be eligible to end your membership during a Special Enrollment Period if any of the following \nsituations apply to you. These are just examples, for the full list you can contact the plan, call Medicare, or \nvisit the Medicare website (www.medicare.gov):\n\u2013Usually, when you have moved\n\u2013If you have MO HealthNet (Medicaid)\n\u2013If you are eligible for \"Extra Help\" with paying for your Medicare prescriptions.\n\u2013If we violate our contract with you\n\u2013If you are getting care in an institution, such as a nursing home or long-term care (LTC) hospital \n\u2013If you enroll in the Program of All-inclusive Care for the Elderly (PACE).\nNote: If you\u2019re in a drug management program, you may not be able to change plans. Chapter 5, Section 10 \ntells you more about drug management programs.\nNote: Section 2.1 tells you more about the special enrollment period for people with Medicaid.\n\u2022The enrollment periods vary depending on your situation.\n\u2022To find out if you are eligible for a Special Enrollment Period, please call Medicare at 1-800-MEDICARE \n(1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048. If you are eligible to end \nyour membership because of a special situation, you can choose to change both your Medicare health \ncoverage and prescription drug coverage. You can choose:\n\u2013Another Medicare health plan with or without prescription drug coverage.\n\u2013Original Medicare with a separate Medicare prescription drug plan\n                                                                               OR\n\u2013Original Medicare without a separate Medicare prescription drug plan.\nNote: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug \ncoverage for 63 days or more in a row, you may have to pay a Part D late enrollment penalty if you join a \nMedicare drug plan later.\nIf you receive \u201cExtra Help\u201d from Medicare to pay for your prescription drugs: If you switch to Original \nMedicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug \nplan, unless you have opted out of automatic enrollment.", "doc_id": "2e10f53b-680d-4721-b124-8a90470bf9e1", "embedding": null, "doc_hash": "46992ee0c2d94c18554a420997cc27da3f3d92bf1b53b66d46e0eb77c592f48d", "extra_info": {"page_label": "171", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2628, "_node_type": "1"}, "relationships": {"1": "5ff7e443-9744-483a-b578-aa5a0d27ac6e"}}, "__type__": "1"}, "1ed8d1ae-6f9a-438d-82a6-3176fcf15f7c": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 172\nChapter 10 Ending your membership in the plan\nYour membership will usually end on the first day of the month after your request to change your plan is \nreceived.\nNote: Sections 2.1 and 2.2 tell you more about the special enrollment period for people with Medicaid and Extra \nHelp.\nSection 2.5 Where can you get more information about when you can end your  \nmembership?\nIf you have any questions about ending your membership:\n\u2022Call Customer Care.\n\u2022Find the information in the Medicare & You 2023 handbook.\n\u2022Contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. (TTY \n1-877-486-2048).", "doc_id": "1ed8d1ae-6f9a-438d-82a6-3176fcf15f7c", "embedding": null, "doc_hash": "8356df9b6a38eee7720aa4afb719f174609e2abda286e60b9258d546aeed7fef", "extra_info": {"page_label": "172", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 697, "_node_type": "1"}, "relationships": {"1": "631f9317-f065-47d7-8911-eb035681c3c4"}}, "__type__": "1"}, "5e94b18e-d90d-4287-b91b-14420ca0c388": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 173\nChapter 10 Ending your membership in the plan\nSECTION 3 How do you end your membership in our plan?\nThe table below explains how you should end your membership in our plan.\nIf you would like to switch  \nfrom our plan to:This is what you should do:\n\u2022Another Medicare health plan. \u2022Enroll in the new Medicare health plan. Your new \ncoverage will begin on the first day of the following \nmonth.\n\u2022You will automatically be disenrolled from Humana \nGold Plus SNP-DE H0028-015 (HMO-POS D-SNP) \nwhen your new plan's coverage begins.\n\u2022Original Medicare with a separate Medicare \nprescription drug plan.\u2022Enroll in the new Medicare prescription drug plan.\n\u2022Your new coverage will begin on the first day of the  \nfollowing month.\n\u2022You will automatically be disenrolled from Humana  \nGold Plus SNP-DE H0028-015 (HMO-POS D-SNP)  \nwhen your new plan's coverage begins.\n\u2022Original Medicare without a separate Medicare  \nprescription drug plan.\n\u2013If you switch to Original Medicare and do not  \nenroll in a separate Medicare prescription drug  \nplan, Medicare may enroll you in a drug plan,  \nunless you have opted out of automatic  \nenrollment.\n\u2013If you disenroll from Medicare prescription drug  \ncoverage and go 63 days or more in a row without  \ncreditable prescription drug coverage, you may  \nhave to pay a late enrollment penalty if you join a  \nMedicare drug plan later.\u2022Send us a written request to disenroll. Contact \nCustomer Care if you need more information on how \nto do this.\n\u2022You can also contact Medicare, at 1-800-MEDICARE \n(1-800-633-4227), 24 hours a day, 7 days a week, \nand ask to be disenrolled. TTY users should call \n1-877-486-2048.\n\u2022You will be disenrolled from Humana Gold Plus \nSNP-DE H0028-015 (HMO-POS D-SNP) when your \ncoverage in Original Medicare begins.\nNote: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug \ncoverage for 63 days or more in a row, you may have to pay a Part D late enrollment penalty if you join a \nMedicare drug plan later.\nFor questions about your Medicaid benefits, contact MO HealthNet (Medicaid). Contact information for MO \nHealthNet (Medicaid) can be found in \"Exhibit A\" in the back of this document. Ask how joining another plan or \nreturning to Original Medicare affects how you get your Medicaid coverage.", "doc_id": "5e94b18e-d90d-4287-b91b-14420ca0c388", "embedding": null, "doc_hash": "7200064717924b786cc44b080efab64160099dbc907379c4cf6daf54983b7270", "extra_info": {"page_label": "173", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2386, "_node_type": "1"}, "relationships": {"1": "e5ec2d86-962c-4ade-a6c0-31b4412b800b"}}, "__type__": "1"}, "c34a5a78-09cb-40e9-9a41-38ed6cf6a093": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 174\nChapter 10 Ending your membership in the plan\nSECTION 4 Until your membership ends, you must keep getting your  \nmedical services and drugs through our plan\nUntil your membership in Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) ends, and your new Medicare \ncoverage goes begins, you must continue to get your medical care and prescription drugs through our plan.\n\u2022Continue to use our network providers to receive medical care.\n\u2022Continue to use our network pharmacies to get your prescriptions filled.\n\u2022If you are hospitalized on the day that your membership ends, your hospital stay will be covered by \nour plan until you are discharged (even if you are discharged after your new health coverage begins).\nSECTION 5 Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) must  \nend your membership in the plan in certain situations\nSection 5.1 When must we end your membership in the plan?\nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) must end your membership in the plan if any of \nthe following happen:\n\u2022If you no longer have Medicare Part A and Part B.\n\u2022If you are no longer eligible for Medicaid. As stated in Chapter 1, Section 2.1, our plan is for people who are \neligible for both Medicare and Medicaid. If you are no longer eligible for the plan, your membership will end after \na six month grace period. You will receive a letter explaining that we must disenroll you from our plan if you do \nnot regain your eligibility for MO HealthNet (Medicaid) assistance within the grace period.\n\u2022If you move out of our service area\n\u2022If you are away from our service area for more than six months\n\u2013If you move or take a long trip, call Customer Care to find out if the place you are moving or traveling to is in \nour plan's area.\n\u2022If you become incarcerated (go to prison).\n\u2022If you are no longer a United States citizen or lawfully present in the United States.\n\u2022If you lie or withhold information about other insurance you have that provides prescription drug coverage.\n\u2022If you intentionally give us incorrect information when you are enrolling in our plan and that information affects \nyour eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from \nMedicare first.)\n\u2022If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for \nyou and other members of our plan. (We cannot make you leave our plan for this reason unless we get \npermission from Medicare first.)", "doc_id": "c34a5a78-09cb-40e9-9a41-38ed6cf6a093", "embedding": null, "doc_hash": "a1adf851eaa1350f40bb07739549e178ca2cd05bb2a54ec8a7e5d7a9858d8032", "extra_info": {"page_label": "174", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 2551, "_node_type": "1"}, "relationships": {"1": "ef9fb24d-3767-4090-be5b-8220237b7c08"}}, "__type__": "1"}, "884cf616-caaf-437b-a58d-a869d578c1d1": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 175\nChapter 10 Ending your membership in the plan\n\u2022If you let someone else use your membership card to get medical care. (We cannot make you leave our plan for \nthis reason unless we get permission from Medicare first.)\n\u2013If we end your membership because of this reason, Medicare may have your case investigated by the \nInspector General.\n\u2022If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will \ndisenroll you from our plan.\nWhere can you get more information?\nIf you have questions or would like more information on when we can end your membership call Customer Care.\nSection 5.2 We cannot ask you to leave our plan for any health-related reason\nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) is not allowed to ask you to leave our plan for any \nhealth-related reason.\nWhat should you do if this happens?\nIf you feel that you are being asked to leave our plan because of a health-related reason, you should call Medicare \nat 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week (TTY 1-877-486-2048).\nSection 5.3You have the right to make a complaint if we end your membership in our  \nplan\nIf we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We \nmust also explain how you can file a grievance or make a complaint about our decision to end your membership. ", "doc_id": "884cf616-caaf-437b-a58d-a869d578c1d1", "embedding": null, "doc_hash": "aa4e318a7acbfffc83e3ae6db1d71a61b07eb60fa71bd4ba17f77e8be12ad63a", "extra_info": {"page_label": "175", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1460, "_node_type": "1"}, "relationships": {"1": "13f9dcfb-473a-4a25-88cc-a3645d3b6bef"}}, "__type__": "1"}, "ecb2f3d8-14d9-4929-9e00-f7b2c22bcf15": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 176\nChapter 11. Legal noticesEOC076\nCHAPTER 11:\nLegal notices", "doc_id": "ecb2f3d8-14d9-4929-9e00-f7b2c22bcf15", "embedding": null, "doc_hash": "b204800c01b6de812dc3a648b24e39b6fec7f56ed29dd1e510b5a9c75f641d3e", "extra_info": {"page_label": "176", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 141, "_node_type": "1"}, "relationships": {"1": "e754db18-3a4e-42f0-a851-9eb873b16211"}}, "__type__": "1"}, "bcddde01-8764-41de-9b6e-6fad27bf1b0d": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 177\nChapter 11. Legal notices\nSECTION 1 Notice about governing law\nThe principal law that applies to this Evidence of Coverage document is Title XVIII of the Social Security Act and the \nregulations created under the Social Security Act by the Centers for Medicare & Medicaid Services, or CMS. In \naddition, other Federal laws may apply and, under certain circumstances, the laws of the state you live in. This may \naffect your rights and responsibilities even if the laws are not included or explained in this document.\nSECTION 2 Notice about nondiscrimination\n We don't discriminate based on race, ethnicity, national origin, color, religion, sex, gender, age, sexual \norientation, mental or physical disability, health status, claims experience, medical history, genetic information, \nevidence of insurability, or geographic location within the service area. All organizations that provide Medicare \nAdvantage plans, like our plan, must obey Federal laws against discrimination, including Title VI of the Civil Rights \nAct of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, \nSection 1557 of the Affordable Care Act, all other laws that apply to organizations that get Federal funding, and \nany other laws and rules that apply for any other reason.\nIf you want more information or have concerns about discrimination or unfair treatment, please call the \nDepartment of Health and Human Services\u2019 Office for Civil Rights at 1-800-368-1019 (TTY 1-800-537-7697) or \nyour local Office for Civil Rights. You can also review information from the Department of Health and Human \nServices\u2019 Office for Civil Rights at https://www.hhs.gov/ocr/index.\nIf you have a disability and need help with access to care, please call us at Customer Care. If you have a complaint, \nsuch as a problem with wheelchair access, Customer Care can help.\nSECTION 3 Notice about Medicare Secondary Payer Subrogation rights\nWe have the right and responsibility to collect for covered Medicare services for which Medicare is not the primary \npayer. According to CMS regulations at 42 CFR sections 422.108 and 423.462, Humana Gold Plus SNP-DE \nH0028-015 (HMO-POS D-SNP), as a Medicare Advantage Organization, will exercise the same rights of recovery \nthat the Secretary exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules \nestablished in this section supersede any State laws.\nSECTION 4 Additional Notice about Subrogation (Recovery from a Third  \nParty)\nOur right to recover payment\nIf we pay a claim for you, we have subrogation rights. This is a very common insurance provision that means we \nhave the right to recover the amount we paid for your claim from any third party that is responsible for the medical \nexpenses or benefits related to your injury, illness, or condition. You assign to us your right to take legal action \nagainst any responsible third party, and you agree to:\n1. Provide any relevant information that we request; and\n2. Participate in any phase of legal action, such as discovery, depositions, and trial testimony, if needed.", "doc_id": "bcddde01-8764-41de-9b6e-6fad27bf1b0d", "embedding": null, "doc_hash": "da27793b5267d95a0900ce7fe2bec6030a38b5ed302973d942b16f6211a7184a", "extra_info": {"page_label": "177", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3203, "_node_type": "1"}, "relationships": {"1": "64b810b6-fb40-4562-86f3-39406f51d672"}}, "__type__": "1"}, "1c0a927f-a2a9-4277-b944-8f01e0a3fafd": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 178\nChapter 11. Legal notices\nIf you don't cooperate with us or our representatives, or you do anything that interferes with our rights, we may \ntake legal action against you. You also agree not to assign your right to take legal action to someone else without \nour written consent.\nOur right of reimbursement\nWe also have the right to be reimbursed if a responsible third party pays you directly. If you receive any amount as \na judgment, settlement, or other payment from any third party, you must immediately reimburse us, up to the \namount we paid for your claim. \nOur rights take priority\nOur rights of recovery and reimbursement have priority over other claims, and will not be affected by any equitable \ndoctrine. This means that we're entitled to recover the amount we paid, even if you haven't been compensated by \nthe responsible third party for all costs related to your injury or illness. If you disagree with our efforts to recover \npayment, you have the right to appeal, as explained in Chapter 9.\nWe are not obligated to pursue reimbursement or take legal action against a third party, either for our own benefit \nor on your behalf. Our rights under Medicare law and this Evidence of Coverage will not be affected if we don't \nparticipate in any legal action you take related to your injury, illness, or condition.\nSECTION 5 Notice of coordination of benefits\nWhy do we need to know if you have other coverage?\nWe coordinate benefits in accordance with the Medicare Secondary Payer rules, which allow us to bill, or authorize \na provider of services to bill, other insurance carriers, plans, policies, employers, or other entities when the other \npayer is responsible for payment of services provided to you. We are also authorized to charge or bill you for \namounts the other payer has already paid to you for such services. We shall have all the rights accorded to the \nMedicare Program under the Medicare Secondary Payer rules.\nWho pays first when you have other coverage?\nWhen you have additional coverage, how we coordinate your coverage depends on your situation. With \ncoordination of benefits, you will often get your care as usual through our plan providers, and the other plan or \nplans you have will simply help pay for the care you receive. If you have group health coverage, you may be able to \nmaximize the benefits available to you if you use providers who participate in your group plan and our plan. In \nother situations, such as for benefits that are not covered by our plan, you may get your care outside of our plan. \nEmployer and employee organization group health plans\nSometimes, a group health plan must provide health benefits to you before we will provide health benefits to you. \nThis happens if:\n\u2022You have coverage under a group health plan (including both employer and employee organization plans), \neither directly or through your spouse, and \n\u2022The employer has twenty (20) or more employees (as determined by Medicare rules), and\n\u2022You are not covered by Medicare due to disability or End-Stage Renal Disease (ESRD). ", "doc_id": "1c0a927f-a2a9-4277-b944-8f01e0a3fafd", "embedding": null, "doc_hash": "847f77bcca9f35da14d167ba7f449900ba409994d5db1d10da7bf1d05f008d45", "extra_info": {"page_label": "178", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3142, "_node_type": "1"}, "relationships": {"1": "12c0f22c-492d-45bb-adb3-2195637e15f5"}}, "__type__": "1"}, "47063983-667a-4ebe-a082-e053b0472887": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 179\nChapter 11. Legal notices\nIf the employer has fewer than twenty (20) employees, generally we will provide your primary health benefits. If \nyou have retiree coverage under a group health plan, either directly or through your spouse, generally we will \nprovide primary health benefits. Special rules apply if you have or develop ESRD.\nEmployer and employee organization group health plans for people who are disabled\nIf you have coverage under a group health plan, and you have Medicare because you are disabled, generally we \nwill provide your primary health benefits. This happens if:\n\u2022You are under age 65, and\n\u2022You do not have ESRD, and\n\u2022You do not have coverage directly or through your spouse under a large group health plan.\nA large group health plan is a health plan offered by an employer with 100 or more employees, or by an employer \nwho is part of a multiple-employer plan where any employer participating in the plan has 100 or more employees. \nIf you have coverage under a large group health plan, either directly or through your spouse, your large group \nhealth plan must provide health benefits to you before we will provide health benefits to you. This happens if:\n\u2022You do not have ESRD, and\n\u2022Are under age 65 and have Medicare based on a disability.\nIn such cases, we will provide only those benefits not covered by your large employer group plan. Special rules \napply if you have or develop ESRD.\nEmployer and employee organization group health plans for people with End-Stage Renal Disease (ESRD)\nIf you are or become eligible for Medicare because of ESRD and have coverage under an employer or employee \norganization group health plan, either directly or through your spouse, your group health plan is responsible for \nproviding primary health benefits to you for the first thirty (30) months after you become eligible for Medicare due \nto your ESRD. We will provide secondary coverage to you during this time, and we will provide primary coverage to \nyou thereafter. If you are already on Medicare because of age or disability when you develop ESRD, we will provide \nprimary coverage. \nWorkers' Compensation and similar programs\nIf you have suffered a job-related illness or injury and workers' compensation benefits are available to you, \nworkers' compensation must provide its benefits first for any healthcare costs related to your job-related illness or \ninjury before we will provide any benefits under this Evidence of Coverage for services rendered in connection with \nyour job-related illness or injury. \nAccidents and injuries\nThe Medicare Secondary Payer rules apply if you have been in an accident or suffered an injury. If benefits under \n\"Med Pay,\" no-fault, automobile, accident, or liability coverage are available to you, the \"Med Pay,\" no-fault, \nautomobile, accident, or liability coverage carrier must provide its benefits first for any healthcare costs related to \nthe accident or injury before we will provide any benefits for services related to your accident or injury. \nLiability insurance claims are often not settled promptly. We may make conditional payments while the liability \nclaim is pending. We may also receive a claim and not know that a liability or other claim is pending. In these ", "doc_id": "47063983-667a-4ebe-a082-e053b0472887", "embedding": null, "doc_hash": "dbfd7fe69a8718c55ecb8236c653e13adf912c69fca4b7e7003071e4816f98f5", "extra_info": {"page_label": "179", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3324, "_node_type": "1"}, "relationships": {"1": "8da80870-f31e-46d9-99d6-dce3b78796f4"}}, "__type__": "1"}, "99e40e95-7ad7-458c-a9c9-7d3637373c43": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 180\nChapter 11. Legal notices\nsituations, our payments are conditional. Conditional payments must be refunded to us upon receipt of the \ninsurance or liability payment. \nIf you recover from a third party for medical expenses, we are entitled to recovery of payments we have made \nwithout regard to any settlement agreement stipulations. Stipulations that the settlement does not include \ndamages for medical expenses will be disregarded. We will recognize allocations of liability payments to \nnon-medical losses only when payment is based on a court order on the merits of the case. We will not seek \nrecovery from any portion of an award that is appropriately designated by the court as payment for losses other \nthan medical services (e.g., property losses). \nWhere we provide benefits in the form of services, we shall be entitled to reimbursement on the basis of the \nreasonable value of the benefits provided.\nNon-duplication of benefits\nWe will not duplicate any benefits or payments you receive under any automobile, accident, liability, or other \ncoverage. You agree to notify us when such coverage is available to you, and it is your responsibility to take any \nactions necessary to receive benefits or payments under such automobile, accident, liability, or other coverage. We \nmay seek reimbursement of the reasonable value of any benefits we have provided in the event that we have \nduplicated benefits to which you are entitled under such coverage. You are obligated to cooperate with us in \nobtaining payment from any automobile, accident, or liability coverage or other carrier. \nIf we do provide benefits to you before any other type of health coverage you may have, we may seek recovery of \nthose benefits in accordance with the Medicare Secondary Payer rules. Please also refer to the Additional Notice \nabout Subrogation (Recovery from a Third Party) section for more information on our recovery rights.\nMore information\nThis is just a brief summary. Whether we pay first or second - or at all - depends on what types of additional \ninsurance you have and the Medicare rules that apply to your situation. For more information, consult the brochure \npublished by the government called \"Medicare & Other Health Benefits: Your Guide to Who Pays First.\" It is CMS Pub. \nNo. 02179. Be sure to consult the most current version. Other details are explained in the Medicare Secondary \nPayer rules, such as the way the number of persons employed by an employer for purposes of the coordination of \nbenefits rules is to be determined. The rules are published in the Code of Federal Regulations.\nAppeal rights\nIf you disagree with any decision or action by our plan in connection with the coordination of benefits and \npayment rules outlined above, you must follow the procedures explained in Chapter 9 What to do if you have a \nproblem or complaint (coverage decisions, appeals, complaints) in this Evidence of Coverage.", "doc_id": "99e40e95-7ad7-458c-a9c9-7d3637373c43", "embedding": null, "doc_hash": "db2d38804d6a55385d7d07767dce15b57f83b7d7c9837d05070a032b190e2ff0", "extra_info": {"page_label": "180", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3010, "_node_type": "1"}, "relationships": {"1": "37d4574e-cad4-48bb-8b69-db9c5a148303"}}, "__type__": "1"}, "f3937a51-edd5-49c2-ad76-baeeddbb98ae": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 181\nChapter 12. Definitions of important wordsEOC076\nCHAPTER 12:\nDefinitions of important words", "doc_id": "f3937a51-edd5-49c2-ad76-baeeddbb98ae", "embedding": null, "doc_hash": "e2ca4bb28733b96c8bc898b59a1d24f79872919110c9be4ae91f4214b7441293", "extra_info": {"page_label": "181", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 175, "_node_type": "1"}, "relationships": {"1": "f69c2141-d86e-4bdc-925c-6d8f9931b193"}}, "__type__": "1"}, "251dbc5f-be3d-46c5-b787-eb912317726d": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 182\nChapter 12. Definitions of important words\nChapter 12. Definitions of important words\nAdvanced Imaging Services - Specialized imaging method that takes more detailed images than standard x-rays. \nThere are several kinds of imaging services, including Computed Tomography Imaging (CT/CAT) Scan, Magnetic \nResonance Angiography (MRA), Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET) \nScan or other similar technology.\nAllowed Amount - The maximum amount a plan will pay for a health care benefit.\nAmbulatory Surgical Center - An Ambulatory Surgical Center is an entity that operates exclusively for the purpose \nof furnishing outpatient surgical services to patients not requiring hospitalization and whose expected stay in the \ncenter does not exceed 24 hours.\nAppeal - An appeal is something you do if you disagree with our decision to deny a request for coverage of health \ncare services or prescription drugs or payment for services or drugs you already received. You may also make an \nappeal if you disagree with our decision to stop services that you are receiving. For example, you may ask for an \nappeal if we don't pay for a drug, item, or service you think you should be able to receive. Chapter 9 explains \nappeals, including the process involved in making an appeal.\nBenefit Period - The way that Original Medicare measures your use of skilled nursing facility (SNF) services. For our  \nplan, you will have a benefit period for your skilled nursing facility benefits. A SNF benefit period begins the day you  \ngo into a skilled nursing facility. The benefit period will accumulate one day for each day you are at a SNF. The  \nbenefit period ends when you haven\u2019t received any skilled care in a SNF for 60 days in a row. If you go into a skilled  \nnursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of  \nbenefit periods.\nBrand Name Drug - A prescription drug that is manufactured and sold by the pharmaceutical company that \noriginally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the \ngeneric version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and \nare generally not available until after the patent on the brand name drug has expired.\nCatastrophic Coverage Stage - The stage in the Part D Drug Benefit where you pay a low copayment or \ncoinsurance for your drugs after you or other qualified parties on your behalf have spent $7,400 in covered drugs \nduring the covered year.\nCenters for Medicare & Medicaid Services (CMS) - The Federal agency that administers Medicare. Chapter 2 \nexplains how to contact CMS.\nChronic-Care Special Needs Plan - C-SNPs are SNPs that restrict enrollment to special needs individuals with \nspecific severe or disabling chronic conditions, defined in 42 CFR 422.2. A C- SNP must have specific attributes that \ngo beyond the provision of basic Medicare Parts A and B services and care coordination that is required of all \nMedicare Advantage Coordinated Care Plans, in order to receive the special designation and marketing and \nenrollment accommodations provided to C-SNPs.\nCoinsurance - An amount you may be required to pay, expressed as a percentage (for example 20%) as your share \nof the cost for services or prescription drugs.\nComplaint - The formal name for \"making a complaint\" is \"filing a grievance.\" The complaint process is used only  \nfor certain types of problems. This includes problems related to quality of care, waiting times, and the customer  \nservice you receive. See also \"Grievance,\" in this list of definitions. ", "doc_id": "251dbc5f-be3d-46c5-b787-eb912317726d", "embedding": null, "doc_hash": "333a210e2d92a56db27a4ad141878363ba374893d036604e7e4d8f7fe1235366", "extra_info": {"page_label": "182", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3746, "_node_type": "1"}, "relationships": {"1": "b7f1b4b8-4e57-4dd7-8c25-03bca6ecdb2c"}}, "__type__": "1"}, "9f6b5c3a-aa0c-43cb-896a-c87f0ef71104": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 183\nChapter 12. Definitions of important words\nComprehensive Outpatient Rehabilitation Facility (CORF) - A facility that mainly provides rehabilitation services \nafter an illness or injury, and provides a variety of services including physical therapy, social or psychological \nservices, respiratory therapy, occupational therapy and speech-language pathology services, and home \nenvironment evaluation services.\nComputed Tomography Imaging (CT/CAT) Scan - Combines the use of a digital computer together with a rotating \nX-ray device to create detailed cross-sectional images of different organs and body parts.\nContracted Rate - The rate the health plan pays to an in-network doctor, provider or pharmacy for covered  \nservices or prescription drugs.\nCopayment (or \"copay\") - An amount you may be required to pay as your share of the cost for a medical service or \nsupply, like a doctor\u2019s visit, hospital outpatient visit, or a prescription drug. A copayment is a set amount (for \nexample $10), rather than a percentage.\nCost-sharing - Cost-sharing refers to amounts that a member has to pay when services or drugs are received. \nCost-sharing includes any combination of the following three types of payments: (1) any deductible amount a plan \nmay impose before services or drugs are covered; (2) any fixed \"copayment\" amount that a plan requires when a \nspecific service or drug is received; or (3) any \"coinsurance\" amount, a percentage of the total amount paid for a \nservice or drug that a plan requires when a specific service or drug is received.\nCoverage Determination - A decision about whether a drug prescribed for you is covered by the plan and the \namount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy \nand the pharmacy tells you the prescription isn\u2019t covered under your plan, that isn\u2019t a coverage determination. You \nneed to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are \ncalled \"coverage decisions\" in this document.\nCovered Drugs - The term we use to mean all of the prescription drugs covered by our plan.\nCovered Services - The term we use to mean all of the health care services and supplies that are covered by our \nplan.\nCreditable Prescription Drug Coverage - Prescription drug coverage (for example, from an employer or union) \nthat is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. People \nwho have this kind of coverage when they become eligible for Medicare can generally keep that coverage without \npaying a penalty, if they decide to enroll in Medicare prescription drug coverage later.\nCustodial Care - Custodial care is personal care provided in a nursing home, hospice, or other facility setting when \nyou do not need skilled medical care or skilled nursing care. Custodial care, provided by people who do not have \nprofessional skills or training includes help with activities of daily living like bathing, dressing, eating, getting in or \nout of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care \nthat most people do themselves, like using eye drops. Medicare doesn\u2019t pay for custodial care.\nCustomer Care - A department within our plan responsible for answering your questions about your membership, \nbenefits, grievances, and appeals.", "doc_id": "9f6b5c3a-aa0c-43cb-896a-c87f0ef71104", "embedding": null, "doc_hash": "def4c3084df4581445bd433f58c044bb6d5f0af368a09d3541abfdab50a1cf68", "extra_info": {"page_label": "183", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3483, "_node_type": "1"}, "relationships": {"1": "51da49e5-6763-4acb-87cf-876d154928d9"}}, "__type__": "1"}, "805b6d5f-1dec-4763-bf3d-318df8061aa3": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 184\nChapter 12. Definitions of important words\nDaily cost-sharing rate - A \"daily cost-sharing rate\" may apply when your doctor prescribes less than a full \nmonth's supply of certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate is the \ncopayment divided by the number of days in a month's supply. Here is an example: If your copayment for a \none-month supply of a drug is $30, and a one-month's supply in your plan is 30 days, then your \"daily cost-sharing \nrate\" is $1 per day.\nDeductible - The amount you must pay for health care or prescriptions before our plan pays.\nDiagnostic Mammogram - A specialized x-ray exam given to a patient who shows signs or symptoms of breast \ndisease.\nDiagnostic Procedure - An exam to identify a patient\u2019s strengths and weaknesses in a specific area, in order to find \nout more about their condition, disease, or illness.\nDisenroll or Disenrollment - The process of ending your membership in our plan.\nDispensing Fee - A fee charged each time a covered drug is dispensed to pay for the cost of filling a prescription, \nsuch as the pharmacist\u2019s time to prepare and package the prescription.\nDual Eligible Special Needs Plans (D-SNP) - D-SNPs enroll individuals who are entitled to both Medicare (title \nXVIII of the Social Security Act) and medical assistance from a state plan under Medicaid (title XIX). States cover \nsome Medicare costs, depending on the state and the individual\u2019s eligibility.\nDual Eligible Individual - A person who qualifies for Medicare and Medicaid coverage.\nDurable Medical Equipment (DME) - Certain medical equipment that is ordered by your doctor for medical \nreasons. Examples include walkers, wheelchairs, crutches, powered mattress systems, diabetic supplies, IV \ninfusion pumps, speech generating devices, oxygen equipment, nebulizers, or hospital beds ordered by a provider \nfor use in the home.\nEmergency - A medical emergency is when you, or any other prudent layperson with an average knowledge of  \nhealth and medicine, believe that you have medical symptoms that require immediate medical attention to  \nprevent loss of life (and if you are a pregnant woman, loss of an unborn child), loss of a limb, or loss of function of a  \nlimb, or loss of or serious impairment to a bodily function. The medical symptoms may be an illness, injury, severe  \npain, or a medical condition that is quickly getting worse.\nEmergency Care - Covered services that are: (1) provided by a provider qualified to furnish emergency services; \nand (2) needed to treat, evaluate, or stabilize an emergency medical condition.\nEvidence of Coverage (EOC) and Disclosure Information - This document, along with your enrollment form and \nany other attachments, riders, or other optional coverage selected, which explains your coverage, what we must \ndo, your rights, and what you have to do as a member of our plan.\nException - A type of coverage decision that, if approved, allows you to get a drug that is not on our formulary (a \nformulary exception), or get a non-preferred drug at a lower cost-sharing level (a tiering exception). You may also \nrequest an exception if our plan requires you to try another drug before receiving the drug you are requesting, or if \nour plan limits the quantity or dosage of the drug you are requesting (a formulary exception).\nExtra Help - A Medicare or a State program to help people with limited income and resources pay Medicare \nprescription drug program costs, such as premiums, deductibles, and coinsurance.", "doc_id": "805b6d5f-1dec-4763-bf3d-318df8061aa3", "embedding": null, "doc_hash": "e64f5f71b05186f48df90077d87736b5c2819312e0c2099eebe7533c7b610a4e", "extra_info": {"page_label": "184", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3607, "_node_type": "1"}, "relationships": {"1": "9cee441f-2b4e-445e-8fae-3115bc05d523"}}, "__type__": "1"}, "bac08d9e-9d1d-4bf2-a234-aae972675994": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 185\nChapter 12. Definitions of important words\nFormulary - A document that lists all prescription drugs covered by a plan.\nFreestanding Dialysis Center - A licensed health facility, other than a hospital, that provides dialysis treatment  \nwith no overnight stay.\nFreestanding Lab - A licensed health facility, other than a hospital, that provides lab tests to prevent, identify, or  \ntreat an injury or illness, with no overnight stay.\nFreestanding Radiology (Imaging) Center - A licensed health facility, other than a hospital, that provides one or \nmore of the following services to prevent, identify, or treat an injury or illness, with no overnight stay: X-rays; \nnuclear medicine; radiation oncology (including MRIs, CT scans and PET scans).\nGeneric Drug - A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same \nactive ingredient(s) as the brand name drug. Generally, a \"generic\" drug works the same as a brand name drug \nand usually costs less.\nGrievance - A type of complaint you make about us or pharmacies, including a complaint concerning the quality of \nyour care. This type of complaint does not involve coverage or payment disputes.\nHealth Maintenance Organization (HMO) - A type of health insurance plan where members must receive care  \nfrom the plan\u2019s network of doctors, hospitals, and other health care providers.\nHome Health Aide - A person who provides services that do not need the skills of a licensed nurse or therapist, \nsuch as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises).\nHome Health Care - Skilled nursing care and certain other health care services given to a patient in their own \nhome for the treatment of an illness or injury. Covered services are listed in Chapter 4 under the heading, \"Home \nhealth agency care.\" If you need home health care services, our plan will cover these services for you, provided the \nMedicare coverage requirements are met. Home health care can include services from a home health aide if the \nservices are part of the home health plan of care for your illness or injury. They aren\u2019t covered unless you are also \ngetting a covered skilled service. Home health services don\u2019t include the services of housekeepers, food service \narrangements, or full time nursing care at home.\nHospice - A benefit that provides special treatment for a member who has been medically certified as terminally \nill, meaning having a life expectancy of 6 months or less. We, your plan, must provide you with a list of hospices in \nyour geographic area. If you elect hospice and continue to pay premiums you are still a member of our plan. You \ncan still obtain all medically necessary services as well as the supplemental benefits we offer.\nHospice Care - Specialized care for people who are terminally ill, focused on comfort not cure. This also includes \ncounseling for patients\u2019 families. Depending on the situation, this type of care may be in the home, a hospice \nfacility, a hospital, or a nursing home, and is given by a team of licensed health professionals.\nHospital Inpatient Stay - A hospital stay when you have been formally admitted to the hospital for skilled \nmedical services. Even if you stay in the hospital overnight, you might still be considered an \u201coutpatient.\u201d\nHumana's National Transplant Network (NTN) - A network of Humana-approved facilities all of which are also \nMedicare-approved facilities.", "doc_id": "bac08d9e-9d1d-4bf2-a234-aae972675994", "embedding": null, "doc_hash": "e0e754e61f324df53f9e47553cab893f25f1bdd5bc01f71732b23fc9979abaa5", "extra_info": {"page_label": "185", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3548, "_node_type": "1"}, "relationships": {"1": "28c40e9c-1430-48ac-88ea-6ab22cad52d2"}}, "__type__": "1"}, "6dc6e153-30b0-4a10-bc23-4b20495e0431": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 186\nChapter 12. Definitions of important words\nIncome Related Monthly Adjustment Amount (IRMAA) - If your modified adjusted gross income as reported on \nyour IRS tax return from 2 years ago is above a certain amount, you\u2019ll pay the standard premium amount and an \nIncome Related Monthly Adjustment Amount, also known as IRMAA. IRMAA is an extra charge added to your \npremium. Less than 5% of people with Medicare are affected, so most people will not pay a higher premium.\nInitial Coverage Limit - The maximum limit of coverage under the Initial Coverage Stage.\nInitial Coverage Stage - This is the stage before your total drug costs including amounts you have paid and what  \nyour plan has paid on your behalf for the year have reached $4,660.\nInitial Enrollment Period - When you are first eligible for Medicare, the period of time when you can sign up for  \nMedicare Part A and Part B. If you\u2019re eligible for Medicare when you turn 65, your Initial Enrollment Period is the  \n7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3  \nmonths after the month you turn 65.\nInpatient Care - Health care that you get when you are admitted to a hospital.\nList of Covered Drugs (Formulary or \"Drug Guide\") - A list of prescription drugs covered by the plan.\nLow Income Subsidy (LIS) - See \"Extra Help.\"\nMagnetic Resonance Angiography (MRA) - A noninvasive method and a form of magnetic resonance imaging \n(MRI) that can measure blood flow through blood vessels.\nMagnetic Resonance Imaging (MRI) - A diagnostic imaging modality method that uses a magnetic field and \ncomputerized analysis of induced radio frequency signals to noninvasively image body tissue.\nMail Order Pharmacy - A pharmacy that fills and sends prescriptions through the mail to the member's home.\nMaximum Out-of-Pocket Amount - The most that you pay out-of-pocket during the calendar year for covered \nPart A and Part B services. Amounts you pay for your plan premiums, Medicare Part A and Part B premiums, and \nprescription drugs do not count toward the maximum out-of-pocket amount. (Note: Because our members also \nget assistance from MO HealthNet (Medicaid), very few members ever reach this out-of-pocket maximum.) See \nChapter 4, Section 1.2 for information about your maximum out-of-pocket amount.\nMedicaid (or Medical Assistance) - A joint Federal and State program that helps with medical costs for some \npeople with low incomes and limited resources. State Medicaid programs vary, but most health care costs are \ncovered if you qualify for both Medicare and Medicaid.\nMedically Accepted Indication - A use of a drug that is either approved by the Food and Drug Administration or  \nsupported by certain reference books.\nMedically Necessary - Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of  \nyour medical condition and meet accepted standards of medical practice.\nMedicare - The Federal health insurance program for people 65 years of age or older, some people under age 65 \nwith certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure \nwho need dialysis or a kidney transplant).", "doc_id": "6dc6e153-30b0-4a10-bc23-4b20495e0431", "embedding": null, "doc_hash": "7ce28b2218b1b724da56f43b8b23c2183a61025a9d986a4e587d58d0e56ba3bd", "extra_info": {"page_label": "186", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3283, "_node_type": "1"}, "relationships": {"1": "ac3462f8-06a2-4f85-ac0e-e0653d1b4538"}}, "__type__": "1"}, "42cb96d2-bf79-4acf-b708-cc0fb03ea4bf": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 187\nChapter 12. Definitions of important words\nMedicare Advantage Open Enrollment Period - The time period from January 1 until March 31 when members in \na Medicare Advantage plan can cancel their plan enrollment and switch to another Medicare Advantage plan, or \nobtain coverage through Original Medicare. If you choose to switch to Original Medicare during this period, you can \nalso join a separate Medicare prescription drug plan at that time. The Medicare Advantage Open Enrollment Period \nis also available for a 3-month period after an individual is first eligible for Medicare.\nMedicare Advantage Organization - A private company that runs Medicare Advantage Plans to offer members \nmore options, and sometimes extra benefits. Medicare Advantage Plans are also called \u201cPart C.\u201d They provide all \nyour Part A (Hospital) and Part B (Medical) coverage, and some may also provide Part D (prescription drug) \ncoverage.\nMedicare Advantage (MA) Plan - Sometimes called Medicare Part C. A plan offered by a private company that \ncontracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage \nPlan can be an i) HMO, ii) PPO, a  iii) Private Fee-for-Service (PFFS) plan, or a iv) Medicare Medical Savings Account \n(MSA) plan. Besides choosing from these types of plans, a Medicare Advantage HMO or PPO plan can also be a \nSpecial Needs Plan (SNP). In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug \ncoverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage.\nMedicare Allowable Charge - The most amount of money that can be charged for a particular medical service \ncovered by Medicare; it is a set amount decided by Medicare.\nMedicare Coverage Gap Discount Program - A program that provides discounts on most covered Part D brand \nname drugs to Part D members who have reached the Coverage Gap Stage and who are not already receiving \n\"Extra Help.\" Discounts are based on agreements between the Federal government and certain drug \nmanufacturers.\nMedicare-Covered Services - Services covered by Medicare Part A and Part B. All Medicare health plans, including \nour plan, must cover all of the services that are covered by Medicare Part A and B. The term Medicare-Covered \nServices does not include the extra benefits, such as vision, dental, or hearing, that a Medicare Advantage plan \nmay offer.\nMedicare Health Plan - A Medicare health plan is offered by a private company that contracts with Medicare to \nprovide Part A and Part B benefits to people with Medicare who enroll in the plan. This term includes all Medicare \nAdvantage Plans, Medicare Cost Plans, Special Needs Plans, Demonstration/Pilot Programs, and Programs of \nAll-inclusive Care for the Elderly (PACE).\nMedicare Limiting Charge - In the Original Medicare plan, the highest amount of money you can be charged for a \ncovered service by doctors and other health care suppliers who do not accept assignment. The limiting charge is 15 \npercent over Medicare\u2019s approved amount. The limiting charge only applies to certain services and does not apply \nto supplies or equipment.\nMedicare Prescription Drug Coverage (Medicare Part D) - Insurance to help pay for outpatient prescription \ndrugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B.\n\"Medigap\" (Medicare Supplement Insurance) Policy - Medicare supplement insurance sold by private insurance \ncompanies to fill \"gaps\" in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare \nAdvantage Plan is not a Medigap policy.)", "doc_id": "42cb96d2-bf79-4acf-b708-cc0fb03ea4bf", "embedding": null, "doc_hash": "bfb659ac7dd505c552b6ade9a83c5a08d4da2a13a077cead958b108d0deb6251", "extra_info": {"page_label": "187", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3693, "_node_type": "1"}, "relationships": {"1": "14d54e81-6d48-4813-81d2-158dc456e8de"}}, "__type__": "1"}, "b62e5a4b-d542-44e8-bfdd-389780c87a95": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 188\nChapter 12. Definitions of important words\nMember (Member of our Plan, or \"Plan Member\") - A person with Medicare who is eligible to get covered \nservices, who has enrolled in our plan and whose enrollment has been confirmed by the Centers for Medicare & \nMedicaid Services (CMS).\nNetwork \u2013 see \"Network Pharmacy\" and \"Network Provider\"\nNetwork Pharmacy - A pharmacy that contracts with our plan where members of our plan can get their \nprescription drug benefits. In most cases, your prescriptions are covered only if they are filled at one of our network \npharmacies.\nNetwork Provider - \"Provider\" is the general term for doctors, other health care professionals, hospitals, and other \nhealth care facilities that are licensed or certified by Medicare and by the State to provide health care services. \n\"Network providers\" have an agreement with our plan to accept our payment as payment in full, and in some \ncases to coordinate as well as provide covered services to members of our plan. Network providers are also called \n\"plan providers.\"\nNuclear Medicine - Radiology in which radioisotopes (compounds containing radioactive forms of atoms) are \nintroduced into the body for the purpose of imaging, evaluating organ function, or localizing disease or tumors.\nObservation services - are hospital outpatient services given to help the doctor decide if a patient needs to be \nadmitted as an inpatient or can be discharged. Observation services may be given in the emergency department or \nanother area of the hospital. Even if you stay overnight in a regular hospital bed, you might be an outpatient.\nOrganization Determination - A decision our plan makes about whether items or services are covered or how \nmuch you have to pay for covered items or services. Organization determinations are called \"coverage decisions\" \nin this document.\nOriginal Medicare (\"Traditional Medicare\" or \"Fee-for-service\" Medicare) \u2013 Original Medicare is offered by the \ngovernment, and not a private health plan like Medicare Advantage Plans and prescription drug plans. Under \nOriginal Medicare, Medicare services are covered by paying doctors, hospitals, and other health care providers \npayment amounts established by Congress. You can see any doctor, hospital, or other health care provider that \naccepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and \nyou pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and \nis available everywhere in the United States.\nOur plan - The plan you are enrolled in, Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP).\nOut-of-Network Pharmacy - A pharmacy that does not have a contract with our plan to coordinate or provide \ncovered drugs to members of our plan. Most drugs you get from out-of-network pharmacies are not covered by our \nplan unless certain conditions apply.\nOut-of-Network Provider or Out-of-Network Facility - A provider or facility that does not have a contract with \nour plan to coordinate or provide covered services to members of our plan. Out-of-network providers are providers \nthat are not employed, owned, or operated by our plan.\nOut-of-Pocket Costs - See the definition for \"cost-sharing\" above. A member's cost-sharing requirement to pay \nfor a portion of services or drugs received is also referred to as the member's \"out-of-pocket\" cost requirement.", "doc_id": "b62e5a4b-d542-44e8-bfdd-389780c87a95", "embedding": null, "doc_hash": "c2d34a337d41dc66abc92b2de402acfb728f9e3c8dd17d6feb68a2ef83f00ea1", "extra_info": {"page_label": "188", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3496, "_node_type": "1"}, "relationships": {"1": "7f82ba6f-0fd0-4977-87eb-b14ed646812d"}}, "__type__": "1"}, "7c33220a-e72f-4a21-9153-075a124a07ff": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 189\nChapter 12. Definitions of important words\nPACE plan - A PACE (Program of All-Inclusive Care for the Elderly) plan combines medical, social, and long-term \ncare (LTC) services for frail people to help people stay independent and living in their community (instead of \nmoving to a nursing home) as long as possible. People enrolled in PACE plans receive both their Medicare and \nMedicaid benefits through the plan.\nPart C - see \"Medicare Advantage (MA) Plan.\"\nPart D - The voluntary Medicare Prescription Drug Benefit Program.\nPart D Drugs - Drugs that can be covered under Part D. We may or may not offer all Part D drugs. Certain \ncategories of drugs have been excluded from Part D coverage by Congress. Certain categories of Part D drugs must \nbe covered by every plan.\nPart D Late Enrollment Penalty - An amount added to your monthly premium for Medicare drug coverage if you  \ngo without creditable coverage (coverage that is expected to pay, on average, at least as much as standard  \nMedicare prescription drug coverage) for a continuous period of 63 days or more after you are first eligible to join a  \nPart D plan. If you lose Extra Help, you may be subject to the late enrollment penalty if you go 63 days or more in a  \nrow without Part D or other creditable prescription drug coverage.\nPlan Provider - see \"Network Provider\".\nPositron Emission Tomography (PET) Scan - A medical imaging technique that involves injecting the patient with \nan isotope and using a PET scanner to detect the radiation emitted.\nPreferred Cost-sharing - Preferred cost-sharing means lower cost-sharing for certain covered Part D drugs at \ncertain network pharmacies.\nPreferred Provider Organization (PPO) Plan - A Preferred Provider Organization plan is a Medicare Advantage \nPlan that has a network of contracted providers that have agreed to treat plan members for a specified payment \namount. A PPO plan must cover all plan benefits whether they are received from network or out-of-network \nproviders. Member cost-sharing will generally be higher when plan benefits are received from out-of-network \nproviders. PPO plans have an annual limit on your out-of-pocket costs for services received from network \n(preferred) providers and a higher limit on your total combined out-of-pocket costs for services from both network \n(preferred) and out-of-network (non-preferred) providers. \nPremium - The periodic payment to Medicare, an insurance company, or a health care plan for health or \nprescription drug coverage.\nPrescription Drug Guide (Formulary) - A list of covered drugs provided by the plan. The drugs on this list are \nselected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic \ndrugs.\nPrimary Care Provider (PCP) - The doctor or other provider you see first for most health problems. In many \nMedicare health plans, you must see your primary care provider before you see any other health care provider.\nPrior Authorization - Approval in advance to get services or certain drugs. Covered services that need prior \nauthorization are marked in the Medical Benefits Chart in Chapter 4. Covered drugs that need prior authorization \nare marked in the formulary.", "doc_id": "7c33220a-e72f-4a21-9153-075a124a07ff", "embedding": null, "doc_hash": "2fd1b8b7be30387a3f8ed90fc0e64e9ee0282f8676551283c582a551e500f65b", "extra_info": {"page_label": "189", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3287, "_node_type": "1"}, "relationships": {"1": "8790262d-3f30-468b-9bff-de566cb7c570"}}, "__type__": "1"}, "6a47ec3c-5055-4089-96d5-169ae3f4ab3e": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 190\nChapter 12. Definitions of important words\nProsthetics and Orthotics \u2013 Medical devices including, but not limited to, arm, back, and neck braces; artificial  \nlimbs; artificial eyes; and devices needed to replace an internal body part or function, including ostomy supplies  \nand enteral and parenteral nutrition therapy.\nQuality Improvement Organization (QIO) - A group of practicing doctors and other health care experts paid by \nthe Federal government to check and improve the care given to Medicare patients.\nQuantity Limits - A management tool that is designed to limit the use of selected drugs for quality, safety, or \nutilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period \nof time.\nRadiology - X-rays and other specialized procedures that use high-energy radiation to identify and treat diseases.\nRehabilitation Services - These services include physical therapy, speech and language therapy, and \noccupational therapy.\nScreening Mammogram - A specialized x-ray procedure to find out early if a patient has breast cancer.\nService Area - A geographic area where you must live to join a particular  health plan. For plans that limit which \ndoctors and hospitals you may use, it\u2019s also generally the area where you can get routine (non-emergency) \nservices. The plan may disenroll you if you permanently move out of the plan\u2019s service area.\nSkilled Nursing Facility (SNF) Care - Skilled nursing care and rehabilitation services provided on a continuous, \ndaily basis, in a skilled nursing facility. Examples of care include physical therapy or intravenous injections that can \nonly be given by a registered nurse or doctor.\nSpecial Enrollment Period - A set time when members can change their health and drug plans or return to \nOriginal Medicare due to certain events or changes in their life. Situations in which you may be eligible for a Special \nEnrollment Period include: if you move outside the service area, if you are getting \"Extra Help\" with your \nprescription drug costs, if you move into a nursing home, or if we violate our contract with you. This is also referred \nto as a Special Election Period or \"SEP.\"\nSpecial Needs Plan - A special type of Medicare Advantage Plan that provides more focused health care for \nspecific groups of people, such as those who have both Medicare and Medicaid, who reside in a nursing home, or \nwho have certain chronic medical conditions.\nStandard Cost-sharing - Standard cost-sharing is cost-sharing other than preferred cost-sharing offered at a \nnetwork pharmacy.\nStep Therapy - A utilization tool that requires you to first try another drug to treat your medical condition before \nwe will cover the drug your physician may have initially prescribed.\nSupplemental Security Income (SSI) - A monthly benefit paid by Social Security to people with limited income \nand resources who are disabled, blind, or age 65 and older. SSI benefits are not the same as Social Security \nbenefits.\nUrgent Care Center - A licensed health facility where doctors and nurses provide services to identify and treat a \nsudden injury or illness, with no overnight stay.", "doc_id": "6a47ec3c-5055-4089-96d5-169ae3f4ab3e", "embedding": null, "doc_hash": "cf0b28002d69d802569521e92a0d5dfb0fd4667c7ab3270d5e09bfcecd61b25e", "extra_info": {"page_label": "190", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 3245, "_node_type": "1"}, "relationships": {"1": "8ac6cb8e-d80a-4c22-8d7b-35f2cd0b7500"}}, "__type__": "1"}, "ba6e6b92-0baa-49cb-94dd-312564b564b8": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 191\nChapter 12. Definitions of important words\nUrgently Needed Services - Covered services that are not emergency services, provided when the network \nproviders are temporarily unavailable or inaccessible or when the enrollee is out of the service area. For example, \nyou need immediate care during the weekend. Services must be immediately needed and medically necessary. ", "doc_id": "ba6e6b92-0baa-49cb-94dd-312564b564b8", "embedding": null, "doc_hash": "5e618758b218418ddf91b4a8aec4cd7453dbafe9f1e8f0ca2057edb5121244fe", "extra_info": {"page_label": "191", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 453, "_node_type": "1"}, "relationships": {"1": "f9b74f6c-594f-43b3-be3c-2636b36f7b74"}}, "__type__": "1"}, "a7730fca-47c4-43d4-bde4-e3e92e2ca435": {"__data__": {"text": "2023 Evidence of Coverage for Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) 192\nExhibit A - State Agency Contact InformationEOC076\nExhibit A- State Agency Contact Information\nThis section provides the contact information for the state agencies referenced in Chapter 2 and in other locations  \nwithin this Evidence of Coverage. If you have trouble locating the information you seek, please contact Customer  \nCare at the phone number on the back cover of this booklet.\nMissouri\nSHIP Name and Contact Information CLAIM\n1105 Lakeview Avenue\nColumbia, MO 65201\n1-800-390-3330 (toll free)\n1-573-817-8300 (local)\nhttp://www.missouriclaim.org\nQuality Improvement Organization Livanta BFCC-QIO Program\n10820 Guilford Road\nSuite 202\nAnnapolis Junction, MD 20701\n1-888-755-5580\n1-888-985-9295 (TTY)\n1-833-868-4061 (Fax)\nhttps://livantaqio.com/\nState Medicaid Office MO HealthNet (Medicaid)\n615 Howerton Court\nP.O. Box 6500\nJefferson City, MO 65102-6500\n1-855-373-4636 (toll free)\n1-573-751-3425 (local)\n1-800-735-2966 (TTY)\nhttp://www.dss.mo.gov/mhd/\nState Pharmacy Assistance Program(s) Missouri RX Plan\nPO Box 6500\nJefferson City, MO 65102\n1-800-375-1406 (toll free)\nwww.morx.mo.gov/\nAIDS Drug Assistance Program Missouri AIDS Drug Assistance Program\nBureau of HIV, STD, and Hepatitis, Missouri Department of Health & \nSenior Services\nPO Box 570\nJefferson City, MO 65102\n1-573-751-6439\n1-573-751-6447 (fax)\nhttp://health.mo.gov/living/healthcondiseases/communicable/hivai\nds/casemgmt.php\nn/a", "doc_id": "a7730fca-47c4-43d4-bde4-e3e92e2ca435", "embedding": null, "doc_hash": "eb7cd043a9e47cbf2661e70df689d0e98150a73a10ee44e3088ab3facce3d124", "extra_info": {"page_label": "192", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1487, "_node_type": "1"}, "relationships": {"1": "e860fbb1-9133-4256-8a33-592f8e569053"}}, "__type__": "1"}, "9f733625-5e72-4c55-8cce-bbbd92dfa9df": {"__data__": {"text": "EOC076\nImportant\nAt Humana, it is important you are treated fairly.\nHumana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color,  \nnational origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity,  \nmarital status, religion or language. Discrimination is against the law. Humana and its subsidiaries  \ncomply with applicable federal civil rights laws. If you believe that you have been discriminated  \nagainst by Humana or its subsidiaries, there are ways to get help.\n\u2022You may file a complaint, also known as a grievance:  \nDiscrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.  \nIf you need help filing a grievance, call 1-877-320-1235 or if you use a TTY, call 711.\n\u2022You can also file a civil rights complaint with the U.S. Department of Health and Human  \nServices, Office for Civil Rights electronically through their Complaint Portal, available at \nhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at U.S. Department of Health and Human  \nServices, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, \n1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at \nhttps://www.hhs.gov/ocr/office/file/index.html.\n\u2022California residents: You may also call California Department of Insurance toll-free hotline  \nnumber: 1-800-927-HELP (4357), to file a grievance.\nAuxiliary aids and services, free of charge, are available to you.  \n1-877-320-1235 (TTY: 711)\nHumana provides free auxiliary aids and services, such as qualified sign language interpreters,  \nvideo remote interpretation, and written information in other formats to people with disabilities  \nwhen such auxiliary aids and services are necessary to ensure an equal opportunity to participate.\nGCHJV5REN_2020", "doc_id": "9f733625-5e72-4c55-8cce-bbbd92dfa9df", "embedding": null, "doc_hash": "4aac22331f72b3edcc7c3f49948a22492bb0aa4540f52dc17cd92af015c4f639", "extra_info": {"page_label": "193", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1800, "_node_type": "1"}, "relationships": {"1": "fd951588-6bb7-40b9-b69c-66e04fd7b003"}}, "__type__": "1"}, "1f95c5d5-a972-45a3-b432-1992a5791ec0": {"__data__": {"text": "Notes\n\u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 ", "doc_id": "1f95c5d5-a972-45a3-b432-1992a5791ec0", "embedding": null, "doc_hash": "263f660998d9471406fe5cf6acff260e0841b45eb2c0733a6f59c548954cfa72", "extra_info": {"page_label": "196", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 238, "_node_type": "1"}, "relationships": {"1": "71f392a5-e16e-4f81-8ae2-c4aeb18934c2"}}, "__type__": "1"}, "efc52289-b9a4-4d1e-8a5d-4d34e31d44b7": {"__data__": {"text": "Notes\n\u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 ", "doc_id": "efc52289-b9a4-4d1e-8a5d-4d34e31d44b7", "embedding": null, "doc_hash": "ba04a2930c3d1e04f1a32f728f84a11c0d9462333d37739b988fa24061031236", "extra_info": {"page_label": "197", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 238, "_node_type": "1"}, "relationships": {"1": "5028fb87-dec4-49f9-8d6a-0ee4ac093852"}}, "__type__": "1"}, "c45cbb7e-c0bc-4880-b1b3-0249d30cc7c4": {"__data__": {"text": "Notes\n\u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022", "doc_id": "c45cbb7e-c0bc-4880-b1b3-0249d30cc7c4", "embedding": null, "doc_hash": "61e4e013764dbb89fb1d4ef576f96e931177750e812ba6e61bcd2967275790e9", "extra_info": {"page_label": "198", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 237, "_node_type": "1"}, "relationships": {"1": "1a2b86bd-c055-4719-8917-2d16ddfdf24d"}}, "__type__": "1"}, "18997e9f-1a64-4181-ba31-3411692b1280": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) Customer Care\nMethod Customer Care \u2013 Contact Information\nCALL 1-800-457-4708 \nCalls to this number are free. You can call us seven days a week, from 8 a.m. to 8  \np.m. \nCustomer Care also has free language interpreter services available for non-English  \nspeakers.\nTTY 711 \nThis number requires special telephone equipment and is only for people who have  \ndifficulties with hearing or speaking.\nCalls to this number are free. Hours of operation are the same as above. \nFAX 1-877-837-7741\nWRITE Humana \nP.O. Box 14168 \nLexington, KY 40512-4168\nWEBSITE Humana.com/customer-support\nState Health Insurance Assistance Program\nThe State Health Insurance Assistance Program (SHIP) is a state program that gets money from the  \nFederal government to give free local health insurance counseling to people with Medicare.\nContact information for your State Health Insurance Assistance Program (SHIP) can be found in  \n\u201cExhibit A\u201d in this document. \nPRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required  \nto respond to a collection of information unless it displays a valid OMB control number. The valid OMB  \ncontrol number for this information collection is 0938-1051. If you have comments or suggestions for  \nimproving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,  \nMail Stop C4-26-05, Baltimore, Maryland 21244-1850.", "doc_id": "18997e9f-1a64-4181-ba31-3411692b1280", "embedding": null, "doc_hash": "cea00cc1a609eaa772449eeea6498ec6ac89f9a15063dcae00002d992f0e1803", "extra_info": {"page_label": "199", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 1456, "_node_type": "1"}, "relationships": {"1": "d679c472-50fc-4e97-85c1-0cb5f883b2aa"}}, "__type__": "1"}, "dc66946a-e8dc-4c79-9ff5-78c72ce07ef4": {"__data__": {"text": "Humana Inc. \nPO Box 14168 \nLexington, KY 40512-4168H0028015000EOC23Important Plan Information\nHumana.com", "doc_id": "dc66946a-e8dc-4c79-9ff5-78c72ce07ef4", "embedding": null, "doc_hash": "d964a066210be15e0a133210de953435fdd82b02fd73dbb9d8858820638481d6", "extra_info": {"page_label": "200", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}, "node_info": {"start": 0, "end": 104, "_node_type": "1"}, "relationships": {"1": "aa5cbdf4-77d8-456e-ac32-af1f6abed965"}}, "__type__": "1"}, "c0f4ba56-8deb-45fa-abfd-d896a4fc85a7": {"__data__": {"text": "Summary of Benefits SBOSB033 \nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) \nMissouri \nSelect Counties in Missouri \nOur service area includes the following county/counties in Missouri: Barry, Cass, Cedar, \nChristian, Clay, Crawford, Dade, Dallas, Douglas, Greene, Howell, Iron, Jackson, Jasper, \nJefferson, Johnson, Laclede, Lafayette, Lawrence, Madison, McDonald, Newton, Perry, \nPike, Platte, Polk, Pulaski, St. Charles, St. Francois, St. Louis, St. Louis City, Stone, Taney, \nWarren, Washington, Webster, Wright. 2023 \nGNHH4HIEN_23_C Summary of Benefits H0028015000SB23 ", "doc_id": "c0f4ba56-8deb-45fa-abfd-d896a4fc85a7", "embedding": null, "doc_hash": "923ca326352b54ac2142734c95fa9e9c7c2b2766425aa7dd5e59b15718fa9ce3", "extra_info": {"page_label": "1", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 577, "_node_type": "1"}, "relationships": {"1": "9be79619-07c4-4908-86f5-c7786f59947a"}}, "__type__": "1"}, "8c63957e-caf8-468e-92ca-c9bffa87bc37": {"__data__": {"text": "Pre-Enrollment Checklist \nBefore making an enrollment decision, it is important that you fully understand our benefits and rules. If you \nhave any questions, you can call and speak to acustomer service representative at  1-800-833-2364 (TTY: \n711) .\nUnderstanding the Benefits \nThe Evidence of Coverage (EOC) provides acomplete list of all coverage and services. It is important \nto review plan coverage, costs and benefits before you enroll. Visit  Humana.com/medicare or call  \n1-800-833-2364  (TTY: 711) to view acopy of the EOC. \nReview the provider directory (or ask your doctor) to make sure the doctors you see now are in the \nnetwork. If they are not listed, it means you will likely have to select anew doctor. \nReview the pharmacy directory to make sure the pharmacy you use for any prescription medicines is \nin the network. If the pharmacy is not listed, you will likely have to select anew pharmacy for your \nprescriptions. \nReview the formulary to make sure your drugs are covered.  \nUnderstanding Important Rules \nBenefits, premiums and/or copayments/co-insurance may change on January 1, 2024. \nWhen selecting an HMO POS product, remember that our plan allows you to see providers outside of \nour network (non-contracted doctors who are not listed in the provider directory) in addition to \nemergency or urgent situations. \nThis plan is adual eligible special needs plan (D-SNP). Your ability to enroll will be based on \nverification that you are entitled to both Medicare and medical assistance from astate plan under \nMedicaid. This plan may enroll FBDE, QMB, QMB+, SLMB+. ", "doc_id": "8c63957e-caf8-468e-92ca-c9bffa87bc37", "embedding": null, "doc_hash": "387a6fe6f65a0d6846fa39a14f2cb8bac0dd8929e5d8d9739b65ced9c47d4b4f", "extra_info": {"page_label": "2", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1591, "_node_type": "1"}, "relationships": {"1": "229b6e18-913f-47ba-bb26-64b19bc43908"}}, "__type__": "1"}, "b6490be2-c886-4817-9564-6e844c819768": {"__data__": {"text": "Summary of Benefits \nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) \nMissouri \nSelect Counties in Missouri 2023 \nOur service area includes the following county/counties in Missouri: Barry, Cass, Cedar, \nChristian, Clay, Crawford, Dade, Dallas, Douglas, Greene, Howell, Iron, Jackson, Jasper, \nJefferson, Johnson, Laclede, Lafayette, Lawrence, Madison, McDonald, Newton, Perry, \nPike, Platte, Polk, Pulaski, St. Charles, St. Francois, St. Louis, St. Louis City, Stone, Taney, \nWarren, Washington, Webster, Wright. \nH0028_SB_MAPD_HMOPOS_015000_2023_M Summary of Benefits H0028015000SB23 ", "doc_id": "b6490be2-c886-4817-9564-6e844c819768", "embedding": null, "doc_hash": "f63356a664d3c8cb0975525a9f21ed2bf3af3f96a000a05f9df2ac4eb88f8c9b", "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 588, "_node_type": "1"}, "relationships": {"1": "4fec7fff-df34-44b5-819d-092f564fa704"}}, "__type__": "1"}, "58be316f-9724-43f6-b92f-9216f49c519e": {"__data__": {"text": "H0028015000SB23 Summary of Benefits 5H0028015000 \nLet's talk about Humana Gold Plus SNP-DE \nH0028-015 (HMO-POS D-SNP) \nFind out more about the Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) plan - \nincluding the health and drug services it covers -in this easy-to-use guide. \nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) is aCoordinated Care plan HMO with a \nMedicare contract and acontract with the MO HealthNet (Medicaid) program. Enrollment in this \nHumana plan depends on contract renewal. \nThe benefit information provided is asummary of what we cover and what you pay. It doesn't \nlist every service that we cover or list every limitation or exclusion. For acomplete list of services \nwe cover, ask us for the \"Evidence of Coverage\". \nAs amember you must select an in-network doctor to act as your Primary Care Provider (PCP).  Humana Gold \nPlus SNP-DE H0028-015 (HMO-POS D-SNP) has anetwork of doctors, hospitals, pharmacies and other \nproviders. If you use providers who aren\u2019t in our network, the plan may not pay for these services. You have \naccess to Care Managers. Care Managers are nurses or care coordinators who support your health and \nwell-being by providing additional services including: acute and chronic-care management, telephonic and \nin-person health support, assistance in coordinating Medicare and Medicaid benefits, educational resources \nand workshops, and support for families and caregivers.  \nTo be eligible \nTo enroll in Humana Gold Plus SNP-DE H0028-015 \n(HMO-POS D-SNP), aDual Eligible Special Needs Plan, \nyou must be entitled to Medicare Part Aand enrolled \nin Medicare Part B, live in our service area and also \nreceive certain levels of assistance from the MO \nHealthNet (Medicaid). If you receive both Medicare \nand Medicaid benefits, this means you are dual \neligible. \nHumana Gold Plus SNP-DE H0028-015 (HMO-POS \nD-SNP) may enroll FBDE, QMB, QMB+, SLMB+. \nQualified Medicare Beneficiary (QMB): Helps pay \nMedicare Part Aand Part Bpremiums, and other cost \nsharing (like deductibles, coinsurance, and \ncopayments). \nQualified Medicare Beneficiary Plus (QMB+): Helps pay \nMedicare Part Aand Part Bpremiums, and other \ncost-sharing (like deductibles, coinsurance, and \ncopayments) and provides full Medicaid benefits for \nMedicaid services provided by Medicaid providers. \nSpecified Low-Income Medicare Beneficiary Plus \n(SLMB+): Helps pay Part Bpremiums and provides full \nMedicaid benefits for Medicaid services provided by \nMedicaid providers. \nFull Benefit Dual Eligible (FBDE): Financial assistance \nmay be available to pay Medicare Part APremiums, \nand/or Medicare Part BPremiums, and other \ncost-sharing (like deductibles, coinsurance, and \ncopayments) and provides full Medicaid benefits. Plan name: \nHumana Gold Plus SNP-DE H0028-015 (HMO-POS \nD-SNP) \nMore about Humana Gold Plus SNP-DE  \nH0028-015 (HMO-POS D-SNP) \nAs amember of this plan, you will not be responsible  \nfor cost sharing for plan benefits. The Medicaid  \nComparison Chart shows specific benefits that  \nMedicaid may cover for some dual eligible members.  \nYou will work with your Humana care coordinator to  \nunderstand and access these benefits from the MO  \nHealthNet (Medicaid) after any Humana Gold Plus  \nSNP-DE H0028-015 (HMO-POS D-SNP) benefits are  \nused. The Covered Medical and Hospital Benefits  \nchart shows the benefits you will receive from  \nHumana.", "doc_id": "58be316f-9724-43f6-b92f-9216f49c519e", "embedding": null, "doc_hash": "2feba669f44e1f2b9b6b82bf41ab9a97171bdabd3d29c45fde8ce3405292cda0", "extra_info": {"page_label": "5", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 3387, "_node_type": "1"}, "relationships": {"1": "6cde3203-80af-4131-8e27-81093c08dc77", "3": "e06bdb89-aff3-40b9-ac7f-98446cbfd50b"}}, "__type__": "1"}, "e06bdb89-aff3-40b9-ac7f-98446cbfd50b": {"__data__": {"text": "Benefits  \nchart shows the benefits you will receive from  \nHumana. \nBe sure to show the MO HealthNet (Medicaid) ID card  \nin addition to your Humana membership card to  \nmake your provider aware that you also have  \nMedicaid coverage. You may be required to pay a  \nsmall Medicaid specific co-payment. Your services are  \npaid first by Humana and then by Medicaid. \nHow to reach us: \nIf you have questions about your benefits or your level  \nof eligibility for assistance from Medicaid, you should  \ncontact Humana's Customer Care department or the  \nMO HealthNet (Medicaid)for further details.\nIf you\u2019re amember of this plan, call toll-free:  \n1-800-457-4708 (TTY: 711) .", "doc_id": "e06bdb89-aff3-40b9-ac7f-98446cbfd50b", "embedding": null, "doc_hash": "3dac364707bfc31f89a98c92ad9169bf58a73cececa37177169c76779b14a69f", "extra_info": {"page_label": "5", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 3320, "end": 3993, "_node_type": "1"}, "relationships": {"1": "6cde3203-80af-4131-8e27-81093c08dc77", "2": "58be316f-9724-43f6-b92f-9216f49c519e"}}, "__type__": "1"}, "112efbfe-7845-4273-9609-d13137a2b4da": {"__data__": {"text": "6 Summary of Benefits H0028015000SB23 H0028015000 \nIf you\u2019re  not amember of this plan, call toll free:  \n1-800-833-2364 (TTY: 711) .\nOctober 1-March 31: \nCall 7days aweek from 8a.m. -8p.m. \nApril 1-September 30: \nCall Monday -Friday, 8a.m. -8p.m. \nOr visit our website:  Humana.com/medicare .\nMedicaid benefits last validated on 07/01/2022 and \nare subject to change. \nFor the most current Missouri Medicaid coverage \ninformation, please visit the MO HealthNet (Medicaid) \nwebsite at  http://www.dss.mo.gov/mhd/  or call the \nMedicaid Hotline at 1-855-373-4636 (TTY: 711). \nAhealthy partnership \nGet more from your plan \u2014with \nextra services and resources \nprovided by Humana !", "doc_id": "112efbfe-7845-4273-9609-d13137a2b4da", "embedding": null, "doc_hash": "fcbed82445783c6506d9ef151c0238e74043a2250119640d36b5c2c138c261ec", "extra_info": {"page_label": "6", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 678, "_node_type": "1"}, "relationships": {"1": "ba921fee-9b6f-4645-852f-24c24af62ee5"}}, "__type__": "1"}, "285ea26c-c168-48d1-a567-80254914332f": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\nH0028015000SB23 Summary of Benefits 7H0028015000 \nMonthly Premium, Deductible and Limits \nMonthly plan premium  $0 \nYou must keep paying your Medicare Part Bpremium. Your Part A \nand/or Part Bpremium may be paid on your behalf by the MO \nHealthNet (Medicaid) Program. \nMedical deductible  This plan does not have adeductible. \nPharmacy (Part D) deductible  $0 if you qualify for \"Extra Help\"  \nMaximum out-of-pocket \nresponsibility  This plan does not have amaximum out-of-pocket responsibility. \nCovered Medical and Hospital Benefits \nN/A WHAT YOU PAY ON THIS HUMANA PLAN \nACUTE INPATIENT HOSPITAL CARE \nN/A $0 copay \nOUTPATIENT HOSPITAL COVERAGE \nOutpatient surgery at \noutpatient hospital $0 copay \nOutpatient surgery at \nambulatory surgical center $0 copay \nDOCTOR OFFICE VISITS \nPrimary care provider (PCP) $0 copay \nSpecialists $0 copay \nPREVENTIVE CARE \nN/A Our plan covers many preventive services at no cost when you see  \nan in-network provider including: \n\u2022Abdominal aortic aneurysm Screening \n\u2022Alcohol misuse counseling \n\u2022Bone mass measurement \n\u2022Breast cancer screening (mammogram) \n\u2022Cardiovascular disease (behavioral therapy) \n\u2022Cardiovascular screenings \n\u2022Cervical and vaginal cancer screening \n\u2022Colorectal cancer screenings (colonoscopy, fecal occult blood test,  \nflexible sigmoidoscopy) \n\u2022Depression screening \n\u2022Diabetes screenings \n\u2022HIV screening ", "doc_id": "285ea26c-c168-48d1-a567-80254914332f", "embedding": null, "doc_hash": "4e067efe72b13c619836e283da905714253f22a39e1d463da1bcab8a34b244d4", "extra_info": {"page_label": "7", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1717, "_node_type": "1"}, "relationships": {"1": "975bea42-71b8-47ff-a7c6-52c6da9a3c2f"}}, "__type__": "1"}, "a1e47307-802a-443c-a3c5-5b879b52cc46": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\n8 Summary of Benefits H0028015000SB23 H0028015000 \nCovered Medical and Hospital Benefits  (cont.) \nN/A WHAT YOU PAY ON THIS HUMANA PLAN \n\u2022Medical nutrition therapy services \n\u2022Obesity screening and counseling \n\u2022Prostate cancer screenings (PSA) \n\u2022Sexually transmitted infections screening and counseling \n\u2022Tobacco use cessation counseling (counseling for people with no  \nsign of tobacco-related disease) \n\u2022Vaccines, including flu shots, hepatitis Bshots, pneumococcal shots \n\u2022\"Welcome to Medicare\" preventive visit (one-time) \n\u2022Annual Wellness Visit \n\u2022Lung cancer screening \n\u2022Routine physical exam \n\u2022Medicare diabetes prevention program \nAny additional preventive services approved by Medicare during the  \ncontract year will be covered. \nEMERGENCY CARE \nEmergency room \nIf you are admitted to the \nhospital within 24 hours, you do \nnot have to pay your share of the \ncost for the emergency care. $0 copay \nUrgently needed services \nUrgently needed services are  \nprovided to treat a non-emergency,  \nunforeseen medical illness, injury or  \ncondition that requires immediate  \nmedical attention.$0 copay \nDIAGNOSTIC SERVICES, LABS AND IMAGING \nDiagnostic mammography $0 copay \nDiagnostic radiology $0 copay \nLab services $0 copay \nDiagnostic tests and procedures $0 copay \nOutpatient X-rays $0 copay \nRadiation therapy $0 copay \nHEARING SERVICES \nMedicare-covered hearing $0 copay \nRoutine hearing HER945 \n\u2022$0 copay for routine hearing exams up to 1every year. ", "doc_id": "a1e47307-802a-443c-a3c5-5b879b52cc46", "embedding": null, "doc_hash": "f80ceed457716458a4e673f77216397c47a2fae53893d1ea3cc13b89d5ede1c3", "extra_info": {"page_label": "8", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1812, "_node_type": "1"}, "relationships": {"1": "d113bb4e-601b-472f-b90d-44e6fb8d5c86"}}, "__type__": "1"}, "008ac8f6-b876-493d-8c16-69ac59680201": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\nH0028015000SB23 Summary of Benefits 9H0028015000 \nCovered Medical and Hospital Benefits  (cont.) \nN/A WHAT YOU PAY ON THIS HUMANA PLAN \n\u2022$0 copay for each Advanced level hearing aid up to 1per ear every  \n3years.  \nHearing aid purchase includes: \n\u2022Unlimited follow-up provider visits during first year following  \nTruHearing hearing aid purchase \n\u202260-day trial period \n\u20223-year extended warranty \n\u202280 batteries per aid for non-rechargeable models \nYou must see aTruHearing provider to use this benefit. Call  \n1-844-255-7144 to schedule an appointment (for TTY, dial 711). \nDENTAL SERVICES  \nMedicare-covered dental $0 copay \nRoutine dental \n \nDental services are subject to our  \nstandard claims review  \nprocedures which could include  \ndental history to approve  \ncoverage. Dental benefits under  \nthis plan may not cover all  \nAmerican Dental Association  \nprocedure codes. Information  \nregarding each plan is available  \nat  Humana.com/sb .\n \nOut-of-network dentists have not  \nagreed to provide services at  \ncontracted fees. Benefits received  \nout-of-network are subject to any  \nin-network benefits maximums,  \nlimitations, and/or exclusions.  \nYou may be billed by the  \nout-of-network provider for any  \namount greater than the  \npayment made by Humana to  \nthe provider. \n \nUse the HumanaDental Medicare  \nnetwork for the Mandatory  \nSupplemental Dental. The  In-network:  \nDEN144 \n\u2022$0 copay for scaling and root planing (deep cleaning) up to 1per  \nquadrant every 3years. \n\u2022$0 copay for comprehensive oral evaluation or periodontal exam,  \nocclusal adjustment, scaling for moderate inflammation up to 1  \nevery 3years. \n\u2022$0 copay for bridges, complete dentures, crown recementation,  \ndenture recementation, panoramic film or diagnostic x-rays, partial  \ndentures up to 1every 5years. \n\u2022$0 copay for crown, root canal, root canal retreatment up to 1per  \ntooth per lifetime. \n\u2022$0 copay for bitewing x-rays, intraoral x-rays up to 1set(s) per year. \n\u2022$0 copay for adjustments to dentures, denture rebase, denture  \nreline, denture repair, emergency diagnostic exam, tissue  \nconditioning up to 1per year. \n\u2022$0 copay for emergency treatment for pain, fluoride treatment, oral  \nsurgery, periodic oral exam, prophylaxis (cleaning) up to 2per year. \n\u2022$0 copay for periodontal maintenance up to 4per year. \n\u2022$0 copay for amalgam and/or composite filling, necessary  \nanesthesia with covered service, simple or surgical extraction up to  \nunlimited per year. \n\u2022$5000 combined maximum benefit coverage amount per year for  \npreventive and comprehensive benefits. \nOut-of-network:  \nDEN144 \n\u2022$0 copay for scaling and root planing (deep cleaning) up to 1per  \nquadrant every 3years. ", "doc_id": "008ac8f6-b876-493d-8c16-69ac59680201", "embedding": null, "doc_hash": "b0e59e8e5b13513c9c2198eab1dd83a66ffc4782553ed2897860df6a175a8dd9", "extra_info": {"page_label": "9", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 3039, "_node_type": "1"}, "relationships": {"1": "ba5a5093-94a6-4c1a-8ce1-c49f79347ea6"}}, "__type__": "1"}, "54415658-387a-4a4e-b1df-ba3d8cf13d4a": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\n10 Summary of Benefits H0028015000SB23 H0028015000 \nCovered Medical and Hospital Benefits  (cont.) \nN/A WHAT YOU PAY ON THIS HUMANA PLAN \nprovider locator can be found at  \nHumana.com >Find aDoctor >  \nfrom the Search Type drop down  \nselect Dental >under Coverage  \ntype select All Dental Networks >  \nenter zip code >from the  \nnetwork drop down select  \nHumanaDental Medicare. \u2022$0 copay for comprehensive oral evaluation or periodontal exam,  \nocclusal adjustment, scaling for moderate inflammation up to 1  \nevery 3years. \n\u2022$0 copay for bridges, complete dentures, crown recementation,  \ndenture recementation, panoramic film or diagnostic x-rays, partial  \ndentures up to 1every 5years. \n\u2022$0 copay for crown, root canal, root canal retreatment up to 1per  \ntooth per lifetime. \n\u2022$0 copay for bitewing x-rays, intraoral x-rays up to 1set(s) per year. \n\u2022$0 copay for adjustments to dentures, denture rebase, denture  \nreline, denture repair, emergency diagnostic exam, tissue  \nconditioning up to 1per year. \n\u2022$0 copay for emergency treatment for pain, fluoride treatment, oral  \nsurgery, periodic oral exam, prophylaxis (cleaning) up to 2per year. \n\u2022$0 copay for periodontal maintenance up to 4per year. \n\u2022$0 copay for amalgam and/or composite filling, necessary  \nanesthesia with covered service, simple or surgical extraction up to  \nunlimited per year. \n\u2022$5000 combined maximum benefit coverage amount per year for  \npreventive and comprehensive benefits. \n\u2022Benefits received out-of-network are subject to any in-network  \nbenefit maximums, limitations, and/or exclusions. \nVISION SERVICES \nMedicare-covered vision \nservices $0 copay \nMedicare-covered diabetic eye  \nexam $0 copay \nMedicare-covered glaucoma \nscreening $0 copay \nMedicare-covered eyewear  \n(post-cataract) $0 copay \nRoutine vision \nThe provider locator for routine  \nvision can be found at  \nHumana.com >Find aDoctor >  \nselect Vision care icon >Vision  \ncoverage through Medicare  \nAdvantage plans. VIS701 \n\u2022$0 copay for routine exam up to 1per year. \n\u2022$400 maximum benefit coverage amount per year for contact  \nlenses or eyeglasses-lenses and frames, fitting for  \neyeglasses-lenses and frames. \n\u2022Eyeglass lens options may be available with the maximum benefit  \ncoverage amount up to 1pair per year. \n\u2022Maximum benefit coverage amount is limited to one time use per  \nyear. ", "doc_id": "54415658-387a-4a4e-b1df-ba3d8cf13d4a", "embedding": null, "doc_hash": "758d9efdd4e9e4f892a617bd1f04aad668040a17bc4f6d85f2f0f9e573078bdb", "extra_info": {"page_label": "10", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 2702, "_node_type": "1"}, "relationships": {"1": "6bf9a1ad-c76b-4a70-9040-736af6596ceb"}}, "__type__": "1"}, "bd4256fa-cedf-40cd-8f57-8685d9cb76bd": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\nH0028015000SB23 Summary of Benefits 11 H0028015000 \nCovered Medical and Hospital Benefits  (cont.) \nN/A WHAT YOU PAY ON THIS HUMANA PLAN \nMENTAL HEALTH SERVICES \nInpatient \nYour plan covers up to 190 days \nin alifetime for inpatient mental \nhealth care in apsychiatric \nhospital $0 copay \nOutpatient group and individual \ntherapy visits $0 copay \nSKILLED NURSING FACILITY (SNF) \nYour plan covers up to 100 days \nin aSNF $0 copay \nPHYSICAL THERAPY \nN/A $0 copay \nAMBULANCE \nAmbulance $0 copay \nTRANSPORTATION \nN/A $0 copay for plan approved location up to 60 one-way trip(s) per year. \nThis benefit is not to exceed 75 miles per trip. \nThe member  must  contact transportation vendor to arrange \ntransportation and should contact Customer Care to be directed to \ntheir plan's specific transportation provider. \nMEDICARE PART BDRUGS \nChemotherapy drugs $0 copay \nOther Part Bdrugs $0 copay \nPrescription Drug Benefits \nPRESCRIPTION DRUGS \nMedicare Part DDrugs See chart below for plan coverage information for \nprescription drugs \n$0 Rx Copay Benefit If you qualify for \"Extra Help\", you will pay  $0 for all Medicare Part Dcovered \nprescription drugs on your formulary, for all tiers, and through all stages.  ", "doc_id": "bd4256fa-cedf-40cd-8f57-8685d9cb76bd", "embedding": null, "doc_hash": "600e46fcd0151157f9b550d0ada3bff6f69dff135ee79726867a4cfb682e15f2", "extra_info": {"page_label": "11", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1561, "_node_type": "1"}, "relationships": {"1": "752815e2-3e43-4b09-a7fb-3f3afe863afd"}}, "__type__": "1"}, "7a359c96-1f90-4392-857e-74ff5a025294": {"__data__": {"text": "12 Summary of Benefits H0028015000SB23 H0028015000 \nPharmacy options \nMail Order Mail Order cost-sharing \n$0 CenterWell Pharmacy \u2122, \nWalmart Mail ,PillPack \nOther pharmacies are available in \nour network. To find pharmacy \nmail order options go to  \nHumana.com/pharmacyfinder \nRetail Retail cost-sharing All network retail pharmacies \nFor generic drugs (including  30-day supply 90-day supply* \nbrand drugs treated as generic), \neither: $0 $0 \nFor all other drugs ,either: $0 $0 \nOther pharmacies are available in our network. \n*Some drugs are limited to a30-day supply \nTo find out if you qualify for \"Extra Help,\" please contact the Social Security Office at 1-800-772-1213  \nMonday \u2014Friday, 7a.m. \u20147p.m. TTY users should call 1-800-325-0778. For more information on  \npharmacy-specific cost-sharing, please call us or refer to Chapter 6of the Evidence of Coverage for more  \ndetails.  \nIf you reside in along-term care facility, you pay the same as at aretail pharmacy. \nYou may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network  \npharmacy. \nCatastrophic Coverage \nAfter your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and \nthrough mail order) reach  $7,400 ,you pay nothing for all drugs. \nAdditional Benefits \nN/A WHAT YOU PAY ON THIS HUMANA PLAN \nMedicare-covered foot care \n(podiatry) $0 copay \nMedicare-covered chiropractic \nservices  $0 copay \nMEDICAL EQUIPMENT/SUPPLIES \nDurable medical equipment \n(like wheelchairs or oxygen) $0 copay \nMedical Supplies $0 copay \nProsthetics (artificial limbs or \nbraces) $0 copay ", "doc_id": "7a359c96-1f90-4392-857e-74ff5a025294", "embedding": null, "doc_hash": "5c22e6179a13baaa8405c76c9a35afac55630eaf04047c5d623f6fc3aea6cdde", "extra_info": {"page_label": "12", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1609, "_node_type": "1"}, "relationships": {"1": "52b78121-7e7e-47da-b0eb-6dd474368b36"}}, "__type__": "1"}, "b92a7b28-9f3c-471b-a3a8-89aa972e75ba": {"__data__": {"text": "H0028015000SB23 Summary of Benefits 13 H0028015000 \nN/A WHAT YOU PAY ON THIS HUMANA PLAN \nDiabetic monitoring supplies $0 copay \nREHABILITATION SERVICES \nOccupational and speech \ntherapy $0 copay \nCardiac rehabilitation $0 copay \nPulmonary rehabilitation $0 copay \nTELEHEALTH SERVICES (in addition to Original Medicare) \nPrimary care provider (PCP) $0 copay \nSpecialist $0 copay \nUrgent care services  $0 copay \nSubstance abuse or behavioral \nhealth services  $0 copay \nMedicaid Benefit Comparison \nThe benefits described in the Covered Medical and Hospital Benefits sections above are covered by \nHumana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP). Below is acomparison of benefits that some \nMedicaid eligible individuals could receive directly from the MO HealthNet (Medicaid). For each benefit \nlisted below, you can see what the MO HealthNet (Medicaid) covers and what our plan covers. All Medicaid \nbenefits are subject to Medicaid eligibility guidelines and requirements, and are available only to full dual \neligible individuals. If you have questions about your Medicaid eligibility and what benefits you are \nentitled to, review your member handbook or contact the MO HealthNet (Medicaid) at 1-855-373-4636. \nBENEFIT MEDICAID BENEFIT OUR PLAN BENEFIT \nAcute inpatient hospital care Covered Covered \nAmbulance Covered Covered \nAmbulatory surgical center Covered Covered \nDentures Covered Covered \nDiagnostic \nservices/labs/imaging Covered Covered \nDoctor office visits (Primary \ncare provider (PCP)/specialists Covered Covered \nEmergency care Covered Covered \nEyeglasses Covered Covered \nHearing aids Covered Covered ", "doc_id": "b92a7b28-9f3c-471b-a3a8-89aa972e75ba", "embedding": null, "doc_hash": "ebcb5839add24bc721280cb6c70cd23280cf0e9e584e3f9d8c1b9305e2ef4fd8", "extra_info": {"page_label": "13", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1625, "_node_type": "1"}, "relationships": {"1": "bd81c912-bb20-4178-b1e3-0df87dde5426"}}, "__type__": "1"}, "0d388ed5-60c8-4c76-8666-fbc2a6257e5a": {"__data__": {"text": "14 Summary of Benefits H0028015000SB23 H0028015000 \nBENEFIT MEDICAID BENEFIT OUR PLAN BENEFIT \nHome and community based \nwaiver service programs Covered Not Covered \nInpatient hospital, nursing \nfacility and intermediate care \nfacility services in institutions \nfor mental diseases (MD), age \n65 and older Covered Covered with limitations \nInpatient psychiatric services, \nunder age 21 Covered Covered with limitations \nIntermediate care facility for \nintellectual disabilities \n(ICF-IDD) Covered Not Covered \nIntermediate care facility \nservices for individuals with \nintellectual disabilities  Covered Covered with limitations \nMental health services \n(outpatient group therapy and \nindividual therapy visit)  Covered Covered \nNursing facility services, other \nthan in an institution for mental \ndiseases Covered Covered with limitations \nOutpatient hospital coverage  Covered Covered \nPersonal emergency response \nsystem (PERS)  Not Covered Covered \nPhysical therapy  Covered Covered \nPrescription drugs \u2013Medicare \nPart Bdrugs Covered Covered \nPrescription drugs \u2013outpatient \nprescription drugs; Medicare \ncovered &non-Medicare \ncovered Covered Covered \nPreventive care (e.g., flu \nvaccine, diabetic screenings) Covered Covered \nRoutine non-emergency medical \ntransportation  Covered Covered \nSkilled nursing facility  Covered Covered \nUrgently needed services  Covered Covered ", "doc_id": "0d388ed5-60c8-4c76-8666-fbc2a6257e5a", "embedding": null, "doc_hash": "2465d7ce39a84ab88143b79aa6d5e040b7fd37a9d88b0c793a14f2a162aee7ff", "extra_info": {"page_label": "14", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1381, "_node_type": "1"}, "relationships": {"1": "b2fe87d3-280d-4abd-8d2f-30bc085b2c9a"}}, "__type__": "1"}, "996c0089-e096-40fc-90e6-a649439f172e": {"__data__": {"text": "H0028015000SB23 Summary of Benefits 15 H0028015000 \nMore benefits with  your plan \nEnjoy some of these extra benefits included in your plan . \nThis is asummary of what we cover. It doesn't list every service that we cover or list \nevery limitation or exclusion. The Evidence of Coverage (EOC) provides acomplete list of \ncoverage and services. Visit  Humana.com/medicare to view acopy of the EOC or call  \n1-800-833-2364 .\nHumana Healthy Options Allowance \n$175 automatically loaded on aprepaid \ncard every month to use toward the \npurchase of food, over-the-counter \n(OTC) products, and home supplies from \nanational network of retailers. The card \nmay also be used to pay for \nnon-medical transportation, general \nsupports for living (such as rent \nassistance, internet, and utilities), social \nneeds, aging support and assistive \ndevices, pest control, and pet care and \nsupplies. Unused funds will roll over to \nthe next month and expire at the end of \nthe plan year. Allowance amounts \ncannot be combined with other benefit \nallowances. Limitations and restrictions \nmay apply.  \nHumana Spending Account Card  \nThe allowance listed below will be \nloaded onto this prepaid card. Each \nallowance is separate from any other \nallowance listed. Allowances shown are \naccessed by using this card. Allowance \namounts cannot be combined with \nother benefit allowances. Limitations \nand restrictions may apply. \n*Healthy Options Allowance  \n \nHMO Travel Benefit \nMembers can receive in-network \nbenefits when services are received \nfrom aparticipating HMO National \nNetwork provider during their travels to \nother states and Puerto Rico. Special Supplemental Benefits for \nthe Chronically Ill (SSBCI) Humana \nFlexible Care Assistance \nHumana Flexible Care Assistance is \navailable to members with chronic \nhealth conditions, who are participating \nin care management services, and meet \nprogram criteria. Eligible members may \nreceive medical expense assistance and \nother additional benefits, either \nprimarily health related or non-primarily \nhealth related, to address the member's \nunique individual needs. Benefits are \nlimited up to  $1,000 per year and must \nbe coordinated and authorized by acare \nmanager. There is no cost to participate.   \nChiropractic services \nRoutine chiropractic: \n$0 copay per visit for up to 12 visits. \nSmoking cessation program \nTo further assist in your effort to quit \nsmoking or tobacco product use, we \ncover one additional counseling quit \nattempt within a12-month period as a \nservice with no cost to you. This is in \naddition to the two counseling attempts \nprovided by Medicare and includes up to \nfour face-to-face visits. This service can \nbe used for either preventive measures \nor for diagnosis with atobacco related \ndisease. \nRoutine foot care \n$0 copay per visit for up to 6visits ", "doc_id": "996c0089-e096-40fc-90e6-a649439f172e", "embedding": null, "doc_hash": "d1932916e25ab01fab7ab18f0608a9ef4c67adaceeb9c07250230619fdc31200", "extra_info": {"page_label": "15", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 2828, "_node_type": "1"}, "relationships": {"1": "7716f194-2b56-4220-9c4e-430c96d738f5"}}, "__type__": "1"}, "826b90ae-3086-43db-b6e9-5b93cf3a4dbb": {"__data__": {"text": "16 Summary of Benefits H0028015000SB23 H0028015000 \nHumana Well Dine \u00aeMeal Program \nHumana's home delivered meal \nprogram for members following an \ninpatient stay in the hospital or nursing \nfacility.  \nSpecial Supplemental Benefits for \nthe Chronically Ill (SSBCI) Worry \nFree TM Meals \nMembers diagnosed with Chronic \nObstructive Pulmonary Disease (COPD), \nDiabetes, or Congestive Heart Failure \n(CHF) ,participating with care \nmanagement services, and who meet \nprogram criteria may receive 2meals \nper day for 12 weeks, 168 meals total. \nAn additional 12 weeks of meals may be \navailable as determined by the plan. \nMembers may qualify for the Worry \nFree TM Meals program up to two times \nper plan year. There is no cost to \nparticipate. Authorization may be \nrequired.  \nPersonal Emergency Response  \nSystem  \nThe personal emergency response  \nsystem provides help in emergency  \nsituations. The medical alert service  \ncomes with an installed in-home  \ncommunication device and awearable  \nbutton. You have the choice between a  \npush button unit (with or without  \nAutoAlert fall detection) or awrist unit  \n(without AutoAlert).  Post Discharge Personal Home Care \n$0 copayment for aminimum of 4 \nhours per day, up to amaximum of 44 \nhours per year for certain in-home \nsupport services following adischarge \nfrom askilled nursing facility or from an \ninpatient hospitalization. Services must \nbe initiated within 30 days of discharge \nevent and utilized within 60 days of \ndischarge for each qualifying event up \nto the maximum annual allowance. \nAuthorization may be required. Contact \nthe plan for details.  \nRewards and Incentives  \nGo365 by Humana \u00aeaRewards and \nIncentive program for completing \ncertain preventive health screenings and \nhealth and wellness activities.  \nWigs (related to chemotherapy \ntreatment) \nUp to a  $500 maximum benefit per \nyear. \nSilverSneakers \u00aefitness program \nBasic fitness center membership \nincluding fitness classes.  ", "doc_id": "826b90ae-3086-43db-b6e9-5b93cf3a4dbb", "embedding": null, "doc_hash": "e1fd41b8fe6769e978cb0f6d68cd230d15d05ddb0a1217b26bd6c27eb807d5d5", "extra_info": {"page_label": "16", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1965, "_node_type": "1"}, "relationships": {"1": "20023176-6484-4ab5-8d9e-1c664e10ce79"}}, "__type__": "1"}, "3a03e341-ab40-498c-8a34-a8cac64d97e6": {"__data__": {"text": "17 \nH0028_SB_MAPD_HMOPOS_015000_2023_M Summary of Benefits H0028015000SB23 To find out more about the coverage and costs of Original Medicare, look in the current \u201cMedicare &You\u201d \nhandbook. View it online at  http://www.medicare.gov or get acopy by calling 1-800-MEDICARE (1-800-633-4227), \n24 hours aday, seven days aweek. TTY users should call 1-877-486-2048. \nHumana has been approved by the National Committee for Quality Assurance (NCQA) to operate as aSpecial \nNeeds Plan (SNP) until 12/31/2025 based on areview of Humana's Model of Care. \nYour provider may choose to submit to the MO HealthNet (Medicaid) for consideration of additional secondary \npayment for an amount applied to deductibles, coinsurance, or copayments. If you are Cost Share Protected, \nproviders are required by federal regulation to accept Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) \nprimary payment and the MO HealthNet (Medicaid) secondary payment as payment in full for covered Medicare \nPart Aand Part Bservices \u2013even when the Medicaid payment is zero or aprovider chooses to not submit to \nMedicaid. \nIf you are cost-share protected by the MO HealthNet (Medicaid), Humana Gold Plus SNP-DE H0028-015 (HMO-POS \nD-SNP) providers aren't allowed to collect or bill you for services and items covered under Medicare Part Aand \nPart B, including deductibles, coinsurance, and copayments \u2013even when Medicaid payment is zero or aprovider \nchooses to not submit to Medicaid. If aprovider asks you to pay, that's against the law. You may however be \nresponsible for asmall Medicaid copayment.  \nIf you are cost-share protected and you are billed or asked to pay the provider for deductibles, coinsurance, or \ncopayments on covered Medicare Part Aand Part Bservices tell your provider you are cost-share protected and \ncan't be charged. If you have already made payment you have the right to arefund. If your provider will not stop \nbilling, you can call us at 1-800-457-4708 or you can call Medicare at 1-800-Medicare (1-800-633-4227), (TTY \n1-877-486-2048). Humana or Medicare can ask your provider to stop billing you and refund any payment you \nhave made. \nTelehealth services shown are in addition to the Original Medicare covered telehealth. Your cost may be different \nfor Original Medicare telehealth.  \nLimitations on telehealth services, also referred to as virtual visits or telemedicine, vary by state. These services \nare not asubstitute for emergency care and are not intended to replace your primary care provider or other \nproviders in your network. Any descriptions of when to use telehealth services are for informational purposes only \nand should not be construed as medical advice. Please refer to your evidence of coverage for additional details \non what your plan may cover or other rules that may apply.  \nPlans 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  \nhumana.com/finder/search or call us at the number listed at the beginning of \nthis booklet and we will send you one. \nYou can see our plan's  drug  guide at our website at  \nhumana.com/medicaredruglist or call us at the number listed at the beginning \nof this booklet and we will send you one. Find out  more ", "doc_id": "3a03e341-ab40-498c-8a34-a8cac64d97e6", "embedding": null, "doc_hash": "c9d5daa150e4ad1d259494c1212d63778ffff9072d22039ebe701464b768ff4b", "extra_info": {"page_label": "17", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 3280, "_node_type": "1"}, "relationships": {"1": "d8c1c01e-7575-43d4-927d-a9c532a0273d"}}, "__type__": "1"}, "44f4e8f1-eb3f-4679-af65-e1f9405fd1ca": {"__data__": {"text": "Notes ", "doc_id": "44f4e8f1-eb3f-4679-af65-e1f9405fd1ca", "embedding": null, "doc_hash": "97de44164f37f1a75a4c9a632652bc283581ba3ef7ed50f9a20f3aa11df2c98e", "extra_info": {"page_label": "18", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 6, "_node_type": "1"}, "relationships": {"1": "49e850e8-753d-4145-b36a-2329929af481"}}, "__type__": "1"}, "87a08bb9-7c8a-4d98-abfe-7d4ecd3f558d": {"__data__": {"text": "Notes ", "doc_id": "87a08bb9-7c8a-4d98-abfe-7d4ecd3f558d", "embedding": null, "doc_hash": "31963625d94d5e9888e8c057bfe9a2ab60d2c5749340745280ad4d6a64ce98b6", "extra_info": {"page_label": "19", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 6, "_node_type": "1"}, "relationships": {"1": "5f9601e8-0495-40eb-92a4-7ac4e58aac0b"}}, "__type__": "1"}, "f2755fa0-28cf-43b1-9f87-9df9be602eda": {"__data__": {"text": "20 Summary of Benefits H0028015000SB23 H0028015000 \nGHHLNNXEN 0522 Important________________________________________________ \nAt Humana, it is important you are treated fairly. \nHumana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color, national \norigin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity, marital status, \nreligion, or language. Discrimination is against the law. Humana and its subsidiaries comply with applicable \nfederal civil rights laws. If you believe that you have been discriminated against by Humana or its \nsubsidiaries, there are ways to get help. \n\u2022You may file acomplaint, also known as agrievance:  \nDiscrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618. \nIf you need help filing agrievance, call  1-877-320-1235 or if you use a  TTY ,call  711 .\n\u2022You can also file acivil rights complaint with the  U.S. Department of Health and Human Services ,Office \nfor Civil Rights electronically through their Complaint Portal, available at  \nhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf ,or at  U.S. Department of Health and Human Services , \n200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201,  1-800-368-1019, \n800-537-7697 (TDD) .Complaint forms are available at  https://www.hhs.gov/ocr/office/file/index.html .\n\u2022California residents: You may also call California Department of Insurance toll-free hotline number:  \n1-800-927-HELP (4357) ,to file agrievance. \nAuxiliary aids and services, free of charge, are available to you. \n1-877-320-1235 (TTY: 711) \nHumana provides free auxiliary aids and services, such as qualified sign language interpreters, video remote \ninterpretation, and written information in other formats to people with disabilities when such auxiliary aids \nand services are necessary to ensure an equal opportunity to participate. ", "doc_id": "f2755fa0-28cf-43b1-9f87-9df9be602eda", "embedding": null, "doc_hash": "7b832283433006c294ff30ec7df4ee161871ad4ff0c98987ad7c24b9167486ba", "extra_info": {"page_label": "20", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1895, "_node_type": "1"}, "relationships": {"1": "adaa0fef-b347-4421-8220-cba702dd4083"}}, "__type__": "1"}, "e051d8c0-7178-4216-8d9c-99a6a749d131": {"__data__": {"text": "H0028015000SB23 Summary of Benefits 21 H0028015000 ", "doc_id": "e051d8c0-7178-4216-8d9c-99a6a749d131", "embedding": null, "doc_hash": "2127f31c8de1178b5f3354bd3feb734a57d187fe6b9414c4b7190e4dd5d49f1c", "extra_info": {"page_label": "21", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 51, "_node_type": "1"}, "relationships": {"1": "393cb6ec-d3a9-4529-a177-0980283db340"}}, "__type__": "1"}, "b3db7605-335f-4e53-a772-ad893c07fa62": {"__data__": {"text": "22 Summary of Benefits H0028015000SB23 H0028015000 ", "doc_id": "b3db7605-335f-4e53-a772-ad893c07fa62", "embedding": null, "doc_hash": "f30893c33c91437d2565cca86e5dacb446b4dac94a23e6860e9d3a6694bb72c7", "extra_info": {"page_label": "22", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 51, "_node_type": "1"}, "relationships": {"1": "117b5627-6afa-46df-a9ac-b69ca5c1e556"}}, "__type__": "1"}, "67cb04fc-08f4-4f16-a639-748e1c3b4840": {"__data__": {"text": "Humana Gold Plus SNP-DE H0028-015 \n(HMO-POS D-SNP) \nH0028015000 ENG \nSelect Counties in Missouri \nHumana.com \nGNHH4HIEN_23_C Summary of Benefits H0028015000SB23 ", "doc_id": "67cb04fc-08f4-4f16-a639-748e1c3b4840", "embedding": null, "doc_hash": "f960981ccab2fbceed113c21e86b2166a779e33ce6f742e568ea97893891d35d", "extra_info": {"page_label": "24", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 161, "_node_type": "1"}, "relationships": {"1": "374ba5d2-d1ed-4668-983b-799dcddeae27"}}, "__type__": "1"}, "966e5bec-4129-4d2f-9e25-74860e7731bd": {"__data__": {"text": "Summary of Benefits SBOSB045 \nHumanaChoice H5216-318 (PPO) \nMissouri and Illinois \nSelect Counties in Missouri and Illinois 2023 \nGNHH4HIEN_23_C Summary of Benefits H5216318001SB23 ", "doc_id": "966e5bec-4129-4d2f-9e25-74860e7731bd", "embedding": null, "doc_hash": "66ee4202f1e6c0149e305ebce4ecae01267ea41fcd2879630a0bc5c5725e6cf9", "extra_info": {"page_label": "1", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 181, "_node_type": "1"}, "relationships": {"1": "29c9ab5d-8207-4f5f-98d9-df267fdb5c6e"}}, "__type__": "1"}, "039eab44-b642-42c4-81ab-cd82828751c0": {"__data__": {"text": "Pre-Enrollment Checklist \nBefore making an enrollment decision, it is important that you fully understand our benefits and rules. If you \nhave any questions, you can call and speak to acustomer service representative at  1-800-833-2364 (TTY: \n711) .\nUnderstanding the Benefits \nThe Evidence of Coverage (EOC) provides acomplete list of all coverage and services. It is important \nto review plan coverage, costs and benefits before you enroll. Visit  Humana.com/medicare or call  \n1-800-833-2364  (TTY: 711) to view acopy of the EOC. \nReview the provider directory (or ask your doctor) to make sure the doctors you see now are in the \nnetwork. If they are not listed, it means you will likely have to select anew doctor. \nReview the pharmacy directory to make sure the pharmacy you use for any prescription medicines is \nin the network. If the pharmacy is not listed, you will likely have to select anew pharmacy for your \nprescriptions. \nReview the formulary to make sure your drugs are covered.  \nUnderstanding Important Rules \nYou must continue to pay your Medicare Part Bpremium. This premium is normally taken out of your \nSocial Security check each month. \nBenefits, premiums and/or copayments/co-insurance may change on January 1, 2024. \nOur plan allows you to see providers outside of our network (non-contracted providers). However, \nwhile we will pay for covered services, the provider must agree to treat you. Except in an emergency \nor urgent situations, non-contracted providers may deny care. In addition, you may pay ahigher \nco-pay for services received by non-contracted providers.  ", "doc_id": "039eab44-b642-42c4-81ab-cd82828751c0", "embedding": null, "doc_hash": "97aafbc371bbca57996d1862752874cd8a78ec7dfbdde5bb0304ae04e6179aee", "extra_info": {"page_label": "2", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1599, "_node_type": "1"}, "relationships": {"1": "4cf51b1a-4278-4234-9894-d38a43ed9a90"}}, "__type__": "1"}, "3bf2a62e-f064-4e5a-9d27-9ed92d13e16e": {"__data__": {"text": "Y0040_MAPDPartBIRAamendSB_Template1_C  Gr\neat news \u2014Part B Insulin and Part B drug benefits on Humana\u2019s Medicare Advantage \nplans are getting even better in 2023.  \nAt Humana, we strive to help our members achieve total health so that they may live their \nbest lives, which includes efforts to provide our members with access to more affordable prescription drugs.  \nWith the passing of the Inflation Reduction Act, all Med icare Advantage plans will have \nenhanced benefits in 2023:  \nEffective April 1, 2023, some rebatable Part B drugs may be subject to a lower coinsurance.  \nThis means beginning April 1, 2023, some Part B drugs will have a lower coinsurance than your standard part B drug coinsurance to help avoid increased cost for your Part B drugs.  Any coinsurance adjustments will be made by the pharmacy at the time of purchase.  Note, this does not impact your Part D prescription drug coverage.\n   \nEffective July 1, 2023, cos t sharing for covered Part B Insulin furnished  through a covered \nitem of durable medical equipment will be no more than $35 for a one- month (up to 30 -day) \nsupply and if your plan has a deductible, it does not apply to Part B Insulin.  Part B Insulin is mos t commonly used through an insulin pump.  \nNote, plan information provided in your previous member materials may not reflect these 2023 benefit enhancements from the passing of the Inflation Reduction Act.  ", "doc_id": "3bf2a62e-f064-4e5a-9d27-9ed92d13e16e", "embedding": null, "doc_hash": "a968b6036ac1acb818cd127267b29b0fe95616a681eef729e1406539a02b555c", "extra_info": {"page_label": "3", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1411, "_node_type": "1"}, "relationships": {"1": "6b150add-7ab4-4461-97f0-5a9b956647e2"}}, "__type__": "1"}, "19a70e81-b38a-4d02-b6ea-134cb2de6e02": {"__data__": {"text": "Summary of Benefits \nHumanaChoice H5216-318 (PPO) \nMissouri and Illinois \nSelect Counties in Missouri and Illinois 2023 \nH5216_SB_MAPD_PPO_318001_2023_M Summary of Benefits H5216318001SB23 ", "doc_id": "19a70e81-b38a-4d02-b6ea-134cb2de6e02", "embedding": null, "doc_hash": "c8c9b78c8868d3f43cda44484b805921e52c27ca8e2324c972ee323edbee952b", "extra_info": {"page_label": "5", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 189, "_node_type": "1"}, "relationships": {"1": "357511cc-c2d4-426a-b505-dcb29f767522"}}, "__type__": "1"}, "197460a7-3d41-4746-ad27-0c6f6e6a1ea7": {"__data__": {"text": "Our service area includes the following county/counties in Illinois: Bond, Calhoun, Clinton, \nJersey, Macoupin, Madison, Monroe, St. Clair \nMissouri: Audrain, Barry, Barton, Bates, Benton, Bollinger, Boone, Butler, Callaway, Camden, \nCarroll, Carter, Cedar, Christian, Cole, Cooper, Crawford, Dade, Dallas, Douglas, Dunklin, \nFranklin, Gasconade, Greene, Henry, Hickory, Howard, Howell, Iron, Jasper, Jefferson, Laclede, \nLawrence, Lincoln, Madison, Maries, Marion, McDonald, Miller, Moniteau, Montgomery, Morgan, \nNewton, Oregon, Osage, Ozark, Perry, Pettis, Phelps, Pike, Polk, Pulaski, Reynolds, Saline, St. \nCharles, St. Clair, St. Francois, St. Louis, St. Louis City, Ste. Genevieve, Stoddard, Stone, Taney, \nTexas, Vernon, Warren, Washington, Webster, Wright. ", "doc_id": "197460a7-3d41-4746-ad27-0c6f6e6a1ea7", "embedding": null, "doc_hash": "b7a04c995a26e687019c55267a2d19b51e4e509f4bf985f0cafcb7f112ecb92a", "extra_info": {"page_label": "6", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 766, "_node_type": "1"}, "relationships": {"1": "15cb8b30-b27c-42dd-91f9-6577da4086ce"}}, "__type__": "1"}, "398513cb-b3f0-498e-9991-1d97093cbbfc": {"__data__": {"text": "H5216318001SB23 Summary of Benefits 5H5216318001 \nLet's talk about HumanaChoice \nH5216-318 (PPO) \nFind out more about the HumanaChoice H5216-318 (PPO) plan -including the health \nand drug services it covers -in this easy-to-use guide. \nHumanaChoice H5216-318 (PPO) is aMedicare Advantage  PPO plan with aMedicare \ncontract. Enrollment in this Humana plan depends on contract renewal. \nThe benefit information provided is asummary of what we cover and what you pay. It \ndoesn't list every service that we cover or list every limitation or exclusion. For a \ncomplete list of services we cover, ask us for the \"Evidence of Coverage\". \nTo be eligible \nTo join HumanaChoice H5216-318 \n(PPO), you must be entitled to Medicare \nPart A, be enrolled in Medicare Part B \nand live in our service area. \nPlan name: \nHumanaChoice H5216-318 (PPO) \nHow to reach us: \nIf you're amember of this plan, call \ntoll-free:  1-800-457-4708 (TTY: 711) .\nIf you're  not amember of this plan, \ncall toll free:  1-800-833-2364 (TTY: \n711) .\nOctober 1-March 31: \nCall 7days aweek from 8a.m. -8p.m. \nApril 1-September 30: \nCall Monday -Friday, 8a.m. -8p.m. \nOr visit our website: \nHumana.com/medicare More about HumanaChoice \nH5216-318 (PPO) \nDoyou have Medicare and Medicaid? If you are a \ndual-eligible beneficiary enrolled in both \nMedicare and the state's program, you may not \nhave to pay the medical costs displayed in this \nbooklet and your prescription drug costs will be \nlower, too. \nIf you have Medicaid, be sure to show your \nMedicaid ID card in addition to your Humana \nmembership card to make your provider aware \nthat you may have additional coverage. Your \nservices are paid first by Humana and then by \nMedicaid. \nAs amember it's agood idea to select adoctor \nas your Primary Care Provider (PCP). \nHumanaChoice H5216-318 (PPO) has anetwork \nof doctors, hospitals, pharmacies and other \nproviders. If you use providers who aren't in our \nnetwork, you may be subject to higher \ncopayments/coinsurance. \nAhealthy partnership \nGet more from your plan \u2014with extra \nservices and resources provided by \nHumana! ", "doc_id": "398513cb-b3f0-498e-9991-1d97093cbbfc", "embedding": null, "doc_hash": "6e93785555e14cc0fb0f9395b846befccec950e90421398e1f392f214487cebc", "extra_info": {"page_label": "7", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 2092, "_node_type": "1"}, "relationships": {"1": "18258d2e-8b7c-43a5-8b4a-cf3210934de6"}}, "__type__": "1"}, "cfde4bef-448b-41a3-8e10-1735dd7af95a": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\n6 Summary of Benefits H5216318001SB23 H5216318001 \nMonthly Premium, Deductible and Limits \nPLAN COSTS \nMonthly plan premium \nYou must keep paying your \nMedicare Part Bpremium. $0  \nMedical deductible This plan does not have adeductible.  \nPharmacy (Part D) deductible This plan does not have adeductible. \n \nMaximum out-of-pocket \nresponsibility \nThe most you pay for copays, \ncoinsurance and other costs for \ncovered medical services for the \nyear. $3,600 in-network  \n$5,450 combined in- and out-of-network  \nCovered Medical and Hospital Benefits \nIN-NETWORK OUT-OF-NETWORK \nACUTE INPATIENT HOSPITAL CARE \nN/A $295 copay per day for days 1-5 \n$0 copay per day for days 6-90 \nYour plan covers an unlimited \nnumber of days for an inpatient \nstay. 50% of the cost \nOUTPATIENT HOSPITAL COVERAGE \nOutpatient surgery at \noutpatient hospital $295 copay 50% of the cost \nOutpatient surgery at \nambulatory surgical center $245 copay 50% of the cost \nDOCTOR OFFICE VISITS \nPrimary care provider (PCP) $0 copay 50% of the cost \nSpecialists $30 copay 50% of the cost \nPREVENTIVE CARE \nN/A Our plan covers many preventive  \nservices at no cost when you see  \nan in-network provider including: \n\u2022Abdominal aortic aneurysm  \nscreening $0 copay or  50% of the cost ,  \ndepending on the service and  \nwhere service is provided  ", "doc_id": "cfde4bef-448b-41a3-8e10-1735dd7af95a", "embedding": null, "doc_hash": "eb6e738cb4cff6fbb102f8bdf2a21eb3ce3649fadde6216937605f5b79b1b781", "extra_info": {"page_label": "8", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1665, "_node_type": "1"}, "relationships": {"1": "2c3f08e2-b793-44a7-8ac2-afa86a417673"}}, "__type__": "1"}, "da5e955d-6ef6-4ce0-b4a5-5034597a9b23": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\nH5216318001SB23 Summary of Benefits 7H5216318001 \nCovered Medical and Hospital Benefits  (cont.) \nIN-NETWORK OUT-OF-NETWORK \n\u2022Alcohol misuse counseling \n\u2022Bone mass measurement \n\u2022Breast cancer screening  \n(mammogram) \n\u2022Cardiovascular disease  \n(behavioral therapy) \n\u2022Cardiovascular screenings \n\u2022Cervical and vaginal cancer  \nscreening \n\u2022Colorectal cancer screenings  \n(colonoscopy, fecal occult blood  \ntest, flexible sigmoidoscopy) \n\u2022Depression screening \n\u2022Diabetes screenings \n\u2022HIV screening \n\u2022Medical nutrition therapy  \nservices \n\u2022Obesity screening and  \ncounseling \n\u2022Prostate cancer screenings  \n(PSA) \n\u2022Sexually transmitted infections  \nscreening and counseling \n\u2022Tobacco use cessation  \ncounseling (counseling for  \npeople with no sign of  \ntobacco-related disease) \n\u2022Vaccines, including flu shots,  \nhepatitis Bshots,  \npneumococcal shots \n\u2022\"Welcome to Medicare\"  \npreventive visit (one-time) \n\u2022Annual Wellness Visit \n\u2022Lung cancer screening \n\u2022Routine physical exam \n\u2022Medicare diabetes prevention  \nprogram \nAny additional preventive services  \napproved by Medicare during the  \ncontract year will be covered. Any additional preventive services  \napproved by Medicare during the  \ncontract year will be covered. ", "doc_id": "da5e955d-6ef6-4ce0-b4a5-5034597a9b23", "embedding": null, "doc_hash": "ae996f62d7530d725630ce8a719c764f0c94359c441a80a011b92e87841da76d", "extra_info": {"page_label": "9", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1570, "_node_type": "1"}, "relationships": {"1": "13f93e02-1bad-4e25-935a-7dd90e472053"}}, "__type__": "1"}, "2a1c59dd-31fb-4379-848c-897872c8e515": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\n8 Summary of Benefits H5216318001SB23 H5216318001 \nCovered Medical and Hospital Benefits  (cont.) \nIN-NETWORK OUT-OF-NETWORK \nEMERGENCY CARE \nEmergency room \nIf you are admitted to the \nhospital within 24 hours, you do \nnot have to pay your share of the \ncost for the emergency care. $125 copay $125 copay \nUrgently needed services \nUrgently needed services are \nprovided to treat a \nnon-emergency, unforeseen \nmedical illness, injury or condition \nthat requires immediate medical \nattention. $30 copay at an urgent care \ncenter $30 copay at an urgent care \ncenter \nOUTPATIENT CARE AND DIAGNOSTIC SERVICES, LABS AND IMAGING \nCost share may vary depending on the service and where service is provided \nDiagnostic mammography $0 to  $30 copay 50% of the cost \nDiagnostic colonoscopy $0 copay 50% of the cost \nDiagnostic radiology $180 to  $295 copay 50% of the cost \nLab services $0 to  $30 copay 50% of the cost \nDiagnostic tests and procedures $0 to  $40 copay or  20% of the \ncost 50% of the cost \nOutpatient X-rays $0 to  $35 copay 50% of the cost \nRadiation therapy $30 to  $40 copay 50% of the cost \nHEARING SERVICES \nMedicare-covered hearing $30 copay 50% of the cost ", "doc_id": "2a1c59dd-31fb-4379-848c-897872c8e515", "embedding": null, "doc_hash": "ac7e09a49902fd1f6a56cb5e4bc64c4c30458adcf2e8d1d7a125873b137ab5e0", "extra_info": {"page_label": "10", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1525, "_node_type": "1"}, "relationships": {"1": "20617c36-7f56-4245-8ca9-106687b9e4ed"}}, "__type__": "1"}, "b20126be-997f-45b2-b3d0-08856a278747": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\nH5216318001SB23 Summary of Benefits 9H5216318001 \nCovered Medical and Hospital Benefits  (cont.) \nIN-NETWORK OUT-OF-NETWORK \nRoutine hearing HER956 \n\u2022$0 copay for routine hearing \nexams up to 1per year. \n\u2022$299 copay for each Advanced \nlevel hearing aid up to 1per ear \nper year. \n\u2022$599 copay for each Premium \nlevel hearing aid up to 1per ear \nper year. \nHearing aid purchase includes: \n\u2022Unlimited follow-up provider \nvisits during first year following \nTruHearing hearing aid \npurchase \n\u202260-day trial period \n\u20223-year extended warranty \n\u202280 batteries per aid for \nnon-rechargeable models HER956 \n\u2022$0 copay for routine hearing \nexams up to 1per year. \n\u2022$299 copay for each Advanced \nlevel hearing aid up to 1per ear \nper year. \n\u2022$599 copay for each Premium \nlevel hearing aid up to 1per ear \nper year.  \n \nYou must see aTruHearing \nprovider to use this benefit. Call \n1-844-255-7144 to schedule an \nappointment (for TTY, dial 711). \nDENTAL SERVICES  \nMedicare-covered dental $30 copay 50% of the cost \nRoutine dental \nDental services are subject to our  \nstandard claims review  \nprocedures which could include  \ndental history to approved  \ncoverage. Dental benefits under  \nthis plan may not cover all  \nAmerican Dental Association  \nprocedure codes. Information  \nregarding each plan is available  \nat  Humana.com/sb .\nOut-of-network dentists have not  \nagreed to provide services at  \ncontracted fees. Benefits received  \nout-of-network are subject to any  \nin-network benefits maximums,  \nlimitations, and/or exclusions.  \nYou may be billed by the  \nout-of-network provider for any  \namount greater than the  DEN447 \n\u2022Plan covers up to  $3,000  \nallowance every year for  \nnon-Medicare covered  \npreventive and comprehensive  \ndental services. \n\u2022You are responsible for any  \namount above the dental  \ncoverage limit. \n\u2022Any amount unused at the end  \nof the year will expire. \n\u2022Your benefit can be used for  \nmost dental treatments such  \nas: \n\u2022Preventive dental services, such  \nas exams, routine cleanings,  \netc. \n\u2022Basic dental services, such as  \nfillings, extractions, etc. \n\u2022Major dental services, such as  \nperiodontal scaling, crowns,  DEN447 \n\u2022Plan covers up to  $3,000  \nallowance every year for  \nnon-Medicare covered  \npreventive and comprehensive  \ndental services. \n\u2022You are responsible for any  \namount above the dental  \ncoverage limit. \n\u2022Any amount unused at the end  \nof the year will expire. \n\u2022Your benefit can be used for  \nmost dental treatments such  \nas: \n\u2022Preventive dental services, such  \nas exams, routine cleanings,  \netc. \n\u2022Basic dental services, such as  \nfillings, extractions, etc. \n\u2022Major dental services, such as  \nperiodontal scaling, crowns,  ", "doc_id": "b20126be-997f-45b2-b3d0-08856a278747", "embedding": null, "doc_hash": "a2dac6886c63aa1a4925956db6d721ab056ddb1f748da63986ae707dc00c0301", "extra_info": {"page_label": "11", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 3035, "_node_type": "1"}, "relationships": {"1": "beea1a87-03ff-4e35-a7d7-cd1efb664e32"}}, "__type__": "1"}, "6eb4f5da-c68d-4086-bf6b-e52fb3754a39": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\n10 Summary of Benefits H5216318001SB23 H5216318001 \nCovered Medical and Hospital Benefits  (cont.) \nIN-NETWORK OUT-OF-NETWORK \npayment made by Humana to  \nthe provider.  \nUse the HumanaDental Medicare  \nnetwork for the Mandatory  \nSupplemental Dental. The  \nprovider locator can be found at  \nHumana.com >Find aDoctor >  \nfrom the Search Type drop down  \nselect Dental >under Coverage  \ntype select All Dental Networks >  \nenter zip code >from the  \nnetwork drop down select  \nHumanaDental Medicare.  dentures, root canals, bridges,  \netc. \n\u2022Note: The allowance cannot be  \nused on cosmetic services and  \nimplants. dentures, root canals, bridges,  \netc. \n\u2022Note: The allowance cannot be  \nused on cosmetic services and  \nimplants. \n\u2022Benefits received  \nout-of-network are subject to  \nany in-network benefit  \nmaximums, limitations, and/or  \nexclusions. \nVISION SERVICES \nMedicare-covered vision \nservices $30 copay 50% of the cost \nMedicare-covered diabetic eye \nexam $0 copay 50% of the cost \nMedicare-covered glaucoma \nscreening $0 copay 50% of the cost \nMedicare-covered eyewear \n(post-cataract) $0 copay 50% of the cost ", "doc_id": "6eb4f5da-c68d-4086-bf6b-e52fb3754a39", "embedding": null, "doc_hash": "7b6dfaf62d1d77a654a0ac1414f736c6f3bc79b67eee0579eac8c62b976e0df4", "extra_info": {"page_label": "12", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1477, "_node_type": "1"}, "relationships": {"1": "680d946f-6933-4e2a-906a-654d78d485c6"}}, "__type__": "1"}, "eb4bcc82-976f-4f4e-914f-2e18368393aa": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\nH5216318001SB23 Summary of Benefits 11 H5216318001 \nCovered Medical and Hospital Benefits  (cont.) \nIN-NETWORK OUT-OF-NETWORK \nRoutine vision  \nThe provider locator for routine \nvision can be found at  \nHumana.com >Find aDoctor > \nselect Vision care icon >Vision \ncoverage through Medicare \nAdvantage plans. VIS711 \n\u2022$0 copay for routine exam up \nto 1per year. \n\u2022$40 combined maximum \nbenefit coverage amount per \nyear for routine exam. \n\u2022$300 combined maximum \nbenefit coverage amount per \nyear for contact lenses or \neyeglasses-lenses and frames, \nfitting for eyeglasses-lenses \nand frames. \n\u2022Eyeglass lens options may be \navailable with the maximum \nbenefit coverage amount up to \n1pair per year. \n\u2022Maximum benefit coverage \namount is limited to one time \nuse per year. VIS711 \n\u2022$0 copay for routine exam up \nto 1per year. \n\u2022$40 combined maximum \nbenefit coverage amount per \nyear for routine exam. \n\u2022$300 combined maximum \nbenefit coverage amount per \nyear for contact lenses or \neyeglasses-lenses and frames, \nfitting for eyeglasses-lenses \nand frames. \n\u2022Eyeglass lens options may be \navailable with the maximum \nbenefit coverage amount up to \n1pair per year. \n\u2022Maximum benefit coverage \namount is limited to one time \nuse per year. \n\u2022Benefits received \nout-of-network are subject to \nany in-network benefit \nmaximums, limitations, and/or \nexclusions. \nMENTAL HEALTH SERVICES \nInpatient \nYour plan covers up to 190 days \nin alifetime for inpatient mental \nhealth care in apsychiatric \nhospital $295 copay per day for days 1-5 \n$0 copay per day for days 6-90 50% of the cost \nOutpatient group and individual \ntherapy visits \nCost share may vary depending \non where service is provided. $30 to  $35 copay 50% of the cost \nSKILLED NURSING FACILITY (SNF) \nYour plan covers up to 100 days \nin aSNF $0 copay per day for days 1-20 \n$196 copay per day for days \n21-100 50% of the cost for days 1-100 \nPHYSICAL THERAPY \n$35 copay 50% of the cost ", "doc_id": "eb4bcc82-976f-4f4e-914f-2e18368393aa", "embedding": null, "doc_hash": "c4d3737c02dbed62adec8804ececca91f6891b517d3d84798265259569294f56", "extra_info": {"page_label": "13", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 2294, "_node_type": "1"}, "relationships": {"1": "401f3a6a-41b6-41ee-a977-c004a98eb067"}}, "__type__": "1"}, "d18c8779-d1d2-4083-990d-46aac9258978": {"__data__": {"text": "You do not need areferral to receive covered services from plan providers. Certain procedures, services and drugs \nmay need advance approval from your plan. This is called a\"prior authorization\" or \"preauthorization.\" Please \ncontact your PCP or refer to the Evidence of Coverage (EOC) for services that require aprior authorization from the \nplan .\nc\n12 Summary of Benefits H5216318001SB23 H5216318001 \nCovered Medical and Hospital Benefits  (cont.) \nIN-NETWORK OUT-OF-NETWORK \nAMBULANCE \nAmbulance $290  copay per date of service $290  copay per date of service \nTRANSPORTATION \nN/A $0 copay for plan approved \nlocation up to 24 one-way trip(s) \nper year. \nThis benefit is not to exceed 50 \nmiles per trip. \nThe member  must  contact \ntransportation vendor to arrange \ntransportation and should contact \nCustomer Care to be directed to \ntheir plan's specific transportation \nprovider. \nMEDICARE PART BDRUGS \nChemotherapy drugs 20% of the cost 50% of the cost \nOther Part Bdrugs 20% of the cost 50% of the cost \nPrescription Drug Benefits \nPRESCRIPTION DRUGS \nImportant Message About What You Pay for Vaccines \nOur plan covers most Part Dvaccines at no cost to you, no matter what cost-sharing tier it\u2019s on .\nImportant Message About What You Pay for Insulin \nYou won\u2019t pay more than $35 for aone-month (up to 30-day) supply of each Part Dinsulin product \ncovered by our plan, no matter what cost-sharing tier it\u2019s on .This applies to all Part Dcovered insulins, \nincluding the Select Insulins covered under the Insulin Savings Program as described below. If you receive \n\"Extra Help\", you will still pay no more than $35 for aone-month supply for each Part Dcovered insulin. \nPlease see your Prescription Drug Guide to find all Part Dinsulins covered by your plan. \nIf you don't receive Extra Help for your drugs, you'll pay the following:  \nDeductible  This plan does not have adeductible.   \nInitial coverage \nYou pay the following until your total yearly drug costs reach  $4,660 .Total yearly drug costs are the total \ndrug costs paid by both you and our plan. Once you reach this amount, you will enter the Coverage Gap. ", "doc_id": "d18c8779-d1d2-4083-990d-46aac9258978", "embedding": null, "doc_hash": "c305d305079ea1a99284969e78b61348b1f48256a93e8ea407847a209b77ec1a", "extra_info": {"page_label": "14", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 2127, "_node_type": "1"}, "relationships": {"1": "e89bcb72-c452-4c27-931b-7e91125c62af"}}, "__type__": "1"}, "a4b6201c-a8f1-4790-8182-763a0d45bb2a": {"__data__": {"text": "H5216318001SB23 Summary of Benefits 13 H5216318001 \nMail Order Cost-Sharing \nPharmacy options Standard  \nWalmart Mail ,PillPack \nOther pharmacies are \navailable in our network. To find \npharmacy mail order options go to  \nHumana.com/pharmacyfinder Preferred \nCenterWell Pharmacy \u2122\nN/A 30-day supply 90-day supply* 30-day supply 90-day supply* \nTier 1: Preferred Generic $10 $30 $0 $0 \nTier 2: Generic $20 $60 $5 $0 \nTier 3: Preferred Brand $47 $141 $47 $131 \nTier 4: Non-Preferred \nDrug $100 $300 $99 $287 \nTier 5: Specialty Tier 33% N/A 33% N/A \nRetail Cost-Sharing \nPharmacy options Retail All network retail pharmacies. To find the retail pharmacies near \nyou, go to  Humana.com/pharmacyfinder \nN/A 30-day supply 90-day supply* \nTier 1: Preferred Generic $0 $0 \nTier 2: Generic $5 $15 \nTier 3: Preferred Brand $47 $141 \nTier 4: Non-Preferred \nDrug $99 $297 \nTier 5: Specialty Tier 33% N/A \nYour plan participates in the Insulin Savings Program. You will pay no more than $35 for aone-month (up \nto a30-day) supply for Select Insulins, no matter what cost-sharing tier it\u2019s on .To identify which Select \nInsulins are included within the Insulin Savings Program, look for the  ISP indicator in your Prescription \nDrug Guide. You are not eligible for this program if you receive \"Extra Help\". \nYour plan also provides enhanced insulin coverage which means you will pay no more than $35 for a \none-month (up to 30-day) supply for all Part Dinsulins covered by our plan, including Select Insulins, no \nmatter what cost-sharing tier it\u2019s on .The enhanced insulin coverage is available, even if you receive \"Extra \nHelp\". \nYour share of the cost for Select Insulins: ", "doc_id": "a4b6201c-a8f1-4790-8182-763a0d45bb2a", "embedding": null, "doc_hash": "f6c804bedce4dde4e15e314cafcf5c3a5c6d9514ef52ba5a9cf241893e72bd84", "extra_info": {"page_label": "15", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1663, "_node_type": "1"}, "relationships": {"1": "5ab029dc-0056-40a3-9ac6-30a8dc3559e3"}}, "__type__": "1"}, "4d0b6992-3be1-4c12-876d-7a845e7138fc": {"__data__": {"text": "14 Summary of Benefits H5216318001SB23 H5216318001 \nMail Order Cost-Sharing for Select Insulins \nPharmacy \noptions  Standard  \nWalmart Mail ,PillPack \nOther pharmacies are available in \nour network. To find pharmacy mail \norder options, go to  \nHumana.com/pharmacyfinder \nWalmart Mail ,PillPack Preferred \nCenterWell Pharmacy \u2122\n- 30-day supply  90-day supply* 30-day supply  90-day supply* \nTier 3: Preferred Brand  $35 $105 $35 $95 \nRetail Cost-Sharing for Select Insulins \nPharmacy \noptions  Retail  \nAll network retail pharmacies. To find the retail pharmacies near you, go \nto  Humana.com/pharmacyfinder \n- 30-day supply  90-day supply* \nTier 3: Preferred Brand  $35 $105 \nIf you receive Extra Help for your drugs, you'll pay the following: \nDeductible  This plan does not have adeductible. \nPharmacy cost-sharing \nFor generic drugs \n(including  30-day supply 90-day supply* \nbrand drugs treated as \ngeneric), either: $0 copay; or  \n$1.45 copay; or  \n$4.15 copay ;or \n15% of the cost $0 copay; or  \n$1.45 copay; or  \n$4.15 copay ;or \n15% of the cost \nFor all other drugs, \neither: $0 copay; or  \n$4 .30 copay; or  \n$10.35 copay ;or \n15%  of the cost  $0 copay; or  \n$4 .30 copay; or  \n$10.35 copay ;or \n15% of the cost  \nOther pharmacies are available in our network. \n*Some drugs are limited to a30-day supply  \nADDITIONAL DRUG COVERAGE \nErectile dysfunction (ED) drugs Covered at Tier 1cost-share amount. \nAnti-Obesity drugs Covered at Tier 2cost-share amount.  \nCost sharing may change depending on the pharmacy you choose, when you enter another phase of the  \nPart Dbenefit and if you qualify for \"Extra Help.\" To find out if you qualify for \"Extra Help,\" please contact  ", "doc_id": "4d0b6992-3be1-4c12-876d-7a845e7138fc", "embedding": null, "doc_hash": "e82db8773bc349b84d780d9eb9ed777b93fedd16b18093c3c470362099dc5702", "extra_info": {"page_label": "16", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1681, "_node_type": "1"}, "relationships": {"1": "6d8c8247-18ed-4810-a605-72c5d8f7c0d0"}}, "__type__": "1"}, "61833f17-15eb-482d-bf8c-c0fd0b6567eb": {"__data__": {"text": "H5216318001SB23 Summary of Benefits 15 H5216318001 the Social Security Office at 1-800-772-1213 Monday \u2014Friday, 7a.m. \u20147p.m. TTY users should call  \n1-800-325-0778. For more information on your prescription drug benefit, please call us or access your  \n\"Evidence of Coverage\" online. \nIf you reside in along-term care facility, you pay the same as at aretail pharmacy. \nYou may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network  \npharmacy. \nCoverage Gap \nAfter you enter the coverage gap, you pay  25 percent of the plan's cost for covered brand name drugs \nand  25 percent of the plan's cost for covered generic drugs until your out-of-pocket costs total  $7,400 \u2014 \nwhich is the end of the coverage gap. Not everyone will enter the coverage gap. \nUnder this plan,  you may pay even less for the following: \nTier 1(Preferred Generic) - All Drugs \nTier 2(Generic) - All Drugs \nTier 3(Preferred Brand) - Select Insulin Drugs \nFor more information on cost sharing in the coverage gap, please call us or access your Evidence of \nCoverage online. \nCatastrophic Coverage \nAfter your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and \nthrough mail order) reach  $7,400 ,you pay the greater of: \n\u20225% of the cost, or \n\u2022$4.15 copay for generic (including brand drugs treated as generic) and a  $10.35 copay for all other \ndrugs \nAdditional Benefits \nIN-NETWORK OUT-OF-NETWORK \nMedicare-covered foot care \n(podiatry) $30 copay 50% of the cost \nMedicare-covered chiropractic \nservices $20 copay 50% of the cost \nMEDICAL EQUIPMENT/SUPPLIES \nDurable medical equipment (like \nwheelchairs or oxygen) 20% of the cost 50% of the cost \nMedical Supplies 20% of the cost 50% of the cost \nProsthetics (artificial limbs or \nbraces) 20% of the cost 50% of the cost \nDiabetic monitoring supplies \nCost share may vary depending \non where service is provided. $0 copay or  10% to  20% of the \ncost 50% of the cost ", "doc_id": "61833f17-15eb-482d-bf8c-c0fd0b6567eb", "embedding": null, "doc_hash": "ebce59687f6975ec93d1d74e555b9f1865109d97a7230ed1d131e064a15d03c9", "extra_info": {"page_label": "17", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1968, "_node_type": "1"}, "relationships": {"1": "bb6f9274-613a-4ef8-ad04-564001cb3c4d"}}, "__type__": "1"}, "6365e49d-afef-4da3-9342-61e260f74fec": {"__data__": {"text": "16 Summary of Benefits H5216318001SB23 H5216318001 \nREHABILITATION SERVICES \nOccupational and speech \ntherapy $35 copay 50% of the cost \nCardiac rehabilitation $10 copay 50% of the cost \nPulmonary rehabilitation $20 copay 50% of the cost \nTELEHEALTH SERVICES (in addition to Original Medicare) \nPrimary care provider (PCP) $0 copay Not Covered \nSpecialist $30 copay Not Covered \nUrgent care services $0 copay Not Covered \nSubstance abuse or behavioral \nhealth services $0 copay Not Covered ", "doc_id": "6365e49d-afef-4da3-9342-61e260f74fec", "embedding": null, "doc_hash": "030471a56c2e32e6ace721141429975721c94adeb7219f806b28e59552b640f0", "extra_info": {"page_label": "18", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 490, "_node_type": "1"}, "relationships": {"1": "e2d27779-6d93-45c6-bd21-6b9defba3fa4"}}, "__type__": "1"}, "42b23314-3cdf-4993-96e4-187f13154b21": {"__data__": {"text": "H5216318001SB23 Summary of Benefits 17 H5216318001 \nMore benefits with  your plan \nEnjoy some of these extra benefits included in your plan . \nThis is asummary of what we cover. It doesn't list every service that we cover or list \nevery limitation or exclusion. The Evidence of Coverage (EOC) provides acomplete list of \ncoverage and services. Visit  Humana.com/medicare to view acopy of the EOC or call  \n1-800-833-2364 .\nTravel Coverage \nThe PPO national network gives you \nin-network coverage across the country, \nso you can see any doctor who accepts \nthe plan terms and conditions. You'll be \nable to travel with ease or split your \ntime between locations. Visit  \nHumana.com  or contact Customer Care \non the back of your ID card if you need \nhelp finding an in-network provider. \nSpecial Supplemental Benefits for \nthe Chronically Ill (SSBCI) Humana \nFlexible Care Assistance \nHumana Flexible Care Assistance is \navailable to members with chronic \nhealth conditions, who are participating \nin care management services, and meet \nprogram criteria. Eligible members may \nreceive medical expense assistance and \nother additional benefits, either \nprimarily health related or non-primarily \nhealth related, to address the member's \nunique individual needs. Benefits are \nlimited up to  $1,000 per year and must \nbe coordinated and authorized by acare \nmanager. There is no cost to participate.   Health Education \nOasis Everywhere benefit offers adult \nlearning and healthy lifestyle courses \nboth virtually and in-person. All \nprograms are live, interactive and \nencourage participation. Learning \nclasses range from History, Music, \nTravel, Culture, Art, Science, Technology, \nExercise and more. $0 copay with an \n$80 allowance per year toward courses \navailable in the Oasis catalog. \nNumerous healthy living courses are at \nno cost and an additional 3,560 \nfee-based classes offered nationwide. \nMember is responsible for costs above \nand beyond the allowance value.  \nHumana Well Dine \u00aeMeal Program \nHumana's home delivered meal \nprogram for members following an \ninpatient stay in the hospital or nursing \nfacility.  \nOver-the-Counter (OTC) mail order \n$50 maximum benefit coverage \namount per quarter (3 months) for \nselect over-the-counter health and \nwellness products. \n \nRewards and Incentives  \nGo365 by Humana \u00aeaRewards and \nIncentive program for completing \ncertain preventive health screenings and \nhealth and wellness activities.  \nSilverSneakers \u00aefitness program \nBasic fitness center membership \nincluding fitness classes.  ", "doc_id": "42b23314-3cdf-4993-96e4-187f13154b21", "embedding": null, "doc_hash": "a08d8971ba6858b03d10ef2814744bbac3176a9db733b6b066345ce7fc114a94", "extra_info": {"page_label": "19", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 2545, "_node_type": "1"}, "relationships": {"1": "3b1f2ce2-ea57-44a5-9f4e-0b9b9185f73c"}}, "__type__": "1"}, "b2fb7ba3-5c27-4fe5-b711-0204e8703256": {"__data__": {"text": "18 \nH5216_SB_MAPD_PPO_318001_2023_M Summary of Benefits H5216318001SB23 To find out more about the coverage and costs of Original Medicare, look in the current \u201cMedicare &You\u201d \nhandbook. View it online at  http://www.medicare.gov or get acopy by calling 1-800-MEDICARE (1-800-633-4227), \n24 hours aday, seven days aweek. TTY users should call 1-877-486-2048. \nTelehealth services shown are in addition to the Original Medicare covered telehealth. Your cost may be different \nfor Original Medicare telehealth.  \nLimitations on telehealth services, also referred to as virtual visits or telemedicine, vary by state. These services \nare not asubstitute for emergency care and are not intended to replace your primary care provider or other \nproviders in your network. Any descriptions of when to use telehealth services are for informational purposes only \nand should not be construed as medical advice. Please refer to your evidence of coverage for additional details \non what your plan may cover or other rules that may apply.  \nPlans may offer supplemental benefits in addition to Part Cbenefits and Part Dbenefits. \nOut-of-network/non-contracted providers are under no obligation to treat Humana members, except in \nemergency situations. Please call our customer service number or see your Evidence of Coverage for more \ninformation, including the cost-sharing that applies to out-of-network services. You can see our plan's  provider and pharmacy directory at our website at  \nhumana.com/finder/search or call us at the number listed at the beginning of \nthis booklet and we will send you one. \nYou can see our plan's  drug  guide at our website at  \nhumana.com/medicaredruglist or call us at the number listed at the beginning \nof this booklet and we will send you one. Find out  more ", "doc_id": "b2fb7ba3-5c27-4fe5-b711-0204e8703256", "embedding": null, "doc_hash": "7d132fe33faa72bcc42aa0195a7d8906533841ca429bbfefaeec74eab8a5bda9", "extra_info": {"page_label": "20", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1788, "_node_type": "1"}, "relationships": {"1": "8eb7950e-eff8-4454-816a-99837b171714"}}, "__type__": "1"}, "a7593103-0bdb-402a-b0f4-abf6c269af73": {"__data__": {"text": "H5216318001SB23 Summary of Benefits 19 H5216318001 \nGHHLNNXEN 0522 Important________________________________________________ \nAt Humana, it is important you are treated fairly. \nHumana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color, national \norigin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity, marital status, \nreligion, or language. Discrimination is against the law. Humana and its subsidiaries comply with applicable \nfederal civil rights laws. If you believe that you have been discriminated against by Humana or its \nsubsidiaries, there are ways to get help. \n\u2022You may file acomplaint, also known as agrievance:  \nDiscrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618. \nIf you need help filing agrievance, call  1-877-320-1235 or if you use a  TTY ,call  711 .\n\u2022You can also file acivil rights complaint with the  U.S. Department of Health and Human Services ,Office \nfor Civil Rights electronically through their Complaint Portal, available at  \nhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf ,or at  U.S. Department of Health and Human Services , \n200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201,  1-800-368-1019, \n800-537-7697 (TDD) .Complaint forms are available at  https://www.hhs.gov/ocr/office/file/index.html .\n\u2022California residents: You may also call California Department of Insurance toll-free hotline number:  \n1-800-927-HELP (4357) ,to file agrievance. \nAuxiliary aids and services, free of charge, are available to you. \n1-877-320-1235 (TTY: 711) \nHumana provides free auxiliary aids and services, such as qualified sign language interpreters, video remote \ninterpretation, and written information in other formats to people with disabilities when such auxiliary aids \nand services are necessary to ensure an equal opportunity to participate. ", "doc_id": "a7593103-0bdb-402a-b0f4-abf6c269af73", "embedding": null, "doc_hash": "d109d9b677b8925ade30a3ced3e3de2c754cbf5a988b6f84d96b0c8c0368de8a", "extra_info": {"page_label": "21", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 1895, "_node_type": "1"}, "relationships": {"1": "e0fef81b-2224-400c-a730-16e21c85198b"}}, "__type__": "1"}, "bde15604-7e37-48c8-ab90-2ed521b2f7f9": {"__data__": {"text": "20 Summary of Benefits H5216318001SB23 H5216318001 ", "doc_id": "bde15604-7e37-48c8-ab90-2ed521b2f7f9", "embedding": null, "doc_hash": "da2a9d8f60c4c7494bde6b413185f29de9b725b754d2574af571f7584c40d497", "extra_info": {"page_label": "22", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 51, "_node_type": "1"}, "relationships": {"1": "9e56681c-beb7-4a84-ada5-ffac8d507ee9"}}, "__type__": "1"}, "07b14f4d-054c-4a84-9f05-17904b7710e3": {"__data__": {"text": "H5216318001SB23 Summary of Benefits 21 H5216318001 ", "doc_id": "07b14f4d-054c-4a84-9f05-17904b7710e3", "embedding": null, "doc_hash": "d27bdfb8e8e9def5d1fea39e244b53986258ced97c27114542ddbb10829a6164", "extra_info": {"page_label": "23", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 51, "_node_type": "1"}, "relationships": {"1": "fe521c7e-e8b4-4cc5-b395-3b0b82c9c569"}}, "__type__": "1"}, "be32b610-eee8-4a72-a38b-187468488aee": {"__data__": {"text": "HumanaChoice H5216-318 (PPO) \nH5216318001 ENG \nSelect Counties in Missouri and Illinois \nHumana.com \nGNHH4HIEN_23_C Summary of Benefits H5216318001SB23 ", "doc_id": "be32b610-eee8-4a72-a38b-187468488aee", "embedding": null, "doc_hash": "77ca589a2d77fc2900dcb16fc8cbe7f41f300d9001c305c5ef28c2b519b9282a", "extra_info": {"page_label": "28", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}, "node_info": {"start": 0, "end": 152, "_node_type": "1"}, "relationships": {"1": "4d224074-18c2-4016-8010-232b17407065"}}, "__type__": "1"}, "a2bfd2bc-7c3a-436a-a5bd-5b4448eebb22": {"__data__": {"text": "Find\nmy\ndetails\nbelow\nN a m e :\nM a y o\nA g e :\n2 0\nH e a l t h :\nG o o d\nP r e s c r i p t i o n\n:\nf l u r b i p r o f e n\n1 0 0\nm g\nC h r o n i c\nc o n d i t i o n :\nH e a d a c h e\nI n s u r a n c e\np l a n :\nH u m a n a\nG o l d\nP l u s\nS N P - D E\nH 0 0 2 8 - 0 1 5\n( H M O - P O S\nD - S N P )\nF a v o r i t e\ns p o r t\nt e a m :\nU I\nG i a n t s\nB a n k\na c c o u n t :\nI C I C I\nB a n k\nb a l a n c e :\n$ 8 5 0 , 0 0 , 0 0 0\nF i n a n c i a l\ng o a l :\nT o\nb u i l d\nU I\nc o m p a n y\nH o s p i t a l\n:\nS t\nL o u i s\nC h i l d r e n ' s\nH o s p i t a l\nP h a r m a c y\n:\nB e v e r l y\nH i l l s\nD o s a g e\n:\nT a k e\n2\nt a b l e t s\nd a i l y\ni n\nt h e\nm o r n i n g\na f t e r\nf o o d\na n d\no n e\ni n\nt h e\ne v e n i n g .\nD o c t o r\n:\nD r . K e n n a r d", "doc_id": "a2bfd2bc-7c3a-436a-a5bd-5b4448eebb22", "embedding": null, "doc_hash": "318b852e7cd1d8ebd895a737cf30f61e12106ef1bdcc3cdc2835eee7726ce8b0", "extra_info": {"page_label": "1", "file_name": "MayoDetails.pdf"}, "node_info": {"start": 0, "end": 761, "_node_type": "1"}, "relationships": {"1": "d381e00b-9565-4607-bd96-e12c32174178"}}, "__type__": "1"}, "0cd36c6b-d231-4442-8aea-8ddf91948570": {"__data__": {"text": "Name phone hours address participation status\nWALGREENS #3652 (636) 343-0754 View hoursOPEN 24 HOURS7 DAYS A WEEK 1001 BOWLES AVE In network\nWALGREENS #6789 (636) 343-8402 Open now: 8 a.m. \u2014 10 p.m.Mon: 8 a.m. \u2014 10 p.m., Tue: 8 a.m. \u2014 10 p.m., Wed: 8 a.m. \u2014 10 p.m., Thurs: 8 a.m. \u2014 10 p.m., Fri: 8 a.m. \u2014 10 p.m., Sat: 8 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 701 GRAVOIS BLUFFS BLVD In network\nWALGREENS #4467 (636) 230-7367 View hoursMon: 9 a.m. \u2014 9 p.m., Tue: 9 a.m. \u2014 9 p.m., Wed: 9 a.m. \u2014 9 p.m., Thurs: 9 a.m. \u2014 9 p.m., Fri: 9 a.m. \u2014 9 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 1205 SULPHUR SPRING RD In network\nWALGREENS #7423 (636) 326-5113 View hoursMon: 9 a.m. \u2014 9 p.m., Tue: 9 a.m. \u2014 9 p.m., Wed: 9 a.m. \u2014 9 p.m., Thurs: 9 a.m. \u2014 9 p.m., Fri: 9 a.m. \u2014 9 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 1210 SUGAR CREEK SQ In network\nFAMILY CARE CENTRAL PHARMACY #54 (314) 657-9000 Please call pharmacy to confirm hours 1234 SOUTH KINGSHIGHWAY BLVD In network\nWALGREENS #5120 (314) 965-0030 Open now: 6 a.m. \u2014 10 p.m.Mon: 6 a.m. \u2014 10 p.m., Tue: 6 a.m. \u2014 10 p.m., Wed: 6 a.m. \u2014 10 p.m., Thurs: 6 a.m. \u2014 10 p.m., Fri: 6 a.m. \u2014 10 p.m., Sat: 6 a.m. \u2014 10 p.m., Sun: 6 a.m. \u2014 10 p.m., 12006 MANCHESTER RD In network\nWALGREENS #5513 (314) 849-6348 View hoursMon: 9 a.m. \u2014 9 p.m., Tue: 9 a.m. \u2014 9 p.m., Wed: 9 a.m. \u2014 9 p.m., Thurs: 9 a.m. \u2014 9 p.m., Fri: 9 a.m. \u2014 9 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 11590 GRAVOIS RD In network\nMERCY PHARMACY KENNERLY #314 (314) 525-1633 View hoursMon: 7 a.m. \u2014 8 p.m., Tue: 7 a.m. \u2014 8 p.m., Wed: 7 a.m. \u2014 8 p.m., Thurs: 7 a.m. \u2014 8 p.m., Fri: 7 a.m. \u2014 8 p.m., Sat: 9 a.m. \u2014 7 p.m., Sun: 9 a.m. \u2014 7 p.m., 10010 KENNERLY ROAD In network\nWALGREENS #9714 (314) 843-3736 View hoursOPEN 24 HOURS7 DAYS A WEEK 9978 KENNERLY ROAD In network\nGOLDSMITH MEDICENTER PHARMACY (314) 432-5020 Please call pharmacy to confirm hours 13354 MANCHESTER RD STE 101 In network\nWALGREENS #854 (314) 842-3372 Open now: 6 a.m. \u2014 12 p.m.Mon: 6 a.m. \u2014 12 p.m., Tue: 6 a.m. \u2014 12 p.m., Wed: 6 a.m. \u2014 12 p.m., Thurs: 6 a.m. \u2014 12 p.m., Fri: 6 a.m. \u2014 12", "doc_id": "0cd36c6b-d231-4442-8aea-8ddf91948570", "embedding": null, "doc_hash": "28ab6041c14dd556d85142ffd9253911c5c0b177dee936692b072f78703bfa8f", "extra_info": {"page_label": "1", "file_name": "Pharmacy List.pdf"}, "node_info": {"start": 0, "end": 2086, "_node_type": "1"}, "relationships": {"1": "d760de93-214b-4af7-b40a-adf7d2d67808", "3": "a0aeb945-9db0-4bfd-9214-f6f0f889df70"}}, "__type__": "1"}, "a0aeb945-9db0-4bfd-9214-f6f0f889df70": {"__data__": {"text": "6 a.m. \u2014 12 p.m., Fri: 6 a.m. \u2014 12 p.m., Sat: 6 a.m. \u2014 12 p.m., Sun: 6 a.m. \u2014 12 p.m., 5764 S LINDBERGH BLVD In network\nCVS PHARMACY #05643 (314) 892-8356 View hoursOPEN 24 HOURS7 DAYS A WEEK 7334 S LINDBERGH BLVD In network\nWALGREENS #7762 (314) 631-8800 Open now: 8 a.m. \u2014 10 p.m.Mon: 8 a.m. \u2014 10 p.m., Tue: 8 a.m. \u2014 10 p.m., Wed: 8 a.m. \u2014 10 p.m., Thurs: 8 a.m. \u2014 10 p.m., Fri: 8 a.m. \u2014 10 p.m., Sat: 8 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 1 GRASSO PLAZA In network\nWALGREENS #5285 (314) 416-1539 View hoursMon: 9 a.m. \u2014 9 p.m., Tue: 9 a.m. \u2014 9 p.m., Wed: 9 a.m. \u2014 9 p.m., Thurs: 9 a.m. \u2014 9 p.m., Fri: 9 a.m. \u2014 9 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 5050 LEMAY FERRY RD In network\nWALGREENS #5228 (314) 487-0636 Open now: 8 a.m. \u2014 10 p.m.Mon: 8 a.m. \u2014 10 p.m., Tue: 8 a.m. \u2014 10 p.m., Wed: 8 a.m. \u2014 10 p.m., Thurs: 8 a.m. \u2014 10 p.m., Fri: 8 a.m. \u2014 10 p.m., Sat: 8 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 4400 LEMAY FERRY RD In network\nCORUM HEALTH SERVICES INC (636) 733-7300 View hoursMon: 8 a.m. \u2014 9 p.m., Tue: 8 a.m. \u2014 9 p.m., Wed: 8 a.m. \u2014 9 p.m., Thurs: 8 a.m. \u2014 9 p.m., Fri: 8 a.m. \u2014 9 p.m., Sat: 9 a.m. \u2014 5 p.m., Sun: 9 a.m. \u2014 5 p.m., 14805 N OUTER 40 RD In network\nWALGREENS #5058 (636) 296-9490 Open now: 8 a.m. \u2014 10 p.m.Mon: 8 a.m. \u2014 10 p.m., Tue: 8 a.m. \u2014 10 p.m., Wed: 8 a.m. \u2014 10 p.m., Thurs: 8 a.m. \u2014 10 p.m., Fri: 8 a.m. \u2014 10 p.m., Sat: 8 a.m. \u2014 10 p.m., Sun: 8 a.m. \u2014 10 p.m., 776 JEFFCO BLVD In network\nCOMMUNITY, A WALGREENS PHARMACY #16552 (314) 739-4503 View hoursMon: 9 a.m. \u2014 5 p.m., Tue: 9 a.m. \u2014 5 p.m., Wed: 9 a.m. \u2014 5 p.m., Thurs: 9 a.m. \u2014 5 p.m., Fri: 9 a.m. \u2014 5 p.m., Sat: ClosedSun: Closed 628 N NEW BALLAS RD In network\nCVS PHARMACY #05669 (314) 351-6728 View hoursOPEN 24 HOURS7 DAYS A WEEK 7320 GRAVOIS AVE In network\nWALGREENS #3305 (314) 878-4413 View hoursOPEN 24 HOURS7 DAYS A WEEK 12661 OLIVE BLVD In network\nWALGREENS #3906 (314) 752-0722 View hoursOPEN 24 HOURS7 DAYS A WEEK 7339 GRAVOIS AVENUE In network\nCVS PHARMACY #05670 (314) 432-2296 View hoursMon: 8 a.m. \u2014 9 p.m., Tue: 8 a.m. \u2014 9 p.m., Wed: 8", "doc_id": "a0aeb945-9db0-4bfd-9214-f6f0f889df70", "embedding": null, "doc_hash": "59c9d3ba0480f50dfb34765f4b8563bcb2492d2a168628b8f96bdec88b3aa43c", "extra_info": {"page_label": "1", "file_name": "Pharmacy List.pdf"}, "node_info": {"start": 2062, "end": 4116, "_node_type": "1"}, "relationships": {"1": "d760de93-214b-4af7-b40a-adf7d2d67808", "2": "0cd36c6b-d231-4442-8aea-8ddf91948570", "3": "e68a1a5e-0748-4a1c-8d95-148e642f09b8"}}, "__type__": "1"}, "e68a1a5e-0748-4a1c-8d95-148e642f09b8": {"__data__": {"text": "p.m., Tue: 8 a.m. \u2014 9 p.m., Wed: 8 a.m. \u2014 9 p.m., Thurs: 8 a.m. \u2014 9 p.m., Fri: 8 a.m. \u2014 9 p.m., Sat: 10 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 9141 OLIVE BLVD In network\nWALGREENS #4345 (314) 416-8123 View hoursMon: 9 a.m. \u2014 9 p.m., Tue: 9 a.m. \u2014 9 p.m., Wed: 9 a.m. \u2014 9 p.m., Thurs: 9 a.m. \u2014 9 p.m., Fri: 9 a.m. \u2014 9 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 2700 TELEGRAPH RD In network\nWALGREENS #5363 (314) 416-7482 View hoursMon: 9 a.m. \u2014 9 p.m., Tue: 9 a.m. \u2014 9 p.m., Wed: 9 a.m. \u2014 9 p.m., Thurs: 9 a.m. \u2014 9 p.m., Fri: 9 a.m. \u2014 9 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 5414 TELEGRAPH ROAD In network\nWALGREENS #1107 (314) 647-7820 View hoursMon: 9 a.m. \u2014 9 p.m., Tue: 9 a.m. \u2014 9 p.m., Wed: 9 a.m. \u2014 9 p.m., Thurs: 9 a.m. \u2014 9 p.m., Fri: 9 a.m. \u2014 9 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 2310 MCCAUSLAND AVE In network\nWALGREENS #6755 (314) 351-2100 View hoursOPEN 24 HOURS7 DAYS A WEEK 3920 HAMPTON AVE In network\nWALGREENS #15265 (314) 991-3402 Open now: 8 a.m. \u2014 10 p.m.Mon: 8 a.m. \u2014 10 p.m., Tue: 8 a.m. \u2014 10 p.m., Wed: 8 a.m. \u2014 10 p.m., Thurs: 8 a.m. \u2014 10 p.m., Fri: 8 a.m. \u2014 10 p.m., Sat: 8 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 8390 DELMAR BLVD In network\nWALGREENS #4833 (314) 631-4769 Open now: 8 a.m. \u2014 10 p.m.Mon: 8 a.m. \u2014 10 p.m., Tue: 8 a.m. \u2014 10 p.m., Wed: 8 a.m. \u2014 10 p.m., Thurs: 8 a.m. \u2014 10 p.m., Fri: 8 a.m. \u2014 10 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 651 LEMAY FERRY RD In network\nWALGREENS #5894 (314) 721-6013 View hoursOPEN 24 HOURS7 DAYS A WEEK 6733 CLAYTON RD In network\nWALGREENS #1679 (314) 832-3650 View hoursMon: 9 a.m. \u2014 9 p.m., Tue: 9 a.m. \u2014 9 p.m., Wed: 9 a.m. \u2014 9 p.m., Thurs: 9 a.m. \u2014 9 p.m., Fri: 9 a.m. \u2014 9 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 6411 GRAVOIS AVENUE In network\nUNITED SCRIPTS LTC LLC (314) 828-4600 View hoursMon: 8 a.m. \u2014 8 p.m., Tue: 8 a.m. \u2014 8 p.m., Wed: 8 a.m. \u2014 8 p.m., Thurs: 8 a.m. \u2014 8 p.m., Fri: 8 a.m. \u2014 8 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 9", "doc_id": "e68a1a5e-0748-4a1c-8d95-148e642f09b8", "embedding": null, "doc_hash": "3fe18074d01ed21792146d5414e3946c6ad68b6d397dfb408c357f4dc4f2d7af", "extra_info": {"page_label": "1", "file_name": "Pharmacy List.pdf"}, "node_info": {"start": 4116, "end": 6075, "_node_type": "1"}, "relationships": {"1": "d760de93-214b-4af7-b40a-adf7d2d67808", "2": "a0aeb945-9db0-4bfd-9214-f6f0f889df70", "3": "11a593a4-999c-43ab-8c28-fb61beaeeab2"}}, "__type__": "1"}, "11a593a4-999c-43ab-8c28-fb61beaeeab2": {"__data__": {"text": "p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 9 a.m. \u2014 5 p.m., 1861 CRAIG PARK COURT In network\nWALGREENS #5667 (314) 846-9265 Open now: 8 a.m. \u2014 10 p.m.Mon: 8 a.m. \u2014 10 p.m., Tue: 8 a.m. \u2014 10 p.m., Wed: 8 a.m. \u2014 10 p.m., Thurs: 8 a.m. \u2014 10 p.m., Fri: 8 a.m. \u2014 10 p.m., Sat: 8 a.m. \u2014 10 p.m., Sun: 8 a.m. \u2014 10 p.m., 6071 TELEGRAPH RD In network\nWALGREENS #11836 (314) 447-1804 View hoursMon: 9 a.m. \u2014 9 p.m., Tue: 9 a.m. \u2014 9 p.m., Wed: 9 a.m. \u2014 9 p.m., Thurs: 9 a.m. \u2014 9 p.m., Fri: 9 a.m. \u2014 9 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 10700 PAGE AVE In network\nWALGREENS #12927 (314) 647-1256 View hoursMon: 9 a.m. \u2014 5 p.m., Tue: 9 a.m. \u2014 5 p.m., Wed: 9 a.m. \u2014 5 p.m., Thurs: 9 a.m. \u2014 5 p.m., Fri: 9 a.m. \u2014 5 p.m., Sat: ClosedSun: Closed 2340 HAMPTON AVE In network\nCVS PHARMACY #04191 (314) 762-0752 View hoursMon: 9 a.m. \u2014 9 p.m., Tue: 9 a.m. \u2014 9 p.m., Wed: 9 a.m. \u2014 9 p.m., Thurs: 9 a.m. \u2014 9 p.m., Fri: 9 a.m. \u2014 9 p.m., Sat: 10 a.m. \u2014 5 p.m., Sun: 10 a.m. \u2014 5 p.m., 4100 GRAVOIS AVE In network\nWALGREENS #6166 (314) 773-1384 View hoursMon: 9 a.m. \u2014 9 p.m., Tue: 9 a.m. \u2014 9 p.m., Wed: 9 a.m. \u2014 9 p.m., Thurs: 9 a.m. \u2014 9 p.m., Fri: 9 a.m. \u2014 9 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 3822 S KINGSHIGHWAY BLVD In network\nPHARMERICA #933 (314) 473-1340 View hoursMon: 9 a.m. \u2014 6 p.m., Tue: 9 a.m. \u2014 6 p.m., Wed: 9 a.m. \u2014 6 p.m., Thurs: 9 a.m. \u2014 6 p.m., Fri: 9 a.m. \u2014 6 p.m., Sat: 9 a.m. \u2014 2 p.m., Sun: 9 a.m. \u2014 2 p.m., 105 ARC DR In network\nWALGREENS #9481 (314) 434-4224 Open now: 8 a.m. \u2014 10 p.m.Mon: 8 a.m. \u2014 10 p.m., Tue: 8 a.m. \u2014 10 p.m., Wed: 8 a.m. \u2014 10 p.m., Thurs: 8 a.m. \u2014 10 p.m., Fri: 8 a.m. \u2014 10 p.m., Sat: 8 a.m. \u2014 10 p.m., Sun: 8 a.m. \u2014 10 p.m., 12509 DORSETT RD In network\nWALGREENS #16326 (314) 773-2767 View hoursMon: 9 a.m. \u2014 9 p.m., Tue: 9 a.m. \u2014 9 p.m., Wed: 9 a.m. \u2014 9 p.m., Thurs: 9 a.m. \u2014 9 p.m., Fri: 9 a.m. \u2014 9 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 2315 S KINGSHIGHWAY BLVD In network\nWALGREENS #7144 (314)", "doc_id": "11a593a4-999c-43ab-8c28-fb61beaeeab2", "embedding": null, "doc_hash": "c64947a1df52fac567f5b22303e7719faec1f63890931fa62064f2afbbdacc93", "extra_info": {"page_label": "1", "file_name": "Pharmacy List.pdf"}, "node_info": {"start": 6076, "end": 8026, "_node_type": "1"}, "relationships": {"1": "d760de93-214b-4af7-b40a-adf7d2d67808", "2": "e68a1a5e-0748-4a1c-8d95-148e642f09b8", "3": "667c4f0a-15e2-4ecd-af2c-b417ec276108"}}, "__type__": "1"}, "667c4f0a-15e2-4ecd-af2c-b417ec276108": {"__data__": {"text": "S KINGSHIGHWAY BLVD In network\nWALGREENS #7144 (314) 772-4446 Open now: 8 a.m. \u2014 10 p.m.Mon: 8 a.m. \u2014 10 p.m., Tue: 8 a.m. \u2014 10 p.m., Wed: 8 a.m. \u2014 10 p.m., Thurs: 8 a.m. \u2014 10 p.m., Fri: 8 a.m. \u2014 10 p.m., Sat: 8 a.m. \u2014 10 p.m., Sun: 8 a.m. \u2014 10 p.m., 3631 GRAVOIS AVE In network\nFAMILY CARE PHARMACY AT BARNES-JEWISH HOSPITAL (314) 657-9006 Please call pharmacy to confirm hours 1 BARNES JEWISH HOSPITAL PLZ In network\nWASHINGTON UNIVERSITY CANCER CENTER PHARMACY #005310 (314) 747-8646 Please call pharmacy to confirm hours 4921 PARKVIEW PLACE In network\nCVS PHARMACY #02376 (314) 535-1048 View hoursOPEN 24 HOURS7 DAYS A WEEK 3925 LINDELL BLVD In network\nCOMMUNITY, A WALGREENS PHARMACY #15311 (314) 454-6676 Please call pharmacy to confirm hours 115A N EUCLID AVE In network\nGATEWAY APOTHECARY (314) 381-1818 View hoursMon: 8 a.m. \u2014 8 p.m., Tue: 8 a.m. \u2014 8 p.m., Wed: 8 a.m. \u2014 8 p.m., Thurs: 8 a.m. \u2014 8 p.m., Fri: 8 a.m. \u2014 8 p.m., Sat: 9 a.m. \u2014 2 p.m., Sun: 9 a.m. \u2014 1 p.m., 4473 FOREST PARK AVE In network\nWALGREENS #4834 (314) 367-8211 View hoursMon: 9 a.m. \u2014 9 p.m., Tue: 9 a.m. \u2014 9 p.m., Wed: 9 a.m. \u2014 9 p.m., Thurs: 9 a.m. \u2014 9 p.m., Fri: 9 a.m. \u2014 9 p.m., Sat: 9 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 1225 UNION BLVD In network", "doc_id": "667c4f0a-15e2-4ecd-af2c-b417ec276108", "embedding": null, "doc_hash": "ef1666c54d14361a771855b0e1bb9a9bef32f48af5fd798e02521980d6de26c2", "extra_info": {"page_label": "1", "file_name": "Pharmacy List.pdf"}, "node_info": {"start": 8000, "end": 9234, "_node_type": "1"}, "relationships": {"1": "d760de93-214b-4af7-b40a-adf7d2d67808", "2": "11a593a4-999c-43ab-8c28-fb61beaeeab2"}}, "__type__": "1"}, "d3224ec5-4901-4e91-b952-b6b0d073ea07": {"__data__": {"text": "WALGREENS #21346 (314) 771-2900 View hoursMon: 9 a.m. \u2014 5 p.m., Tue: 9 a.m. \u2014 5 p.m., Wed: 9 a.m. \u2014 5 p.m., Thurs: 9 a.m. \u2014 5 p.m., Fri: 9 a.m. \u2014 5 p.m., Sat: ClosedSun: Closed 3527 CHOUTEAU AVE In network\nSSM CARDINAL GLENNON CHILDREN'S PHARMACY (314) 577-5677 View hoursMon: 8 a.m. \u2014 6 p.m., Tue: 8 a.m. \u2014 6 p.m., Wed: 8 a.m. \u2014 6 p.m., Thurs: 8 a.m. \u2014 6 p.m., Fri: 8 a.m. \u2014 6 p.m., Sat: ClosedSun: Closed 1465 S GRAND BLVD In network\nWALGREENS #6472 (314) 371-4286 View hoursOPEN 24 HOURS7 DAYS A WEEK 4218 LINDELL BLVD In network\nSSM HEALTH PHARMACY AT SAINT LOUIS UNIVERSITY HOSPITAL (314) 257-3450 View hoursMon: 8 a.m. \u2014 6 p.m., Tue: 8 a.m. \u2014 6 p.m., Wed: 8 a.m. \u2014 6 p.m., Thurs: 8 a.m. \u2014 6 p.m., Fri: 8 a.m. \u2014 6 p.m., Sat: 9 a.m. \u2014 1 p.m., Sun: Closed 1225 S GRAND BLVD In network\nBEVERLY HILLS PHARMACY (314) 381-8600 Please call pharmacy to confirm hours 7150 NATURAL BRIDGE RD In network\nWALGREENS #6254 (314) 382-9926 Open now: 8 a.m. \u2014 10 p.m.Mon: 8 a.m. \u2014 10 p.m., Tue: 8 a.m. \u2014 10 p.m., Wed: 8 a.m. \u2014 10 p.m., Thurs: 8 a.m. \u2014 10 p.m., Fri: 8 a.m. \u2014 10 p.m., Sat: 8 a.m. \u2014 6 p.m., Sun: 10 a.m. \u2014 6 p.m., 7199 NATURAL BRIDGE RD In network\nWALGREENS #2501 (314) 770-2479 View hoursOPEN 24 HOURS7 DAYS A WEEK 12345 ST CHARLES ROCK RD In network\nCHILDREN'S HOSPITAL SPECIALTY CARE CENTER SOUTH COUNTY PHARM #29 (314) 657-9009 View hoursMon: 6 a.m. \u2014 6 p.m., Tue: 6 a.m. \u2014 6 p.m., Wed: 6 a.m. \u2014 6 p.m., Thurs: 6 a.m. \u2014 6 p.m., Fri: 6 a.m. \u2014 6 p.m., Sat: ClosedSun: Closed 5114 MID AMERICA PLAZA Out of network", "doc_id": "d3224ec5-4901-4e91-b952-b6b0d073ea07", "embedding": null, "doc_hash": "bcb480fdd6e503eae1aaaaa379d87edb5ffc8ca61224c5935a3a441a6e01c9d5", "extra_info": {"page_label": "2", "file_name": "Pharmacy List.pdf"}, "node_info": {"start": 0, "end": 1517, "_node_type": "1"}, "relationships": {"1": "86da5c77-71b8-47b9-bae5-57fffbe0a8af"}}, "__type__": "1"}, "31943ac9-6514-4b11-9ab4-16ef93e5a8a5": {"__data__": {"text": "Y0040_PDG23_FINAL_43C_C 20230043PDG2349423C_v132023\nPrescription Drug Guide\nHumana Formulary\nList of covered drugs\nHumana Community (HMO-POS)\nHumana Gold Plus (HMO)\nHumana Gold Plus (HMO-POS)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION  \nABOUT THE DRUGS WE COVER IN THIS PLAN.\nThis formulary was updated on 06/05/2023. For more recent information or other questions, please contact \nHumana with any questions at 1-800-457-4708 or for TTY users, 711, five days a week April 1 \u2013 September  \n30 or seven days a week October 1 \u2013 March 31 from 8 a.m. - 8 p.m. Our automated phone system is  \navailable after hours, weekends, and holidays. Our website is also available 24 hours a day 7 days a week, by  \nvisiting Humana.com.\nImportant Message About What You Pay for Vaccines \u2013 Our plan covers most Part D vaccines at no cost to  \nyou, even if your plan has a deductible and you haven\u2019t paid it. Call Humana for more information. \nImportant Message About What You Pay for Insulin \u2013 You won\u2019t pay more than $35 for a one-month  \nsupply of each insulin product covered by our plan, no matter what cost-sharing tier it\u2019s on, even if your plan  \nhas a deductible and you haven\u2019t paid it. \nFor a complete list of Contract/PBP numbers this document relates to, please see the final page of this  \ndocument.", "doc_id": "31943ac9-6514-4b11-9ab4-16ef93e5a8a5", "embedding": null, "doc_hash": "b5f844885cd113c8f237da366133d4f71fad9c974d3b9a8379fa4b242f61f660", "extra_info": {"page_label": "1", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 1297, "_node_type": "1"}, "relationships": {"1": "3e5d6b6f-1e0b-4e2c-a720-28ce323585aa"}}, "__type__": "1"}, "9de2a99c-2c10-4b37-a263-35c612ac1909": {"__data__": {"text": "Blank Page", "doc_id": "9de2a99c-2c10-4b37-a263-35c612ac1909", "embedding": null, "doc_hash": "c6b4d5a42ea481c442ec96e7f9a144e910f85574415310b299577885cc96656c", "extra_info": {"page_label": "2", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 10, "_node_type": "1"}, "relationships": {"1": "9b4e637f-2b8d-4ed7-9771-0392df077484"}}, "__type__": "1"}, "ee022ded-f9e0-486d-9ca6-4f4bb618ec8b": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 3PDG026\nWelcome to Humana!\nNote to existing members: This formulary has changed since last year. Please review this document to make sure  \nthat it still contains the drugs you take. When this drug list (formulary) refers to \"we,\" \"us\", or \"our,\" it means  \nHumana. When it refers to \"plan\" or \"our plan,\" it means Humana. This document includes a list of the drugs  \n(formulary) for our plan which is current as of June 2023. For an updated formulary, please contact us on our  \nwebsite at Humana.com/PlanDocuments or you can call the number below to request a paper copy. Our contact  \ninformation, along with the date we last updated the formulary, appears on the front and back cover pages. You  \nmust generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy  \nnetwork, and/or copayments/coinsurance may change on January 1 of each year, and from time to time during  \nthe year.\nWhat is the Humana Medicare formulary? \nA formulary is the entire list of covered drugs or medicines selected by Humana. The terms formulary and Drug List  \nmay be used interchangeably throughout communications regarding changes to your pharmacy benefits.  \nHumana worked with a team of doctors and pharmacists to make a formulary that represents the prescription  \ndrugs we think you need for a quality treatment program. Humana will generally cover the drugs listed in the  \nformulary as long as the drug is medically necessary, the prescription is filled at a Humana network pharmacy, and  \nother plan rules are followed. For more information on how to fill your medicines, please review your Evidence of  \nCoverage. \nCan the formulary change?\nMost changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the \nyear, move them to different cost sharing tiers, or add new restrictions. We must follow Medicare rules in making \nthese changes. \nChanges that can affect you this year: In the below cases, you will be affected by coverage changes during the \nyear:\n\u2022New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with \na new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer \nrestrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug \nList, but immediately move it to a different cost sharing tier or add new restrictions. If you are currently taking \nthat brand name drug, we may not tell you in advance before we make that change, but we will later provide \nyou with information about the specific change(s) we have made.\n\u2013If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the \nbrand name drug for you. The notice we provide you will also include information on how to request an \nexception, and you can also find information in the section below titled \"How do I request an exception to the \nHumana Formulary?\"\n\u2022Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be \nunsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug \nfrom our formulary and provide notice to members who take the drug. \n\u2022Other changes. We may make other changes that affect members currently taking a drug. For instance, we \nmay add a generic drug that is not new to market to replace a brand name drug currently on the formulary or \nadd new restrictions to the brand name drug or move it to a different cost sharing tier or both. Or we may make \nchanges based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, \nquantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost sharing tier, we must \nnotify affected members of the change at least 30 days before the change becomes effective, or at the time the \nmember requests a refill of the drug, at which time", "doc_id": "ee022ded-f9e0-486d-9ca6-4f4bb618ec8b", "embedding": null, "doc_hash": "f5474c488d2260e6518f5e740b1f1fc1354c11b5c50f2e2b40976818994d31ba", "extra_info": {"page_label": "3", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 4022, "_node_type": "1"}, "relationships": {"1": "366ecee9-4ca8-4b22-b8f7-456109e0290b", "3": "ea1702f5-dc3b-4d0a-9a4d-0d05b3715831"}}, "__type__": "1"}, "ea1702f5-dc3b-4d0a-9a4d-0d05b3715831": {"__data__": {"text": "or at the time the \nmember requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.", "doc_id": "ea1702f5-dc3b-4d0a-9a4d-0d05b3715831", "embedding": null, "doc_hash": "0f4286f63f1fd150f35736cde0da46a938ada0fa3a8f5f2efabc80a7b6f5cb0b", "extra_info": {"page_label": "3", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 3951, "end": 4075, "_node_type": "1"}, "relationships": {"1": "366ecee9-4ca8-4b22-b8f7-456109e0290b", "2": "ee022ded-f9e0-486d-9ca6-4f4bb618ec8b"}}, "__type__": "1"}, "cbb34b17-31fa-46ca-8240-6701e936bb5c": {"__data__": {"text": "4 - 2023 HUMANA FORMULARY UPDATED 06/2023We will notify members who are affected by the following changes to the formulary:\n\u2022When a drug is removed from the formulary\n\u2022When prior authorization, quantity limits, or step-therapy restrictions are added to a drug or made more  \nrestrictive\n\u2022When a drug is moved to a higher cost sharing tier\nIf we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the \nbrand name drug for you. The notice we provide you will also include information on how to request an exception, \nand you can also find information in the section below titled \"How do I request an exception to the Humana \nFormulary?\"\nChanges that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our \n2023 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the \ndrug during the 2023 coverage year except as described above. This means these drugs will remain available at \nthe same cost sharing and with no new restrictions for those members taking them for the remainder of the \ncoverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 \nof the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year \nfor any changes to drugs.\nWhat if you are affected by a Drug List change?\nWe will notify you by mail at least 30 days before one of these changes happens or we will provide a 30-day refill of \nthe affected medicine with notice of the change. \nThe enclosed formulary is current as of June 2023. We will update the printed formularies each month and they \nwill be available on Humana.com/medicaredruglist.\nTo get updated information about the drugs that Humana covers, please visit Humana.com/medicaredruglist.  \nThe Drug List Search tool lets you search for your drug by name or drug type.\nPlease contact Humana Customer Care with any questions at 1-800-457-4708 (TTY: 711), five days a week April  \n1- September 30 or seven days a week October 1 \u2013 March 31 from 8 a.m. \u2013 8 p.m. (EST). Our automated phone  \nsystem is available after hours, weekends, and holidays. Our website is also available 24 hours a day 7 days a  \nweek, by visiting Humana.com.\nHow do I use the formulary? \nThere are two ways to find your drug in the formulary:\nMedical condition\nthat they are used to treat. For example, drugs that treat a heart condition are listed under the category  \n\"Cardiovascular Agents.\" If you know what medical condition your drug is used for, look for the category name in \nManagement Requirements).\nAlphabetical listing\nIndex is an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic  \ndrugs are listed. Look in the Index to search for your drug. Next to each drug, you will see the page number where  \nyou can find coverage information. Turn to the page listed in the Index and find the name of the drug in the first  \ncolumn of the list. The formulary starts on page 11. We have put the drugs into groups depending on the type of medical conditions \nthe list that begins on page 11. Then look under the category name for your drug. The formulary also lists the Tier \nand Utilization Management Requirements for each drug (see page 5 for more information on Utilization \nIf you are not sure about your drug's group, you should look for your drug in the Index that begins on page 107. The ", "doc_id": "cbb34b17-31fa-46ca-8240-6701e936bb5c", "embedding": null, "doc_hash": "af3bd5a37ec594c664d20f6effc80ad60d85b0989d576aa47b38f03bf9da192a", "extra_info": {"page_label": "4", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 3506, "_node_type": "1"}, "relationships": {"1": "7fbe6697-faf5-4478-b277-a0bb3168ebb5"}}, "__type__": "1"}, "60ee3c0e-fd55-4305-bfa0-7f12a9ba1db3": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 5Prescription drugs are grouped into one of five tiers. \nHumana covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the  \nsame active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.\n\u2022Tier 1 - Preferred Generic: Generic or brand drugs that are available at the lowest cost share for the plan\n\u2022Tier 2 - Generic: Generic or brand drugs that the plan offers at a higher cost to you than Tier 1 Preferred Generic  \ndrugs\n\u2022Tier 3 - Preferred Brand: Generic or brand drugs that the plan offers at a lower cost to you than Tier 4  \nNon-Preferred drugs \n\u2022Tier 4 - Non-Preferred Drug: Generic or brand drugs that the plan offers at a higher cost to you than Tier 3  \nPreferred Brand drugs\n\u2022Tier 5 - Specialty Tier: Some injectables and other high-cost drugs\nHow much will I pay for covered drugs? \nHumana pays part of the costs for your covered drugs and you pay part of the costs, too. \nThe amount of money you pay depends on:\n\u2022Which tier your drug is on\n\u2022Whether you fill your prescription at a network pharmacy\n\u2022Your current drug payment stage - please read your Evidence of Coverage (EOC) for more information\nIf you qualified for extra help with your drug costs, your costs may be different from those described above.  \nPlease refer to your Evidence of Coverage (EOC) or call Customer Care to find out what your costs are.\nAre there any restrictions on my coverage? \nSome covered drugs may have additional requirements or limits on coverage. These are called Utilization  \nManagement Requirements. These requirements and limits may include: \n\u2022Prior Authorization (PA): Humana requires you to get prior authorization for certain drugs to be covered under  \nyour plan. This means that you will need to get approval from Humana before you fill your prescriptions. If you  \ndo not get approval, Humana may not cover the drug. \n\u2022Quantity Limits (QL): For some drugs, Humana limits the amount of the drug that is covered. Humana might  \nlimit how many refills you can get or how much of a drug you can get each time you fill your prescription. For  \nexample, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage  \nfor your prescription to no more than one pill per day. Some drugs are limited to a 30-day supply regardless of  \ntier placement. \n\u2022Step Therapy (ST): In some cases, Humana requires that you first try certain drugs to treat your medical  \ncondition before coverage is available for another drug for that condition. For example, if Drug A and Drug B  \nboth treat your medical condition, Humana may not cover Drug B unless you try Drug A first. If Drug A does not  \nwork for you, Humana will then cover Drug B. \n\u2022Part B versus Part D (B vs D): Some drugs may be covered under Medicare Part B or Part D depending upon the  \ncircumstances. Information may need to be submitted to Humana that describes the use and the place where  \nyou receive and take the drug so a determination can be made.\nFor drugs that need prior authorization or step therapy, or drugs that fall outside of quantity limits, your health care  \nprovider can fax information about your condition and need for those drugs to Humana at 1-877-486-2621.  \nRepresentatives are available Monday - Friday, 8 a.m. - 8 p.m. (EST).", "doc_id": "60ee3c0e-fd55-4305-bfa0-7f12a9ba1db3", "embedding": null, "doc_hash": "aaa8e505b6635f0b0eef32ba5f73425ac437e7797813f0e7100d5be0ee12bc22", "extra_info": {"page_label": "5", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 3374, "_node_type": "1"}, "relationships": {"1": "d64b618a-a2a8-46f9-838e-341c9ab91b2a"}}, "__type__": "1"}, "0d5afc54-41b0-47d4-b93f-d90cf5bf1b9d": {"__data__": {"text": "6 - 2023 HUMANA FORMULARY UPDATED 06/2023Insulin Savings Program\nYour plan participates in the Insulin Savings Program which provides affordable, predictable copayments for Select  \nInsulins through the first three drug payment stages (Deductible (if applicable), Initial Coverage, and Coverage  \nGap) of the Part D benefit.  To find out more about the Insulin Savings Program, visit Humana.com/insulin or refer  \nto your Evidence of Coverage for additional details. \n  \nTo identify which Select Insulins are included within in the Insulin Savings Program, look for the ISP indicator in the  \nUtilization Management column.\nYou can find out if your drug has any additional requirements or limits by looking in the formulary that begins on \npage 11. \nYou can also visit Humana.com/medicaredruglist to get more information about the restrictions applied to  \nspecific covered drugs.\nYou can ask Humana to make an exception to these restrictions or limits. See the section \"How do I request an \nexception to the formulary?\" on page 7 for information about how to request an exception. \nWhat if my drug is not on the formulary? \nIf your drug is not included in this list of covered drugs, visit Humana.com/medicaredruglist to see if your plan  \ncovers your drug. You can also call Customer Care and ask if your drug is covered. \nIf Humana does not cover your drug, you have two options: \n\u2022You can ask Customer Care for a list of similar drugs that Humana covers. Show the list to your doctor and ask  \nhim or her to prescribe a similar drug that is covered by Humana. \n\u2022You can ask Humana to make an exception and cover your drug. See below for information about how to  \nrequest an exception.\nTalk to your health care provider to decide if you should switch to another drug that is covered or if you should  \nrequest a formulary exception so that it can be considered for coverage.\nWhat is a compounded drug? \nA compounded drug is used to provide drug therapies that are not commercially available as FDA-approved  \nfinished products in the same dose, formulation, and/or combination of ingredients, but are instead created by a  \npharmacist by combining or mixing ingredients to create a prescription medication customized to the needs of an  \nindividual patient. While some compounded drugs may be Part D eligible, most compounded drugs are  \nnon-formulary drugs (not covered) by your plan. You may need to ask for and receive an approved coverage  \ndetermination from us to have your compounded drug covered.", "doc_id": "0d5afc54-41b0-47d4-b93f-d90cf5bf1b9d", "embedding": null, "doc_hash": "a82a81a7e5b33c0c72e3d1dd647942cf38ac9842e39f0369f5990d46045aad76", "extra_info": {"page_label": "6", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2508, "_node_type": "1"}, "relationships": {"1": "997cda37-ca5e-4fe1-ada1-76db62fd55eb"}}, "__type__": "1"}, "a242925b-5711-452d-bdb7-8ef423133aa4": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 7How do I request an exception to the Humana formulary? \nYou can ask Humana to make an exception to the coverage rules. There are several types of exceptions that you  \ncan ask to be made. \n\u2022Formulary exception: You can request that your drug be covered if it is not on the formulary. If approved, this  \ndrug will be covered at a pre-determined cost sharing level, and you would not be able to ask us to provide the  \ndrug at a lower cost sharing level.\n\u2022Utilization restriction exception: You can request coverage restrictions or limits not be applied to your drug.  \nFor example, if your drug has a quantity limit, you can ask for the limit not to be applied and to cover more doses  \nof the drug.\n\u2022Tier exception: You can request a higher level of coverage for your drug. For example, if your drug is usually  \nconsidered a non-preferred drug, you can request it to be covered as a preferred drug instead. This would lower  \nhow much money you must pay for your drug. Please remember a higher level of coverage cannot be requested  \nfor the drug if approval was granted to cover a drug that was not on the formulary. You can ask us to cover a  \nformulary drug at a lower cost-sharing level, unless the drug is on the specialty tier.\nGenerally, Humana will only approve your request for an exception if the alternative drugs included on the plan's  \nformulary, the lower cost sharing drug, or other restrictions would not be as effective in treating your health  \ncondition and/or would cause adverse medical effects. \nYou should contact us to ask for an initial coverage decision for a formulary, tier, or utilization restriction exception.\nWhen you ask for an exception, you should submit a statement from your health care provider that\nsupports your request. This is called a supporting statement. \nGenerally, we must make the decision within 72 hours of receiving your health care provider's supporting  \nstatement. You can request a fast, or expedited, exception if you or your health care provider thinks your health  \nwould seriously suffer if you wait as long as 72 hours for a decision. If your request to expedite is granted, we must  \ngive you a decision no later than 24 hours after we receive your health care provider's supporting statement. \nWill my plan cover my drugs if they are not on the formulary? \nYou may take drugs that your plan does not cover. Or you may talk to your provider about taking a different drug \nthat your plan covers, but that drug might have a Utilization Management Requirement, such as a Prior \nAuthorization or Step Therapy, that keeps you from getting the drug right away. In certain cases, we may cover as \nmuch as a 30-day supply of your drug during the first 90 days you are a member of the plan. \nHere is what we will do for each of your current Part D drugs that are not on the formulary, or if you have limited \nability to get your drugs:\n\u2022We will temporarily cover a 30-day supply of your drug unless you have a prescription written for fewer days (in \nwhich case we will allow multiple fills to provide up to a total of 30 days of a drug) when you go to a pharmacy.\n\u2022There will be no coverage for the drugs after your first 30-day supply, even if you have been a member of the \nplan for less than 90 days, unless a formulary exception has been approved.\nIf you are a resident of a long-term care facility and you take Part D drugs that are not on the formulary, we will \ncover a 31-day supply unless you have a prescription written for fewer days (in which case we will allow multiple \nfills to provide up to a total of 31 days of a drug) during the first 90 days you are a member of our plan. We will \ncover a 31-day emergency supply of your drug unless you have a prescription for fewer days (in which we will \nallow multiple fills to provide up to a total of 31 days of a drug) while you request a formulary exception if:\n\u2022You need a drug that is not", "doc_id": "a242925b-5711-452d-bdb7-8ef423133aa4", "embedding": null, "doc_hash": "f715e45e04083e39ce660f99cb6ea62b54b6d4455fbd60e89470c8d597706828", "extra_info": {"page_label": "7", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 3948, "_node_type": "1"}, "relationships": {"1": "fd51257b-dff5-4081-928f-3230efea4245", "3": "2686860a-77d9-42cc-9786-d490cd244a94"}}, "__type__": "1"}, "2686860a-77d9-42cc-9786-d490cd244a94": {"__data__": {"text": "while you request a formulary exception if:\n\u2022You need a drug that is not on the formulary or\n\u2022You have limited ability to get your drugs and\n\u2022You are past the first 90 days of membership in the plan\nThroughout the plan year, your treatment setting (the place where you receive and take your medicine) may \nchange. These changes include: \n\u2022Members who are discharged from a hospital or skilled-nursing facility to a home setting", "doc_id": "2686860a-77d9-42cc-9786-d490cd244a94", "embedding": null, "doc_hash": "2f756e53d85b51062257d5b17442a25fc300f4ac89cda76f648c0c572d121b20", "extra_info": {"page_label": "7", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 3876, "end": 4303, "_node_type": "1"}, "relationships": {"1": "fd51257b-dff5-4081-928f-3230efea4245", "2": "a242925b-5711-452d-bdb7-8ef423133aa4"}}, "__type__": "1"}, "16de8c9f-3aba-4328-a7dc-1c84c4339618": {"__data__": {"text": "8 - 2023 HUMANA FORMULARY UPDATED 06/2023\u2022Members who are admitted to a hospital or skilled-nursing facility from a home setting\n\u2022Members who transfer from one skilled-nursing facility to another and use a different pharmacy\n\u2022Members who end their skilled-nursing facility Medicare Part A stay (where payments include all pharmacy \ncharges) and who now need to use their Part D plan benefit\n\u2022Members who give up Hospice Status and go back to standard Medicare Part A and B coverage\n\u2022Members discharged from chronic psychiatric hospitals with highly individualized drug regimens\nFor these changes in treatment settings, Humana will cover as much as a 31-day temporary supply of a Part \nD-covered drug when you fill your prescription at a pharmacy. If you change treatment settings multiple times \nwithin the same month, you may have to request an exception or prior authorization and receive approval for \ncontinued coverage of your drug. Humana will review requests for continuation of therapy on a case-by-case basis \nunderstanding when you are on a stabilized drug regimen that, if changed, is known to have risks.\nTransition extension\nHumana will consider on a case-by-case basis an extension of the transition period if your exception request or  \nappeal has not been processed by the end of your initial transition period. We will continue to provide necessary  \ndrugs to you if your transition period is extended.\nA Transition Policy is available on Humana's Medicare website, Humana.com, in the same area where the  \nPrescription Drug Guides are displayed.\nCenterWell Pharmacy\u2122\nYou may fill your medicines at any network pharmacy. CenterWell Pharmacy \u2013 Humana's mail-delivery pharmacy  \nis one option. CenterWell Pharmacy is the preferred cost-sharing mail order pharmacy for many Humana MAPD  \nand prescription drug plans (PDP). You can have your maintenance medicines, specialty medicines, or supplies  \nmailed to a place that is most convenient for you. You should get your new prescription by mail in 7 \u2013 10 days after  \nCenterWell Pharmacy has received your prescription and all the necessary information. Refills should arrive within  \n5 \u2013 7 days. To get started or learn more, visit CenterWellpharmacy.com. You can also call CenterWell Pharmacy at \n1-844-222-2151 (TTY: 711) Monday \u2013 Friday, 8 a.m. to 11 p.m. (EST), and Saturday, 8 a.m. to 6:30 p.m. (EST).\nOther pharmacies are available in our network.", "doc_id": "16de8c9f-3aba-4328-a7dc-1c84c4339618", "embedding": null, "doc_hash": "aed2d7ef301c568dc6961ac9c2e78c56bea638d1cf678c79626cb9645b847ee2", "extra_info": {"page_label": "8", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2418, "_node_type": "1"}, "relationships": {"1": "e0c9b6c8-d5cb-4e66-bd49-8a7cdb6d9899"}}, "__type__": "1"}, "58b89eb8-874d-41a6-bfa2-38ba2dae3742": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 9For More Information\n  \nFor more detailed information about your Humana prescription drug coverage, please read your Evidence of  \nCoverage (EOC) and other plan materials. \nPlease contact Humana Customer Care with any questions at 1-800-457-4708 (TTY: 711), five days a week April 1  \n\u2013 September 30 or seven days a week October 1 \u2013 March 31 from 8 a.m. \u2013 8 p.m. (EST). Our automated phone  \nsystem is available after hours, weekends, and holidays. Our website is also available 24 hours a day 7 days a  \nweek, by visiting Humana.com.\nIf you have general questions about Medicare prescription drug coverage, please call Medicare at \n1-800-MEDICARE (1-800-633-4227) 24 hours a day, seven days a week. TTY users should call 1-877-486-2048.  \nYou can also visit www.medicare.gov.", "doc_id": "58b89eb8-874d-41a6-bfa2-38ba2dae3742", "embedding": null, "doc_hash": "3a8f3188f32a0b2b68832450967503549a56cc55cd1dca1fb073f7ca668095be", "extra_info": {"page_label": "9", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 817, "_node_type": "1"}, "relationships": {"1": "46ef5e97-65f4-4374-8a40-20991775651c"}}, "__type__": "1"}, "7207c704-40a1-4b59-803a-2fee1f146691": {"__data__": {"text": "10 - 2023 HUMANA FORMULARY UPDATED 06/2023Humana Formulary\n  \nThe formulary that begins on the next page provides coverage information about the drugs covered by Humana. If \nyou have trouble finding your drug in the list, turn to the Index that begins on page 107.\nYour Humana plan has additional coverage of some drugs. These drugs are not normally covered under Medicare \nPart D and are not subject to the Medicare appeals process. These drugs are listed separately on page 106.\nHow to read your formulary\nThe first column of the chart lists categories of medical conditions in alphabetical order. The drug names are then  \nlisted in alphabetical order within each category. Brand-name drugs are CAPITALIZED and generic drugs are listed  \nin lower-case italics. Next to the drug name or Utilization Management column, you may see an indicator to tell  \nyou about additional coverage information for that drug. You might see the following indicators:\nGC - Tier 1 or Tier 2 drugs that are covered in the gap\nDL - Dispensing Limit; Drugs that may be limited to a 30 day supply, regardless of tier placement.\nMO - Drugs that are typically available through mail-order. Please contact your mail-order pharmacy to make sure  \nyour drug is available.\nLA - Limited Access; The health plan has authorized certain pharmacies to dispense this medicine, as it requires  \nextra handling, doctor coordination or patient education.  Please call the number on the back of your ID card for  \nadditional information.\nThe third column shows the Utilization Management Requirements for the drug. Humana may have special  \nrequirements for covering that drug. If the column is blank, then there are no utilization requirements for that drug.  \nThe supply for each drug is based on benefits and whether your health care provider prescribes a supply for 30, 60,  \nor 90 days. The amount of any quantity limits will also be in this column (Example: \"QL - 30 for 30 days\" means you The second column lists the tier of the drug. See page 5 for more details on the drug tiers in your plan. \ncan only get 30 doses every 30 days). See page 5 for more information about these requirements.", "doc_id": "7207c704-40a1-4b59-803a-2fee1f146691", "embedding": null, "doc_hash": "9371e2e345192cff075d520878896202c801b3409ceeeed28a25612284266cd8", "extra_info": {"page_label": "10", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2161, "_node_type": "1"}, "relationships": {"1": "ca032878-3313-4906-8fa7-092cb864d91b"}}, "__type__": "1"}, "f03f1576-0741-4693-968f-cf4a2b80dab6": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 11Formulary Start Cross Reference \nDRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.ANALGESICS\nacetaminophen-codeine 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300  \nmg-30 mg /12.5 ml SOLUTION DL3 QL(2700 per 30 days) \nacetaminophen-codeine 300-15 mg TABLET DL 3 QL(390 per 30 days) \nacetaminophen-codeine 300-30 mg TABLET DL 3 QL(360 per 30 days) \nacetaminophen-codeine 300-60 mg TABLET DL 3 QL(180 per 30 days) \nBELBUCA 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900  \nMCG FILM DL4 QL(60 per 30 days) \nbuprenorphine 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5  \nmcg/hour PATCH, WEEKLY DL4 QL(4 per 28 days) \ncelecoxib 100 mg, 200 mg CAPSULE GC,MO 2 QL(60 per 30 days) \ncelecoxib 400 mg, 50 mg CAPSULE GC,MO 2 QL(60 per 30 days) \ndiclofenac epolamine 1.3 % PATCH, 12 HR. MO 4 PA,QL(60 per 30 days) \ndiclofenac sodium 1 % GEL MO 3 QL(1000 per 30 days) \ndiclofenac sodium 100 mg TABLET, ER 24 HR. GC,MO 2  \ndiclofenac sodium 25 mg TABLET, DR/EC MO 3  \ndiclofenac sodium 50 mg TABLET, DR/EC GC,MO 2  \ndiclofenac sodium 75 mg TABLET, DR/EC GC,MO 2  \ndiclofenac-misoprostol 50-200 mg-mcg, 75-200 mg-mcg TABLET, IR, DR,  \nBIPHASIC MO4  \nec-naproxen 500 mg TABLET, DR/EC GC,MO 1  \nendocet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg TABLET DL 3 QL(360 per 30 days) \netodolac 200 mg, 300 mg CAPSULE MO 3  \netodolac 400 mg, 500 mg TABLET MO 3  \netodolac 400 mg, 500 mg, 600 mg TABLET, ER 24 HR. MO 4  \nfentanyl 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5  \nmcg/hour, 75 mcg/hr, 87.5 mcg/hour PATCH. 72 HR. DL4 QL(20 per 30 days) \nfentanyl citrate 1,200 mcg, 1,600 mcg, 400 mcg, 600 mcg, 800 mcg LOZENGE \nDL5 PA,QL(120 per 30 days) \nfentanyl citrate 200 mcg LOZENGE DL 4 PA,QL(120 per 30 days) \nfentanyl citrate (pf) 50 mcg/ml SOLUTION DL 4 BvsD,QL(720 per 30 days) \nflurbiprofen 100 mg TABLET GC,MO 2  \nhydrocodone-acetaminophen 10-300 mg, 5-300 mg, 7.5-300 mg TABLET DL 3 QL(390 per 30 days) \nhydrocodone-acetaminophen 10-325 mg, 5-325 mg, 7.5-325 mg TABLET DL 3 QL(360 per 30 days) \nhydrocodone-acetaminophen 10-325 mg/15 ml(15 ml) SOLUTION DL", "doc_id": "f03f1576-0741-4693-968f-cf4a2b80dab6", "embedding": null, "doc_hash": "41752b537b805b5a40d8fbfb311c2712f825e87f82537480cbc44ad1caa3da9d", "extra_info": {"page_label": "11", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2523, "_node_type": "1"}, "relationships": {"1": "98f431f6-a2e7-49c3-a058-19f508d4a697", "3": "9863c3a4-6838-42da-94ad-83f2a407a015"}}, "__type__": "1"}, "9863c3a4-6838-42da-94ad-83f2a407a015": {"__data__": {"text": "DL 4 QL(2700 per 30 days) \nhydrocodone-acetaminophen 2.5-325 mg TABLET DL 3 QL(360 per 30 days) \nhydrocodone-acetaminophen 7.5-325 mg/15 ml SOLUTION DL 4 QL(5520 per 30 days) ", "doc_id": "9863c3a4-6838-42da-94ad-83f2a407a015", "embedding": null, "doc_hash": "5167986a462f480e34482e6cd1f30fcd8dcb7cc4d91b6e4a64c8c68042ae1408", "extra_info": {"page_label": "11", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2521, "end": 2696, "_node_type": "1"}, "relationships": {"1": "98f431f6-a2e7-49c3-a058-19f508d4a697", "2": "f03f1576-0741-4693-968f-cf4a2b80dab6"}}, "__type__": "1"}, "85a31859-f378-4f6b-8506-7b862f739090": {"__data__": {"text": "12 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.hydrocodone-ibuprofen 10-200 mg, 5-200 mg TABLET DL 4 QL(150 per 30 days) \nhydrocodone-ibuprofen 7.5-200 mg TABLET DL 3 QL(150 per 30 days) \nhydromorphone 2 mg, 4 mg TABLET DL 3 QL(360 per 30 days) \nhydromorphone 2 mg/ml SOLUTION DL 4 BvsD,QL(360 per 30 days) \nhydromorphone 8 mg TABLET DL 3 QL(240 per 30 days) \nibu 400 mg, 600 mg, 800 mg TABLET GC,MO 1  \nibuprofen 100 mg/5 ml SUSPENSION GC,MO 2  \nibuprofen 400 mg TABLET GC,MO 1  \nibuprofen 600 mg, 800 mg TABLET GC,MO 1  \nindomethacin 25 mg, 50 mg CAPSULE GC,MO 2  \nindomethacin 75 mg CAPSULE, ER GC,MO 2  \nketorolac 10 mg TABLET GC,MO 2 QL(20 per 30 days) \nmeloxicam 15 mg TABLET GC,MO 1 QL(30 per 30 days) \nmeloxicam 7.5 mg TABLET GC,MO 1 QL(60 per 30 days) \nmethadone 10 mg TABLET DL 3 QL(240 per 30 days) \nmethadone 10 mg/5 ml SOLUTION DL 3 QL(1800 per 30 days) \nmethadone 10 mg/ml CONCENTRATE DL 3 QL(360 per 30 days) \nmethadone 10 mg/ml SOLUTION DL 3 QL(360 per 30 days) \nmethadone 5 mg TABLET DL 3 QL(480 per 30 days) \nmethadone 5 mg/5 ml SOLUTION DL 3 QL(3600 per 30 days) \nmethadone intensol 10 mg/ml CONCENTRATE DL 3 QL(360 per 30 days) \nmorphine 10 mg/5 ml SOLUTION DL 3 QL(2700 per 30 days) \nmorphine 10 mg/ml SOLUTION DL 4 BvsD,QL(360 per 30 days) \nmorphine 100 mg TABLET ER DL 3 QL(180 per 30 days) \nmorphine 15 mg TABLET ER DL 3 QL(120 per 30 days) \nmorphine 15 mg, 30 mg TABLET DL 3 QL(180 per 30 days) \nmorphine 20 mg/5 ml (4 mg/ml) SOLUTION DL 3 QL(1350 per 30 days) \nmorphine 200 mg TABLET ER DL 3 QL(90 per 30 days) \nmorphine 30 mg, 60 mg TABLET ER DL 3 QL(120 per 30 days) \nmorphine concentrate 100 mg/5 ml (20 mg/ml) SOLUTION DL 3 QL(540 per 30 days) \nnabumetone 500 mg, 750 mg TABLET GC,MO 1  \nnaproxen 250 mg, 375 mg TABLET GC,MO 1  \nnaproxen 375 mg, 500 mg TABLET, DR/EC GC,MO 1  \nnaproxen 500 mg TABLET GC,MO 1  \nnaproxen sodium 275 mg, 550 mg TABLET MO 4  \nnaproxen sodium 375 mg TABLET, ER 24 HR., MULTIPHASE MO 4 ST,QL(120 per 30 days) ", "doc_id": "85a31859-f378-4f6b-8506-7b862f739090", "embedding": null, "doc_hash": "a0774ad70925cf3e3addef8c9dfeba92514a739d56bfb15bce1a955dbef54bad", "extra_info": {"page_label": "12", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2414, "_node_type": "1"}, "relationships": {"1": "10ba02cc-f43d-45ad-8b0a-627c37976ecd"}}, "__type__": "1"}, "9078ea14-2971-43c7-a15c-322715ab7c0a": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 13DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.naproxen sodium 500 mg TABLET, ER 24 HR., MULTIPHASE MO 4 ST,QL(90 per 30 days) \nnaproxen sodium 750 mg TABLET, ER 24 HR., MULTIPHASE MO 4 ST,QL(60 per 30 days) \noxycodone 10 mg, 15 mg, 5 mg TABLET DL 3 QL(360 per 30 days) \noxycodone 20 mg, 30 mg TABLET DL 3 QL(360 per 30 days) \noxycodone 20 mg/ml CONCENTRATE DL 4 QL(270 per 30 days) \noxycodone 5 mg CAPSULE DL 4 QL(360 per 30 days) \noxycodone 5 mg/5 ml SOLUTION DL 4 QL(5400 per 30 days) \noxycodone-acetaminophen 10-325 mg, 5-325 mg, 7.5-325 mg TABLET DL 3 QL(360 per 30 days) \noxycodone-acetaminophen 2.5-325 mg TABLET DL 3 QL(360 per 30 days) \noxycodone-acetaminophen 5-325 mg/5 ml SOLUTION DL 4 QL(1800 per 30 days) \noxycodone-aspirin 4.8355-325 mg TABLET DL 3 QL(360 per 30 days) \npiroxicam 10 mg, 20 mg CAPSULE MO 3  \nsulindac 150 mg, 200 mg TABLET GC,MO 2  \ntramadol 100 mg TABLET DL 4 QL(120 per 30 days) \ntramadol 100 mg, 200 mg, 300 mg TABLET, ER 24 HR. DL 3 ST,QL(30 per 30 days) \ntramadol 100 mg, 200 mg, 300 mg TABLET, ER 24 HR., MULTIPHASE DL 3 ST,QL(30 per 30 days) \ntramadol 50 mg TABLET DL,GC 2 QL(240 per 30 days) \ntramadol-acetaminophen 37.5-325 mg TABLET DL,GC 2 QL(240 per 30 days) \nXTAMPZA ER 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG CAPSULE ER SPRINKLE 12  \nHR. DL3 QL(60 per 30 days) \nANESTHETICS\nbupivacaine (pf) 0.25 % (2.5 mg/ml), 0.5 % (5 mg/ml), 0.75 % (7.5 mg/ml)  \nSOLUTION GC,MO1  \nbupivacaine hcl 0.25 % (2.5 mg/ml), 0.5 % (5 mg/ml) SOLUTION GC,MO 1  \nlidocaine 5 % ADHESIVE PATCH, MEDICATED MO 4 PA,QL(90 per 30 days) \nlidocaine  (pf) in d7.5w 50 mg/ml (5 %) SOLUTION GC,MO 1  \nlidocaine hcl 2 % JELLY MO 3  \nlidocaine hcl 2 % JELLY IN APPLICATOR MO 3  \nlidocaine hcl 2 % SOLUTION GC,MO 2  \nlidocaine viscous 2 % SOLUTION GC,MO 2  \nlidocaine-epinephrine 0.5 %-1:200,000, 1 %-1:100,000, 2 %-1:100,000  \nSOLUTION GC,MO2  \nlidocaine-prilocaine 2.5-2.5 % CREAM MO 4  \npolocaine 1 % (10 mg/ml), 2 % SOLUTION GC,MO 1  ", "doc_id": "9078ea14-2971-43c7-a15c-322715ab7c0a", "embedding": null, "doc_hash": "7ab42f325ed04b0114fc0e0e8de5c95adae802199584453235bc37f3acc400bd", "extra_info": {"page_label": "13", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2387, "_node_type": "1"}, "relationships": {"1": "ed6f8eaa-232d-4db1-a407-3f2b9204740e"}}, "__type__": "1"}, "e55a28d6-15d3-4010-8762-e2b7056e5b83": {"__data__": {"text": "14 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.polocaine-mpf 10 mg/ml (1 %), 15 mg/ml (1.5 %), 20 mg/ml (2 %) SOLUTION \nGC,MO1  \nropivacaine (pf) 10 mg/ml (1 %), 2 mg/ml (0.2 %), 5 mg/ml (0.5 %), 7.5 mg/ml  \n(0.75 %) SOLUTION MO4  \nANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS\nacamprosate 333 mg TABLET, DR/EC MO 4  \nbuprenorphine hcl 2 mg, 8 mg SUBLINGUAL TABLET GC,MO 2 QL(90 per 30 days) \nbuprenorphine-naloxone 12-3 mg FILM GC,MO 2 QL(60 per 30 days) \nbuprenorphine-naloxone 2-0.5 mg, 4-1 mg, 8-2 mg FILM GC,MO 2 QL(90 per 30 days) \nbupropion hcl (smoking deter) 150 mg TABLET, ER 12 HR. MO 3 QL(90 per 30 days) \ndisulfiram 250 mg, 500 mg TABLET MO 3  \nnalmefene 1 mg/ml SOLUTION GC,MO 1  \nnaloxone 0.4 mg/ml SOLUTION GC,MO 1  \nnaloxone 0.4 mg/ml, 1 mg/ml SYRINGE GC,MO 1  \nnaloxone 4 mg/actuation SPRAY, NON-AEROSOL MO 3 QL(2 per 30 days) \nnaltrexone 50 mg TABLET GC,MO 2  \nNICOTROL NS 10 MG/ML SPRAY, NON-AEROSOL MO 4  \nvarenicline 0.5 mg (11)- 1 mg (42) TABLET, DOSE PACK MO 3 QL(53 per 28 days) \nvarenicline 0.5 mg, 1 mg TABLET MO 3 QL(56 per 28 days) \nVIVITROL 380 MG SUSPENSION, ER, RECON DL 5 QL(1 per 28 days) \nZUBSOLV 0.7-0.18 MG, 1.4-0.36 MG SUBLINGUAL TABLET GC,MO 2 QL(90 per 30 days) \nZUBSOLV 11.4-2.9 MG SUBLINGUAL TABLET GC,MO 2 QL(30 per 30 days) \nZUBSOLV 2.9-0.71 MG, 5.7-1.4 MG SUBLINGUAL TABLET GC,MO 2 QL(90 per 30 days) \nZUBSOLV 8.6-2.1 MG SUBLINGUAL TABLET GC,MO 2 QL(60 per 30 days) \nANTIBACTERIALS\nacetic acid 2 % SOLUTION GC,MO 2  \namikacin 1,000 mg/4 ml, 500 mg/2 ml SOLUTION MO 4  \namoxicillin 125 mg, 250 mg CHEWABLE TABLET GC,MO 1  \namoxicillin 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml  \nSUSPENSION FOR RECONSTITUTION GC,MO1  \namoxicillin 250 mg CAPSULE GC,MO 1  \namoxicillin 500 mg CAPSULE GC,MO 1  \namoxicillin 500 mg TABLET GC,MO 1  \namoxicillin 875 mg TABLET GC,MO 1  \namoxicillin-pot clavulanate 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57  \nmg/5 ml, 600-42.9 mg/5 ml SUSPENSION FOR RECONSTITUTION MO3  ", "doc_id": "e55a28d6-15d3-4010-8762-e2b7056e5b83", "embedding": null, "doc_hash": "c4080345ce4122aec06a58851e29912242f7a926ffd691eaa69160240fafff6e", "extra_info": {"page_label": "14", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2401, "_node_type": "1"}, "relationships": {"1": "12566ae1-6c1d-4d53-83dd-9f8a92cd589d"}}, "__type__": "1"}, "869779ab-6817-41b3-a233-3d14f8c8e7ac": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 15DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.amoxicillin-pot clavulanate 250-125 mg, 500-125 mg TABLET GC,MO 2  \namoxicillin-pot clavulanate 875-125 mg TABLET GC,MO 2  \nampicillin 500 mg CAPSULE GC,MO 2  \nampicillin sodium 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg RECON  \nSOLUTION MO4  \nampicillin-sulbactam 1.5 gram, 15 gram, 3 gram RECON SOLUTION MO 4  \nAUGMENTIN 500-125 MG TABLET MO 4 PA \nazithromycin 1 gram PACKET MO 3  \nazithromycin 100 mg/5 ml, 200 mg/5 ml SUSPENSION FOR RECONSTITUTION \nMO3  \nazithromycin 250 mg TABLET GC,MO 2  \nazithromycin 500 mg RECON SOLUTION GC,MO 2  \nazithromycin 500 mg, 600 mg TABLET GC,MO 2  \naztreonam 1 gram, 2 gram RECON SOLUTION MO 4  \nbacitracin 50,000 unit RECON SOLUTION GC,MO 2  \nBICILLIN C-R 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2  \nML(900K/300K) SYRINGE MO4  \nBICILLIN L-A 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML  \nSYRINGE MO4  \ncefaclor 250 mg, 500 mg CAPSULE MO 3  \ncefadroxil 250 mg/5 ml, 500 mg/5 ml SUSPENSION FOR RECONSTITUTION MO 3  \ncefadroxil 500 mg CAPSULE GC,MO 2  \ncefazolin 1 gram, 10 gram, 2 gram, 500 mg RECON SOLUTION MO 3  \nCEFAZOLIN 2 GRAM, 3 GRAM RECON SOLUTION MO 3  \ncefazolin in dextrose (iso-os) 1 gram/50 ml, 2 gram/100 ml, 2 gram/50 ml  \nPIGGYBACK MO4  \ncefdinir 125 mg/5 ml, 250 mg/5 ml SUSPENSION FOR RECONSTITUTION MO 3  \ncefdinir 300 mg CAPSULE GC,MO 2  \ncefepime 1 gram, 2 gram RECON SOLUTION MO 4  \ncefepime in dextrose 5 % 1 gram/50 ml, 2 gram/50 ml PIGGYBACK MO 4  \ncefepime in dextrose,iso-osm 1 gram/50 ml, 2 gram/100 ml PIGGYBACK MO 4  \ncefixime 400 mg CAPSULE MO 4  \ncefotaxime 1 gram RECON SOLUTION GC,MO 2  \ncefotetan 1 gram, 10 gram, 2 gram RECON SOLUTION MO 4  \ncefoxitin 1 gram, 10 gram, 2 gram RECON SOLUTION MO 4  \ncefoxitin in dextrose, iso-osm 1 gram/50 ml, 2 gram/50 ml PIGGYBACK MO 4  \ncefpodoxime 100 mg, 200 mg TABLET MO 4  ", "doc_id": "869779ab-6817-41b3-a233-3d14f8c8e7ac", "embedding": null, "doc_hash": "cacdcc99e3ce0b227ef81a47cf882e8a9e1ab15332af9afee15e6b1e6cf17045", "extra_info": {"page_label": "15", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2307, "_node_type": "1"}, "relationships": {"1": "105d814a-3ff6-45d5-8666-d0c1b09236c5"}}, "__type__": "1"}, "d5fc10e7-53e4-4c48-92e9-732aa15b1040": {"__data__": {"text": "16 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.cefprozil 125 mg/5 ml, 250 mg/5 ml SUSPENSION FOR RECONSTITUTION MO 3  \ncefprozil 250 mg, 500 mg TABLET MO 3  \nceftazidime 1 gram, 2 gram, 6 gram RECON SOLUTION MO 4  \nceftazidime in d5w 1 gram/50 ml, 2 gram/50 ml PIGGYBACK MO 4  \nceftriaxone 1 gram, 10 gram, 2 gram, 250 mg, 500 mg RECON SOLUTION MO 3  \nceftriaxone in dextrose,iso-os 1 gram/50 ml, 2 gram/50 ml PIGGYBACK MO 3  \ncefuroxime axetil 250 mg, 500 mg TABLET MO 3  \ncefuroxime sodium 1.5 gram, 7.5 gram, 750 mg RECON SOLUTION MO 3  \ncephalexin 125 mg/5 ml, 250 mg/5 ml SUSPENSION FOR RECONSTITUTION \nGC,MO2  \ncephalexin 250 mg CAPSULE GC,MO 2  \ncephalexin 500 mg CAPSULE GC,MO 2  \nchloramphenicol sod succinate 1 gram RECON SOLUTION MO 3  \nciprofloxacin hcl 100 mg TABLET MO 4  \nciprofloxacin hcl 250 mg, 750 mg TABLET GC,MO 1  \nciprofloxacin hcl 500 mg TABLET GC,MO 1  \nciprofloxacin in 5 % dextrose 200 mg/100 ml, 400 mg/200 ml PIGGYBACK GC,MO 2  \nclarithromycin 125 mg/5 ml SUSPENSION FOR RECONSTITUTION MO 4  \nclarithromycin 250 mg, 500 mg TABLET MO 3  \nclarithromycin 250 mg/5 ml SUSPENSION FOR RECONSTITUTION MO 4  \nclarithromycin 500 mg TABLET, ER 24 HR. MO 3  \nCLEOCIN 100 MG SUPPOSITORY MO 4  \nclindamycin hcl 150 mg, 75 mg CAPSULE GC,MO 2  \nclindamycin hcl 300 mg CAPSULE GC,MO 2  \nclindamycin in 0.9 % sod chlor 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml  \nPIGGYBACK MO4  \nclindamycin in 5 % dextrose 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml  \nPIGGYBACK MO4  \nclindamycin pediatric 75 mg/5 ml RECON SOLUTION MO 4  \nclindamycin phosphate 150 mg/ml SOLUTION MO 4  \nclindamycin phosphate 2 % CREAM MO 4  \ncolistin (colistimethate na) 150 mg RECON SOLUTION MO 4  \ndaptomycin 350 mg, 500 mg RECON SOLUTION DL 5  \ndemeclocycline 150 mg TABLET MO 4 QL(240 per 30 days) \ndemeclocycline 300 mg TABLET MO 4 QL(120 per 30 days) \ndicloxacillin 250 mg, 500 mg CAPSULE GC,MO 2  ", "doc_id": "d5fc10e7-53e4-4c48-92e9-732aa15b1040", "embedding": null, "doc_hash": "09696ca2f9805f34441a04a83383209eef165ca1b5b11801969fe6b47a5aecb3", "extra_info": {"page_label": "16", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2329, "_node_type": "1"}, "relationships": {"1": "d43a3d71-79bc-4f19-beb4-9a2279fadce1"}}, "__type__": "1"}, "71ce9552-8830-485a-88ca-3c24590fc8a7": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 17DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.DIFICID 200 MG TABLET DL 5  \nDIFICID 40 MG/ML SUSPENSION FOR RECONSTITUTION DL 5  \ndoxy-100 100 mg RECON SOLUTION MO 4  \ndoxycycline hyclate 100 mg CAPSULE MO 3  \ndoxycycline hyclate 100 mg TABLET MO 3  \ndoxycycline hyclate 20 mg TABLET GC,MO 2  \ndoxycycline hyclate 50 mg CAPSULE MO 3  \ndoxycycline monohydrate 100 mg, 50 mg CAPSULE GC,MO 2  \ndoxycycline monohydrate 100 mg, 50 mg, 75 mg TABLET MO 3  \ndoxycycline monohydrate 25 mg/5 ml SUSPENSION FOR RECONSTITUTION MO 4  \nertapenem 1 gram RECON SOLUTION MO 4  \nERYTHROCIN 500 MG RECON SOLUTION MO 4  \nerythromycin 250 mg CAPSULE, DR/EC MO 4  \nerythromycin lactobionate 500 mg RECON SOLUTION MO 4  \ngentamicin 0.1 % CREAM MO 4  \ngentamicin 0.1 % OINTMENT MO 4  \ngentamicin 20 mg/2 ml, 40 mg/ml SOLUTION GC,MO 2  \ngentamicin in nacl (iso-osm) 100 mg/100 ml, 100 mg/50 ml, 120 mg/100 ml,  \n60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml  \nPIGGYBACK GC,MO2  \ngentamicin sulfate (ped) (pf) 20 mg/2 ml SOLUTION GC,MO 2  \ngentamicin sulfate (pf) 100 mg/10 ml, 60 mg/6 ml SOLUTION GC,MO 2  \nimipenem-cilastatin 250 mg, 500 mg RECON SOLUTION MO 4  \nlevofloxacin 25 mg/ml, 250 mg/10 ml SOLUTION MO 4  \nlevofloxacin 250 mg, 750 mg TABLET GC,MO 2  \nlevofloxacin 500 mg TABLET GC,MO 2  \nlevofloxacin in d5w 250 mg/50 ml, 500 mg/100 ml, 750 mg/150 ml PIGGYBACK \nMO3  \nlincomycin 300 mg/ml SOLUTION MO 4  \nlinezolid 100 mg/5 ml SUSPENSION FOR RECONSTITUTION DL 5 QL(1800 per 30 days) \nlinezolid 600 mg TABLET MO 4 QL(60 per 30 days) \nlinezolid in dextrose 5% 600 mg/300 ml PIGGYBACK MO 4  \nlinezolid-0.9% sodium chloride 600 mg/300 ml PARENTERAL SOLUTION MO 4  \nmeropenem 1 gram, 500 mg RECON SOLUTION MO 4  \nmeropenem-0.9% sodium chloride 1 gram/50 ml, 500 mg/50 ml PIGGYBACK \nMO4  \nmethenamine hippurate 1 gram TABLET MO 4  ", "doc_id": "71ce9552-8830-485a-88ca-3c24590fc8a7", "embedding": null, "doc_hash": "18548f34cf6e85e5de14fb8eb04b807d45f740901413a3c722e2bb4556dcd262", "extra_info": {"page_label": "17", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2278, "_node_type": "1"}, "relationships": {"1": "30347475-d829-4651-807a-e2af387792ed"}}, "__type__": "1"}, "d6621d66-2f81-495c-9b2b-65063cdabdb1": {"__data__": {"text": "18 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.metronidazole 0.75 % CREAM MO 4  \nmetronidazole 0.75 % LOTION MO 4  \nmetronidazole 0.75 %, 0.75 % (37.5mg/5 gram), 1 % GEL MO 4  \nmetronidazole 1 % GEL WITH PUMP MO 4  \nmetronidazole 250 mg TABLET GC,MO 2  \nmetronidazole 500 mg TABLET GC,MO 2  \nmetronidazole in nacl (iso-os) 500 mg/100 ml PIGGYBACK GC,MO 2  \nminocycline 100 mg, 50 mg, 75 mg CAPSULE GC,MO 2  \nmondoxyne nl 100 mg CAPSULE GC,MO 2  \nmoxifloxacin 400 mg TABLET MO 3  \nnafcillin 1 gram, 10 gram, 2 gram RECON SOLUTION MO 4  \nnafcillin in dextrose iso-osm 1 gram/50 ml, 2 gram/100 ml PIGGYBACK DL 5  \nneomycin 500 mg TABLET MO 3  \nnitrofurantoin macrocrystal 100 mg, 50 mg CAPSULE MO 4  \nnitrofurantoin monohyd/m-cryst 100 mg CAPSULE MO 3  \nNUZYRA 150 MG TABLET DL 5 QL(30 per 14 days) \nofloxacin 300 mg, 400 mg TABLET MO 4  \nORBACTIV 400 MG RECON SOLUTION DL 5 QL(3 per 28 days) \noxacillin 1 gram, 10 gram, 2 gram RECON SOLUTION MO 4  \noxacillin in dextrose(iso-osm) 1 gram/50 ml, 2 gram/50 ml PIGGYBACK MO 4  \nparomomycin 250 mg CAPSULE MO 4  \npenicillin g pot in dextrose 1 million unit/50 ml, 2 million unit/50 ml, 3 million  \nunit/50 ml PIGGYBACK MO4  \npenicillin g potassium 20 million unit, 5 million unit RECON SOLUTION MO 4  \npenicillin g procaine 1.2 million unit/2 ml, 600,000 unit/ml SYRINGE MO 4  \npenicillin g sodium 5 million unit RECON SOLUTION DL 5  \npenicillin v potassium 125 mg/5 ml, 250 mg/5 ml RECON SOLUTION GC,MO 2  \npenicillin v potassium 250 mg, 500 mg TABLET GC,MO 2  \npfizerpen-g 20 million unit, 5 million unit RECON SOLUTION MO 4  \npiperacillin-tazobactam 13.5 gram, 2.25 gram, 3.375 gram, 4.5 gram, 40.5  \ngram RECON SOLUTION MO4  \npolymyxin b sulfate 500,000 unit RECON SOLUTION MO 3  \nPRIMSOL 50 MG/5 ML SOLUTION MO 4  \nSIVEXTRO 200 MG RECON SOLUTION DL 5 QL(6 per 28 days) \nSIVEXTRO 200 MG TABLET DL 5 QL(6 per 28 days) \nstreptomycin 1 gram RECON SOLUTION DL 5  ", "doc_id": "d6621d66-2f81-495c-9b2b-65063cdabdb1", "embedding": null, "doc_hash": "d7f517b61e0988285424d16f961ff4399834b7bec93bd3a6770ceef36f3b99c2", "extra_info": {"page_label": "18", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2354, "_node_type": "1"}, "relationships": {"1": "3a741f35-8044-4ff0-9a22-92c91913396b"}}, "__type__": "1"}, "4f552d33-03d0-483b-ab9c-d9a897b137c7": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 19DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.sulfacetamide sodium 10 % OINTMENT MO 3  \nsulfacetamide sodium (acne) 10 % SUSPENSION MO 4 QL(118 per 30 days) \nsulfadiazine 500 mg TABLET MO 4  \nsulfamethoxazole-trimethoprim 200-40 mg/5 ml SUSPENSION MO 4  \nsulfamethoxazole-trimethoprim 400-80 mg TABLET GC,MO 1  \nsulfamethoxazole-trimethoprim 400-80 mg/5 ml SOLUTION MO 4  \nsulfamethoxazole-trimethoprim 800-160 mg TABLET GC,MO 1  \nSUPRAX 400 MG CAPSULE MO 4  \nSYNERCID 500 MG RECON SOLUTION DL 5  \nTEFLARO 400 MG, 600 MG RECON SOLUTION DL 5  \ntigecycline 50 mg RECON SOLUTION DL 5  \ntinidazole 250 mg, 500 mg TABLET MO 3  \ntobramycin 300 mg/4 ml SOLUTION FOR NEBULIZATION DL 5 PA \ntobramycin sulfate 10 mg/ml, 40 mg/ml SOLUTION GC,MO 2  \ntobramycin with nebulizer 300 mg/5 ml SOLUTION FOR NEBULIZATION DL 5 PA \ntrimethoprim 100 mg TABLET GC,MO 2  \nvancomycin 1,000 mg, 1.25 gram, 1.5 gram, 10 gram, 250 mg, 5 gram, 500  \nmg, 750 mg RECON SOLUTION MO4  \nvancomycin 125 mg CAPSULE MO 4 PA,QL(120 per 30 days) \nvancomycin 250 mg CAPSULE MO 4 PA,QL(240 per 30 days) \nvancomycin in 0.9 % sodium chl 1 gram/200 ml, 500 mg/100 ml, 750 mg/150  \nml PIGGYBACK MO4  \nvancomycin in dextrose 5 % 1 gram/200 ml, 500 mg/100 ml, 750 mg/150 ml  \nPIGGYBACK MO4  \nvancomycin-diluent combo no.1 1 gram/200 ml, 1.25 gram/250 ml, 1.5  \ngram/300 ml, 1.75 gram/350 ml, 2 gram/400 ml, 500 mg/100 ml, 750 mg/150  \nml PIGGYBACK MO4  \nZERBAXA 1.5 GRAM RECON SOLUTION DL 5  \nANTICONVULSANTS\nAPTIOM 200 MG, 400 MG TABLET DL 5 PA,QL(30 per 30 days) \nAPTIOM 600 MG, 800 MG TABLET DL 5 PA,QL(60 per 30 days) \nBRIVIACT 10 MG, 100 MG, 25 MG, 50 MG, 75 MG TABLET DL 5 PA,QL(60 per 30 days) \nBRIVIACT 10 MG/ML SOLUTION DL 5 PA,QL(600 per 30 days) \nBRIVIACT 50 MG/5 ML SOLUTION DL 5 PA \ncarbamazepine 100 mg CHEWABLE TABLET MO 3  \ncarbamazepine 100 mg, 200 mg TABLET, ER 12 HR. MO 4 QL(120 per 30 days) \ncarbamazepine 100 mg, 200 mg, 300 mg CAPSULE ER MULTIPHASE 12 HR. MO 4  ", "doc_id": "4f552d33-03d0-483b-ab9c-d9a897b137c7", "embedding": null, "doc_hash": "0daffe5a7373881d27811945ad9ccb6ae626e847acedcb370d3df1ace79bee9a", "extra_info": {"page_label": "19", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2387, "_node_type": "1"}, "relationships": {"1": "2b7347f4-4104-4ef2-8a91-7615b9fea354"}}, "__type__": "1"}, "cfac342b-2f49-41a1-99ad-30f47649702d": {"__data__": {"text": "20 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.carbamazepine 100 mg/5 ml, 200 mg/10 ml SUSPENSION MO 4  \ncarbamazepine 200 mg TABLET MO 3  \ncarbamazepine 400 mg TABLET, ER 12 HR. MO 4 QL(225 per 30 days) \nCELONTIN 300 MG CAPSULE MO 4  \nclobazam 10 mg, 20 mg TABLET DL 4 PA \nclobazam 2.5 mg/ml SUSPENSION DL 4 PA \nDIACOMIT 250 MG, 500 MG CAPSULE DL 5 PA,QL(180 per 30 days) \nDIACOMIT 250 MG, 500 MG POWDER IN PACKET DL 5 PA,QL(180 per 30 days) \ndiazepam 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg KIT DL 4  \nDILANTIN INFATABS 50 MG CHEWABLE TABLET MO 4  \nDILANTIN-125 125 MG/5 ML SUSPENSION MO 4  \ndivalproex 125 mg CAPSULE, DR SPRINKLE MO 3  \ndivalproex 125 mg, 250 mg, 500 mg TABLET, DR/EC GC,MO 2  \ndivalproex 250 mg, 500 mg TABLET, ER 24 HR. MO 3  \nEPIDIOLEX 100 MG/ML SOLUTION DL 5 PA \nepitol 200 mg TABLET MO 3  \nethosuximide 250 mg CAPSULE MO 3  \nethosuximide 250 mg/5 ml SOLUTION MO 4  \nfelbamate 400 mg, 600 mg TABLET MO 4  \nfelbamate 600 mg/5 ml SUSPENSION MO 4  \nFINTEPLA 2.2 MG/ML SOLUTION DL,LA 5 PA,QL(360 per 30 days) \nfosphenytoin 100 mg pe/2 ml, 500 mg pe/10 ml SOLUTION MO 3  \nFYCOMPA 0.5 MG/ML SUSPENSION DL 5 PA,QL(680 per 28 days) \nFYCOMPA 10 MG, 12 MG, 4 MG, 6 MG, 8 MG TABLET DL 5 PA,QL(30 per 30 days) \nFYCOMPA 2 MG TABLET MO 4 PA,QL(30 per 30 days) \ngabapentin 100 mg, 300 mg, 400 mg CAPSULE GC,MO 2 QL(270 per 30 days) \ngabapentin 250 mg/5 ml, 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) SOLUTION \nMO4 QL(2250 per 30 days) \ngabapentin 600 mg, 800 mg TABLET GC,MO 2 QL(180 per 30 days) \nlacosamide 10 mg/ml SOLUTION MO 4 QL(1395 per 30 days) \nlacosamide 100 mg, 150 mg, 200 mg, 50 mg TABLET MO 4 QL(60 per 30 days) \nlacosamide 200 mg/20 ml SOLUTION MO 4  \nlamotrigine 100 mg, 200 mg TABLET GC,MO 1  \nlamotrigine 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg TABLET, ER 24  \nHR. MO4  \nlamotrigine 100 mg, 200 mg, 25 mg, 50 mg TABLET, DISINTEGRATING MO 4  ", "doc_id": "cfac342b-2f49-41a1-99ad-30f47649702d", "embedding": null, "doc_hash": "b12af2a213ddfe688b49a89c4cd250193448cfced1499edbf04a9f0784b2c3fb", "extra_info": {"page_label": "20", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2317, "_node_type": "1"}, "relationships": {"1": "0fa826c7-f6ef-460a-bdaf-1c96e5c1c782"}}, "__type__": "1"}, "3226d0eb-4dc4-40c5-82c6-d8368e4a506e": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 21DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.lamotrigine 150 mg, 25 mg TABLET GC,MO 1  \nlamotrigine 25 mg (21) -50 mg (7), 25 mg(14)-50 mg (14)-100 mg (7), 50 mg  \n(42) -100 mg (14) TABLET, DISINTEGRATING,DOSE PK MO4  \nlamotrigine 25 mg (35), 25 mg (42) -100 mg (7), 25 mg (84) -100 mg (14)  \nTABLET, DOSE PACK GC,MO2  \nlamotrigine 25 mg, 5 mg TABLET, CHEWABLE DISPERSIBLE GC,MO 2  \nlevetiracetam 1,000 mg, 250 mg, 750 mg TABLET GC,MO 2  \nlevetiracetam 100 mg/ml SOLUTION GC,MO 2  \nlevetiracetam 500 mg TABLET GC,MO 2  \nlevetiracetam 500 mg TABLET, ER 24 HR. MO 3 QL(180 per 30 days) \nlevetiracetam 500 mg/5 ml (5 ml) SOLUTION GC,MO 2 QL(900 per 30 days) \nlevetiracetam 500 mg/5 ml SOLUTION MO 4  \nlevetiracetam 750 mg TABLET, ER 24 HR. MO 3 QL(120 per 30 days) \nlevetiracetam in nacl (iso-os) 1,000 mg/100 ml, 1,500 mg/100 ml, 500 mg/100  \nml PIGGYBACK GC,MO2  \nmethsuximide 300 mg CAPSULE MO 4  \nNAYZILAM 5 MG/SPRAY (0.1 ML) SPRAY, NON-AEROSOL DL 4 QL(10 per 30 days) \noxcarbazepine 150 mg, 300 mg, 600 mg TABLET MO 3  \noxcarbazepine 300 mg/5 ml (60 mg/ml) SUSPENSION MO 4  \nphenobarbital 100 mg, 16.2 mg, 32.4 mg, 64.8 mg, 97.2 mg TABLET MO 3 QL(90 per 30 days) \nphenobarbital 15 mg, 60 mg TABLET MO 3 QL(120 per 30 days) \nphenobarbital 20 mg/5 ml (4 mg/ml) ELIXIR MO 4 QL(1500 per 30 days) \nphenobarbital 30 mg TABLET MO 3 QL(300 per 30 days) \nPHENYTEK 200 MG, 300 MG CAPSULE MO 4  \nphenytoin 100 mg/4 ml, 125 mg/5 ml SUSPENSION GC,MO 2  \nphenytoin 50 mg CHEWABLE TABLET GC,MO 2  \nphenytoin sodium 50 mg/ml SOLUTION MO 4  \nphenytoin sodium 50 mg/ml SYRINGE MO 4  \nphenytoin sodium extended 100 mg, 200 mg, 300 mg CAPSULE GC,MO 2  \nprimidone 125 mg, 250 mg TABLET GC,MO 2  \nprimidone 50 mg TABLET GC,MO 2  \nroweepra 1,000 mg, 500 mg, 750 mg TABLET GC,MO 2  \nroweepra xr 500 mg TABLET, ER 24 HR. GC,MO 2 QL(180 per 30 days) \nroweepra xr 750 mg TABLET, ER 24 HR. GC,MO 2 QL(120 per 30 days) \nrufinamide 200 mg TABLET MO 4 PA,QL(480 per 30 days) \nrufinamide 40 mg/ml SUSPENSION MO 4 PA,QL(2760 per 30 days) ", "doc_id": "3226d0eb-4dc4-40c5-82c6-d8368e4a506e", "embedding": null, "doc_hash": "a7c0f9f9b90f604f99bb71bea43c264bcb905f0111f6656bdc3d66aebb39e17d", "extra_info": {"page_label": "21", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2457, "_node_type": "1"}, "relationships": {"1": "9868ff8a-fa79-4f9e-9162-77d73c591944"}}, "__type__": "1"}, "2cf09e2e-1eff-4c08-9148-770a16ff27ce": {"__data__": {"text": "22 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.rufinamide 400 mg TABLET DL 5 PA,QL(240 per 30 days) \nSPRITAM 1,000 MG TABLET FOR SUSPENSION MO 4 ST,QL(90 per 30 days) \nSPRITAM 250 MG TABLET FOR SUSPENSION MO 4 ST,QL(360 per 30 days) \nSPRITAM 500 MG TABLET FOR SUSPENSION MO 4 ST,QL(180 per 30 days) \nSPRITAM 750 MG TABLET FOR SUSPENSION MO 4 ST,QL(120 per 30 days) \nsubvenite 100 mg, 150 mg, 200 mg, 25 mg TABLET GC,MO 2  \nsubvenite starter (blue) kit 25 mg (35) TABLET, DOSE PACK GC,MO 2  \nsubvenite starter (green) kit 25 mg (84) -100 mg (14) TABLET, DOSE PACK GC,MO 2  \nsubvenite starter (orange) kit 25 mg (42) -100 mg (7) TABLET, DOSE PACK GC,MO 2  \nSYMPAZAN 10 MG, 20 MG, 5 MG FILM DL 5 PA,QL(60 per 30 days) \ntiagabine 12 mg, 16 mg, 2 mg, 4 mg TABLET MO 4  \nvalproate sodium 500 mg/5 ml (100 mg/ml) SOLUTION MO 3  \nvalproic acid 250 mg CAPSULE GC,MO 2  \nvalproic acid (as sodium salt) 250 mg/5 ml, 250 mg/5 ml (5 ml), 500 mg/10 ml  \n(10 ml) SOLUTION GC,MO2  \nVALTOCO 10 MG/SPRAY (0.1 ML), 15 MG/2 SPRAY (7.5/0.1ML X 2), 20 MG/2  \nSPRAY (10MG/0.1ML X2), 5 MG/SPRAY (0.1 ML) SPRAY, NON-AEROSOL DL5 QL(10 per 30 days) \nvigabatrin 500 mg POWDER IN PACKET DL 5 PA,QL(180 per 30 days) \nvigabatrin 500 mg TABLET DL 5 PA,QL(180 per 30 days) \nvigadrone 500 mg POWDER IN PACKET DL 5 PA,QL(180 per 30 days) \nXCOPRI 100 MG, 50 MG TABLET DL 5 QL(30 per 30 days) \nXCOPRI 150 MG, 200 MG TABLET DL 5 QL(60 per 30 days) \nXCOPRI MAINTENANCE PACK 250 MG/DAY (200 MG X1-50 MG X1),  \n250MG/DAY(150 MG X1-100MG X1), 350 MG/DAY (200 MG X1-150MG X1)  \nTABLET DL5 QL(56 per 28 days) \nXCOPRI TITRATION PACK 12.5 MG (14)- 25 MG (14) TABLET, DOSE PACK MO 4 QL(28 per 28 days) \nXCOPRI TITRATION PACK 150 MG (14)- 200 MG (14), 50 MG (14)- 100 MG  \n(14) TABLET, DOSE PACK DL5 QL(28 per 28 days) \nZONISADE 100 MG/5 ML SUSPENSION DL 5 PA,QL(900 per 30 days) \nzonisamide 100 mg, 25 mg, 50 mg CAPSULE GC,MO 2  \nZTALMY 50 MG/ML SUSPENSION DL 5 PA,QL(1080 per 30 days) \nANTIDEMENTIA AGENTS\ndonepezil 10 mg TABLET GC,MO 1 QL(60 per 30 days) \ndonepezil 10 mg, 5 mg TABLET, DISINTEGRATING GC,MO 1 QL(30 per 30 days) \ndonepezil 5 mg TABLET GC,MO 1 QL(30 per 30 days) \ngalantamine", "doc_id": "2cf09e2e-1eff-4c08-9148-770a16ff27ce", "embedding": null, "doc_hash": "1478db6a320a927a79694133484bf999b840af35f3c939167ae2cf66e2505c14", "extra_info": {"page_label": "22", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2593, "_node_type": "1"}, "relationships": {"1": "2d21a2d9-c14d-4fb0-8ca9-f7da9cc59e86", "3": "6ae63a60-700a-44ce-a3ba-ff3d1d220d2e"}}, "__type__": "1"}, "6ae63a60-700a-44ce-a3ba-ff3d1d220d2e": {"__data__": {"text": "5 mg TABLET GC,MO 1 QL(30 per 30 days) \ngalantamine 12 mg, 4 mg, 8 mg TABLET MO 4 QL(60 per 30 days) \ngalantamine 16 mg, 24 mg, 8 mg CAPSULE ER PELLETS 24 HR. MO 4 QL(30 per 30 days) ", "doc_id": "6ae63a60-700a-44ce-a3ba-ff3d1d220d2e", "embedding": null, "doc_hash": "f4e952c93d3db4b4d1f5f7030ce65abb8d53f99adbbbc35b355ed7034912d475", "extra_info": {"page_label": "22", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2542, "end": 2725, "_node_type": "1"}, "relationships": {"1": "2d21a2d9-c14d-4fb0-8ca9-f7da9cc59e86", "2": "2cf09e2e-1eff-4c08-9148-770a16ff27ce"}}, "__type__": "1"}, "fdb94132-8f7a-4314-a971-8ffb3546b9ab": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 23DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.galantamine 4 mg/ml SOLUTION MO 4 QL(200 per 30 days) \nmemantine 10 mg, 5 mg TABLET GC,MO 2 PA,QL(60 per 30 days) \nmemantine 14 mg, 21 mg, 28 mg, 7 mg CAPSULE ER SPRINKLE 24 HR. MO 4 PA,QL(30 per 30 days) \nmemantine 2 mg/ml SOLUTION MO 4 PA,QL(360 per 30 days) \nmemantine 5-10 mg TABLET, DOSE PACK GC,MO 2 PA,QL(98 per 30 days) \nNAMZARIC 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG CAPSULE ER SPRINKLE  \n24 HR. MO3 QL(30 per 30 days) \nNAMZARIC 7/14/21/28 MG-10 MG CAPSULE ER SPRINKLE 24 HR. MO 3 QL(28 per 28 days) \nrivastigmine 13.3 mg/24 hour, 4.6 mg/24 hour, 9.5 mg/24 hour PATCH, 24 HR. \nMO4 QL(30 per 30 days) \nrivastigmine tartrate 1.5 mg, 3 mg CAPSULE MO 3 QL(90 per 30 days) \nrivastigmine tartrate 4.5 mg, 6 mg CAPSULE MO 3 QL(60 per 30 days) \nANTIDEPRESSANTS\namitriptyline 10 mg, 100 mg, 150 mg, 50 mg, 75 mg TABLET GC,MO 2  \namitriptyline 25 mg TABLET GC,MO 2  \namoxapine 100 mg, 150 mg, 25 mg, 50 mg TABLET MO 3  \nAUVELITY 45-105 MG TABLET, IR/ER, BIPHASIC DL 5 PA,QL(60 per 30 days) \nbupropion hcl 100 mg TABLET, SR 12 HR. MO 3 QL(120 per 30 days) \nbupropion hcl 100 mg, 75 mg TABLET MO 3 QL(180 per 30 days) \nbupropion hcl 150 mg TABLET, ER 24 HR. MO 3 QL(90 per 30 days) \nbupropion hcl 150 mg TABLET, SR 12 HR. MO 3 QL(90 per 30 days) \nbupropion hcl 200 mg TABLET, SR 12 HR. MO 3 QL(60 per 30 days) \nbupropion hcl 300 mg TABLET, ER 24 HR. MO 3 QL(60 per 30 days) \ncitalopram 10 mg, 40 mg TABLET GC,MO 1 QL(30 per 30 days) \ncitalopram 10 mg/5 ml SOLUTION MO 3  \ncitalopram 20 mg TABLET GC,MO 1 QL(60 per 30 days) \nclomipramine 25 mg, 50 mg, 75 mg CAPSULE MO 4  \ndesipramine 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg TABLET MO 3  \ndesvenlafaxine succinate 100 mg, 25 mg, 50 mg TABLET, ER 24 HR. MO 3 QL(30 per 30 days) \nDRIZALMA SPRINKLE 20 MG, 30 MG, 40 MG, 60 MG CAPSULE, DR SPRINKLE MO 4 PA,QL(60 per 30 days) \nduloxetine 20 mg CAPSULE, DR/EC GC,MO 2 QL(120 per 30 days) \nduloxetine 30 mg CAPSULE, DR/EC GC,MO 2 QL(90 per 30 days) \nduloxetine 60 mg CAPSULE, DR/EC GC,MO 2 QL(60 per 30 days) \nEMSAM 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR PATCH, 24 HR. DL 5 PA,QL(30 per 30", "doc_id": "fdb94132-8f7a-4314-a971-8ffb3546b9ab", "embedding": null, "doc_hash": "51ead4755f122f501f1507fc34f017645deaf2862b56268c358a8d5c7724f454", "extra_info": {"page_label": "23", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2573, "_node_type": "1"}, "relationships": {"1": "9feda2cb-7916-4181-ab8a-e025f5eacb86", "3": "a58564b1-972b-4a44-ab5a-af0508dafde8"}}, "__type__": "1"}, "a58564b1-972b-4a44-ab5a-af0508dafde8": {"__data__": {"text": "days) \nescitalopram oxalate 10 mg TABLET GC,MO 1 QL(45 per 30 days) \nescitalopram oxalate 20 mg, 5 mg TABLET GC,MO 1 QL(30 per 30 days) ", "doc_id": "a58564b1-972b-4a44-ab5a-af0508dafde8", "embedding": null, "doc_hash": "7dc63ef0202213e614133f32899eb61f7889a715afa68e24aaf3243293aa5008", "extra_info": {"page_label": "23", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2574, "end": 2710, "_node_type": "1"}, "relationships": {"1": "9feda2cb-7916-4181-ab8a-e025f5eacb86", "2": "fdb94132-8f7a-4314-a971-8ffb3546b9ab"}}, "__type__": "1"}, "154b239d-a900-4c93-a8ee-49b1e06651b9": {"__data__": {"text": "24 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.escitalopram oxalate 5 mg/5 ml SOLUTION MO 4 QL(600 per 30 days) \nFETZIMA 120 MG, 20 MG, 40 MG, 80 MG CAPSULE, ER 24 HR. MO 4 PA,QL(30 per 30 days) \nFETZIMA 20 MG (2)- 40 MG (26) CAPSULE, ER 24 HR. MO 4 PA,QL(28 per 28 days) \nfluoxetine 10 mg CAPSULE GC,MO 1 QL(60 per 30 days) \nfluoxetine 20 mg CAPSULE GC,MO 1 QL(120 per 30 days) \nfluoxetine 20 mg/5 ml (4 mg/ml) SOLUTION MO 3  \nfluoxetine 40 mg CAPSULE GC,MO 1 QL(60 per 30 days) \nfluoxetine 90 mg CAPSULE, DR/EC MO 4 QL(4 per 28 days) \nfluvoxamine 100 mg, 25 mg, 50 mg TABLET GC,MO 2 QL(90 per 30 days) \nimipramine hcl 10 mg TABLET MO 3  \nimipramine hcl 25 mg, 50 mg TABLET MO 3  \nimipramine pamoate 100 mg, 125 mg, 150 mg, 75 mg CAPSULE MO 4  \nMARPLAN 10 MG TABLET MO 4  \nmirtazapine 15 mg, 30 mg, 45 mg TABLET, DISINTEGRATING MO 4 QL(30 per 30 days) \nmirtazapine 15 mg, 30 mg, 7.5 mg TABLET GC,MO 2  \nmirtazapine 45 mg TABLET GC,MO 2  \nnefazodone 100 mg, 150 mg, 200 mg, 250 mg, 50 mg TABLET MO 4  \nnortriptyline 10 mg, 25 mg, 50 mg, 75 mg CAPSULE MO 4  \nnortriptyline 10 mg/5 ml SOLUTION MO 4  \nparoxetine hcl 10 mg TABLET GC,MO 1 QL(30 per 30 days) \nparoxetine hcl 10 mg/5 ml SUSPENSION MO 4  \nparoxetine hcl 12.5 mg, 37.5 mg TABLET, ER 24 HR. MO 4 QL(60 per 30 days) \nparoxetine hcl 20 mg TABLET GC,MO 1 QL(30 per 30 days) \nparoxetine hcl 25 mg TABLET, ER 24 HR. MO 4 QL(90 per 30 days) \nparoxetine hcl 30 mg, 40 mg TABLET GC,MO 1 QL(60 per 30 days) \nPAXIL 10 MG/5 ML SUSPENSION MO 4  \nperphenazine-amitriptyline 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg  \nTABLET MO4  \nphenelzine 15 mg TABLET MO 3  \nprotriptyline 10 mg, 5 mg TABLET MO 4  \nsertraline 100 mg TABLET GC,MO 1 QL(60 per 30 days) \nsertraline 20 mg/ml CONCENTRATE MO 3  \nsertraline 25 mg, 50 mg TABLET GC,MO 1 QL(90 per 30 days) \ntranylcypromine 10 mg TABLET MO 4  \ntrazodone 100 mg, 150 mg, 50 mg TABLET GC,MO 1  \ntrazodone 300 mg TABLET MO 3  ", "doc_id": "154b239d-a900-4c93-a8ee-49b1e06651b9", "embedding": null, "doc_hash": "a081549ed5d91693a2f2c0f9e8da779c839af69f6f3414a1901536bc0d80058c", "extra_info": {"page_label": "24", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2363, "_node_type": "1"}, "relationships": {"1": "ad59ef01-bbcb-43f2-94b7-82a5ec25eb02"}}, "__type__": "1"}, "6e2153ef-8f10-4da2-963d-513bf96bf2bb": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 25DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.trimipramine 100 mg, 25 mg, 50 mg CAPSULE MO 4  \nTRINTELLIX 10 MG, 20 MG, 5 MG TABLET MO 4 ST,QL(30 per 30 days) \nvenlafaxine 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg TABLET GC,MO 2  \nvenlafaxine 150 mg CAPSULE, ER 24 HR. GC,MO 2 QL(60 per 30 days) \nvenlafaxine 37.5 mg CAPSULE, ER 24 HR. GC,MO 2 QL(90 per 30 days) \nvenlafaxine 75 mg CAPSULE, ER 24 HR. GC,MO 2 QL(90 per 30 days) \nVIIBRYD 10 MG (7)- 20 MG (23) TABLET, DOSE PACK MO 4 PA,QL(30 per 30 days) \nvilazodone 10 mg, 20 mg, 40 mg TABLET MO 4 PA,QL(30 per 30 days) \nANTIEMETICS\naprepitant 125 mg (1)- 80 mg (2) CAPSULE, DOSE PACK MO 4 BvsD,QL(6 per 28 days) \naprepitant 125 mg, 40 mg CAPSULE MO 4 BvsD,QL(2 per 28 days) \naprepitant 80 mg CAPSULE MO 4 BvsD,QL(4 per 28 days) \ncompro 25 mg SUPPOSITORY MO 4  \ndronabinol 10 mg, 2.5 mg, 5 mg CAPSULE MO 4 BvsD,QL(120 per 30 days) \ngranisetron (pf) 1 mg/ml (1 ml), 100 mcg/ml SOLUTION MO 3  \ngranisetron hcl 1 mg TABLET MO 3 BvsD,QL(28 per 28 days) \ngranisetron hcl 1 mg/ml, 1 mg/ml (1 ml) SOLUTION MO 3  \nmeclizine 12.5 mg TABLET GC,MO 2  \nmeclizine 25 mg TABLET GC,MO 2  \nmetoclopramide hcl 10 mg, 5 mg TABLET GC,MO 1  \nondansetron 4 mg TABLET, DISINTEGRATING GC,MO 2 BvsD,QL(90 per 30 days) \nondansetron 8 mg TABLET, DISINTEGRATING GC,MO 2 BvsD,QL(90 per 30 days) \nondansetron hcl 2 mg/ml SOLUTION MO 4  \nondansetron hcl 4 mg TABLET GC,MO 2 BvsD,QL(90 per 30 days) \nondansetron hcl 4 mg/5 ml SOLUTION MO 4 BvsD,QL(450 per 30 days) \nondansetron hcl 8 mg TABLET GC,MO 2 BvsD,QL(90 per 30 days) \nondansetron hcl (pf) 4 mg/2 ml SOLUTION MO 4  \nondansetron hcl (pf) 4 mg/2 ml SYRINGE MO 4  \nprochlorperazine 25 mg SUPPOSITORY MO 4  \nprochlorperazine edisylate 10 mg/2 ml (5 mg/ml), 5 mg/ml SOLUTION MO 4  \nprochlorperazine maleate 10 mg, 5 mg TABLET GC,MO 2 BvsD \npromethazine 12.5 mg, 50 mg TABLET MO 4  \npromethazine 25 mg TABLET MO 4  \nSANCUSO 3.1 MG/24 HOUR PATCH, WEEKLY DL 5 QL(4 per 30 days) \nscopolamine base 1 mg over 3 days PATCH, 3 DAY MO 3 QL(10 per 30 days) \ntrimethobenzamide 300 mg CAPSULE MO 4 BvsD ", "doc_id": "6e2153ef-8f10-4da2-963d-513bf96bf2bb", "embedding": null, "doc_hash": "23efe2f5bcf5a44b1f90b7c89718ff8bf69a36b40ae50fef44a6b7d96c297382", "extra_info": {"page_label": "25", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2507, "_node_type": "1"}, "relationships": {"1": "c0678fff-d10f-4018-85e6-49f8081615c1"}}, "__type__": "1"}, "53849443-d9b0-4c63-b3e2-fc9b45b720f7": {"__data__": {"text": "26 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.ANTIFUNGALS\nABELCET 5 MG/ML SUSPENSION MO 4 BvsD \nAMBISOME 50 MG SUSPENSION FOR RECONSTITUTION DL 5 BvsD \namphotericin b 50 mg RECON SOLUTION MO 4 BvsD \namphotericin b liposome 50 mg SUSPENSION FOR RECONSTITUTION DL 5 BvsD \ncaspofungin 50 mg RECON SOLUTION DL 5  \ncaspofungin 70 mg RECON SOLUTION MO 4  \nciclodan 8 % SOLUTION GC,MO 2 QL(13.2 per 30 days) \nciclopirox 0.77 % CREAM GC,MO 2 QL(90 per 30 days) \nciclopirox 0.77 % GEL MO 4 QL(100 per 30 days) \nciclopirox 0.77 % SUSPENSION MO 4 QL(60 per 30 days) \nciclopirox 8 % SOLUTION GC,MO 2 QL(13.2 per 30 days) \nclotrimazole 1 % CREAM GC,MO 2  \nclotrimazole 1 % SOLUTION MO 3  \nclotrimazole 10 mg TROCHE GC,MO 2  \nclotrimazole-betamethasone 1-0.05 % CREAM MO 3 QL(180 per 30 days) \nclotrimazole-betamethasone 1-0.05 % LOTION MO 4 QL(90 per 28 days) \neconazole 1 % CREAM MO 4 PA,QL(85 per 30 days) \nfluconazole 10 mg/ml, 40 mg/ml SUSPENSION FOR RECONSTITUTION MO 3  \nfluconazole 100 mg, 200 mg, 50 mg TABLET GC,MO 2  \nfluconazole 150 mg TABLET GC,MO 2  \nfluconazole in nacl (iso-osm) 100 mg/50 ml, 200 mg/100 ml, 400 mg/200 ml  \nPIGGYBACK MO3  \nflucytosine 250 mg, 500 mg CAPSULE DL 5  \ngriseofulvin microsize 125 mg/5 ml SUSPENSION MO 4  \ngriseofulvin microsize 500 mg TABLET MO 4  \ngriseofulvin ultramicrosize 125 mg, 250 mg TABLET MO 4  \nitraconazole 100 mg CAPSULE MO 4 QL(120 per 30 days) \nketoconazole 2 % CREAM MO 3 QL(60 per 30 days) \nketoconazole 2 % SHAMPOO GC,MO 2 QL(120 per 30 days) \nketoconazole 200 mg TABLET MO 4 PA \nmicafungin 100 mg, 50 mg RECON SOLUTION DL 5  \nmiconazole-3 200 mg SUPPOSITORY MO 3  \nNOXAFIL 100 MG TABLET, DR/EC DL 5 PA \nNOXAFIL 200 MG/5 ML (40 MG/ML) SUSPENSION DL 5 PA,QL(840 per 28 days) \nNOXAFIL 300 MG SUSPENSION, DR FOR RECON DL 5 PA,QL(32 per 30 days) ", "doc_id": "53849443-d9b0-4c63-b3e2-fc9b45b720f7", "embedding": null, "doc_hash": "9b43a59bfdf471af7e74d80a771db5516d42f802ca03b5d9249feeb7105a6567", "extra_info": {"page_label": "26", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2241, "_node_type": "1"}, "relationships": {"1": "1f8ae18c-28c1-4a8b-bf4b-9ef2c2d9905f"}}, "__type__": "1"}, "f15fdc14-12c1-4928-bc5d-d2b5bfcccb46": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 27DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.NOXAFIL 300 MG/16.7 ML SOLUTION DL 5 PA \nnyamyc 100,000 unit/gram POWDER MO 4 PA \nnystatin 100,000 unit/gram CREAM GC,MO 2  \nnystatin 100,000 unit/gram OINTMENT GC,MO 2  \nnystatin 100,000 unit/gram POWDER MO 4 PA \nnystatin 100,000 unit/ml SUSPENSION GC,MO 2  \nnystatin 500,000 unit TABLET MO 3  \nnystatin-triamcinolone 100,000-0.1 unit/g-% CREAM MO 4  \nnystatin-triamcinolone 100,000-0.1 unit/gram-% OINTMENT MO 4  \nnystop 100,000 unit/gram POWDER MO 4 PA \nposaconazole 100 mg TABLET, DR/EC DL 5 PA \nposaconazole 200 mg/5 ml (40 mg/ml) SUSPENSION DL 5 PA,QL(840 per 28 days) \nterbinafine hcl 250 mg TABLET GC,MO 1  \nterconazole 0.4 %, 0.8 % CREAM GC,MO 2  \nterconazole 80 mg SUPPOSITORY MO 4  \nvoriconazole 200 mg RECON SOLUTION DL 5 PA \nvoriconazole 200 mg, 50 mg TABLET MO 4 PA,QL(120 per 30 days) \nvoriconazole 200 mg/5 ml (40 mg/ml) SUSPENSION FOR RECONSTITUTION DL 5 PA,QL(400 per 30 days) \nANTIGOUT AGENTS\nallopurinol 100 mg, 300 mg TABLET GC,MO 1  \ncolchicine 0.6 mg TABLET MO 3 QL(120 per 30 days) \nMITIGARE 0.6 MG CAPSULE MO 3  \nprobenecid 500 mg TABLET MO 3  \nprobenecid-colchicine 500-0.5 mg TABLET MO 3  \nANTIMIGRAINE AGENTS\nAIMOVIG AUTOINJECTOR 140 MG/ML AUTO-INJECTOR MO 4 PA,QL(1 per 30 days) \nAIMOVIG AUTOINJECTOR 70 MG/ML AUTO-INJECTOR MO 4 PA,QL(2 per 30 days) \ndihydroergotamine 0.5 mg/pump act. (4 mg/ml) SPRAY, NON-AEROSOL DL 5 PA,QL(8 per 30 days) \ndihydroergotamine 1 mg/ml SOLUTION DL 5 PA \nEMGALITY PEN 120 MG/ML PEN INJECTOR MO 4 PA,QL(2 per 30 days) \nEMGALITY SYRINGE 120 MG/ML SYRINGE MO 4 PA,QL(2 per 30 days) \nEMGALITY SYRINGE 300 MG/3 ML (100 MG/ML X 3) SYRINGE MO 4 PA,QL(3 per 30 days) \nEPRONTIA 25 MG/ML SOLUTION MO 4 PA,QL(480 per 30 days) \nergotamine-caffeine 1-100 mg TABLET MO 3 QL(40 per 30 days) \nnaratriptan 1 mg, 2.5 mg TABLET GC,MO 2 QL(9 per 30 days) \nQULIPTA 10 MG, 30 MG, 60 MG TABLET MO 4 PA,QL(30 per 30 days) ", "doc_id": "f15fdc14-12c1-4928-bc5d-d2b5bfcccb46", "embedding": null, "doc_hash": "cf0f64cdf8d97cd3be475333c462ce7e710bffb9a3c044d899a79b05cf0442fc", "extra_info": {"page_label": "27", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2353, "_node_type": "1"}, "relationships": {"1": "eba6d0d8-89a7-443a-affd-728f92bc8f29"}}, "__type__": "1"}, "d6ef5232-a3ec-4cea-863c-cc6cdfa53ffb": {"__data__": {"text": "28 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.rizatriptan 10 mg TABLET GC,MO 2 QL(12 per 30 days) \nrizatriptan 10 mg, 5 mg TABLET, DISINTEGRATING MO 3 QL(12 per 30 days) \nrizatriptan 5 mg TABLET GC,MO 2 QL(12 per 30 days) \nsumatriptan 20 mg/actuation, 5 mg/actuation SPRAY, NON-AEROSOL MO 4 QL(12 per 30 days) \nsumatriptan succinate 100 mg TABLET GC,MO 1 QL(9 per 30 days) \nsumatriptan succinate 25 mg, 50 mg TABLET GC,MO 1 QL(9 per 30 days) \nsumatriptan succinate 4 mg/0.5 ml, 6 mg/0.5 ml CARTRIDGE MO 4 QL(6 per 30 days) \nsumatriptan succinate 4 mg/0.5 ml, 6 mg/0.5 ml PEN INJECTOR MO 4 QL(6 per 30 days) \nsumatriptan succinate 6 mg/0.5 ml SOLUTION MO 4 QL(6 per 30 days) \nsumatriptan succinate 6 mg/0.5 ml SYRINGE MO 4 QL(6 per 30 days) \ntopiramate 100 mg, 200 mg TABLET GC,MO 2 QL(120 per 30 days) \ntopiramate 15 mg, 25 mg CAPSULE, SPRINKLE MO 3  \ntopiramate 25 mg TABLET GC,MO 2 QL(90 per 30 days) \ntopiramate 50 mg TABLET GC,MO 2 QL(120 per 30 days) \nANTIMYASTHENIC AGENTS\npyridostigmine bromide 30 mg, 60 mg TABLET MO 3  \nANTIMYCOBACTERIALS\ncycloserine 250 mg CAPSULE DL 5  \ndapsone 100 mg, 25 mg TABLET MO 3  \nethambutol 100 mg, 400 mg TABLET MO 3  \nisoniazid 100 mg, 300 mg TABLET GC,MO 1  \nisoniazid 100 mg/ml SOLUTION GC,MO 1  \nisoniazid 50 mg/5 ml SOLUTION MO 4  \nPASER 4 GRAM DR GRANULES IN PACKET MO 4  \nPRIFTIN 150 MG TABLET MO 4  \npyrazinamide 500 mg TABLET MO 4  \nrifabutin 150 mg CAPSULE MO 4  \nrifampin 150 mg, 300 mg CAPSULE MO 3  \nrifampin 600 mg RECON SOLUTION MO 4  \nSIRTURO 100 MG TABLET DL 5 PA,QL(68 per 28 days) \nSIRTURO 20 MG TABLET DL 5 PA,QL(340 per 28 days) \nTRECATOR 250 MG TABLET MO 4  \nANTINEOPLASTICS\nabiraterone 250 mg TABLET DL 5 PA,QL(120 per 30 days) \nABRAXANE 100 MG SUSPENSION FOR RECONSTITUTION DL 5 PA \nADCETRIS 50 MG RECON SOLUTION DL 5 PA ", "doc_id": "d6ef5232-a3ec-4cea-863c-cc6cdfa53ffb", "embedding": null, "doc_hash": "68e8985aa0336bfd36a7b38cb1cce5808cb33129be31bb4fe9fa043c611af487", "extra_info": {"page_label": "28", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2233, "_node_type": "1"}, "relationships": {"1": "89d7aca4-811b-4064-b93e-11e4293fd880"}}, "__type__": "1"}, "c7d3c1b4-f38d-4769-987f-0c5cc060ee9b": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 29DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.adriamycin 10 mg RECON SOLUTION MO 4 BvsD \nadriamycin 10 mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml SOLUTION MO 4 BvsD \nADRIAMYCIN 50 MG RECON SOLUTION MO 4 BvsD \nALECENSA 150 MG CAPSULE DL 5 PA,QL(240 per 30 days) \nALIMTA 100 MG, 500 MG RECON SOLUTION DL 5 PA \nALIQOPA 60 MG RECON SOLUTION DL 5 PA,QL(3 per 28 days) \nALUNBRIG 180 MG, 90 MG TABLET DL 5 PA,QL(30 per 30 days) \nALUNBRIG 30 MG TABLET DL 5 PA,QL(180 per 30 days) \nALUNBRIG 90 MG (7)- 180 MG (23) TABLET, DOSE PACK DL 5 PA,QL(30 per 30 days) \nanastrozole 1 mg TABLET GC,MO 1 QL(30 per 30 days) \nARRANON 250 MG/50 ML SOLUTION DL 5  \narsenic trioxide 1 mg/ml, 2 mg/ml SOLUTION DL 5 PA \nASPARLAS 750 UNIT/ML SOLUTION DL 5 PA \nAYVAKIT 100 MG, 200 MG, 25 MG, 300 MG, 50 MG TABLET DL 5 PA,QL(30 per 30 days) \nazacitidine 100 mg RECON SOLUTION DL 5 PA \nBALVERSA 3 MG TABLET DL 5 PA,QL(90 per 30 days) \nBALVERSA 4 MG TABLET DL 5 PA,QL(60 per 30 days) \nBALVERSA 5 MG TABLET DL 5 PA,QL(30 per 30 days) \nBAVENCIO 20 MG/ML SOLUTION DL 5 PA \nBELEODAQ 500 MG RECON SOLUTION DL 5 PA \nbendamustine 100 mg, 25 mg RECON SOLUTION DL 5 PA \nBENDEKA 25 MG/ML SOLUTION DL 5 PA \nBESPONSA 0.9 MG (0.25 MG/ML INITIAL) RECON SOLUTION DL 5 PA \nbexarotene 1 % GEL DL 5 PA,QL(240 per 30 days) \nbexarotene 75 mg CAPSULE DL 5 PA,QL(300 per 30 days) \nbicalutamide 50 mg TABLET MO 3 QL(30 per 30 days) \nBICNU 100 MG RECON SOLUTION MO 4  \nBLENREP 100 MG RECON SOLUTION DL 5 PA \nbleomycin 15 unit, 30 unit RECON SOLUTION MO 3 BvsD \nBORTEZOMIB 1 MG, 2.5 MG RECON SOLUTION DL 5 PA \nbortezomib 3.5 mg RECON SOLUTION DL 5 PA \nBOSULIF 100 MG TABLET DL 5 PA,QL(120 per 30 days) \nBOSULIF 400 MG, 500 MG TABLET DL 5 PA,QL(30 per 30 days) \nBRAFTOVI 75 MG CAPSULE DL 5 PA,QL(180 per 30 days) \nBRUKINSA 80 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nbusulfan 60 mg/10 ml SOLUTION MO 4  ", "doc_id": "c7d3c1b4-f38d-4769-987f-0c5cc060ee9b", "embedding": null, "doc_hash": "5480d964b2321ebff4ba3c57432192163f5d06c5b78ea45ea11e86a291edc905", "extra_info": {"page_label": "29", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2292, "_node_type": "1"}, "relationships": {"1": "a37fd933-9557-4cab-8ca8-9831ba6bef7f"}}, "__type__": "1"}, "9ad5e653-6a22-442c-9b4f-55fc842928d9": {"__data__": {"text": "30 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.BUSULFEX 60 MG/10 ML SOLUTION MO 4  \nCABOMETYX 20 MG, 40 MG, 60 MG TABLET DL 5 PA,QL(30 per 30 days) \nCALQUENCE 100 MG CAPSULE DL 5 PA,QL(60 per 30 days) \nCALQUENCE (ACALABRUTINIB MAL) 100 MG TABLET DL 5 PA,QL(60 per 30 days) \nCAPRELSA 100 MG TABLET DL,LA 5 PA,QL(60 per 30 days) \nCAPRELSA 300 MG TABLET DL,LA 5 PA,QL(30 per 30 days) \ncarboplatin 10 mg/ml SOLUTION MO 3  \ncarmustine 100 mg RECON SOLUTION MO 4  \ncisplatin 1 mg/ml SOLUTION MO 4  \ncladribine 10 mg/10 ml SOLUTION DL 5 BvsD \nclofarabine 1 mg/ml SOLUTION DL 5  \nCLOLAR 1 MG/ML SOLUTION DL 5  \nCOMETRIQ 100 MG/DAY(80 MG X1-20 MG X1) CAPSULE DL 5 PA,QL(56 per 28 days) \nCOMETRIQ 140 MG/DAY(80 MG X1-20 MG X3) CAPSULE DL 5 PA,QL(112 per 28 days) \nCOMETRIQ 60 MG/DAY (20 MG X 3/DAY) CAPSULE DL 5 PA,QL(84 per 28 days) \nCOPIKTRA 15 MG, 25 MG CAPSULE DL 5 PA,QL(56 per 28 days) \nCOSMEGEN 0.5 MG RECON SOLUTION DL 5  \nCOTELLIC 20 MG TABLET DL 5 PA,QL(63 per 28 days) \ncyclophosphamide 1 gram, 2 gram, 500 mg RECON SOLUTION MO 4 BvsD \ncyclophosphamide 200 mg/ml SOLUTION MO 4 BvsD \nCYCLOPHOSPHAMIDE 200 MG/ML SOLUTION MO 4 BvsD \ncyclophosphamide 25 mg, 50 mg CAPSULE MO 4 BvsD \ncyclophosphamide 25 mg, 50 mg TABLET MO 3 BvsD \nCYRAMZA 10 MG/ML SOLUTION DL 5 PA \ncytarabine 20 mg/ml SOLUTION GC,MO 1 BvsD \ncytarabine (pf) 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml), 20 mg/ml  \nSOLUTION GC,MO1 BvsD \ndacarbazine 100 mg, 200 mg RECON SOLUTION MO 4  \ndactinomycin 0.5 mg RECON SOLUTION DL 5  \nDANYELZA 4 MG/ML SOLUTION DL 5 PA,QL(120 per 28 days) \nDARZALEX 20 MG/ML SOLUTION DL 5 PA \nDARZALEX FASPRO 1,800 MG-30,000 UNIT/15 ML SOLUTION DL 5 PA \ndaunorubicin 5 mg/ml SOLUTION GC,MO 1  \nDAURISMO 100 MG TABLET DL 5 PA,QL(30 per 30 days) \nDAURISMO 25 MG TABLET DL 5 PA,QL(60 per 30 days) \ndecitabine 50 mg RECON SOLUTION DL 5 PA ", "doc_id": "9ad5e653-6a22-442c-9b4f-55fc842928d9", "embedding": null, "doc_hash": "ad46a5329d84980b60d02d09be56a464b204076c49c12850b3e30f5cc1d695f9", "extra_info": {"page_label": "30", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2277, "_node_type": "1"}, "relationships": {"1": "d85e6c07-f342-459d-9814-360643069e0d"}}, "__type__": "1"}, "f547f0c1-48d9-4915-a559-b915099768a1": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 31DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.dexrazoxane hcl 250 mg, 500 mg RECON SOLUTION MO 4  \nDOCEFREZ 20 MG RECON SOLUTION MO 4  \nDOCEFREZ 80 MG RECON SOLUTION DL 5  \ndocetaxel 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10  \nmg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)  \nSOLUTION MO4  \ndoxorubicin 10 mg, 50 mg RECON SOLUTION MO 4 BvsD \ndoxorubicin 10 mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml SOLUTION MO 3 BvsD \ndoxorubicin, peg-liposomal 2 mg/ml SUSPENSION DL 5 PA \nELZONRIS 1,000 MCG/ML SOLUTION DL 5 PA,QL(10 per 21 days) \nEMCYT 140 MG CAPSULE DL 5  \nEMPLICITI 300 MG, 400 MG RECON SOLUTION DL 5 PA \nENHERTU 100 MG RECON SOLUTION DL 5 PA \nepirubicin 200 mg/100 ml, 50 mg/25 ml SOLUTION MO 4  \nepirubicin 50 mg RECON SOLUTION MO 4  \nEPKINLY 4 MG/0.8 ML, 48 MG/0.8 ML SOLUTION DL 5 PA \nERBITUX 100 MG/50 ML, 200 MG/100 ML SOLUTION DL 5 PA \nERIVEDGE 150 MG CAPSULE DL 5 PA,QL(28 per 28 days) \nERLEADA 240 MG TABLET DL 5 PA,QL(30 per 30 days) \nERLEADA 60 MG TABLET DL 5 PA,QL(120 per 30 days) \nerlotinib 100 mg, 150 mg TABLET DL 5 PA,QL(30 per 30 days) \nerlotinib 25 mg TABLET DL 5 PA,QL(90 per 30 days) \nERWINAZE 10,000 UNIT RECON SOLUTION DL 5 PA \nETOPOPHOS 100 MG RECON SOLUTION MO 4  \netoposide 20 mg/ml SOLUTION MO 3  \nEULEXIN 125 MG CAPSULE DL 5 PA \neverolimus (antineoplastic) 10 mg, 2.5 mg, 5 mg, 7.5 mg TABLET DL 5 PA,QL(30 per 30 days) \neverolimus (antineoplastic) 2 mg, 3 mg, 5 mg TABLET FOR SUSPENSION DL 5 PA \nEVOMELA 50 MG RECON SOLUTION DL 5 PA \nexemestane 25 mg TABLET MO 4 QL(60 per 30 days) \nEXKIVITY 40 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nfloxuridine 0.5 gram RECON SOLUTION GC,MO 1 BvsD \nfludarabine 50 mg RECON SOLUTION MO 4  \nfludarabine 50 mg/2 ml SOLUTION DL 5  \nfluorouracil 1 gram/20 ml, 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml  \nSOLUTION MO3 BvsD ", "doc_id": "f547f0c1-48d9-4915-a559-b915099768a1", "embedding": null, "doc_hash": "d530e05238ce89b152d6bc146a82986b9ea387bbd708c29b6f614123e580aed7", "extra_info": {"page_label": "31", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2283, "_node_type": "1"}, "relationships": {"1": "c421011f-f926-48d0-806f-65164086660e"}}, "__type__": "1"}, "c0942f2a-24b1-4f8c-b0fa-9d86c59ed22a": {"__data__": {"text": "32 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.flutamide 125 mg CAPSULE MO 4  \nFOLOTYN 20 MG/ML (1 ML), 40 MG/2 ML (20 MG/ML) SOLUTION DL 5 PA \nFOTIVDA 0.89 MG, 1.34 MG CAPSULE DL 5 PA,QL(21 per 28 days) \nfulvestrant 250 mg/5 ml SYRINGE MO 4 PA,QL(30 per 30 days) \nFYARRO 100 MG SUSPENSION FOR RECONSTITUTION DL 5 PA \nGAVRETO 100 MG CAPSULE DL,LA 5 PA,QL(120 per 30 days) \nGAZYVA 1,000 MG/40 ML SOLUTION DL 5 PA,QL(120 per 28 days) \ngefitinib 250 mg TABLET DL 5 PA,QL(30 per 30 days) \ngemcitabine 1 gram, 2 gram, 200 mg RECON SOLUTION MO 4  \ngemcitabine 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200  \nmg/5.26 ml (38 mg/ml) SOLUTION MO4  \nGILOTRIF 20 MG, 30 MG, 40 MG TABLET DL,LA 5 PA,QL(30 per 30 days) \nGLEOSTINE 10 MG, 40 MG CAPSULE 5 PA \nGLEOSTINE 100 MG CAPSULE DL 5 PA \nHALAVEN 1 MG/2 ML (0.5 MG/ML) SOLUTION DL 5 PA \nhydroxyurea 500 mg CAPSULE GC,MO 2  \nIBRANCE 100 MG, 125 MG, 75 MG CAPSULE DL 5 PA,QL(21 per 28 days) \nIBRANCE 100 MG, 125 MG, 75 MG TABLET DL 5 PA,QL(21 per 28 days) \nICLUSIG 10 MG, 30 MG, 45 MG TABLET DL 5 PA,QL(30 per 30 days) \nICLUSIG 15 MG TABLET DL 5 PA,QL(60 per 30 days) \nidarubicin 1 mg/ml SOLUTION DL 5  \nIDHIFA 100 MG, 50 MG TABLET DL 5 PA,QL(30 per 30 days) \nifosfamide 1 gram, 3 gram RECON SOLUTION MO 3  \nifosfamide 1 gram/20 ml, 3 gram/60 ml SOLUTION MO 3  \nimatinib 100 mg TABLET DL 5 PA,QL(90 per 30 days) \nimatinib 400 mg TABLET DL 5 PA,QL(60 per 30 days) \nIMBRUVICA 140 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nIMBRUVICA 420 MG, 560 MG TABLET DL 5 PA,QL(28 per 28 days) \nIMBRUVICA 70 MG CAPSULE DL 5 PA,QL(28 per 28 days) \nIMBRUVICA 70 MG/ML SUSPENSION DL 5 PA \nIMFINZI 50 MG/ML SOLUTION DL 5 PA \nIMJUDO 20 MG/ML SOLUTION DL 5 PA \nIMLYGIC 10EXP6 (1 MILLION) PFU/ML SUSPENSION DL 5 PA,QL(4 per 365 days) \nIMLYGIC 10EXP8 (100 MILLION) PFU/ML SUSPENSION DL 5 PA,QL(8 per 28 days) \nINLYTA 1 MG TABLET DL 5 PA,QL(180 per 30 days) \nINLYTA 5 MG TABLET DL 5 PA,QL(60 per 30 days) ", "doc_id": "c0942f2a-24b1-4f8c-b0fa-9d86c59ed22a", "embedding": null, "doc_hash": "35adab371d1056098ae26e8e2f9df00b48c966b23d9c1855f957995420fbe750", "extra_info": {"page_label": "32", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2375, "_node_type": "1"}, "relationships": {"1": "009fc9e2-66b2-4c46-b9cf-c7cbc02025bf"}}, "__type__": "1"}, "0983cd3c-221c-4e95-9673-8e8178b73cff": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 33DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.INQOVI 35-100 MG TABLET DL 5 PA,QL(5 per 28 days) \nINREBIC 100 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nIRESSA 250 MG TABLET DL 5 PA,QL(30 per 30 days) \nirinotecan 100 mg/5 ml, 300 mg/15 ml, 40 mg/2 ml, 500 mg/25 ml SOLUTION \nMO4  \nISTODAX 10 MG/2 ML RECON SOLUTION DL 5 PA \nIXEMPRA 15 MG, 45 MG RECON SOLUTION DL 5 PA \nJAKAFI 10 MG, 15 MG, 20 MG, 25 MG, 5 MG TABLET DL 5 PA,QL(60 per 30 days) \nJAYPIRCA 100 MG, 50 MG TABLET DL 5 PA,QL(90 per 30 days) \nJEMPERLI 50 MG/ML SOLUTION 5 PA,QL(20 per 42 days) \nJEVTANA 10 MG/ML (FIRST DILUTION) SOLUTION DL 5 PA \nKADCYLA 100 MG, 160 MG RECON SOLUTION DL 5 PA \nKANJINTI 150 MG, 420 MG RECON SOLUTION DL 5 PA \nKEYTRUDA 25 MG/ML SOLUTION DL 5 PA \nKIMMTRAK 100 MCG/0.5 ML SOLUTION DL 5 PA \nKISQALI 200 MG/DAY (200 MG X 1) TABLET DL 5 PA,QL(21 per 28 days) \nKISQALI 400 MG/DAY (200 MG X 2) TABLET DL 5 PA,QL(42 per 28 days) \nKISQALI 600 MG/DAY (200 MG X 3) TABLET DL 5 PA,QL(63 per 28 days) \nKISQALI FEMARA CO-PACK 200 MG/DAY(200 MG X 1)-2.5 MG TABLET DL 5 PA,QL(49 per 28 days) \nKISQALI FEMARA CO-PACK 400 MG/DAY(200 MG X 2)-2.5 MG TABLET DL 5 PA,QL(70 per 28 days) \nKISQALI FEMARA CO-PACK 600 MG/DAY(200 MG X 3)-2.5 MG TABLET DL 5 PA,QL(91 per 28 days) \nKOSELUGO 10 MG CAPSULE DL 5 PA,QL(240 per 30 days) \nKOSELUGO 25 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nKRAZATI 200 MG TABLET DL 5 PA,QL(180 per 30 days) \nKYPROLIS 10 MG RECON SOLUTION DL 5 PA,QL(6 per 28 days) \nKYPROLIS 30 MG RECON SOLUTION DL 5 PA,QL(3 per 28 days) \nKYPROLIS 60 MG RECON SOLUTION DL 5 PA,QL(12 per 28 days) \nlapatinib 250 mg TABLET DL 5 PA,QL(180 per 30 days) \nlenalidomide 10 mg, 15 mg, 2.5 mg, 20 mg, 25 mg, 5 mg CAPSULE DL 5 PA,QL(28 per 28 days) \nLENVIMA 10 MG/DAY (10 MG X 1), 4 MG CAPSULE DL 5 PA,QL(30 per 30 days) \nLENVIMA 12 MG/DAY (4 MG X 3), 18 MG/DAY (10 MG X 1-4 MG X2), 24  \nMG/DAY(10 MG X 2-4 MG X 1) CAPSULE DL5 PA,QL(90 per 30 days) \nLENVIMA 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY  \n(4 MG X 2) CAPSULE DL5 PA,QL(60 per 30 days) \nletrozole 2.5 mg TABLET GC,MO 2 QL(30", "doc_id": "0983cd3c-221c-4e95-9673-8e8178b73cff", "embedding": null, "doc_hash": "d05acd37d6adaa7c502a7d4c8d33d78fa5092f6b30464a3c4b6cb1361a4bb113", "extra_info": {"page_label": "33", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2515, "_node_type": "1"}, "relationships": {"1": "b3434ad0-6a4b-4f5c-9257-0d207cc9bf8c", "3": "973cb306-f3f4-4f56-ad07-faac69cd9646"}}, "__type__": "1"}, "973cb306-f3f4-4f56-ad07-faac69cd9646": {"__data__": {"text": "days) \nletrozole 2.5 mg TABLET GC,MO 2 QL(30 per 30 days) \nleucovorin calcium 10 mg, 15 mg, 25 mg, 5 mg TABLET GC,MO 2  ", "doc_id": "973cb306-f3f4-4f56-ad07-faac69cd9646", "embedding": null, "doc_hash": "268a6f66ed52bc021800418f20f3d0a50811ccfd0860706a5dae49f6b987d7e3", "extra_info": {"page_label": "33", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2471, "end": 2591, "_node_type": "1"}, "relationships": {"1": "b3434ad0-6a4b-4f5c-9257-0d207cc9bf8c", "2": "0983cd3c-221c-4e95-9673-8e8178b73cff"}}, "__type__": "1"}, "11c24e56-649f-49c9-8089-8514099dc111": {"__data__": {"text": "34 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.leucovorin calcium 10 mg/ml SOLUTION GC,MO 2  \nleucovorin calcium 100 mg, 200 mg, 350 mg, 50 mg, 500 mg RECON SOLUTION \nMO4  \nLEUKERAN 2 MG TABLET DL 5  \nlevoleucovorin calcium 10 mg/ml SOLUTION DL 5 PA \nlevoleucovorin calcium 50 mg RECON SOLUTION DL 5 PA \nLEVULAN 20 % SOLUTION MO 4  \nLIBTAYO 50 MG/ML SOLUTION DL 5 PA,QL(7 per 21 days) \nLONSURF 15-6.14 MG TABLET DL 5 PA,QL(100 per 30 days) \nLONSURF 20-8.19 MG TABLET DL 5 PA,QL(80 per 30 days) \nLORBRENA 100 MG TABLET DL 5 PA,QL(30 per 30 days) \nLORBRENA 25 MG TABLET DL 5 PA,QL(90 per 30 days) \nLUMAKRAS 120 MG TABLET DL 5 PA,QL(240 per 30 days) \nLUMAKRAS 320 MG TABLET DL 5 PA,QL(90 per 30 days) \nLUMOXITI 1 MG RECON SOLUTION DL 5 PA \nLUNSUMIO 1 MG/ML SOLUTION DL 5 PA \nLYNPARZA 100 MG, 150 MG TABLET DL 5 PA,QL(120 per 30 days) \nLYTGOBI 4 MG TABLET DL 5 PA,QL(140 per 28 days) \nMARGENZA 25 MG/ML SOLUTION DL 5 PA \nMATULANE 50 MG CAPSULE DL 5  \nMEKINIST 0.05 MG/ML RECON SOLUTION DL 5 PA,QL(1170 per 28 days) \nMEKINIST 0.5 MG TABLET DL 5 PA,QL(120 per 30 days) \nMEKINIST 2 MG TABLET DL 5 PA,QL(30 per 30 days) \nMEKTOVI 15 MG TABLET DL 5 PA,QL(180 per 30 days) \nmelphalan 2 mg TABLET MO 4 BvsD \nmelphalan hcl 50 mg RECON SOLUTION GC,MO 1  \nmercaptopurine 50 mg TABLET MO 3  \nMESNEX 400 MG TABLET DL 5  \nmitomycin 20 mg, 40 mg, 5 mg RECON SOLUTION DL 5  \nmitoxantrone 2 mg/ml CONCENTRATE MO 3  \nMUTAMYCIN 20 MG, 40 MG, 5 MG RECON SOLUTION DL 5  \nMVASI 25 MG/ML SOLUTION DL 5 PA \nMYLOTARG 4.5 MG (1 MG/ML INITIAL CONC) RECON SOLUTION DL 5 PA \nnelarabine 250 mg/50 ml SOLUTION DL 5  \nNERLYNX 40 MG TABLET DL 5 PA,QL(180 per 30 days) \nnilutamide 150 mg TABLET DL 5 QL(60 per 30 days) ", "doc_id": "11c24e56-649f-49c9-8089-8514099dc111", "embedding": null, "doc_hash": "f4b6ff31e4d29481c1678e3f1dd59674eb4048bf1bdf288ce265d71942d8ddb5", "extra_info": {"page_label": "34", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2129, "_node_type": "1"}, "relationships": {"1": "a58c715b-251c-48d9-915e-a5d58ca52a04"}}, "__type__": "1"}, "54c8c7f5-b676-4b45-8604-29382816b200": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 35DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.NINLARO 2.3 MG, 3 MG, 4 MG CAPSULE DL 5 PA,QL(3 per 28 days) \nNIPENT 10 MG RECON SOLUTION DL 5  \nNUBEQA 300 MG TABLET DL 5 PA,QL(120 per 30 days) \nODOMZO 200 MG CAPSULE DL 5 PA,QL(30 per 30 days) \nONCASPAR 750 UNIT/ML SOLUTION DL 5 PA \nONIVYDE 4.3 MG/ML DISPERSION DL 5 PA \nONUREG 200 MG, 300 MG TABLET DL 5 PA,QL(14 per 28 days) \nOPDIVO 100 MG/10 ML SOLUTION DL 5 PA,QL(40 per 28 days) \nOPDIVO 120 MG/12 ML, 240 MG/24 ML SOLUTION DL 5 PA,QL(48 per 28 days) \nOPDIVO 40 MG/4 ML SOLUTION DL 5 PA,QL(16 per 28 days) \nOPDUALAG 240-80 MG/20 ML SOLUTION DL 5 PA,QL(40 per 28 days) \nORSERDU 345 MG TABLET DL 5 PA,QL(30 per 30 days) \nORSERDU 86 MG TABLET DL 5 PA,QL(90 per 30 days) \noxaliplatin 100 mg, 50 mg RECON SOLUTION MO 4  \noxaliplatin 100 mg/20 ml, 200 mg/40 ml, 50 mg/10 ml (5 mg/ml) SOLUTION MO 4  \npaclitaxel 6 mg/ml CONCENTRATE MO 4  \npaclitaxel protein-bound 100 mg SUSPENSION FOR RECONSTITUTION DL 5 PA \nPADCEV 20 MG RECON SOLUTION DL 5 PA,QL(21 per 28 days) \nPADCEV 30 MG RECON SOLUTION DL 5 PA,QL(15 per 28 days) \nPANRETIN 0.1 % GEL DL 5 PA \nparaplatin 10 mg/ml SOLUTION MO 3  \nPEMAZYRE 13.5 MG, 4.5 MG, 9 MG TABLET DL 5 PA,QL(28 per 28 days) \npemetrexed 1 gram, 100 mg, 500 mg RECON SOLUTION DL 5 PA \npemetrexed disodium 1,000 mg, 100 mg, 500 mg, 750 mg RECON SOLUTION \nDL5 PA \npemetrexed disodium 25 mg/ml SOLUTION DL 5 PA \nPERJETA 420 MG/14 ML (30 MG/ML) SOLUTION DL 5 PA \nPIQRAY 200 MG/DAY (200 MG X 1) TABLET DL 5 PA,QL(28 per 28 days) \nPIQRAY 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2)  \nTABLET DL5 PA,QL(56 per 28 days) \nPOLIVY 140 MG RECON SOLUTION DL 5 PA,QL(2 per 21 days) \nPOLIVY 30 MG RECON SOLUTION DL 5 PA,QL(8 per 21 days) \nPOMALYST 1 MG, 2 MG, 3 MG, 4 MG CAPSULE DL 5 PA,QL(21 per 28 days) \nPORTRAZZA 800 MG/50 ML (16 MG/ML) SOLUTION DL 5 PA,QL(100 per 21 days) \nPOTELIGEO 4 MG/ML SOLUTION DL 5 PA \nPROLEUKIN 22 MILLION UNIT RECON SOLUTION DL 5  ", "doc_id": "54c8c7f5-b676-4b45-8604-29382816b200", "embedding": null, "doc_hash": "229708a3e67e623da28f73d2770242ce1b763ba3fa5a5f8805d287d6b3395005", "extra_info": {"page_label": "35", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2379, "_node_type": "1"}, "relationships": {"1": "d77102b6-39ba-4fda-89ad-8e805ce31913"}}, "__type__": "1"}, "24082785-35a7-46e4-b4d7-28f78524d38a": {"__data__": {"text": "36 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.PURIXAN 20 MG/ML SUSPENSION DL 5 QL(300 per 30 days) \nQINLOCK 50 MG TABLET DL 5 PA,QL(90 per 30 days) \nRETEVMO 40 MG CAPSULE DL 5 PA,QL(180 per 30 days) \nRETEVMO 80 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nREZLIDHIA 150 MG CAPSULE DL 5 PA,QL(60 per 30 days) \nRIABNI 10 MG/ML SOLUTION DL 5 PA \nromidepsin 10 mg/2 ml RECON SOLUTION DL 5 PA \nROMIDEPSIN 5 MG/ML SOLUTION DL 5 PA \nROZLYTREK 100 MG CAPSULE DL 5 PA,QL(150 per 30 days) \nROZLYTREK 200 MG CAPSULE DL 5 PA,QL(90 per 30 days) \nRUBRACA 200 MG, 250 MG, 300 MG TABLET DL 5 PA,QL(120 per 30 days) \nRUXIENCE 10 MG/ML SOLUTION DL 5 PA \nRYBREVANT 50 MG/ML SOLUTION DL 5 PA,QL(784 per 365 days) \nRYDAPT 25 MG CAPSULE DL 5 PA,QL(224 per 28 days) \nRYLAZE 10 MG/0.5 ML SOLUTION DL 5 PA \nSARCLISA 20 MG/ML SOLUTION DL 5 PA \nSCEMBLIX 20 MG TABLET DL 5 PA,QL(60 per 30 days) \nSCEMBLIX 40 MG TABLET DL 5 PA,QL(300 per 30 days) \nSOLTAMOX 20 MG/10 ML SOLUTION DL 5  \nsorafenib 200 mg TABLET DL 5 PA,QL(120 per 30 days) \nSPRYCEL 100 MG, 50 MG, 70 MG, 80 MG TABLET DL 5 PA,QL(60 per 30 days) \nSPRYCEL 140 MG TABLET DL 5 PA,QL(30 per 30 days) \nSPRYCEL 20 MG TABLET DL 5 PA,QL(90 per 30 days) \nSTIVARGA 40 MG TABLET DL 5 PA,QL(84 per 28 days) \nsunitinib malate 12.5 mg, 25 mg, 37.5 mg, 50 mg CAPSULE DL 5 PA,QL(28 per 28 days) \nSYNRIBO 3.5 MG RECON SOLUTION DL 5 PA \nTABLOID 40 MG TABLET MO 4  \nTABRECTA 150 MG, 200 MG TABLET DL 5 PA,QL(112 per 28 days) \nTAFINLAR 10 MG TABLET FOR SUSPENSION DL 5 PA,QL(840 per 28 days) \nTAFINLAR 50 MG CAPSULE DL 5 PA,QL(180 per 30 days) \nTAFINLAR 75 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nTAGRISSO 40 MG, 80 MG TABLET DL 5 PA,QL(30 per 30 days) \nTALZENNA 0.25 MG CAPSULE DL 5 PA,QL(90 per 30 days) \nTALZENNA 0.5 MG, 0.75 MG, 1 MG CAPSULE DL 5 PA,QL(30 per 30 days) \ntamoxifen 10 mg, 20 mg TABLET GC,MO 2  \nTARGRETIN 75 MG CAPSULE DL 5 PA,QL(300 per 30 days) ", "doc_id": "24082785-35a7-46e4-b4d7-28f78524d38a", "embedding": null, "doc_hash": "a8579513ffe07b212cbecc1bf3091d35047f0ddfed5bc439afca76d325cfe501", "extra_info": {"page_label": "36", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2323, "_node_type": "1"}, "relationships": {"1": "92bf58ef-8898-4573-915a-40a60f900fb1"}}, "__type__": "1"}, "11f220c1-1db5-4391-a680-317ad64416c6": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 37DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.TASIGNA 150 MG, 200 MG, 50 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nTAZVERIK 200 MG TABLET DL 5 PA,QL(240 per 30 days) \nTECENTRIQ 1,200 MG/20 ML (60 MG/ML) SOLUTION DL 5 PA,QL(20 per 21 days) \nTECENTRIQ 840 MG/14 ML (60 MG/ML) SOLUTION DL 5 PA,QL(28 per 28 days) \nTECVAYLI 10 MG/ML, 90 MG/ML SOLUTION DL 5 PA \ntemsirolimus 30 mg/3 ml (10 mg/ml) (first) RECON SOLUTION DL 5 PA,QL(8 per 28 days) \nteniposide 50 mg/5 ml SOLUTION MO 4  \nTEPMETKO 225 MG TABLET DL 5 PA,QL(60 per 30 days) \nTHALOMID 100 MG, 200 MG, 50 MG CAPSULE DL 5 PA,QL(30 per 30 days) \nTHALOMID 150 MG CAPSULE DL 5 PA,QL(60 per 30 days) \nthiotepa 100 mg RECON SOLUTION DL 5  \nthiotepa 15 mg RECON SOLUTION GC,MO 1  \nTIBSOVO 250 MG TABLET DL 5 PA,QL(60 per 30 days) \nTIVDAK 40 MG RECON SOLUTION DL 5 PA,QL(5 per 21 days) \ntopotecan 4 mg RECON SOLUTION MO 4  \ntopotecan 4 mg/4 ml (1 mg/ml) SOLUTION MO 4  \ntoremifene 60 mg TABLET DL 5 QL(30 per 30 days) \nTRAZIMERA 150 MG, 420 MG RECON SOLUTION DL 5 PA \nTREANDA 100 MG, 25 MG RECON SOLUTION DL 5 PA \ntretinoin (antineoplastic) 10 mg CAPSULE DL 5  \nTRISENOX 2 MG/ML SOLUTION DL 5 PA \nTRODELVY 180 MG RECON SOLUTION DL 5 PA \nTRUSELTIQ 100 MG/DAY (100 MG X 1) CAPSULE DL 5 PA,QL(21 per 28 days) \nTRUSELTIQ 125 MG/DAY(100 MG X1-25MG X1), 50 MG/DAY (25 MG X 2)  \nCAPSULE DL5 PA,QL(42 per 28 days) \nTRUSELTIQ 75 MG/DAY (25 MG X 3) CAPSULE DL 5 PA,QL(63 per 28 days) \nTUKYSA 150 MG TABLET DL 5 PA,QL(120 per 30 days) \nTUKYSA 50 MG TABLET DL 5 PA,QL(300 per 30 days) \nTURALIO 125 MG, 200 MG CAPSULE DL,LA 5 PA,QL(120 per 30 days) \nUNITUXIN 3.5 MG/ML SOLUTION DL 5 PA \nVALCHLOR 0.016 % GEL DL 5 PA,QL(60 per 28 days) \nvalrubicin 40 mg/ml SOLUTION DL 5 PA,QL(80 per 28 days) \nVALSTAR 40 MG/ML SOLUTION DL 5 PA,QL(80 per 28 days) \nVECTIBIX 100 MG/5 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML) SOLUTION DL 5 PA \nVENCLEXTA 10 MG TABLET MO 3 PA,QL(56 per 28 days) \nVENCLEXTA 100 MG TABLET DL 5 PA,QL(180 per 30 days) ", "doc_id": "11f220c1-1db5-4391-a680-317ad64416c6", "embedding": null, "doc_hash": "b9273671b5ef80ff5e1f39269346cb45a8b1c55d3d4773b5a6d66a7bddbf906e", "extra_info": {"page_label": "37", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2405, "_node_type": "1"}, "relationships": {"1": "f6b2aade-f614-4c20-9645-795dbe8080c8"}}, "__type__": "1"}, "1b66f01d-2b6d-42e5-b374-0fe3200e705e": {"__data__": {"text": "38 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.VENCLEXTA 50 MG TABLET MO 3 PA,QL(28 per 28 days) \nVENCLEXTA STARTING PACK 10 MG-50 MG- 100 MG TABLET, DOSE PACK DL 5 PA,QL(42 per 28 days) \nVERZENIO 100 MG, 150 MG, 200 MG, 50 MG TABLET DL 5 PA,QL(60 per 30 days) \nvinblastine 1 mg/ml SOLUTION MO 3 BvsD \nvincasar pfs 1 mg/ml, 2 mg/2 ml SOLUTION MO 3 BvsD \nvincristine 1 mg/ml, 2 mg/2 ml SOLUTION MO 3 BvsD \nvinorelbine 10 mg/ml, 50 mg/5 ml SOLUTION MO 4  \nVISTOGARD 10 GRAM GRANULES IN PACKET DL 5 QL(20 per 365 days) \nVITRAKVI 100 MG CAPSULE DL 5 PA,QL(60 per 30 days) \nVITRAKVI 20 MG/ML SOLUTION DL 5 PA,QL(300 per 30 days) \nVITRAKVI 25 MG CAPSULE DL 5 PA,QL(180 per 30 days) \nVIZIMPRO 15 MG, 30 MG, 45 MG TABLET DL 5 PA,QL(30 per 30 days) \nVONJO 100 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nVOTRIENT 200 MG TABLET DL 5 PA,QL(120 per 30 days) \nVYXEOS 44-100 MG RECON SOLUTION DL 5 PA \nWELIREG 40 MG TABLET DL 5 PA,QL(90 per 30 days) \nXALKORI 200 MG, 250 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nXOSPATA 40 MG TABLET DL 5 PA,QL(90 per 30 days) \nXPOVIO 100 MG/WEEK (20 MG X 5) TABLET DL 5 PA,QL(20 per 28 days) \nXPOVIO 100 MG/WEEK (50 MG X 2), 40 MG/WEEK (20 MG X 2), 40MG TWICE  \nWEEK (40 MG X 2), 80 MG/WEEK (40 MG X 2) TABLET DL5 PA,QL(8 per 28 days) \nXPOVIO 40 MG/WEEK (40 MG X 1), 60 MG/WEEK (60 MG X 1) TABLET DL 5 PA,QL(4 per 28 days) \nXPOVIO 40MG TWICE WEEK (80 MG/WEEK), 80 MG/WEEK (20 MG X 4)  \nTABLET DL5 PA,QL(16 per 28 days) \nXPOVIO 60 MG/WEEK (20 MG X 3) TABLET DL 5 PA,QL(12 per 28 days) \nXPOVIO 60MG TWICE WEEK (120 MG/WEEK) TABLET DL 5 PA,QL(24 per 28 days) \nXPOVIO 80MG TWICE WEEK (160 MG/WEEK) TABLET DL 5 PA,QL(32 per 28 days) \nXTANDI 40 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nXTANDI 40 MG TABLET DL 5 PA,QL(120 per 30 days) \nXTANDI 80 MG TABLET DL 5 PA,QL(60 per 30 days) \nYERVOY 200 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) SOLUTION DL 5 PA \nYONDELIS 1 MG RECON SOLUTION DL 5 PA \nZALTRAP 100 MG/4 ML (25 MG/ML), 200 MG/8 ML (25 MG/ML) SOLUTION DL 5 PA \nZANOSAR 1 GRAM RECON SOLUTION MO 4  \nZEJULA 100 MG CAPSULE DL 5 PA,QL(90 per 30 days) \nZELBORAF 240 MG TABLET DL 5 PA,QL(240 per 30 days) ", "doc_id": "1b66f01d-2b6d-42e5-b374-0fe3200e705e", "embedding": null, "doc_hash": "04879201ba68a65404c92a77a40a7b1c7adae2989258fd75fc8a4edabb573274", "extra_info": {"page_label": "38", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2559, "_node_type": "1"}, "relationships": {"1": "95e171c5-9daf-4f5e-a3c1-ca6506032202"}}, "__type__": "1"}, "bd3584a8-8699-4b2f-b8df-d933804cc7f6": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 39DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.ZEPZELCA 4 MG RECON SOLUTION DL 5 PA \nZIRABEV 25 MG/ML SOLUTION DL 5 PA \nZOLINZA 100 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nZYDELIG 100 MG, 150 MG TABLET DL 5 PA,QL(60 per 30 days) \nZYKADIA 150 MG TABLET DL 5 PA,QL(150 per 30 days) \nZYNLONTA 10 MG RECON SOLUTION DL 5 PA \nZYNYZ 500 MG/20 ML SOLUTION DL 5 PA,QL(20 per 28 days) \nANTIPARASITICS\nalbendazole 200 mg TABLET MO 4  \natovaquone 750 mg/5 ml SUSPENSION MO 4  \natovaquone-proguanil 250-100 mg, 62.5-25 mg TABLET MO 4  \nchloroquine phosphate 250 mg, 500 mg TABLET MO 4  \nCOARTEM 20-120 MG TABLET MO 4 QL(24 per 30 days) \nhydroxychloroquine 100 mg, 300 mg, 400 mg TABLET GC,MO 2  \nhydroxychloroquine 200 mg TABLET GC,MO 2  \nivermectin 3 mg TABLET MO 3  \nKRINTAFEL 150 MG TABLET MO 3 QL(4 per 180 days) \nLAMPIT 120 MG, 30 MG TABLET MO 4  \nmefloquine 250 mg TABLET GC,MO 2  \nNEBUPENT 300 MG RECON SOLUTION MO 4 BvsD \nnitazoxanide 500 mg TABLET DL 5 QL(40 per 30 days) \nPENTAM 300 MG RECON SOLUTION MO 4  \npentamidine 300 mg RECON SOLUTION MO 4  \npentamidine 300 mg RECON SOLUTION MO 4 BvsD \npraziquantel 600 mg TABLET MO 4  \nprimaquine 26.3 mg TABLET MO 3  \npyrimethamine 25 mg TABLET DL 5 QL(90 per 30 days) \nquinine sulfate 324 mg CAPSULE MO 4 PA,QL(42 per 7 days) \nANTIPARKINSON AGENTS\namantadine hcl 100 mg CAPSULE MO 4  \namantadine hcl 50 mg/5 ml SOLUTION MO 3  \nbenztropine 0.5 mg, 1 mg, 2 mg TABLET GC,MO 2  \nbenztropine 1 mg/ml SOLUTION MO 4  \nbromocriptine 2.5 mg TABLET MO 4  \ncarbidopa-levodopa 10-100 mg, 25-100 mg, 25-250 mg TABLET,  \nDISINTEGRATING MO4  ", "doc_id": "bd3584a8-8699-4b2f-b8df-d933804cc7f6", "embedding": null, "doc_hash": "454b276146e1114732283eeb3f6fc8129d12789eb6083e7aa76e73fdaeceedee", "extra_info": {"page_label": "39", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2016, "_node_type": "1"}, "relationships": {"1": "514e0d12-f1a4-437c-8c28-dc7fc34bd1ed"}}, "__type__": "1"}, "13217e5f-1750-4171-9948-7e1621561e38": {"__data__": {"text": "40 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.carbidopa-levodopa 10-100 mg, 25-250 mg TABLET GC,MO 2  \ncarbidopa-levodopa 25-100 mg TABLET GC,MO 2  \ncarbidopa-levodopa 25-100 mg, 50-200 mg TABLET ER MO 3  \ncarbidopa-levodopa-entacapone 12.5-50-200 mg, 18.75-75-200 mg,  \n25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg TABLET MO4 QL(240 per 30 days) \ncarbidopa-levodopa-entacapone 50-200-200 mg TABLET MO 4  \nentacapone 200 mg TABLET MO 3 QL(300 per 30 days) \nKYNMOBI 10 MG, 15 MG, 20 MG, 25 MG, 30 MG FILM DL 5 PA,QL(150 per 30 days) \nKYNMOBI 10-15-20-25-30 MG FILM DL 5 PA,QL(150 per 30 days) \npramipexole 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg TABLET GC,MO 2  \nrasagiline 0.5 mg, 1 mg TABLET MO 4 PA,QL(30 per 30 days) \nropinirole 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg TABLET GC,MO 2  \nRYTARY 23.75-95 MG CAPSULE, ER MO 4 ST,QL(360 per 30 days) \nRYTARY 36.25-145 MG CAPSULE, ER MO 4 ST,QL(270 per 30 days) \nRYTARY 48.75-195 MG CAPSULE, ER MO 4 ST,QL(360 per 30 days) \nRYTARY 61.25-245 MG CAPSULE, ER MO 4 ST,QL(300 per 30 days) \nselegiline hcl 5 mg CAPSULE MO 3  \nselegiline hcl 5 mg TABLET MO 3  \ntrihexyphenidyl 0.4 mg/ml ELIXIR MO 3  \ntrihexyphenidyl 2 mg, 5 mg TABLET MO 3  \nANTIPSYCHOTICS\nABILIFY ASIMTUFII 720 MG/2.4 ML SUSPENSION, ER, SYRINGE 5 QL(2.4 per 56 days) \nABILIFY ASIMTUFII 960 MG/3.2 ML SUSPENSION, ER, SYRINGE 5 QL(3.2 per 56 days) \nABILIFY MAINTENA 300 MG, 400 MG SUSPENSION, ER, RECON DL 5 QL(1 per 28 days) \nABILIFY MAINTENA 300 MG, 400 MG SUSPENSION, ER, SYRINGE DL 5 QL(1 per 28 days) \naripiprazole 1 mg/ml SOLUTION MO 4 QL(750 per 30 days) \naripiprazole 10 mg, 15 mg TABLET, DISINTEGRATING MO 4 QL(60 per 30 days) \naripiprazole 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg TABLET MO 3  \nARISTADA 1,064 MG/3.9 ML SUSPENSION, ER, SYRINGE 5 QL(3.9 per 56 days) \nARISTADA 441 MG/1.6 ML SUSPENSION, ER, SYRINGE DL 5 QL(1.6 per 28 days) \nARISTADA 662 MG/2.4 ML SUSPENSION, ER, SYRINGE DL 5 QL(2.4 per 28 days) \nARISTADA 882 MG/3.2 ML", "doc_id": "13217e5f-1750-4171-9948-7e1621561e38", "embedding": null, "doc_hash": "1b764fbf9b2291807a6d5d4d7fcd15b8adb621674609703e94ee588d5600c7ab", "extra_info": {"page_label": "40", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2417, "_node_type": "1"}, "relationships": {"1": "ae0ee819-0056-4fd4-9162-116599ff81ec", "3": "5878cb32-b662-4691-916c-5cc3ed2825f3"}}, "__type__": "1"}, "5878cb32-b662-4691-916c-5cc3ed2825f3": {"__data__": {"text": "SUSPENSION, ER, SYRINGE DL 5 QL(3.2 per 28 days) \nARISTADA INITIO 675 MG/2.4 ML SUSPENSION, ER, SYRINGE DL 5 QL(2.4 per 42 days) \nasenapine maleate 10 mg, 2.5 mg, 5 mg SUBLINGUAL TABLET MO 4 PA,QL(60 per 30 days) \nCAPLYTA 10.5 MG, 21 MG, 42 MG CAPSULE DL 5 PA,QL(30 per 30 days) \nchlorpromazine 10 mg, 25 mg TABLET MO 4 BvsD ", "doc_id": "5878cb32-b662-4691-916c-5cc3ed2825f3", "embedding": null, "doc_hash": "0c1d1c91007112ba6af8b97c24a76e7b9827d409fc0456361ca70e1006341b72", "extra_info": {"page_label": "40", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2418, "end": 2743, "_node_type": "1"}, "relationships": {"1": "ae0ee819-0056-4fd4-9162-116599ff81ec", "2": "13217e5f-1750-4171-9948-7e1621561e38"}}, "__type__": "1"}, "fcbd8e4e-fa18-4895-9ddf-a6fb42aa5502": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 41DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.chlorpromazine 100 mg, 200 mg, 50 mg TABLET MO 4  \nchlorpromazine 100 mg/ml, 30 mg/ml CONCENTRATE MO 4  \nchlorpromazine 25 mg/ml SOLUTION MO 4  \nclozapine 100 mg TABLET MO 3 QL(270 per 30 days) \nclozapine 100 mg TABLET, DISINTEGRATING MO 4 PA,QL(270 per 30 days) \nclozapine 12.5 mg TABLET, DISINTEGRATING MO 4 PA \nclozapine 150 mg TABLET, DISINTEGRATING MO 4 PA,QL(180 per 30 days) \nclozapine 200 mg TABLET MO 3 QL(135 per 30 days) \nclozapine 200 mg TABLET, DISINTEGRATING MO 4 PA,QL(135 per 30 days) \nclozapine 25 mg TABLET MO 3 QL(1080 per 30 days) \nclozapine 25 mg TABLET, DISINTEGRATING MO 4 PA,QL(1080 per 30 days) \nclozapine 50 mg TABLET MO 3  \ndroperidol 2.5 mg/ml SOLUTION MO 3  \nFANAPT 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG TABLET DL 5 PA,QL(60 per 30 days) \nFANAPT 1MG(2)-2MG(2)- 4MG(2)-6MG(2) TABLET, DOSE PACK MO 4 PA,QL(56 per 28 days) \nfluphenazine decanoate 25 mg/ml SOLUTION MO 4  \nfluphenazine hcl 1 mg, 10 mg, 2.5 mg, 5 mg TABLET MO 4  \nfluphenazine hcl 2.5 mg/5 ml ELIXIR MO 4  \nfluphenazine hcl 2.5 mg/ml SOLUTION MO 4  \nfluphenazine hcl 5 mg/ml CONCENTRATE MO 4  \nhaloperidol 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg TABLET GC,MO 2  \nhaloperidol decanoate 100 mg/ml, 50 mg/ml SOLUTION MO 4  \nhaloperidol lactate 2 mg/ml CONCENTRATE GC,MO 2  \nhaloperidol lactate 5 mg/ml SOLUTION GC,MO 2  \nhaloperidol lactate 5 mg/ml SYRINGE GC,MO 2  \nINVEGA HAFYERA 1,092 MG/3.5 ML SYRINGE 5 QL(3.5 per 180 days) \nINVEGA HAFYERA 1,560 MG/5 ML SYRINGE 5 QL(5 per 180 days) \nINVEGA SUSTENNA 117 MG/0.75 ML, 234 MG/1.5 ML, 78 MG/0.5 ML SYRINGE \nDL5 QL(1.5 per 28 days) \nINVEGA SUSTENNA 156 MG/ML SYRINGE DL 5 QL(1 per 28 days) \nINVEGA SUSTENNA 39 MG/0.25 ML SYRINGE MO 4 QL(1.5 per 28 days) \nINVEGA TRINZA 273 MG/0.88 ML SYRINGE 5 QL(0.88 per 90 days) \nINVEGA TRINZA 410 MG/1.32 ML SYRINGE 5 QL(1.32 per 90 days) \nINVEGA TRINZA 546 MG/1.75 ML SYRINGE 5 QL(1.75 per 90 days) \nINVEGA TRINZA 819 MG/2.63 ML SYRINGE 5 QL(2.63 per 90 days) \nLATUDA 120 MG, 20 MG, 40 MG, 60 MG TABLET DL 5 PA,QL(30 per 30 days) ", "doc_id": "fcbd8e4e-fa18-4895-9ddf-a6fb42aa5502", "embedding": null, "doc_hash": "3448e1de3745b3f889b162cb898876fa89656d6646cc97d57e2db8a7d2820d17", "extra_info": {"page_label": "41", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2505, "_node_type": "1"}, "relationships": {"1": "df907850-1548-43ab-823a-bc3c26c3d15e"}}, "__type__": "1"}, "af543220-f827-4be3-b884-663b1f721236": {"__data__": {"text": "42 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.LATUDA 80 MG TABLET DL 5 PA,QL(60 per 30 days) \nloxapine succinate 10 mg, 25 mg, 5 mg, 50 mg CAPSULE GC,MO 2  \nlurasidone 120 mg, 20 mg, 40 mg, 60 mg TABLET GC,MO 2 PA,QL(30 per 30 days) \nlurasidone 80 mg TABLET GC,MO 2 PA,QL(60 per 30 days) \nLYBALVI 10-10 MG, 15-10 MG, 20-10 MG, 5-10 MG TABLET DL 5 PA,QL(30 per 30 days) \nmolindone 10 mg TABLET MO 4 PA,QL(240 per 30 days) \nmolindone 25 mg TABLET MO 4 PA,QL(270 per 30 days) \nmolindone 5 mg TABLET MO 4 PA,QL(360 per 30 days) \nNUPLAZID 10 MG TABLET DL 5 PA,QL(30 per 30 days) \nNUPLAZID 34 MG CAPSULE DL 5 PA,QL(30 per 30 days) \nolanzapine 10 mg RECON SOLUTION MO 4  \nolanzapine 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg TABLET MO 3  \nolanzapine 10 mg, 5 mg TABLET, DISINTEGRATING MO 4 QL(30 per 30 days) \nolanzapine 15 mg, 20 mg TABLET, DISINTEGRATING MO 4 QL(60 per 30 days) \npaliperidone 1.5 mg, 3 mg, 9 mg TABLET, ER 24 HR. MO 4 QL(30 per 30 days) \npaliperidone 6 mg TABLET, ER 24 HR. MO 4 QL(60 per 30 days) \nperphenazine 16 mg, 2 mg, 4 mg, 8 mg TABLET MO 4  \nPERSERIS 120 MG, 90 MG SUSPENSION, ER, SYRINGE DL 5 QL(1 per 28 days) \npimozide 1 mg, 2 mg TABLET MO 4  \nquetiapine 100 mg TABLET GC,MO 2 QL(90 per 30 days) \nquetiapine 150 mg TABLET GC,MO 2 QL(30 per 30 days) \nquetiapine 150 mg TABLET, ER 24 HR. MO 3 QL(90 per 30 days) \nquetiapine 200 mg TABLET GC,MO 2 QL(120 per 30 days) \nquetiapine 200 mg TABLET, ER 24 HR. MO 3 QL(30 per 30 days) \nquetiapine 25 mg, 50 mg TABLET GC,MO 2 QL(120 per 30 days) \nquetiapine 300 mg, 400 mg TABLET GC,MO 2 QL(60 per 30 days) \nquetiapine 300 mg, 400 mg TABLET, ER 24 HR. MO 3 QL(60 per 30 days) \nquetiapine 50 mg TABLET, ER 24 HR. MO 3 QL(120 per 30 days) \nREXULTI 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG TABLET MO 4 PA,QL(30 per 30 days) \nRISPERDAL CONSTA 12.5 MG/2 ML, 25 MG/2 ML SUSPENSION, ER, RECON MO 4 QL(2 per 28 days) \nRISPERDAL CONSTA 37.5 MG/2 ML, 50 MG/2 ML SUSPENSION, ER, RECON DL 5 QL(2 per 28 days) \nrisperidone 0.25 mg, 1 mg, 2 mg, 3 mg, 4 mg TABLET GC,MO 1 QL(60 per 30 days) \nrisperidone 0.25 mg, 1 mg, 2 mg, 3 mg, 4 mg TABLET, DISINTEGRATING", "doc_id": "af543220-f827-4be3-b884-663b1f721236", "embedding": null, "doc_hash": "87b9f44d67d48374f16ce003a95560bcd104975644448cefe7aa767bcde25bb3", "extra_info": {"page_label": "42", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2553, "_node_type": "1"}, "relationships": {"1": "39ea412b-6dee-455c-8d56-251d6a269237", "3": "257ce1e2-82e7-40d4-ae7b-13cf733adf76"}}, "__type__": "1"}, "257ce1e2-82e7-40d4-ae7b-13cf733adf76": {"__data__": {"text": "MO 4 ST,QL(60 per 30 days) \nrisperidone 0.5 mg TABLET GC,MO 1 QL(120 per 30 days) \nrisperidone 0.5 mg TABLET, DISINTEGRATING MO 4 ST,QL(120 per 30 days) \nrisperidone 1 mg/ml SOLUTION GC,MO 2  ", "doc_id": "257ce1e2-82e7-40d4-ae7b-13cf733adf76", "embedding": null, "doc_hash": "0b53738143a179074c9528f1302ef9db6863537d2ee2fc9e725ece7c3e9779e6", "extra_info": {"page_label": "42", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2554, "end": 2746, "_node_type": "1"}, "relationships": {"1": "39ea412b-6dee-455c-8d56-251d6a269237", "2": "af543220-f827-4be3-b884-663b1f721236"}}, "__type__": "1"}, "28665762-0c23-41d9-8832-93c980aa3210": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 43DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.SECUADO 3.8 MG/24 HOUR, 5.7 MG/24 HOUR, 7.6 MG/24 HOUR PATCH, 24 HR. \nDL5 PA,QL(30 per 30 days) \nthioridazine 10 mg, 100 mg, 25 mg, 50 mg TABLET MO 3  \nthiothixene 1 mg, 10 mg, 2 mg, 5 mg CAPSULE MO 4  \ntrifluoperazine 1 mg, 10 mg, 2 mg, 5 mg TABLET MO 3  \nVERSACLOZ 50 MG/ML SUSPENSION DL 5 PA,QL(540 per 30 days) \nVRAYLAR 1.5 MG (1)- 3 MG (6) CAPSULE, DOSE PACK MO 4 PA \nVRAYLAR 1.5 MG, 3 MG, 4.5 MG, 6 MG CAPSULE DL 5 PA,QL(30 per 30 days) \nziprasidone hcl 20 mg, 40 mg, 60 mg, 80 mg CAPSULE MO 3  \nziprasidone mesylate 20 mg/ml (final conc.) RECON SOLUTION MO 4  \nZYPREXA RELPREVV 210 MG SUSPENSION FOR RECONSTITUTION MO 4 QL(4 per 28 days) \nZYPREXA RELPREVV 300 MG SUSPENSION FOR RECONSTITUTION DL 5 QL(2 per 28 days) \nZYPREXA RELPREVV 405 MG SUSPENSION FOR RECONSTITUTION DL 5 QL(1 per 28 days) \nANTISPASTICITY AGENTS\nbaclofen 10 mg TABLET GC,MO 2  \nbaclofen 20 mg TABLET GC,MO 2  \nbaclofen 5 mg TABLET GC,MO 2 QL(90 per 30 days) \ndantrolene 100 mg, 50 mg CAPSULE MO 4  \ndantrolene 25 mg CAPSULE MO 3  \ntizanidine 2 mg, 4 mg TABLET GC,MO 1  \nANTIVIRALS\nabacavir 20 mg/ml SOLUTION MO 4 QL(960 per 30 days) \nabacavir 300 mg TABLET MO 4 QL(60 per 30 days) \nabacavir-lamivudine 600-300 mg TABLET MO 4 QL(30 per 30 days) \nabacavir-lamivudine-zidovudine 300-150-300 mg TABLET DL 5 QL(60 per 30 days) \nacyclovir 200 mg CAPSULE GC,MO 2  \nacyclovir 400 mg TABLET GC,MO 2  \nacyclovir 5 % OINTMENT MO 4 PA,QL(30 per 30 days) \nacyclovir 800 mg TABLET GC,MO 2  \nacyclovir sodium 1,000 mg, 500 mg RECON SOLUTION MO 4 BvsD \nacyclovir sodium 50 mg/ml SOLUTION MO 4 BvsD \nadefovir 10 mg TABLET MO 4  \nAPRETUDE 600 MG/3 ML (200 MG/ML) SUSPENSION, ER DL 5 QL(21 per 365 days) \nAPTIVUS 250 MG CAPSULE DL 5 QL(120 per 30 days) \nAPTIVUS (WITH VITAMIN E) 100 MG/ML SOLUTION DL 5 QL(285 per 28 days) \natazanavir 150 mg, 200 mg CAPSULE MO 4 QL(60 per 30 days) ", "doc_id": "28665762-0c23-41d9-8832-93c980aa3210", "embedding": null, "doc_hash": "77c91a0672cdfc527e5ed489a6c3078872b022307ce55307d7bf79221634a0ae", "extra_info": {"page_label": "43", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2336, "_node_type": "1"}, "relationships": {"1": "d6711024-e820-4845-9eaf-e3e4d24fabd2"}}, "__type__": "1"}, "ca2f55f4-194a-4efb-9b57-c512f4e30199": {"__data__": {"text": "44 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.atazanavir 300 mg CAPSULE MO 4 QL(30 per 30 days) \nBARACLUDE 0.05 MG/ML SOLUTION DL 5 QL(630 per 30 days) \nBIKTARVY 30-120-15 MG, 50-200-25 MG TABLET DL 5 QL(30 per 30 days) \nCABENUVA 400 MG/2 ML- 600 MG/2 ML, 600 MG/3 ML- 900 MG/3 ML  \nSUSPENSION, ER DL5 QL(50 per 365 days) \ncidofovir 75 mg/ml SOLUTION DL 5  \nCIMDUO 300-300 MG TABLET DL 5 QL(30 per 30 days) \nCOMPLERA 200-25-300 MG TABLET DL 5 QL(30 per 30 days) \nDELSTRIGO 100-300-300 MG TABLET DL 5 QL(30 per 30 days) \nDESCOVY 120-15 MG TABLET DL 5 QL(30 per 30 days) \nDESCOVY 200-25 MG TABLET DL 5 QL(30 per 30 days) \ndidanosine 250 mg, 400 mg CAPSULE, DR/EC MO 4 QL(30 per 30 days) \nDOVATO 50-300 MG TABLET DL 5 QL(30 per 30 days) \nEDURANT 25 MG TABLET DL 5 QL(30 per 30 days) \nefavirenz 200 mg CAPSULE MO 4 QL(120 per 30 days) \nefavirenz 50 mg CAPSULE MO 4 QL(480 per 30 days) \nefavirenz 600 mg TABLET MO 4 QL(30 per 30 days) \nefavirenz-emtricitabin-tenofov 600-200-300 mg TABLET MO 4 QL(30 per 30 days) \nefavirenz-lamivu-tenofov disop 400-300-300 mg, 600-300-300 mg TABLET DL 5 QL(30 per 30 days) \nemtricitabine 200 mg CAPSULE MO 4 QL(30 per 30 days) \nemtricitabine-tenofovir (tdf) 100-150 mg, 133-200 mg, 167-250 mg, 200-300  \nmg TABLET MO4 QL(30 per 30 days) \nEMTRIVA 10 MG/ML SOLUTION MO 4 QL(680 per 28 days) \nEMTRIVA 200 MG CAPSULE MO 4 QL(30 per 30 days) \nentecavir 0.5 mg, 1 mg TABLET MO 4 QL(30 per 30 days) \nEPCLUSA 150-37.5 MG PELLETS IN PACKET DL 5 PA,QL(28 per 28 days) \nEPCLUSA 200-50 MG PELLETS IN PACKET DL 5 PA,QL(56 per 28 days) \nEPCLUSA 200-50 MG, 400-100 MG TABLET DL 5 PA,QL(28 per 28 days) \nEPIVIR HBV 25 MG/5 ML (5 MG/ML) SOLUTION MO 4  \netravirine 100 mg TABLET DL 5 QL(120 per 30 days) \netravirine 200 mg TABLET DL 5 QL(60 per 30 days) \nEVOTAZ 300-150 MG TABLET DL 5 QL(30 per 30 days) \nfamciclovir 125 mg, 250 mg, 500 mg TABLET MO 3 QL(90 per 30 days) \nfosamprenavir 700 mg TABLET DL 5 QL(120 per 30 days) \nFUZEON 90 MG RECON SOLUTION DL 5 QL(60 per 30 days) \nGENVOYA 150-150-200-10 MG TABLET DL 5 QL(30 per 30 days) ", "doc_id": "ca2f55f4-194a-4efb-9b57-c512f4e30199", "embedding": null, "doc_hash": "4913f4293f5da0f3bb2517f601b766907a4b01f26941b83f189112a1c5facb3c", "extra_info": {"page_label": "44", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2496, "_node_type": "1"}, "relationships": {"1": "06a88d02-fe43-4815-877d-29a7760b1bba"}}, "__type__": "1"}, "c57aa113-b013-4d52-b245-c47032c5fdc0": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 45DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.HARVONI 33.75-150 MG PELLETS IN PACKET DL 5 PA,QL(28 per 28 days) \nHARVONI 45-200 MG PELLETS IN PACKET DL 5 PA,QL(56 per 28 days) \nHARVONI 45-200 MG TABLET DL 5 PA,QL(28 per 28 days) \nHARVONI 90-400 MG TABLET DL 5 PA,QL(28 per 28 days) \nINTELENCE 200 MG TABLET DL 5 QL(60 per 30 days) \nINTELENCE 25 MG TABLET MO 4 QL(120 per 30 days) \nINVIRASE 500 MG TABLET DL 5 QL(120 per 30 days) \nISENTRESS 100 MG CHEWABLE TABLET DL 5 QL(180 per 30 days) \nISENTRESS 100 MG POWDER IN PACKET MO 3 QL(300 per 30 days) \nISENTRESS 25 MG CHEWABLE TABLET MO 4 QL(180 per 30 days) \nISENTRESS 400 MG TABLET DL 5 QL(120 per 30 days) \nISENTRESS HD 600 MG TABLET DL 5 QL(60 per 30 days) \nJULUCA 50-25 MG TABLET DL 5 QL(30 per 30 days) \nlamivudine 10 mg/ml SOLUTION MO 3 QL(900 per 30 days) \nlamivudine 100 mg TABLET MO 3 QL(90 per 30 days) \nlamivudine 150 mg TABLET MO 3 QL(60 per 30 days) \nlamivudine 300 mg TABLET MO 3 QL(30 per 30 days) \nlamivudine-zidovudine 150-300 mg TABLET MO 4 QL(60 per 30 days) \nledipasvir-sofosbuvir 90-400 mg TABLET DL 5 PA,QL(28 per 28 days) \nLEXIVA 50 MG/ML SUSPENSION MO 4 QL(1575 per 28 days) \nlopinavir-ritonavir 100-25 mg TABLET MO 4 QL(300 per 30 days) \nlopinavir-ritonavir 200-50 mg TABLET MO 4 QL(150 per 30 days) \nlopinavir-ritonavir 400-100 mg/5 ml SOLUTION MO 4  \nmaraviroc 150 mg TABLET DL 5 QL(240 per 30 days) \nmaraviroc 300 mg TABLET DL 5 QL(120 per 30 days) \nnevirapine 100 mg TABLET, ER 24 HR. MO 4 QL(120 per 30 days) \nnevirapine 200 mg TABLET GC,MO 2 QL(60 per 30 days) \nnevirapine 400 mg TABLET, ER 24 HR. MO 4 QL(30 per 30 days) \nnevirapine 50 mg/5 ml SUSPENSION MO 4 QL(1200 per 30 days) \nNORVIR 100 MG POWDER IN PACKET MO 4 QL(360 per 30 days) \nNORVIR 80 MG/ML SOLUTION MO 4 QL(480 per 30 days) \nODEFSEY 200-25-25 MG TABLET DL 5 QL(30 per 30 days) \noseltamivir 30 mg CAPSULE MO 3 QL(224 per 365 days) \noseltamivir 45 mg, 75 mg CAPSULE MO 3 QL(112 per 365 days) \noseltamivir 6 mg/ml SUSPENSION FOR RECONSTITUTION MO 4 QL(1440 per 365 days) \nPIFELTRO 100 MG TABLET DL 5 QL(60 per 30 days) ", "doc_id": "c57aa113-b013-4d52-b245-c47032c5fdc0", "embedding": null, "doc_hash": "bc6b265e981a49f017991362cd605e526fe27390debe4700467a9ed88e571c36", "extra_info": {"page_label": "45", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2510, "_node_type": "1"}, "relationships": {"1": "a6703883-5883-4ea4-b0d6-2420402bd717"}}, "__type__": "1"}, "919db0b7-824b-4e73-9a33-b76939d1c8b0": {"__data__": {"text": "46 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.PREVYMIS 240 MG TABLET DL 5 PA,QL(28 per 28 days) \nPREVYMIS 480 MG TABLET DL 5 PA \nPREZCOBIX 800-150 MG-MG TABLET DL 5 QL(30 per 30 days) \nPREZISTA 100 MG/ML SUSPENSION DL 5 QL(360 per 30 days) \nPREZISTA 150 MG TABLET DL 5 QL(240 per 30 days) \nPREZISTA 600 MG TABLET DL 5 QL(60 per 30 days) \nPREZISTA 75 MG TABLET MO 4 QL(480 per 30 days) \nPREZISTA 800 MG TABLET DL 5 QL(30 per 30 days) \nRELENZA DISKHALER 5 MG/ACTUATION BLISTER WITH DEVICE MO 4 QL(60 per 180 days) \nRETROVIR 10 MG/ML SOLUTION MO 4  \nREYATAZ 50 MG POWDER IN PACKET MO 4  \nribavirin 200 mg CAPSULE MO 3 QL(168 per 28 days) \nribavirin 200 mg TABLET MO 3 QL(168 per 28 days) \nrimantadine 100 mg TABLET MO 4  \nritonavir 100 mg TABLET MO 3 QL(360 per 30 days) \nRUKOBIA 600 MG TABLET, ER 12 HR. DL 5 QL(60 per 30 days) \nSELZENTRY 20 MG/ML SOLUTION DL 5 QL(1800 per 30 days) \nSELZENTRY 25 MG TABLET MO 4 QL(240 per 30 days) \nSELZENTRY 75 MG TABLET DL 5 QL(120 per 30 days) \nstavudine 15 mg, 20 mg CAPSULE MO 3 QL(120 per 30 days) \nstavudine 30 mg, 40 mg CAPSULE MO 3 QL(60 per 30 days) \nSTRIBILD 150-150-200-300 MG TABLET DL 5 QL(30 per 30 days) \nSUNLENCA 300 MG TABLET DL 5 QL(10 per 365 days) \nSUNLENCA 309 MG/ML SOLUTION 5 QL(9 per 365 days) \nSYMFI 600-300-300 MG TABLET DL 5 QL(30 per 30 days) \nSYMFI LO 400-300-300 MG TABLET DL 5 QL(30 per 30 days) \nSYMTUZA 800-150-200-10 MG TABLET DL 5 QL(30 per 30 days) \nTEMIXYS 300-300 MG TABLET DL 5 QL(30 per 30 days) \ntenofovir disoproxil fumarate 300 mg TABLET MO 3 QL(30 per 30 days) \nTIVICAY 10 MG TABLET MO 4 QL(60 per 30 days) \nTIVICAY 25 MG, 50 MG TABLET DL 5 QL(60 per 30 days) \nTIVICAY PD 5 MG TABLET FOR SUSPENSION DL 5 QL(180 per 30 days) \nTRIUMEQ 600-50-300 MG TABLET DL 5 QL(30 per 30 days) \nTRIUMEQ PD 60-5-30 MG TABLET FOR SUSPENSION DL 5 QL(180 per 30 days) \nTRIZIVIR 300-150-300 MG TABLET DL 5 QL(60 per 30 days) \nTROGARZO 200 MG/1.33 ML (150 MG/ML) SOLUTION DL 5  ", "doc_id": "919db0b7-824b-4e73-9a33-b76939d1c8b0", "embedding": null, "doc_hash": "6e1a9f962ade9e6c042cf4829885a8a25fc64a7c8b9b5a5c918b1cd15579f80e", "extra_info": {"page_label": "46", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2382, "_node_type": "1"}, "relationships": {"1": "4dcb409d-54a1-4424-93b5-30fe5c588db8"}}, "__type__": "1"}, "791a2a1f-fa4b-4b99-92ce-9dad973f8557": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 47DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.TYBOST 150 MG TABLET MO 3 QL(30 per 30 days) \nvalacyclovir 1 gram, 500 mg TABLET MO 3  \nvalganciclovir 450 mg TABLET MO 3 QL(120 per 30 days) \nvalganciclovir 50 mg/ml RECON SOLUTION DL 5 QL(1056 per 30 days) \nVEMLIDY 25 MG TABLET DL 5 QL(30 per 30 days) \nVIRACEPT 250 MG TABLET DL 5 QL(300 per 30 days) \nVIRACEPT 625 MG TABLET DL 5 QL(120 per 30 days) \nVIREAD 150 MG, 200 MG, 250 MG TABLET DL 5 QL(30 per 30 days) \nVIREAD 40 MG/SCOOP (40 MG/GRAM) POWDER DL 5 QL(240 per 30 days) \nVOCABRIA 30 MG TABLET DL 5 QL(30 per 30 days) \nVOSEVI 400-100-100 MG TABLET DL 5 PA,QL(28 per 28 days) \nXOFLUZA 20 MG TABLET MO 4 QL(10 per 365 days) \nXOFLUZA 40 MG TABLET MO 4 QL(10 per 365 days) \nXOFLUZA 80 MG TABLET MO 4 QL(5 per 365 days) \nzidovudine 10 mg/ml SYRUP MO 3 QL(1680 per 28 days) \nzidovudine 100 mg CAPSULE MO 4 QL(180 per 30 days) \nzidovudine 300 mg TABLET GC,MO 2 QL(60 per 30 days) \nZIRGAN 0.15 % GEL MO 4 QL(5 per 30 days) \nANXIOLYTICS\nalprazolam 0.25 mg, 0.5 mg, 1 mg TABLET DL,GC 2 QL(120 per 30 days) \nalprazolam 2 mg TABLET DL,GC 2 QL(150 per 30 days) \nbuspirone 10 mg, 15 mg, 5 mg TABLET GC,MO 1  \nbuspirone 30 mg, 7.5 mg TABLET GC,MO 1  \nclonazepam 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg TABLET, DISINTEGRATING \nDL4  \nclonazepam 0.5 mg, 1 mg TABLET DL 3  \nclonazepam 2 mg TABLET DL 3  \nclorazepate dipotassium 15 mg, 3.75 mg, 7.5 mg TABLET DL 4  \ndiazepam 10 mg TABLET DL 3 QL(120 per 30 days) \ndiazepam 2 mg TABLET DL 3 QL(90 per 30 days) \ndiazepam 5 mg TABLET DL 3 QL(90 per 30 days) \ndiazepam 5 mg/5 ml (1 mg/ml), 5 mg/5 ml (1 mg/ml, 5 ml) SOLUTION DL 4 QL(1200 per 30 days) \ndiazepam 5 mg/ml CONCENTRATE DL 4 QL(240 per 30 days) \ndiazepam intensol 5 mg/ml CONCENTRATE DL 4 QL(240 per 30 days) \ndoxepin 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg CAPSULE MO 4  \ndoxepin 10 mg/ml CONCENTRATE MO 4  ", "doc_id": "791a2a1f-fa4b-4b99-92ce-9dad973f8557", "embedding": null, "doc_hash": "ca2acea957f3f3eb01090cb5980e37e54bf5c8d2cedc8bbf1b9ac0716bbe77e6", "extra_info": {"page_label": "47", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2299, "_node_type": "1"}, "relationships": {"1": "914ad209-77c3-4a52-843c-b3e2c0f636e0"}}, "__type__": "1"}, "5ab61c14-7c2b-4e11-b7f8-eb286b235f3e": {"__data__": {"text": "48 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.hydroxyzine hcl 10 mg, 50 mg TABLET MO 3  \nhydroxyzine hcl 10 mg/5 ml SOLUTION MO 3  \nhydroxyzine hcl 25 mg TABLET MO 3  \nlorazepam 0.5 mg, 1 mg TABLET DL,GC 2 QL(90 per 30 days) \nlorazepam 2 mg TABLET DL,GC 2 QL(150 per 30 days) \nlorazepam 2 mg/ml CONCENTRATE DL 3 QL(150 per 30 days) \nlorazepam intensol 2 mg/ml CONCENTRATE DL 3 QL(150 per 30 days) \noxazepam 10 mg, 15 mg, 30 mg CAPSULE DL 4  \nBIPOLAR AGENTS\nlithium carbonate 150 mg, 300 mg, 600 mg CAPSULE GC,MO 1  \nlithium carbonate 300 mg TABLET GC,MO 1  \nlithium carbonate 300 mg, 450 mg TABLET ER GC,MO 2  \nBLOOD GLUCOSE REGULATORS\nacarbose 100 mg, 25 mg, 50 mg TABLET GC,MO 2  \nBAQSIMI 3 MG/ACTUATION SPRAY, NON-AEROSOL MO 3  \nBYDUREON BCISE 2 MG/0.85 ML AUTO-INJECTOR MO 4 QL(3.4 per 28 days) \ndiazoxide 50 mg/ml SUSPENSION DL 5  \nFARXIGA 10 MG TABLET MO 4 QL(30 per 30 days) \nFARXIGA 5 MG TABLET MO 4 QL(30 per 30 days) \nFIASP FLEXTOUCH U-100 INSULIN 100 UNIT/ML (3 ML) INSULIN PEN MO 3 ISP \nFIASP PENFILL U-100 INSULIN 100 UNIT/ML (3 ML) CARTRIDGE MO 3 ISP \nFIASP U-100 INSULIN 100 UNIT/ML SOLUTION MO 3 ISP \nglimepiride 1 mg TABLET GC,MO 1  \nglimepiride 2 mg, 4 mg TABLET GC,MO 1  \nglipizide 10 mg TABLET, ER 24 HR. GC,MO 1  \nglipizide 10 mg, 5 mg TABLET GC,MO 1  \nglipizide 2.5 mg, 5 mg TABLET, ER 24 HR. GC,MO 1  \nglipizide-metformin 2.5-250 mg, 2.5-500 mg, 5-500 mg TABLET GC,MO 1  \nGLUCAGEN HYPOKIT 1 MG RECON SOLUTION MO 3  \nglyburide 1.25 mg, 2.5 mg, 5 mg TABLET GC,MO 2  \nglyburide micronized 1.5 mg, 3 mg, 6 mg TABLET GC,MO 2  \nglyburide-metformin 1.25-250 mg, 2.5-500 mg, 5-500 mg TABLET GC,MO 2  \nGLYXAMBI 10-5 MG, 25-5 MG TABLET MO 3 QL(30 per 30 days) \nGVOKE 1 MG/0.2 ML SOLUTION MO 3  \nGVOKE HYPOPEN 1-PACK 0.5 MG/0.1 ML, 1 MG/0.2 ML AUTO-INJECTOR MO 3  \nGVOKE HYPOPEN 2-PACK 0.5 MG/0.1 ML, 1 MG/0.2 ML AUTO-INJECTOR MO 3  ", "doc_id": "5ab61c14-7c2b-4e11-b7f8-eb286b235f3e", "embedding": null, "doc_hash": "b8d64b903a5dff117e136bd4edb683002554e45aa6603bf546d574fa6652b36a", "extra_info": {"page_label": "48", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2294, "_node_type": "1"}, "relationships": {"1": "9329db6a-02f5-4a2d-8a42-d1c98a2ce4ce"}}, "__type__": "1"}, "8a6f8dba-9ace-4bbf-a565-511e18620cab": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 49DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.GVOKE PFS 1-PACK SYRINGE 0.5 MG/0.1 ML, 1 MG/0.2 ML SYRINGE MO 3  \nGVOKE PFS 2-PACK SYRINGE 0.5 MG/0.1 ML, 1 MG/0.2 ML SYRINGE MO 3  \nHUMULIN R U-500 (CONC) INSULIN 500 UNIT/ML SOLUTION DL 5  \nHUMULIN R U-500 (CONC) KWIKPEN 500 UNIT/ML (3 ML) INSULIN PEN DL 5  \nINVOKAMET 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG TABLET \nMO3 QL(60 per 30 days) \nINVOKAMET XR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG  \nTABLET, IR/ER 24 HR., BIPHASIC MO3 QL(60 per 30 days) \nINVOKANA 100 MG, 300 MG TABLET MO 3 QL(30 per 30 days) \nJANUMET 50-1,000 MG TABLET MO 3 QL(60 per 30 days) \nJANUMET 50-500 MG TABLET MO 3 QL(60 per 30 days) \nJANUMET XR 100-1,000 MG TABLET, ER 24 HR., MULTIPHASE MO 3 QL(30 per 30 days) \nJANUMET XR 50-1,000 MG TABLET, ER 24 HR., MULTIPHASE MO 3 QL(60 per 30 days) \nJANUMET XR 50-500 MG TABLET, ER 24 HR., MULTIPHASE MO 3 QL(60 per 30 days) \nJANUVIA 100 MG, 25 MG, 50 MG TABLET MO 3 QL(30 per 30 days) \nJARDIANCE 10 MG, 25 MG TABLET MO 3 QL(30 per 30 days) \nJENTADUETO 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG TABLET MO 3 QL(60 per 30 days) \nJENTADUETO XR 2.5-1,000 MG TABLET, IR/ER 24 HR., BIPHASIC MO 3 QL(60 per 30 days) \nJENTADUETO XR 5-1,000 MG TABLET, IR/ER 24 HR., BIPHASIC MO 3 QL(30 per 30 days) \nKOMBIGLYZE XR 2.5-1,000 MG TABLET, ER 24 HR., MULTIPHASE MO 4 QL(60 per 30 days) \nKOMBIGLYZE XR 5-1,000 MG TABLET, ER 24 HR., MULTIPHASE MO 4 QL(30 per 30 days) \nKOMBIGLYZE XR 5-500 MG TABLET, ER 24 HR., MULTIPHASE MO 4 QL(30 per 30 days) \nLANTUS SOLOSTAR U-100 INSULIN 100 UNIT/ML (3 ML) INSULIN PEN MO 3 ISP \nLANTUS U-100 INSULIN 100 UNIT/ML SOLUTION MO 3 ISP \nLEVEMIR FLEXPEN 100 UNIT/ML (3 ML) INSULIN PEN MO 3 ISP \nLEVEMIR FLEXTOUCH U100 INSULIN 100 UNIT/ML (3 ML) INSULIN PEN MO 3 ISP \nLEVEMIR U-100 INSULIN 100 UNIT/ML SOLUTION MO 3 ISP \nmetformin 1,000 mg, 500 mg TABLET GC,MO 1  \nmetformin 500 mg TABLET, ER 24 HR. GC,MO 1 QL(120 per 30 days) \nmetformin 750 mg TABLET, ER 24", "doc_id": "8a6f8dba-9ace-4bbf-a565-511e18620cab", "embedding": null, "doc_hash": "a493ad8b412fe80bff6ebb6874871196000b82a4e9b08b68858206f8bf187a76", "extra_info": {"page_label": "49", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2401, "_node_type": "1"}, "relationships": {"1": "8fdde9df-aaab-4cbc-93c3-d5b37d6b3f4b", "3": "9c47187b-c473-4369-900b-5401efb8bec1"}}, "__type__": "1"}, "9c47187b-c473-4369-900b-5401efb8bec1": {"__data__": {"text": "750 mg TABLET, ER 24 HR. GC,MO 1 QL(60 per 30 days) \nmetformin 850 mg TABLET GC,MO 1  \nMOUNJARO 10 MG/0.5 ML, 12.5 MG/0.5 ML, 15 MG/0.5 ML, 2.5 MG/0.5 ML, 5  \nMG/0.5 ML, 7.5 MG/0.5 ML PEN INJECTOR MO3 QL(2 per 28 days) \nnateglinide 120 mg, 60 mg TABLET MO 3  \nNOVOLIN 70-30 FLEXPEN U-100 100 UNIT/ML (70-30) INSULIN PEN MO 3 ISP \nNOVOLIN 70/30 U-100 INSULIN 100 UNIT/ML (70-30) SUSPENSION MO 3 ISP ", "doc_id": "9c47187b-c473-4369-900b-5401efb8bec1", "embedding": null, "doc_hash": "1c04922c395f2b433a0191f805be908f9f237d02df7e1e22a485bd12961b05b5", "extra_info": {"page_label": "49", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2381, "end": 2779, "_node_type": "1"}, "relationships": {"1": "8fdde9df-aaab-4cbc-93c3-d5b37d6b3f4b", "2": "8a6f8dba-9ace-4bbf-a565-511e18620cab"}}, "__type__": "1"}, "651db6e2-eb3c-4cfb-b36d-9a107307eea2": {"__data__": {"text": "50 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.NOVOLIN N FLEXPEN 100 UNIT/ML (3 ML) INSULIN PEN MO 3 ISP \nNOVOLIN N NPH U-100 INSULIN 100 UNIT/ML SUSPENSION MO 3 ISP \nNOVOLIN R FLEXPEN 100 UNIT/ML (3 ML) INSULIN PEN MO 3 ISP \nNOVOLIN R REGULAR U-100 INSULN 100 UNIT/ML SOLUTION MO 3 ISP \nNOVOLOG FLEXPEN U-100 INSULIN 100 UNIT/ML (3 ML) INSULIN PEN MO 3 ISP \nNOVOLOG MIX 70-30 U-100 INSULN 100 UNIT/ML (70-30) SOLUTION MO 3 ISP \nNOVOLOG MIX 70-30FLEXPEN U-100 100 UNIT/ML (70-30) INSULIN PEN MO 3 ISP \nNOVOLOG PENFILL U-100 INSULIN 100 UNIT/ML CARTRIDGE MO 3 ISP \nNOVOLOG U-100 INSULIN ASPART 100 UNIT/ML SOLUTION MO 3 ISP \nONGLYZA 2.5 MG, 5 MG TABLET MO 4 QL(30 per 30 days) \nOZEMPIC 0.25 MG OR 0.5 MG (2 MG/3 ML), 1 MG/DOSE (2 MG/1.5 ML) PEN  \nINJECTOR MO3 QL(3 per 28 days) \nOZEMPIC 0.25 MG OR 0.5 MG(2 MG/1.5 ML) PEN INJECTOR MO 3 QL(1.5 per 28 days) \nOZEMPIC 1 MG/DOSE (4 MG/3 ML), 2 MG/DOSE (8 MG/3 ML) PEN INJECTOR MO 3 QL(3 per 28 days) \npioglitazone 15 mg, 30 mg TABLET GC,MO 1 QL(30 per 30 days) \npioglitazone 45 mg TABLET GC,MO 1 QL(30 per 30 days) \npioglitazone-metformin 15-500 mg, 15-850 mg TABLET MO 3 QL(90 per 30 days) \nrepaglinide 0.5 mg, 1 mg, 2 mg TABLET MO 3  \nRYBELSUS 14 MG, 3 MG, 7 MG TABLET MO 3 QL(30 per 30 days) \nSOLIQUA 100/33 100 UNIT-33 MCG/ML INSULIN PEN MO 3 QL(15 per 24 days),ISP \nSYMLINPEN 120 2,700 MCG/2.7 ML PEN INJECTOR DL 5 QL(10.8 per 30 days) \nSYMLINPEN 60 1,500 MCG/1.5 ML PEN INJECTOR DL 5 QL(10.5 per 28 days) \nSYNJARDY 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG TABLET MO 3 QL(60 per 30 days) \nSYNJARDY XR 10-1,000 MG, 25-1,000 MG TABLET, IR/ER 24 HR., BIPHASIC MO 3 QL(30 per 30 days) \nSYNJARDY XR 12.5-1,000 MG, 5-1,000 MG TABLET, IR/ER 24 HR., BIPHASIC MO 3 QL(60 per 30 days) \nTOUJEO MAX U-300 SOLOSTAR 300 UNIT/ML (3 ML) INSULIN PEN MO 3 ISP \nTOUJEO SOLOSTAR U-300 INSULIN 300 UNIT/ML (1.5 ML) INSULIN PEN MO 3 ISP \nTRADJENTA 5 MG TABLET MO 3 QL(30 per 30 days) \nTRESIBA FLEXTOUCH U-100 100 UNIT/ML", "doc_id": "651db6e2-eb3c-4cfb-b36d-9a107307eea2", "embedding": null, "doc_hash": "e0c63edfe62110352fdf72694f60628da9c6894aa6df8070e2ee13089d0e5947", "extra_info": {"page_label": "50", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2404, "_node_type": "1"}, "relationships": {"1": "d600d3e3-4d74-4c9a-8755-0d92a9b1a62f", "3": "a8074fde-379e-4f43-bbdd-5ff2316881bb"}}, "__type__": "1"}, "a8074fde-379e-4f43-bbdd-5ff2316881bb": {"__data__": {"text": "FLEXTOUCH U-100 100 UNIT/ML (3 ML) INSULIN PEN MO 3 ISP \nTRESIBA FLEXTOUCH U-200 200 UNIT/ML (3 ML) INSULIN PEN MO 3 ISP \nTRESIBA U-100 INSULIN 100 UNIT/ML SOLUTION MO 3 ISP \nTRIJARDY XR 10-5-1,000 MG, 25-5-1,000 MG TABLET, IR/ER 24 HR., BIPHASIC \nMO3 QL(30 per 30 days) \nTRIJARDY XR 12.5-2.5-1,000 MG, 5-2.5-1,000 MG TABLET, IR/ER 24 HR.,  \nBIPHASIC MO3 QL(60 per 30 days) \nTRULICITY 0.75 MG/0.5 ML, 1.5 MG/0.5 ML, 3 MG/0.5 ML, 4.5 MG/0.5 ML PEN  \nINJECTOR MO3 QL(2 per 28 days) ", "doc_id": "a8074fde-379e-4f43-bbdd-5ff2316881bb", "embedding": null, "doc_hash": "1b901eec772768943599ab9c5f2408c881cf3b552f7af15ab2c0a1d5a0d152f8", "extra_info": {"page_label": "50", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2377, "end": 2857, "_node_type": "1"}, "relationships": {"1": "d600d3e3-4d74-4c9a-8755-0d92a9b1a62f", "2": "651db6e2-eb3c-4cfb-b36d-9a107307eea2"}}, "__type__": "1"}, "6e917c32-4d6e-4aa4-b972-5e74e3146ad2": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 51DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.VICTOZA 2-PAK 0.6 MG/0.1 ML (18 MG/3 ML) PEN INJECTOR MO 3 QL(9 per 30 days) \nVICTOZA 3-PAK 0.6 MG/0.1 ML (18 MG/3 ML) PEN INJECTOR MO 3 QL(9 per 30 days) \nXIGDUO XR 10-1,000 MG, 10-500 MG TABLET, IR/ER 24 HR., BIPHASIC MO 4 QL(30 per 30 days) \nXIGDUO XR 2.5-1,000 MG, 5-1,000 MG TABLET, IR/ER 24 HR., BIPHASIC MO 4 QL(60 per 30 days) \nXIGDUO XR 5-500 MG TABLET, IR/ER 24 HR., BIPHASIC MO 4 QL(30 per 30 days) \nXULTOPHY 100/3.6 100 UNIT-3.6 MG /ML (3 ML) INSULIN PEN MO 3 QL(15 per 30 days),ISP \nZEGALOGUE AUTOINJECTOR 0.6 MG/0.6 ML AUTO-INJECTOR MO 3  \nZEGALOGUE SYRINGE 0.6 MG/0.6 ML SYRINGE MO 3  \nBLOOD PRODUCTS AND MODIFIERS\naminocaproic acid 1,000 mg, 500 mg TABLET DL 5  \naminocaproic acid 250 mg/ml (25 %) SOLUTION DL 5  \nanagrelide 0.5 mg, 1 mg CAPSULE MO 3  \naspirin-dipyridamole 25-200 mg CAPSULE ER MULTIPHASE 12 HR. MO 4 ST,QL(60 per 30 days) \nBRILINTA 60 MG, 90 MG TABLET MO 3 QL(60 per 30 days) \nCABLIVI 11 MG KIT DL 5 PA,QL(30 per 30 days) \ncilostazol 100 mg, 50 mg TABLET GC,MO 2  \nclopidogrel 300 mg TABLET MO 4  \nclopidogrel 75 mg TABLET GC,MO 1 QL(30 per 30 days) \ndabigatran etexilate 150 mg, 75 mg CAPSULE MO 4 QL(60 per 30 days) \ndipyridamole 25 mg, 50 mg, 75 mg TABLET MO 4  \nELIQUIS 2.5 MG TABLET MO 3 QL(60 per 30 days) \nELIQUIS 5 MG TABLET MO 3 QL(74 per 30 days) \nELIQUIS DVT-PE TREAT 30D START 5 MG (74 TABS) TABLET, DOSE PACK MO 3 QL(74 per 30 days) \nenoxaparin 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4  \nml, 60 mg/0.6 ml, 80 mg/0.8 ml SYRINGE MO4  \nenoxaparin 300 mg/3 ml SOLUTION MO 4  \nFULPHILA 6 MG/0.6 ML SYRINGE DL 5 PA,QL(1.2 per 28 days) \nheparin (porcine) 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml  \nSOLUTION MO3  \nheparin (porcine) 5,000 unit/ml (1 ml) CARTRIDGE MO 3  \nheparin (porcine) 5,000 unit/ml SYRINGE MO 3  \nheparin, porcine (pf) 1,000 unit/ml, 5,000 unit/0.5 ml SOLUTION MO 3", "doc_id": "6e917c32-4d6e-4aa4-b972-5e74e3146ad2", "embedding": null, "doc_hash": "701e386c10a5ee887dac4f1a100b354a062ce5c5751cd2a606c44b15191b2bc2", "extra_info": {"page_label": "51", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2359, "_node_type": "1"}, "relationships": {"1": "56b9c672-3cff-4fbe-ba4d-6bbc57a5310d", "3": "2b4b29b2-4be6-48c7-8160-a1b849aa4a12"}}, "__type__": "1"}, "2b4b29b2-4be6-48c7-8160-a1b849aa4a12": {"__data__": {"text": " \nheparin, porcine (pf) 5,000 unit/0.5 ml, 5,000 unit/ml SYRINGE MO 3  \njantoven 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg TABLET \nGC,MO1  \nMOZOBIL 24 MG/1.2 ML (20 MG/ML) SOLUTION DL 5 PA,QL(9.6 per 30 days) ", "doc_id": "2b4b29b2-4be6-48c7-8160-a1b849aa4a12", "embedding": null, "doc_hash": "58d632e93d1b2a68fefbd00e04b1b80a7b4fcf5a04bb95e8b54934e56753c0c4", "extra_info": {"page_label": "51", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2360, "end": 2585, "_node_type": "1"}, "relationships": {"1": "56b9c672-3cff-4fbe-ba4d-6bbc57a5310d", "2": "6e917c32-4d6e-4aa4-b972-5e74e3146ad2"}}, "__type__": "1"}, "a791b139-ee4b-410a-9df8-876575a52b13": {"__data__": {"text": "52 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.NEULASTA 6 MG/0.6 ML SYRINGE DL 5 PA,QL(1.2 per 28 days) \nNEULASTA ONPRO 6 MG/0.6 ML SYRINGE W/WEARABLE INJECTOR DL 5 PA,QL(1.2 per 28 days) \nNIVESTYM 300 MCG/0.5 ML SYRINGE DL 5 PA,QL(7 per 30 days) \nNIVESTYM 300 MCG/ML SOLUTION DL 5 PA,QL(14 per 30 days) \nNIVESTYM 480 MCG/0.8 ML SYRINGE DL 5 PA,QL(11.2 per 30 days) \nNIVESTYM 480 MCG/1.6 ML SOLUTION DL 5 PA,QL(22.4 per 30 days) \nPRADAXA 110 MG, 150 MG, 75 MG CAPSULE MO 4 QL(60 per 30 days) \nprasugrel 10 mg, 5 mg TABLET MO 4 QL(30 per 30 days) \nPROCRIT 10,000 UNIT/ML SOLUTION MO 4 PA,QL(14 per 30 days) \nPROCRIT 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML SOLUTION MO 4 PA,QL(14 per 30 days) \nPROCRIT 20,000 UNIT/2 ML SOLUTION 5 PA,QL(28 per 30 days) \nPROCRIT 20,000 UNIT/ML, 40,000 UNIT/ML SOLUTION 5 PA,QL(14 per 30 days) \nPROMACTA 12.5 MG POWDER IN PACKET DL,LA 5 PA,QL(360 per 30 days) \nPROMACTA 12.5 MG, 75 MG TABLET DL,LA 5 PA,QL(60 per 30 days) \nPROMACTA 25 MG POWDER IN PACKET DL,LA 5 PA,QL(180 per 30 days) \nPROMACTA 25 MG TABLET DL,LA 5 PA,QL(30 per 30 days) \nPROMACTA 50 MG TABLET DL,LA 5 PA,QL(90 per 30 days) \nPYRUKYND 20 MG (7)- 5 MG (7), 50 MG (7)- 20 MG (7) TABLET, DOSE PACK DL 5 PA,QL(14 per 14 days) \nPYRUKYND 20 MG, 5 MG, 50 MG TABLET DL 5 PA,QL(60 per 30 days) \nRETACRIT 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000  \nUNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML SOLUTION MO4 PA,QL(14 per 30 days) \ntranexamic acid 650 mg TABLET MO 3 QL(30 per 5 days) \nUDENYCA 6 MG/0.6 ML SYRINGE DL 5 PA,QL(1.2 per 28 days) \nUDENYCA AUTOINJECTOR 6 MG/0.6 ML AUTO-INJECTOR DL 5 PA,QL(1.2 per 28 days) \nwarfarin 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 6 mg, 7.5 mg TABLET GC,MO 1  \nwarfarin 5 mg TABLET GC,MO 1  \nXARELTO 1 MG/ML SUSPENSION FOR RECONSTITUTION MO 3 ST,QL(600 per 30 days) \nXARELTO 10 MG, 20 MG TABLET MO 3 QL(30 per 30 days) \nXARELTO 15 MG, 2.5 MG TABLET MO 3 QL(60 per 30 days) \nXARELTO DVT-PE TREAT 30D START 15 MG (42)- 20 MG (9) TABLET,", "doc_id": "a791b139-ee4b-410a-9df8-876575a52b13", "embedding": null, "doc_hash": "1dab21aa163a4a142043eba0355932125e089adc402ed7ba83ee0278f98a5350", "extra_info": {"page_label": "52", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2429, "_node_type": "1"}, "relationships": {"1": "44ec8bee-b6a7-4b4e-94fb-3f61e7330623", "3": "dd475cce-4efa-4e2f-a705-10d20954da0b"}}, "__type__": "1"}, "dd475cce-4efa-4e2f-a705-10d20954da0b": {"__data__": {"text": "TREAT 30D START 15 MG (42)- 20 MG (9) TABLET, DOSE PACK \nMO3 QL(51 per 30 days) \nZARXIO 300 MCG/0.5 ML SYRINGE DL 5 PA,QL(7 per 30 days) \nZARXIO 480 MCG/0.8 ML SYRINGE DL 5 PA,QL(11.2 per 30 days) \nCARDIOVASCULAR AGENTS\nacebutolol 200 mg, 400 mg CAPSULE GC,MO 2  \nacetazolamide 125 mg, 250 mg TABLET MO 4  ", "doc_id": "dd475cce-4efa-4e2f-a705-10d20954da0b", "embedding": null, "doc_hash": "2fa4b5862edcaf29b644afcb7469f9b70fae6601bbb5605b27e57646dcd84ad0", "extra_info": {"page_label": "52", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2384, "end": 2690, "_node_type": "1"}, "relationships": {"1": "44ec8bee-b6a7-4b4e-94fb-3f61e7330623", "2": "a791b139-ee4b-410a-9df8-876575a52b13"}}, "__type__": "1"}, "bc89fc15-8557-47b3-9b2d-40c3d287faf2": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 53DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.acetazolamide 500 mg CAPSULE, ER MO 3  \nacetazolamide sodium 500 mg RECON SOLUTION GC,MO 2  \nadenosine 3 mg/ml SOLUTION GC,MO 1  \nadenosine 3 mg/ml SYRINGE GC,MO 1  \naliskiren 150 mg, 300 mg TABLET MO 4 QL(30 per 30 days) \namiloride 5 mg TABLET MO 3  \namiloride-hydrochlorothiazide 5-50 mg TABLET GC,MO 2  \namiodarone 100 mg TABLET MO 4  \namiodarone 150 mg/3 ml SYRINGE GC,MO 2  \namiodarone 200 mg TABLET GC,MO 2  \namiodarone 400 mg TABLET MO 4 QL(60 per 30 days) \namiodarone 50 mg/ml SOLUTION GC,MO 2  \namlodipine 10 mg, 2.5 mg, 5 mg TABLET GC,MO 1  \namlodipine-atorvastatin 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10  \nmg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg TABLET MO4 QL(30 per 30 days) \namlodipine-benazepril 10-20 mg, 2.5-10 mg, 5-10 mg, 5-20 mg CAPSULE GC,MO 1 QL(60 per 30 days) \namlodipine-benazepril 10-40 mg, 5-40 mg CAPSULE GC,MO 1 QL(30 per 30 days) \namlodipine-olmesartan 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg TABLET GC,MO 2 QL(30 per 30 days) \namlodipine-valsartan 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg TABLET \nGC,MO2 QL(30 per 30 days) \natenolol 100 mg TABLET GC,MO 1  \natenolol 25 mg, 50 mg TABLET GC,MO 1  \natenolol-chlorthalidone 100-25 mg, 50-25 mg TABLET GC,MO 1  \natorvastatin 10 mg, 20 mg, 40 mg, 80 mg TABLET GC,MO 1  \nbenazepril 10 mg, 20 mg, 40 mg, 5 mg TABLET GC,MO 1  \nbenazepril-hydrochlorothiazide 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg  \nTABLET GC,MO2  \nbisoprolol fumarate 10 mg, 5 mg TABLET GC,MO 2  \nbisoprolol-hydrochlorothiazide 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg TABLET \nGC,MO1  \nbumetanide 0.25 mg/ml SOLUTION GC,MO 2  \nbumetanide 0.5 mg, 2 mg TABLET GC,MO 2  \nbumetanide 1 mg TABLET GC,MO 2  \nCAMZYOS 10 MG, 15 MG, 2.5 MG, 5 MG CAPSULE DL 5 PA,QL(30 per 30 days) \ncandesartan 16 mg, 4 mg, 8 mg TABLET MO 3 QL(60 per 30 days) \ncandesartan 32 mg TABLET MO 3 QL(30 per 30 days) ", "doc_id": "bc89fc15-8557-47b3-9b2d-40c3d287faf2", "embedding": null, "doc_hash": "a47dc9ce2884498e4413ab2eb175f35caf0303ef9339962bd274c59bfb11a78a", "extra_info": {"page_label": "53", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2341, "_node_type": "1"}, "relationships": {"1": "3d93def9-58fe-4564-a3b2-f42dbb29c1ad"}}, "__type__": "1"}, "4619c404-bc29-4bad-87c8-975c4cbd888e": {"__data__": {"text": "54 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.candesartan-hydrochlorothiazid 16-12.5 mg, 32-12.5 mg, 32-25 mg TABLET \nGC,MO2 QL(30 per 30 days) \ncaptopril 100 mg, 12.5 mg, 25 mg, 50 mg TABLET MO 3  \ncaptopril-hydrochlorothiazide 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg  \nTABLET MO3  \ncartia xt 120 mg, 180 mg, 240 mg CAPSULE, ER 24 HR. GC,MO 2 QL(60 per 30 days) \ncartia xt 300 mg CAPSULE, ER 24 HR. GC,MO 2 QL(30 per 30 days) \ncarvedilol 12.5 mg, 25 mg, 3.125 mg, 6.25 mg TABLET GC,MO 1  \ncarvedilol phosphate 10 mg, 20 mg, 40 mg, 80 mg CAPSULE ER MULTIPHASE 24  \nHR. MO4 QL(30 per 30 days) \nchlorothiazide sodium 500 mg RECON SOLUTION GC,MO 2  \nchlorthalidone 25 mg TABLET GC,MO 2  \nchlorthalidone 50 mg TABLET GC,MO 2  \ncholestyramine (with sugar) 4 gram POWDER MO 3  \ncholestyramine (with sugar) 4 gram POWDER IN PACKET MO 3  \ncholestyramine light 4 gram POWDER MO 3  \ncholestyramine light 4 gram POWDER IN PACKET MO 3  \ncholestyramine-aspartame 4 gram POWDER IN PACKET MO 3  \nclonidine 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr PATCH, WEEKLY MO 4 QL(4 per 28 days) \nclonidine hcl 0.1 mg TABLET GC,MO 1  \nclonidine hcl 0.2 mg, 0.3 mg TABLET GC,MO 1  \ncolestipol 1 gram TABLET MO 3  \ncolestipol 5 gram GRANULES MO 4 QL(1000 per 30 days) \ncolestipol 5 gram PACKET MO 4  \nCORLANOR 5 MG, 7.5 MG TABLET MO 4 PA,QL(60 per 30 days) \nCORLOPAM 10 MG/ML SOLUTION MO 4  \nDEMSER 250 MG CAPSULE DL 5  \ndigitek 125 mcg (0.125 mg), 250 mcg (0.25 mg) TABLET GC,MO 2 QL(30 per 30 days) \ndigox 125 mcg (0.125 mg), 250 mcg (0.25 mg) TABLET GC,MO 2 QL(30 per 30 days) \ndigoxin 125 mcg (0.125 mg) TABLET GC,MO 2 QL(30 per 30 days) \ndigoxin 250 mcg (0.25 mg) TABLET GC,MO 2 QL(30 per 30 days) \ndilt-xr 120 mg, 180 mg, 240 mg CAPSULE, ER 24 HR. GC,MO 2 QL(60 per 30 days) \ndiltiazem hcl 100 mg RECON SOLUTION MO 4  \ndiltiazem hcl 120 mg CAPSULE, ER 12 HR. GC,MO 2 QL(90 per 30 days) \ndiltiazem hcl 120 mg, 180 mg, 240 mg CAPSULE, ER 24 HR. GC,MO 2 QL(60 per 30 days) \ndiltiazem hcl 120 mg, 180 mg, 240 mg CAPSULE, ER 24 HR. GC,MO 2 QL(60 per 30 days) ", "doc_id": "4619c404-bc29-4bad-87c8-975c4cbd888e", "embedding": null, "doc_hash": "e2483b1126a959ca8c50041642bbf9823e8355608d2af2d7eb287717739752d2", "extra_info": {"page_label": "54", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2479, "_node_type": "1"}, "relationships": {"1": "eba31375-450f-4e37-8767-4e07a77df9c6"}}, "__type__": "1"}, "40379dff-3627-4a73-818b-d9926a647d15": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 55DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.diltiazem hcl 120 mg, 30 mg, 60 mg, 90 mg TABLET GC,MO 2  \ndiltiazem hcl 300 mg, 360 mg, 420 mg CAPSULE, ER 24 HR. GC,MO 2 QL(30 per 30 days) \ndiltiazem hcl 5 mg/ml SOLUTION GC,MO 2  \ndiltiazem hcl 60 mg, 90 mg CAPSULE, ER 12 HR. GC,MO 2 QL(180 per 30 days) \nDIURIL 250 MG/5 ML SUSPENSION MO 4  \ndofetilide 125 mcg, 250 mcg, 500 mcg CAPSULE MO 4  \ndoxazosin 1 mg, 2 mg, 4 mg, 8 mg TABLET GC,MO 2  \nenalapril maleate 10 mg, 2.5 mg, 20 mg, 5 mg TABLET GC,MO 1  \nenalapril-hydrochlorothiazide 10-25 mg, 5-12.5 mg TABLET GC,MO 1  \nenalaprilat 1.25 mg/ml SOLUTION GC,MO 2  \nENTRESTO 24-26 MG, 49-51 MG, 97-103 MG TABLET MO 3 QL(60 per 30 days) \nethacrynate sodium 50 mg RECON SOLUTION MO 4  \nezetimibe 10 mg TABLET GC,MO 1 QL(30 per 30 days) \nezetimibe-simvastatin 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg TABLET \nGC,MO2 QL(30 per 30 days) \nfelodipine 10 mg, 2.5 mg, 5 mg TABLET, ER 24 HR. GC,MO 2 QL(30 per 30 days) \nfenofibrate 160 mg TABLET GC,MO 2 QL(30 per 30 days) \nfenofibrate 54 mg TABLET GC,MO 2 QL(60 per 30 days) \nfenofibrate micronized 130 mg, 43 mg CAPSULE MO 4 ST,QL(30 per 30 days) \nfenofibrate micronized 134 mg, 200 mg CAPSULE MO 3 QL(30 per 30 days) \nfenofibrate micronized 67 mg CAPSULE MO 3 QL(60 per 30 days) \nfenofibrate nanocrystallized 145 mg TABLET MO 3 QL(30 per 30 days) \nfenofibrate nanocrystallized 48 mg TABLET MO 3 QL(60 per 30 days) \nfenofibric acid 105 mg, 35 mg TABLET MO 3 QL(30 per 30 days) \nflecainide 100 mg, 150 mg, 50 mg TABLET MO 3  \nfluvastatin 20 mg, 40 mg CAPSULE MO 4 ST,QL(60 per 30 days) \nfluvastatin 80 mg TABLET, ER 24 HR. MO 4 ST,QL(30 per 30 days) \nfosinopril 10 mg, 20 mg, 40 mg TABLET GC,MO 1  \nfosinopril-hydrochlorothiazide 10-12.5 mg, 20-12.5 mg TABLET GC,MO 2  \nfurosemide 10 mg/ml SYRINGE GC,MO 2  \nfurosemide 10 mg/ml, 40 mg/5 ml (8 mg/ml) SOLUTION GC,MO 2  \nfurosemide 20 mg, 40 mg TABLET GC,MO 1  \nfurosemide 80 mg TABLET GC,MO 1  \ngemfibrozil 600 mg TABLET GC,MO 1 QL(60 per 30 days) \nguanfacine 1 mg TABLET GC,MO 2  \nguanfacine 2 mg TABLET GC,MO 2  ", "doc_id": "40379dff-3627-4a73-818b-d9926a647d15", "embedding": null, "doc_hash": "e0b531494241b5a5aa3642d5e6fcc40e9e8b2e124e295b61fb684a498a6b7613", "extra_info": {"page_label": "55", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2500, "_node_type": "1"}, "relationships": {"1": "023c2bfd-d788-44f3-9d99-e0a988c1085e"}}, "__type__": "1"}, "98e9afc0-f51e-49e4-af16-26e6ff202b3d": {"__data__": {"text": "56 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.hydralazine 10 mg, 100 mg TABLET GC,MO 2  \nhydralazine 20 mg/ml SOLUTION MO 4  \nhydralazine 25 mg, 50 mg TABLET GC,MO 2  \nhydrochlorothiazide 12.5 mg CAPSULE GC,MO 1  \nhydrochlorothiazide 12.5 mg, 25 mg TABLET GC,MO 1  \nhydrochlorothiazide 50 mg TABLET GC,MO 1  \nibutilide fumarate 0.1 mg/ml SOLUTION GC,MO 1  \nindapamide 1.25 mg, 2.5 mg TABLET GC,MO 1  \nirbesartan 150 mg, 75 mg TABLET GC,MO 1 QL(30 per 30 days) \nirbesartan 300 mg TABLET GC,MO 1 QL(30 per 30 days) \nirbesartan-hydrochlorothiazide 150-12.5 mg TABLET GC,MO 1 QL(60 per 30 days) \nirbesartan-hydrochlorothiazide 300-12.5 mg TABLET GC,MO 1 QL(30 per 30 days) \nisosorbide dinitrate 10 mg, 20 mg, 30 mg, 5 mg TABLET MO 3  \nisosorbide mononitrate 10 mg, 20 mg TABLET GC,MO 1  \nisosorbide mononitrate 120 mg TABLET, ER 24 HR. GC,MO 2  \nisosorbide mononitrate 30 mg, 60 mg TABLET, ER 24 HR. GC,MO 1  \nisradipine 2.5 mg, 5 mg CAPSULE MO 4  \nISUPREL 0.2 MG/ML SOLUTION MO 4  \nKERENDIA 10 MG, 20 MG TABLET MO 3 PA,QL(30 per 30 days) \nlabetalol 100 mg, 200 mg, 300 mg TABLET GC,MO 2  \nlabetalol 5 mg/ml SOLUTION MO 4  \nlidocaine (pf) 20 mg/ml (2 %) SOLUTION GC,MO 2  \nlidocaine in 5 % dextrose (pf) 4 mg/ml (0.4 %), 8 mg/ml (0.8 %) PARENTERAL  \nSOLUTION GC,MO1  \nLIPOFEN 150 MG CAPSULE MO 4 QL(30 per 30 days) \nLIPOFEN 50 MG CAPSULE MO 4 QL(60 per 30 days) \nlisinopril 10 mg, 2.5 mg, 20 mg, 40 mg, 5 mg TABLET GC,MO 1  \nlisinopril 30 mg TABLET GC,MO 1  \nlisinopril-hydrochlorothiazide 10-12.5 mg, 20-12.5 mg, 20-25 mg TABLET GC,MO 1  \nlosartan 100 mg, 25 mg, 50 mg TABLET GC,MO 1 QL(60 per 30 days) \nlosartan-hydrochlorothiazide 100-12.5 mg, 100-25 mg, 50-12.5 mg TABLET \nGC,MO1 QL(60 per 30 days) \nlovastatin 10 mg TABLET GC,MO 1  \nlovastatin 20 mg, 40 mg TABLET GC,MO 1  \nmannitol 10 % 10 % PARENTERAL SOLUTION GC,MO 2  \nmannitol 20 % 20 % PARENTERAL SOLUTION GC,MO 2  ", "doc_id": "98e9afc0-f51e-49e4-af16-26e6ff202b3d", "embedding": null, "doc_hash": "2e6571bf981331e04f5274dc6948c35142dae1729caea60fcb3056b8b679f825", "extra_info": {"page_label": "56", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2321, "_node_type": "1"}, "relationships": {"1": "3f19b669-8135-4ad4-a451-1b749261056a"}}, "__type__": "1"}, "2cda68ce-e5f6-419d-aa20-ce007dcca89d": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 57DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.mannitol 25 % 25 % SOLUTION GC,MO 2  \nmannitol 5 % 5 % PARENTERAL SOLUTION GC,MO 2  \nmethazolamide 25 mg, 50 mg TABLET MO 4  \nmethyldopa 250 mg, 500 mg TABLET GC,MO 2  \nmethyldopa-hydrochlorothiazide 250-15 mg, 250-25 mg TABLET MO 3  \nmetolazone 10 mg, 2.5 mg, 5 mg TABLET GC,MO 2  \nmetoprolol succinate 100 mg, 50 mg TABLET, ER 24 HR. GC,MO 1 QL(60 per 30 days) \nmetoprolol succinate 200 mg TABLET, ER 24 HR. GC,MO 1 QL(60 per 30 days) \nmetoprolol succinate 25 mg TABLET, ER 24 HR. GC,MO 1 QL(90 per 30 days) \nmetoprolol ta-hydrochlorothiaz 100-25 mg, 100-50 mg, 50-25 mg TABLET \nGC,MO2  \nmetoprolol tartrate 100 mg, 25 mg, 50 mg TABLET GC,MO 1  \nmetoprolol tartrate 37.5 mg, 75 mg TABLET GC,MO 1  \nmetoprolol tartrate 5 mg/5 ml SOLUTION MO 3  \nmetyrosine 250 mg CAPSULE DL 5  \nmidodrine 10 mg, 2.5 mg, 5 mg TABLET MO 3  \nminoxidil 10 mg, 2.5 mg TABLET GC,MO 2  \nmoexipril 15 mg, 7.5 mg TABLET GC,MO 2  \nMULTAQ 400 MG TABLET MO 3 QL(60 per 30 days) \nnadolol 20 mg, 40 mg, 80 mg TABLET MO 3  \nnebivolol 10 mg TABLET MO 3 QL(120 per 30 days) \nnebivolol 2.5 mg, 5 mg TABLET MO 3 QL(30 per 30 days) \nnebivolol 20 mg TABLET MO 3 QL(60 per 30 days) \nNEXLETOL 180 MG TABLET MO 3 PA,QL(30 per 30 days) \nNEXLIZET 180-10 MG TABLET MO 3 PA,QL(30 per 30 days) \nNEXTERONE 150 MG/100 ML (1.5 MG/ML), 360 MG/200 ML (1.8 MG/ML)  \nSOLUTION MO4  \nniacin 1,000 mg, 500 mg, 750 mg TABLET, ER 24 HR. MO 4  \nniacin 500 mg TABLET MO 4  \nniacor 500 mg TABLET MO 4  \nnifedipine 30 mg, 60 mg, 90 mg TABLET ER MO 3 QL(60 per 30 days) \nnifedipine 30 mg, 60 mg, 90 mg TABLET, ER 24 HR. MO 3 QL(60 per 30 days) \nnimodipine 30 mg CAPSULE MO 4  \nnisoldipine 17 mg, 20 mg, 34 mg, 40 mg, 8.5 mg TABLET, ER 24 HR. MO 4 QL(30 per 30 days) \nnisoldipine 25.5 mg, 30 mg TABLET, ER 24 HR. MO 4 QL(60 per 30 days) \nnitroglycerin 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr PATCH, 24 HR. GC,MO 2 QL(30 per 30 days) ", "doc_id": "2cda68ce-e5f6-419d-aa20-ce007dcca89d", "embedding": null, "doc_hash": "2628fb6843cfe34342eb3c435131506468c821ca44352bffced3f793c0ca8cbc", "extra_info": {"page_label": "57", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2357, "_node_type": "1"}, "relationships": {"1": "260502f2-6abf-4813-ae16-bcf28f6b494f"}}, "__type__": "1"}, "9c2629dd-53d5-49dc-b73d-f6877853df01": {"__data__": {"text": "58 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.nitroglycerin 0.3 mg, 0.6 mg SUBLINGUAL TABLET MO 3  \nnitroglycerin 0.4 mg SUBLINGUAL TABLET MO 3  \nnitroglycerin 0.4 mg/hr PATCH, 24 HR. GC,MO 2 QL(60 per 30 days) \nnitroglycerin 50 mg/10 ml (5 mg/ml) SOLUTION GC,MO 2  \nnitroglycerin in 5 % dextrose 100 mg/250 ml (400 mcg/ml), 200 mg/500 ml  \n(400 mcg/ml), 25 mg/250 ml (100 mcg/ml), 50 mg/250 ml (200 mcg/ml), 50  \nmg/500 ml (100 mcg/ml) SOLUTION GC,MO2  \nNITROSTAT 0.3 MG, 0.4 MG, 0.6 MG SUBLINGUAL TABLET MO 3  \nnorepinephrine bitartrate 1 mg/ml SOLUTION GC,MO 1  \nolmesartan 20 mg TABLET GC,MO 1 QL(30 per 30 days) \nolmesartan 40 mg TABLET GC,MO 1 QL(30 per 30 days) \nolmesartan 5 mg TABLET GC,MO 1 QL(60 per 30 days) \nolmesartan-amlodipin-hcthiazid 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg,  \n40-5-12.5 mg, 40-5-25 mg TABLET MO4 QL(30 per 30 days) \nolmesartan-hydrochlorothiazide 20-12.5 mg, 40-12.5 mg, 40-25 mg TABLET \nGC,MO2 QL(30 per 30 days) \nomega-3 acid ethyl esters 1 gram CAPSULE MO 4 QL(120 per 30 days) \nOSMITROL 10 % 10 % PARENTERAL SOLUTION MO 4  \nOSMITROL 15 % 15 % PARENTERAL SOLUTION MO 4  \nOSMITROL 20 % 20 % PARENTERAL SOLUTION MO 4  \nOSMITROL 5 % 5 % PARENTERAL SOLUTION MO 4  \nPACERONE 100 MG TABLET MO 4  \npacerone 200 mg TABLET GC,MO 2  \nPACERONE 400 MG TABLET MO 4 QL(60 per 30 days) \npentoxifylline 400 mg TABLET ER GC,MO 2  \nperindopril erbumine 2 mg, 4 mg, 8 mg TABLET GC,MO 2  \npravastatin 10 mg, 20 mg, 40 mg, 80 mg TABLET GC,MO 1  \nprazosin 1 mg, 2 mg, 5 mg CAPSULE GC,MO 2  \nprevalite 4 gram POWDER MO 3  \nprevalite 4 gram POWDER IN PACKET MO 3  \nprocainamide 100 mg/ml, 500 mg/ml SOLUTION GC,MO 1  \npropafenone 150 mg, 225 mg, 300 mg TABLET MO 3  \npropafenone 225 mg, 325 mg CAPSULE, ER 12 HR. MO 4 QL(60 per 30 days) \npropafenone 425 mg CAPSULE, ER 12 HR. MO 4  \npropranolol 1 mg/ml SOLUTION GC,MO 2  \npropranolol 10 mg, 20 mg, 40 mg, 60 mg, 80 mg TABLET GC,MO 2  \npropranolol 120 mg, 160 mg, 60 mg, 80 mg CAPSULE, ER 24 HR. MO 3  ", "doc_id": "9c2629dd-53d5-49dc-b73d-f6877853df01", "embedding": null, "doc_hash": "31e1a50664366dfde76bc139b349c8c049c17ab7e9ec9441acf434744f61d2c4", "extra_info": {"page_label": "58", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2415, "_node_type": "1"}, "relationships": {"1": "ab372910-0e5e-4bb0-acbf-8d6e76c93c23"}}, "__type__": "1"}, "1dfcaa14-71ad-4309-9cc5-7b1adb968674": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 59DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.propranolol-hydrochlorothiazid 40-25 mg, 80-25 mg TABLET MO 3  \nquinapril 10 mg, 20 mg, 40 mg, 5 mg TABLET GC,MO 1  \nquinapril-hydrochlorothiazide 10-12.5 mg, 20-12.5 mg, 20-25 mg TABLET GC,MO 2  \nquinidine sulfate 200 mg, 300 mg TABLET GC,MO 2  \nramipril 1.25 mg, 10 mg, 2.5 mg, 5 mg CAPSULE GC,MO 1  \nranolazine 1,000 mg, 500 mg TABLET, ER 12 HR. MO 3 QL(120 per 30 days) \nREPATHA PUSHTRONEX 420 MG/3.5 ML WEARABLE INJECTOR MO 3 PA,QL(3.5 per 28 days) \nREPATHA SURECLICK 140 MG/ML PEN INJECTOR MO 3 PA,QL(3 per 28 days) \nREPATHA SYRINGE 140 MG/ML SYRINGE MO 3 PA,QL(3 per 28 days) \nrosuvastatin 10 mg, 20 mg, 40 mg, 5 mg TABLET GC,MO 1  \nsimvastatin 10 mg, 20 mg, 40 mg TABLET GC,MO 1  \nsimvastatin 5 mg, 80 mg TABLET GC,MO 1  \nsorine 120 mg, 160 mg, 240 mg, 80 mg TABLET GC,MO 2  \nsotalol 120 mg, 160 mg, 240 mg, 80 mg TABLET GC,MO 2  \nsotalol af 120 mg, 160 mg, 80 mg TABLET GC,MO 2  \nspironolacton-hydrochlorothiaz 25-25 mg TABLET GC,MO 2  \nspironolactone 100 mg TABLET GC,MO 1  \nspironolactone 25 mg, 50 mg TABLET GC,MO 1  \ntaztia xt 120 mg, 180 mg, 240 mg CAPSULE, ER 24 HR. GC,MO 2 QL(60 per 30 days) \ntaztia xt 300 mg, 360 mg CAPSULE, ER 24 HR. GC,MO 2 QL(30 per 30 days) \ntelmisartan 20 mg, 40 mg TABLET GC,MO 2 QL(30 per 30 days) \ntelmisartan 80 mg TABLET GC,MO 2 QL(60 per 30 days) \ntelmisartan-amlodipine 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg TABLET MO 4 QL(30 per 30 days) \ntelmisartan-hydrochlorothiazid 40-12.5 mg, 80-25 mg TABLET MO 3 QL(30 per 30 days) \ntelmisartan-hydrochlorothiazid 80-12.5 mg TABLET MO 3 QL(60 per 30 days) \nterazosin 1 mg, 10 mg, 2 mg, 5 mg CAPSULE GC,MO 1  \ntiadylt er 120 mg, 180 mg, 240 mg CAPSULE, ER 24 HR. GC,MO 2 QL(60 per 30 days) \ntiadylt er 300 mg, 360 mg, 420 mg CAPSULE, ER 24 HR. GC,MO 2 QL(30 per 30 days) \ntimolol maleate 10 mg, 20 mg, 5 mg TABLET MO 4  \ntorsemide 10 mg, 100 mg, 5 mg TABLET GC,MO 2  \ntorsemide 20 mg TABLET GC,MO 2  \ntrandolapril 1 mg, 2 mg, 4 mg TABLET GC,MO 1  \ntrandolapril-verapamil 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg TABLET, ", "doc_id": "1dfcaa14-71ad-4309-9cc5-7b1adb968674", "embedding": null, "doc_hash": "fd359c17e28c37eb79a76df09223955e88ba25b09b7c33ce050f82f80c2a6dcf", "extra_info": {"page_label": "59", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2500, "_node_type": "1"}, "relationships": {"1": "9542b88a-dc23-459d-831b-a868e566791a", "3": "2a388a6e-eb61-4f43-a39b-f3b070326884"}}, "__type__": "1"}, "2a388a6e-eb61-4f43-a39b-f3b070326884": {"__data__": {"text": "\nIR/ER 24 HR., BIPHASIC MO4  \ntriamterene-hydrochlorothiazid 37.5-25 mg CAPSULE GC,MO 1  \ntriamterene-hydrochlorothiazid 37.5-25 mg TABLET GC,MO 1  ", "doc_id": "2a388a6e-eb61-4f43-a39b-f3b070326884", "embedding": null, "doc_hash": "92fe1e7db29fd76fbc4eaeed3d456b14b798d26b73c60aa897d3cace4def6ec6", "extra_info": {"page_label": "59", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2501, "end": 2649, "_node_type": "1"}, "relationships": {"1": "9542b88a-dc23-459d-831b-a868e566791a", "2": "1dfcaa14-71ad-4309-9cc5-7b1adb968674"}}, "__type__": "1"}, "89ef4e8b-eece-423e-a094-e5839aa63dfa": {"__data__": {"text": "60 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.triamterene-hydrochlorothiazid 75-50 mg TABLET GC,MO 1  \nvalsartan 160 mg TABLET GC,MO 1 QL(60 per 30 days) \nvalsartan 320 mg, 40 mg, 80 mg TABLET GC,MO 1 QL(60 per 30 days) \nvalsartan-hydrochlorothiazide 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25  \nmg, 80-12.5 mg TABLET GC,MO1 QL(30 per 30 days) \nVASCEPA 0.5 GRAM CAPSULE MO 3 QL(240 per 30 days) \nVASCEPA 1 GRAM CAPSULE MO 3 QL(120 per 30 days) \nverapamil 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg CAPSULE ER  \nPELLETS 24 HR. MO3  \nverapamil 120 mg, 180 mg, 240 mg TABLET ER GC,MO 2  \nverapamil 120 mg, 40 mg, 80 mg TABLET GC,MO 1 QL(120 per 30 days) \nverapamil 2.5 mg/ml SOLUTION GC,MO 2  \nverapamil 2.5 mg/ml SYRINGE GC,MO 2  \nverapamil 360 mg CAPSULE ER PELLETS 24 HR. MO 3 QL(60 per 30 days) \nZYPITAMAG 2 MG, 4 MG TABLET MO 3 ST,QL(30 per 30 days) \nCENTRAL NERVOUS SYSTEM AGENTS\natomoxetine 10 mg, 18 mg, 25 mg, 40 mg CAPSULE MO 3 QL(60 per 30 days) \natomoxetine 100 mg, 60 mg, 80 mg CAPSULE MO 3 QL(30 per 30 days) \nAUSTEDO 12 MG, 9 MG TABLET DL 5 PA,QL(120 per 30 days) \nAUSTEDO 6 MG TABLET DL 5 PA,QL(60 per 30 days) \nAUSTEDO XR 12 MG, 6 MG TABLET, ER 24 HR. DL 5 PA,QL(90 per 30 days) \nAUSTEDO XR 24 MG TABLET, ER 24 HR. DL 5 PA,QL(60 per 30 days) \nBETASERON 0.3 MG KIT DL 5 PA,QL(15 per 30 days) \nCOPAXONE 20 MG/ML SYRINGE DL 5 PA,QL(30 per 30 days) \nCOPAXONE 40 MG/ML SYRINGE DL 5 PA,QL(12 per 28 days) \ndalfampridine 10 mg TABLET, ER 12 HR. MO 3 PA,QL(60 per 30 days) \ndexmethylphenidate 10 mg, 2.5 mg, 5 mg TABLET MO 3 QL(60 per 30 days) \ndextroamphetamine sulfate 10 mg TABLET MO 4 QL(180 per 30 days) \ndextroamphetamine sulfate 15 mg TABLET MO 4 QL(120 per 30 days) \ndextroamphetamine sulfate 20 mg TABLET MO 4 QL(90 per 30 days) \ndextroamphetamine sulfate 30 mg TABLET MO 4 QL(60 per 30 days) \ndextroamphetamine sulfate 5 mg TABLET MO 4 QL(150 per 30 days) \ndextroamphetamine-amphetamine 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5  \nmg TABLET MO3 QL(90 per 30 days) \ndextroamphetamine-amphetamine 30 mg TABLET MO 3 QL(60 per 30 days) \ndimethyl fumarate 120 mg (14)- 240 mg (46), 240 mg CAPSULE, DR/EC DL 5 PA,QL(60 per 30 days) ", "doc_id": "89ef4e8b-eece-423e-a094-e5839aa63dfa", "embedding": null, "doc_hash": "4ecbf1c7b22324f22196ce0c33d3d9e32a8c0ca8274169ee042f11549b56e1e8", "extra_info": {"page_label": "60", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2594, "_node_type": "1"}, "relationships": {"1": "cbeecbcc-69c7-4b12-97a8-bd60cc92ecad"}}, "__type__": "1"}, "18f7ec40-2df9-442f-b4f4-85d834c768a1": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 61DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.dimethyl fumarate 120 mg CAPSULE, DR/EC DL 5 PA,QL(14 per 30 days) \nfingolimod 0.5 mg CAPSULE DL 5 PA,QL(30 per 30 days) \nFIRDAPSE 10 MG TABLET DL 5 PA,QL(240 per 30 days) \nGILENYA 0.25 MG CAPSULE DL 5 PA,QL(30 per 30 days) \nGILENYA 0.5 MG CAPSULE DL 5 PA,QL(30 per 30 days) \nglatiramer 20 mg/ml SYRINGE DL 5 PA,QL(30 per 30 days) \nglatiramer 40 mg/ml SYRINGE DL 5 PA,QL(12 per 28 days) \nglatopa 20 mg/ml SYRINGE DL 5 PA,QL(30 per 30 days) \nglatopa 40 mg/ml SYRINGE DL 5 PA,QL(12 per 28 days) \nguanfacine 1 mg, 2 mg, 3 mg, 4 mg TABLET, ER 24 HR. GC,MO 2 QL(30 per 30 days) \nINGREZZA 40 MG, 60 MG, 80 MG CAPSULE DL 5 PA,QL(30 per 30 days) \nINGREZZA INITIATION PACK 40 MG (7)- 80 MG (21) CAPSULE, DOSE PACK DL 5 PA,QL(28 per 28 days) \nKESIMPTA PEN 20 MG/0.4 ML PEN INJECTOR DL 5 PA,QL(1.2 per 28 days) \nmethylphenidate hcl 10 mg TABLET ER MO 4 QL(180 per 30 days) \nmethylphenidate hcl 10 mg, 20 mg, 5 mg TABLET MO 3 QL(90 per 30 days) \nmethylphenidate hcl 20 mg TABLET ER MO 4 QL(90 per 30 days) \nNUEDEXTA 20-10 MG CAPSULE DL 5 PA,QL(60 per 30 days) \npregabalin 100 mg, 150 mg, 50 mg, 75 mg CAPSULE MO 3 QL(90 per 30 days) \npregabalin 20 mg/ml SOLUTION MO 3 QL(900 per 30 days) \npregabalin 200 mg, 25 mg CAPSULE MO 3 QL(90 per 30 days) \npregabalin 225 mg, 300 mg CAPSULE MO 3 QL(60 per 30 days) \nriluzole 50 mg TABLET MO 4  \nRUZURGI 10 MG TABLET DL 5 PA,QL(300 per 30 days) \nSAVELLA 100 MG, 12.5 MG, 25 MG, 50 MG TABLET MO 3 QL(60 per 30 days) \nSAVELLA 12.5 MG (5)-25 MG(8)-50 MG(42) TABLET, DOSE PACK MO 3 QL(55 per 28 days) \nteriflunomide 14 mg, 7 mg TABLET MO 4 PA,QL(30 per 30 days) \ntetrabenazine 12.5 mg TABLET MO 4 PA,QL(240 per 30 days) \ntetrabenazine 25 mg TABLET DL 5 PA,QL(120 per 30 days) \nVUMERITY 231 MG CAPSULE, DR/EC DL 5 PA,QL(120 per 30 days) \nDENTAL & ORAL AGENTS\ncevimeline 30 mg CAPSULE MO 4  \nchlorhexidine gluconate 0.12 % MOUTHWASH GC,MO 1  \noralone 0.1 % PASTE MO 3  \nparoex oral rinse 0.12 % MOUTHWASH GC,MO 1  \nperiogard 0.12 % MOUTHWASH GC,MO 1  ", "doc_id": "18f7ec40-2df9-442f-b4f4-85d834c768a1", "embedding": null, "doc_hash": "d62f3d0500aa3819dcffdd87ad622cf0de44e6c08a0a2fc5d3b51b8bc17c00af", "extra_info": {"page_label": "61", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2467, "_node_type": "1"}, "relationships": {"1": "643f4e34-4014-414e-9b12-dc862d7c9473"}}, "__type__": "1"}, "b98f6cb3-5780-433e-9908-73da6e0ea863": {"__data__": {"text": "62 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.pilocarpine hcl 5 mg, 7.5 mg TABLET MO 4  \ntriamcinolone acetonide 0.1 % PASTE MO 3  \nDERMATOLOGICAL AGENTS\naccutane 10 mg, 20 mg, 30 mg CAPSULE MO 4 QL(60 per 30 days) \naccutane 40 mg CAPSULE MO 4 QL(120 per 30 days) \nacitretin 10 mg CAPSULE MO 4 PA,QL(90 per 30 days) \nacitretin 17.5 mg CAPSULE MO 4 PA,QL(60 per 30 days) \nacitretin 25 mg CAPSULE MO 4 PA \nadapalene 0.1 %, 0.3 % GEL MO 4 QL(45 per 30 days) \nadapalene 0.3 % GEL WITH PUMP MO 4 QL(45 per 30 days) \nammonium lactate 12 % CREAM GC,MO 2  \nammonium lactate 12 % LOTION GC,MO 2  \namnesteem 10 mg, 20 mg CAPSULE MO 4 QL(60 per 30 days) \namnesteem 40 mg CAPSULE MO 4 QL(120 per 30 days) \nazelaic acid 15 % GEL MO 4 ST,QL(50 per 30 days) \nbetamethasone dipropionate 0.05 % CREAM MO 3 QL(90 per 30 days) \nbetamethasone dipropionate 0.05 % LOTION MO 3 QL(120 per 30 days) \nbetamethasone dipropionate 0.05 % OINTMENT MO 4 QL(90 per 30 days) \nbetamethasone valerate 0.1 % CREAM GC,MO 2 QL(180 per 30 days) \nbetamethasone valerate 0.1 % LOTION MO 3 QL(120 per 30 days) \nbetamethasone valerate 0.1 % OINTMENT GC,MO 2 QL(180 per 30 days) \nbetamethasone, augmented 0.05 % CREAM GC,MO 2 QL(100 per 30 days) \nbetamethasone, augmented 0.05 % GEL MO 4 QL(100 per 30 days) \nbetamethasone, augmented 0.05 % LOTION MO 4 QL(120 per 30 days) \nbetamethasone, augmented 0.05 % OINTMENT MO 4 QL(100 per 30 days) \ncalcipotriene 0.005 % CREAM MO 4 PA,QL(120 per 30 days) \ncalcipotriene 0.005 % SOLUTION MO 4 QL(60 per 30 days) \nclaravis 10 mg, 20 mg, 30 mg CAPSULE MO 4 QL(60 per 30 days) \nclaravis 40 mg CAPSULE MO 4 QL(120 per 30 days) \nclindamycin phosphate 1 % GEL MO 4 QL(60 per 30 days) \nclindamycin phosphate 1 % LOTION MO 4 QL(60 per 30 days) \nclindamycin phosphate 1 % SOLUTION MO 4 QL(60 per 30 days) \nclindamycin phosphate 1 % SWAB GC,MO 2  \nclobetasol 0.05 % CREAM MO 4 QL(120 per 30 days) \nclobetasol 0.05 % GEL MO 4 QL(120 per 28 days) \nclobetasol 0.05 % LOTION MO 4 QL(240 per 28 days) ", "doc_id": "b98f6cb3-5780-433e-9908-73da6e0ea863", "embedding": null, "doc_hash": "17c38238e3ea4e0af0398b02ab8038f2c2494ca2dae98082bb6eaa9e954df897", "extra_info": {"page_label": "62", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2433, "_node_type": "1"}, "relationships": {"1": "24a3e9b9-b1ad-4ee4-9f18-061b8dbe8440"}}, "__type__": "1"}, "ae460863-8b0c-4bd2-a91c-a6e4a3ba4f9a": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 63DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.clobetasol 0.05 % OINTMENT MO 4 QL(120 per 28 days) \nclobetasol 0.05 % SOLUTION MO 3 QL(100 per 30 days) \nclobetasol-emollient 0.05 % CREAM MO 4 QL(120 per 30 days) \ndiclofenac sodium 3 % GEL MO 3 PA \nENSTILAR 0.005-0.064 % FOAM MO 4 QL(120 per 30 days) \nery pads 2 % SWAB MO 3 QL(60 per 30 days) \nerythromycin with ethanol 2 % SOLUTION MO 4 QL(120 per 30 days) \nfluocinolone 0.01 % OIL MO 4 QL(118.28 per 30 days) \nfluocinolone 0.01 % SOLUTION MO 4 QL(180 per 30 days) \nfluocinolone 0.01 %, 0.025 % CREAM MO 4 QL(120 per 30 days) \nfluocinolone 0.025 % OINTMENT MO 4 QL(120 per 30 days) \nfluocinolone and shower cap 0.01 % OIL MO 4 QL(118.28 per 30 days) \nfluocinonide 0.05 % CREAM MO 4 QL(120 per 30 days) \nfluocinonide 0.05 % GEL MO 4 QL(120 per 30 days) \nfluocinonide 0.05 % OINTMENT MO 4 QL(120 per 30 days) \nfluocinonide 0.05 % SOLUTION MO 4 QL(120 per 30 days) \nfluocinonide-e 0.05 % CREAM MO 4 QL(120 per 30 days) \nfluocinonide-emollient 0.05 % CREAM MO 4 QL(120 per 30 days) \nfluorouracil 2 % SOLUTION MO 3 QL(30 per 30 days) \nfluorouracil 5 % CREAM MO 4  \nfluorouracil 5 % SOLUTION MO 3 QL(60 per 30 days) \nfluticasone propionate 0.005 % OINTMENT GC,MO 2 QL(240 per 30 days) \nfluticasone propionate 0.05 % CREAM GC,MO 2 QL(240 per 30 days) \nhydrocortisone 1 % CREAM W/PERINEAL APPLICATOR GC,MO 2 QL(28.4 per 30 days) \nhydrocortisone 1 %, 2.5 % CREAM GC,MO 2 QL(240 per 30 days) \nhydrocortisone 1 %, 2.5 % OINTMENT GC,MO 2 QL(240 per 30 days) \nhydrocortisone 10 mg, 20 mg, 5 mg TABLET GC,MO 2  \nhydrocortisone 2.5 % CREAM W/PERINEAL APPLICATOR MO 4 QL(60 per 30 days) \nhydrocortisone 2.5 % LOTION GC,MO 2 QL(236 per 30 days) \nHYFTOR 0.2 % GEL DL 5 PA \nimiquimod 5 % CREAM IN PACKET MO 3 QL(12 per 30 days) \nisotretinoin 10 mg, 20 mg, 30 mg CAPSULE MO 4 QL(60 per 30 days) \nisotretinoin 40 mg CAPSULE MO 4 QL(120 per 30 days) \nlindane 1 % SHAMPOO MO 4 QL(60 per 30 days) \nLOCOID LIPOCREAM 0.1 % CREAM MO 4 QL(240 per 30 days) \nmalathion 0.5 % LOTION MO 4  ", "doc_id": "ae460863-8b0c-4bd2-a91c-a6e4a3ba4f9a", "embedding": null, "doc_hash": "881e60133867030dae04054729011fccaba3f8110c7478af898837bf49f1f8a2", "extra_info": {"page_label": "63", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2458, "_node_type": "1"}, "relationships": {"1": "9722d874-72a7-4490-92bf-a4652f6449ca"}}, "__type__": "1"}, "f0744fe7-df50-429d-941c-f7263318e962": {"__data__": {"text": "64 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.methoxsalen 10 mg CAPSULE, LIQ FILLED, RAPID REL DL 5  \nmometasone 0.1 % CREAM GC,MO 2 QL(180 per 30 days) \nmometasone 0.1 % OINTMENT GC,MO 2 QL(180 per 30 days) \nmometasone 0.1 % SOLUTION GC,MO 2 QL(180 per 30 days) \nmupirocin 2 % OINTMENT GC,MO 2  \nmyorisan 10 mg, 20 mg, 30 mg CAPSULE MO 4 QL(60 per 30 days) \nmyorisan 40 mg CAPSULE MO 4 QL(120 per 30 days) \nOTEZLA 30 MG TABLET DL 5 PA,QL(60 per 30 days) \nOTEZLA STARTER 10 MG (4)-20 MG (4)-30 MG (47) TABLET, DOSE PACK DL 5 PA,QL(55 per 28 days) \nOTEZLA STARTER 10 MG (4)-20 MG (4)-30 MG(19) TABLET, DOSE PACK DL 5 PA,QL(27 per 30 days) \npermethrin 5 % CREAM MO 3  \npimecrolimus 1 % CREAM MO 4 PA,QL(100 per 30 days) \npodofilox 0.5 % SOLUTION MO 4 QL(7 per 30 days) \nprocto-med hc 2.5 % CREAM W/PERINEAL APPLICATOR MO 4 QL(60 per 30 days) \nproctosol hc 2.5 % CREAM W/PERINEAL APPLICATOR MO 4 QL(60 per 30 days) \nproctozone-hc 2.5 % CREAM W/PERINEAL APPLICATOR MO 4 QL(60 per 30 days) \nREGRANEX 0.01 % GEL DL 5 PA \nSANTYL 250 UNIT/GRAM OINTMENT MO 4 QL(180 per 30 days) \nselenium sulfide 2.5 % LOTION GC,MO 2 QL(120 per 30 days) \nsilver sulfadiazine 1 % CREAM GC,MO 2  \nSSD 1 % CREAM GC,MO 2  \ntacrolimus 0.03 %, 0.1 % OINTMENT MO 4 QL(200 per 30 days) \ntazarotene 0.1 % CREAM MO 3 PA,QL(120 per 30 days) \ntretinoin 0.01 % GEL MO 3 PA,QL(45 per 30 days) \ntretinoin 0.025 %, 0.05 % GEL MO 4 PA,QL(45 per 30 days) \ntretinoin 0.025 %, 0.05 %, 0.1 % CREAM MO 4 PA,QL(45 per 30 days) \nUVADEX 20 MCG/ML SOLUTION MO 4  \nzenatane 10 mg, 20 mg, 30 mg CAPSULE MO 4 QL(60 per 30 days) \nzenatane 40 mg CAPSULE MO 4 QL(120 per 30 days) \nELECTROLYTES/MINERALS/METALS/VITAMINS\nAMINOSYN 10 % 10 % PARENTERAL SOLUTION MO 4 BvsD \nAMINOSYN 7 % WITH ELECTROLYTES 7 % PARENTERAL SOLUTION MO 4 BvsD \nAMINOSYN 8.5 % 8.5 % PARENTERAL SOLUTION MO 4 BvsD \nAMINOSYN 8.5 %-ELECTROLYTES 8.5 % PARENTERAL SOLUTION MO 4 BvsD \nAMINOSYN II 10 % 10 % PARENTERAL SOLUTION MO 4 BvsD \nAMINOSYN II 15 % 15 % PARENTERAL SOLUTION MO 4 BvsD ", "doc_id": "f0744fe7-df50-429d-941c-f7263318e962", "embedding": null, "doc_hash": "8bee94c912d134d662e15859bf79302ee26eb533ed54a14ee413ddfc93748158", "extra_info": {"page_label": "64", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2449, "_node_type": "1"}, "relationships": {"1": "38cc7271-0a7d-4ead-bbf7-3f556753166e"}}, "__type__": "1"}, "807ca88b-e79e-42c6-b912-f75436a0c99f": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 65DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.AMINOSYN II 7 % 7 % PARENTERAL SOLUTION MO 4 BvsD \nAMINOSYN II 8.5 % 8.5 % PARENTERAL SOLUTION MO 4 BvsD \nAMINOSYN II 8.5 %-ELECTROLYTES 8.5 % PARENTERAL SOLUTION MO 4 BvsD \nAMINOSYN M 3.5 % 3.5 % PARENTERAL SOLUTION MO 4 BvsD \nAMINOSYN-HBC 7% 7 % PARENTERAL SOLUTION MO 4 BvsD \nAMINOSYN-PF 10 % 10 % PARENTERAL SOLUTION MO 4 BvsD \nAMINOSYN-PF 7 % (SULFITE-FREE) 7 % PARENTERAL SOLUTION MO 4 BvsD \nAMINOSYN-RF 5.2 % 5.2 % PARENTERAL SOLUTION MO 4 BvsD \nbal-care dha 27-1-430 mg COMBO PACK, DR TAB/DR CAP MO 4  \nc-nate dha 28 mg iron-1 mg -200 mg CAPSULE MO 4  \ncalcium acetate(phosphat bind) 667 mg CAPSULE MO 3  \ncalcium acetate(phosphat bind) 667 mg TABLET MO 3  \ncalcium chloride 100 mg/ml (10 %) SOLUTION GC,MO 1  \ncalcium chloride 100 mg/ml (10 %) SYRINGE GC,MO 1  \ncalcium gluconate 100 mg/ml (10%) SOLUTION GC,MO 1  \ncarglumic acid 200 mg TABLET, DISPERSIBLE DL 5 PA \nCHEMET 100 MG CAPSULE DL 5  \nCLINIMIX  5%/D15W SULFITE FREE 5 % PARENTERAL SOLUTION MO 4 BvsD \nCLINIMIX 4.25%/D10W SULF FREE 4.25 % PARENTERAL SOLUTION MO 4 BvsD \nCLINIMIX 4.25%/D5W SULFIT FREE 4.25 % PARENTERAL SOLUTION MO 4 BvsD \nCLINIMIX 5%-D20W(SULFITE-FREE) 5 % PARENTERAL SOLUTION MO 4 BvsD \nCLINIMIX 6%-D5W (SULFITE-FREE) 6-5 % PARENTERAL SOLUTION MO 4 BvsD \nCLINIMIX 8%-D10W(SULFITE-FREE) 8-10 % PARENTERAL SOLUTION MO 4 BvsD \nCLINIMIX 8%-D14W(SULFITE-FREE) 8-14 % PARENTERAL SOLUTION MO 4 BvsD \nCLINIMIX E 2.75%/D5W SULF FREE 2.75 % PARENTERAL SOLUTION MO 4 BvsD \nCLINIMIX E 4.25%/D10W SUL FREE 4.25 % PARENTERAL SOLUTION MO 4 BvsD \nCLINIMIX E 4.25%/D5W SULF FREE 4.25 % PARENTERAL SOLUTION MO 4 BvsD \nCLINIMIX E 5%/D15W SULFIT FREE 5 % PARENTERAL SOLUTION MO 4 BvsD \nCLINIMIX E 5%/D20W SULFIT FREE 5 % PARENTERAL SOLUTION MO 4 BvsD \nCLINIMIX E 8%-D10W SULFITEFREE 8-10 % PARENTERAL SOLUTION MO 4 BvsD \nCLINIMIX E 8%-D14W SULFITEFREE 8-14 % PARENTERAL SOLUTION MO 4 BvsD \nCLINISOL SF 15 % 15 % PARENTERAL SOLUTION MO 4 BvsD \nCLINOLIPID 20 % EMULSION MO 4 BvsD \nclovique 250", "doc_id": "807ca88b-e79e-42c6-b912-f75436a0c99f", "embedding": null, "doc_hash": "1ae7915554281e62cde6ba295bca94c884a5f8c95d469744438d184d50c10505", "extra_info": {"page_label": "65", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2452, "_node_type": "1"}, "relationships": {"1": "50ca3d37-7d2b-439c-b773-19398cde035b", "3": "a1fa33f1-5366-4ece-bbb7-8f0941218ff2"}}, "__type__": "1"}, "a1fa33f1-5366-4ece-bbb7-8f0941218ff2": {"__data__": {"text": "20 % EMULSION MO 4 BvsD \nclovique 250 mg CAPSULE DL 5 QL(240 per 30 days) \ncomplete natal dha 29-1-250-200 mg COMBO PACK MO 4  \nd10 %-0.45 % sodium chloride  PARENTERAL SOLUTION GC,MO 2  ", "doc_id": "a1fa33f1-5366-4ece-bbb7-8f0941218ff2", "embedding": null, "doc_hash": "0d5ac8c11fe45ca70b62b2f4c316536b70b7d9e5f002641231b80e28d0971d63", "extra_info": {"page_label": "65", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2415, "end": 2602, "_node_type": "1"}, "relationships": {"1": "50ca3d37-7d2b-439c-b773-19398cde035b", "2": "807ca88b-e79e-42c6-b912-f75436a0c99f"}}, "__type__": "1"}, "0e26515f-d2fc-4c7b-a103-d8140ce7599c": {"__data__": {"text": "66 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.d2.5 %-0.45 % sodium chloride  PARENTERAL SOLUTION GC,MO 2  \nd5 % and 0.9 % sodium chloride  PARENTERAL SOLUTION GC,MO 2  \nd5 %-0.45 % sodium chloride  PARENTERAL SOLUTION GC,MO 2  \ndeferasirox 125 mg, 250 mg, 500 mg TABLET, DISPERSIBLE DL 5 PA \ndextrose 10 % and 0.2 % nacl  PARENTERAL SOLUTION GC,MO 2  \ndextrose 10 % in water (d10w) 10 % PARENTERAL SOLUTION GC,MO 2  \ndextrose 20 % in water (d20w) 20 % PARENTERAL SOLUTION GC,MO 2  \ndextrose 25 % in water (d25w)  SYRINGE GC,MO 2  \ndextrose 30 % in water (d30w)  PARENTERAL SOLUTION GC,MO 2  \ndextrose 40 % in water (d40w) 40 % PARENTERAL SOLUTION GC,MO 2  \ndextrose 5 % in water (d5w)  PARENTERAL SOLUTION GC,MO 2  \ndextrose 5 % in water (d5w) 5 % PIGGYBACK GC,MO 2  \ndextrose 5 %-lactated ringers  PARENTERAL SOLUTION GC,MO 2  \ndextrose 5%-0.2 % sod chloride  PARENTERAL SOLUTION GC,MO 2  \ndextrose 5%-0.3 % sod.chloride  PARENTERAL SOLUTION GC,MO 2  \ndextrose 50 % in water (d50w)  PARENTERAL SOLUTION GC,MO 2  \ndextrose 50 % in water (d50w)  SYRINGE GC,MO 2  \ndextrose 70 % in water (d70w)  PARENTERAL SOLUTION GC,MO 2  \nelectrolyte-48 in d5w  PARENTERAL SOLUTION GC,MO 2  \nFREAMINE III 10 % 10 % PARENTERAL SOLUTION MO 4 BvsD \nGLYCOPHOS 1 MMOL/ML SOLUTION GC,MO 1  \nINTRALIPID 20 %, 30 % EMULSION MO 4 BvsD \nIONOSOL-B IN D5W 5 % PARENTERAL SOLUTION MO 4  \nIONOSOL-MB IN D5W 5 % PARENTERAL SOLUTION MO 4  \nISOLYTE S PH 7.4  PARENTERAL SOLUTION MO 4  \nISOLYTE-P IN 5 % DEXTROSE 5 % PARENTERAL SOLUTION MO 4  \nISOLYTE-S  PARENTERAL SOLUTION MO 4  \nK-TAB 10 MEQ, 20 MEQ, 8 MEQ TABLET ER MO 4  \nKABIVEN 3.31-9.8-3.9 % EMULSION MO 4 BvsD \nKLOR-CON 10 10 MEQ TABLET ER GC,MO 2  \nKLOR-CON 8 8 MEQ TABLET ER GC,MO 2  \nklor-con m10 10 meq TABLET, ER PARTICLES/CRYSTALS GC,MO 2  \nKLOR-CON M15 15 MEQ TABLET, ER PARTICLES/CRYSTALS GC,MO 2  \nklor-con m20 20 meq TABLET, ER PARTICLES/CRYSTALS GC,MO 2  \nlactated ringers  PARENTERAL SOLUTION GC,MO 2  \nlevocarnitine 330 mg TABLET MO 4  ", "doc_id": "0e26515f-d2fc-4c7b-a103-d8140ce7599c", "embedding": null, "doc_hash": "88f4f23a04844dccae2cd0dbea493d8a796f6666350ccc449cfaf9263f35fe61", "extra_info": {"page_label": "66", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2424, "_node_type": "1"}, "relationships": {"1": "89dc2e45-6571-46a6-9561-f1995ee977ee"}}, "__type__": "1"}, "a97bed54-5d30-4c9c-8a9d-45d91e3731aa": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 67DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.levocarnitine (with sugar) 100 mg/ml SOLUTION MO 4  \nm-natal plus 27 mg iron- 1 mg TABLET MO 4  \nmagnesium sulfate 4 meq/ml (50 %) SOLUTION GC,MO 2  \nmagnesium sulfate 4 meq/ml SYRINGE GC,MO 2  \nmagnesium sulfate in d5w 1 gram/100 ml PIGGYBACK GC,MO 2  \nmagnesium sulfate in water 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4  \ngram/50 ml (8 %) PIGGYBACK GC,MO2  \nmagnesium sulfate in water 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %)  \nPARENTERAL SOLUTION GC,MO2  \nNEONATAL COMPLETE 29-1 MG TABLET MO 4  \nNEONATAL PLUS VITAMIN 27 MG IRON- 1 MG TABLET MO 4  \nNEONATAL-DHA 29-1-200-500 MG COMBO PACK MO 4  \nNORMOSOL-M IN 5 % DEXTROSE  PARENTERAL SOLUTION MO 4  \nNORMOSOL-R  PARENTERAL SOLUTION MO 4  \nNORMOSOL-R IN 5 % DEXTROSE 5 % PARENTERAL SOLUTION MO 4  \nNORMOSOL-R PH 7.4  PARENTERAL SOLUTION MO 4  \nNUTRILIPID 20 % EMULSION MO 4 BvsD \nO-CAL PRENATAL 15 MG IRON- 1,000 MCG TABLET MO 4  \npenicillamine 250 mg TABLET DL 5  \nPERIKABIVEN 2.36-6.8-3.5 % EMULSION MO 4 BvsD \nPLASMA-LYTE 148  PARENTERAL SOLUTION MO 4  \nPLASMA-LYTE A  PARENTERAL SOLUTION MO 4  \nPLENAMINE 15 % PARENTERAL SOLUTION MO 4 BvsD \npotassium acetate 2 meq/ml SOLUTION GC,MO 1  \npotassium chlorid-d5-0.45%nacl 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l  \nPARENTERAL SOLUTION GC,MO2  \npotassium chloride 10 meq CAPSULE, ER GC,MO 2  \npotassium chloride 10 meq, 20 meq TABLET ER GC,MO 2  \npotassium chloride 10 meq, 20 meq TABLET, ER PARTICLES/CRYSTALS GC,MO 2  \npotassium chloride 15 meq TABLET, ER PARTICLES/CRYSTALS GC,MO 2  \npotassium chloride 2 meq/ml SOLUTION GC,MO 2  \npotassium chloride 20 meq/15 ml LIQUID MO 4 QL(1125 per 30 days) \npotassium chloride 40 meq/15 ml LIQUID MO 4  \npotassium chloride 8 meq CAPSULE, ER GC,MO 2  \npotassium chloride 8 meq TABLET ER GC,MO 2  \npotassium chloride in 0.9%nacl 20 meq/l, 40 meq/l PARENTERAL SOLUTION \nGC,MO2  ", "doc_id": "a97bed54-5d30-4c9c-8a9d-45d91e3731aa", "embedding": null, "doc_hash": "871773ed237fdd949e06dac6e00ece4f6dfbd64546789887abc679cbddaee3a2", "extra_info": {"page_label": "67", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2318, "_node_type": "1"}, "relationships": {"1": "9f170c36-3765-4f17-bf08-93eabf3615ec"}}, "__type__": "1"}, "6a924746-c8ec-4a1a-989f-299fe63496a1": {"__data__": {"text": "68 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.potassium chloride in 5 % dex 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l  \nPARENTERAL SOLUTION GC,MO2  \npotassium chloride in lr-d5 20 meq/l, 40 meq/l PARENTERAL SOLUTION GC,MO 2  \npotassium chloride in water 10 meq/100 ml, 10 meq/50 ml, 20 meq/100 ml, 20  \nmeq/50 ml, 30 meq/100 ml, 40 meq/100 ml PIGGYBACK GC,MO2  \npotassium chloride-0.45 % nacl 20 meq/l PARENTERAL SOLUTION GC,MO 2  \npotassium chloride-d5-0.2%nacl 20 meq/l, 40 meq/l PARENTERAL SOLUTION \nGC,MO2  \npotassium chloride-d5-0.3%nacl 20 meq/l PARENTERAL SOLUTION GC,MO 2  \npotassium chloride-d5-0.9%nacl 20 meq/l, 40 meq/l PARENTERAL SOLUTION \nGC,MO2  \npotassium citrate 10 meq (1,080 mg), 15 meq, 5 meq (540 mg) TABLET ER MO 3  \npr natal 400 29-1-400 mg COMBO PACK MO 4  \npr natal 400 ec 29-1-400 mg COMBO PACK, DR TAB/DR CAP MO 4  \npr natal 430 29 mg iron-1 mg -430 mg COMBO PACK MO 4  \npr natal 430 ec 29-1-430 mg COMBO PACK, DR TAB/DR CAP MO 4  \nPREMASOL 10 % 10 % PARENTERAL SOLUTION MO 4 BvsD \nPRENATA 29 MG IRON- 1 MG CHEWABLE TABLET MO 4  \nPRENATABS FA 29-1 MG TABLET MO 4  \nprenatal plus (calcium carb) 27 mg iron- 1 mg TABLET MO 4  \nprenatal plus vitamin-mineral 27 mg iron- 1 mg TABLET MO 4  \nPRENATE ELITE 26 MG IRON- 1 MG TABLET MO 4  \npreplus 27 mg iron- 1 mg TABLET MO 4  \nPROCALAMINE 3% 3 % PARENTERAL SOLUTION MO 4 BvsD \nPROSOL 20 %  PARENTERAL SOLUTION MO 4 BvsD \nringer's  PARENTERAL SOLUTION GC,MO 1  \nse-natal 19 chewable 29 mg iron- 1 mg CHEWABLE TABLET MO 4  \nsevelamer carbonate 0.8 gram POWDER IN PACKET MO 4 QL(540 per 30 days) \nsevelamer carbonate 2.4 gram POWDER IN PACKET MO 4 QL(180 per 30 days) \nsevelamer carbonate 800 mg TABLET MO 4 QL(540 per 30 days) \nSMOFLIPID 20 % EMULSION MO 4 BvsD \nsodium bicarbonate 8.4 % (1 meq/ml) SYRINGE MO 4  \nsodium chloride 2.5 meq/ml PARENTERAL SOLUTION GC,MO 2  \nsodium chloride 0.45 % 0.45 % PARENTERAL SOLUTION GC,MO 2  \nsodium chloride 0.9 %  PARENTERAL SOLUTION GC,MO 2  \nsodium chloride 0.9 %  PIGGYBACK GC,MO 2  \nsodium chloride 0.9 %  SOLUTION GC,MO 2  ", "doc_id": "6a924746-c8ec-4a1a-989f-299fe63496a1", "embedding": null, "doc_hash": "68ea85cee1e29e3aaba6b9f70c8c28d218fe3c78312f9218195af7c2cec79a6b", "extra_info": {"page_label": "68", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2482, "_node_type": "1"}, "relationships": {"1": "1469ce25-7566-49fa-8aba-fbe0ede9d677"}}, "__type__": "1"}, "7a0db42b-293f-414b-a4ee-d093e896e75e": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 69DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.sodium chloride 3 % hypertonic 3 % PARENTERAL SOLUTION GC,MO 2  \nsodium chloride 5 % hypertonic 5 % PARENTERAL SOLUTION GC,MO 2  \nsodium phosphate 3 mmol/ml SOLUTION GC,MO 1  \nsodium polystyrene sulfonate  POWDER MO 3  \nSPS (WITH SORBITOL) 15-20 GRAM/60 ML SUSPENSION MO 3  \nTPN ELECTROLYTES 35-20-5 MEQ/20 ML SOLUTION MO 4  \nTRAVASOL 10 % 10 % PARENTERAL SOLUTION MO 4 BvsD \ntrientine 250 mg CAPSULE DL 5 QL(240 per 30 days) \ntrinatal rx 1 60 mg iron-1 mg TABLET MO 4  \ntriveen-duo dha 29-1-400 mg COMBO PACK MO 4  \nTROPHAMINE 10 % 10 % PARENTERAL SOLUTION MO 4 BvsD \nVELTASSA 16.8 GRAM, 25.2 GRAM, 8.4 GRAM POWDER IN PACKET MO 3 QL(30 per 30 days) \nvirt-c dha 35-1-200 mg CAPSULE MO 4  \nvirt-nate dha 28 mg iron-1 mg -200 mg CAPSULE MO 4  \nwesnate dha 28 mg iron-1 mg -200 mg CAPSULE MO 4  \nwestab plus 27 mg iron- 1 mg TABLET MO 4  \nGASTROINTESTINAL AGENTS\namoxicil-clarithromy-lansopraz 500-500-30 mg COMBO PACK MO 4 ST,QL(112 per 30 days) \nbismuth subcit k-metronidz-tcn 140-125-125 mg CAPSULE MO 4 QL(120 per 30 days) \nCHENODAL 250 MG TABLET DL 5 PA \ncimetidine 200 mg, 300 mg, 400 mg, 800 mg TABLET GC,MO 2  \ncimetidine hcl 300 mg/5 ml SOLUTION MO 3  \nCLENPIQ 10 MG-3.5 GRAM- 12 GRAM/160 ML SOLUTION MO 3  \nCLENPIQ 10 MG-3.5 GRAM- 12 GRAM/175 ML SOLUTION MO 3  \nconstulose 10 gram/15 ml SOLUTION GC,MO 2  \ndicyclomine 10 mg CAPSULE GC,MO 2  \ndicyclomine 10 mg/5 ml SOLUTION MO 4  \ndicyclomine 20 mg TABLET GC,MO 2  \ndiphenoxylate-atropine 2.5-0.025 mg TABLET MO 4  \nenulose 10 gram/15 ml SOLUTION GC,MO 2  \nesomeprazole magnesium 20 mg CAPSULE, DR/EC MO 3 QL(60 per 30 days) \nesomeprazole magnesium 40 mg CAPSULE, DR/EC MO 3 QL(60 per 30 days) \nfamotidine 10 mg/ml SOLUTION GC,MO 2  \nfamotidine 20 mg, 40 mg TABLET GC,MO 2  \nfamotidine 40 mg/5 ml (8 mg/ml) SUSPENSION MO 4  \nfamotidine (pf) 20 mg/2 ml SOLUTION GC,MO 2  ", "doc_id": "7a0db42b-293f-414b-a4ee-d093e896e75e", "embedding": null, "doc_hash": "6f320229434a146d96b3ea516d4f540e757af6571f20b67a2f176131e96a1225", "extra_info": {"page_label": "69", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2322, "_node_type": "1"}, "relationships": {"1": "57360270-3d8a-4e22-9fd4-fbc9fb78789f"}}, "__type__": "1"}, "bf70ff21-322b-4115-b60a-8fa480876486": {"__data__": {"text": "70 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.famotidine (pf)-nacl  (iso-os) 20 mg/50 ml PIGGYBACK GC,MO 2  \nGATTEX 30-VIAL 5 MG KIT DL,LA 5 PA \nGATTEX ONE-VIAL 5 MG KIT DL,LA 5 PA \ngavilyte-c 240-22.72-6.72 -5.84 gram RECON SOLUTION GC,MO 2  \ngavilyte-g 236-22.74-6.74 -5.86 gram RECON SOLUTION GC,MO 2  \ngavilyte-n 420 gram RECON SOLUTION GC,MO 2  \ngenerlac 10 gram/15 ml SOLUTION GC,MO 2  \nglycopyrrolate 0.2 mg/ml SOLUTION MO 4  \nglycopyrrolate 1 mg, 2 mg TABLET MO 3  \nlactulose 10 gram/15 ml (15 ml), 20 gram/30 ml SOLUTION GC,MO 2  \nlactulose 10 gram/15 ml SOLUTION GC,MO 2  \nlansoprazole 15 mg, 30 mg CAPSULE, DR/EC GC,MO 2 QL(60 per 30 days) \nLINZESS 145 MCG, 290 MCG, 72 MCG CAPSULE MO 3 QL(30 per 30 days) \nloperamide 2 mg CAPSULE GC,MO 2  \nmethscopolamine 2.5 mg, 5 mg TABLET MO 4  \nmisoprostol 100 mcg TABLET MO 3  \nmisoprostol 200 mcg TABLET MO 3  \nMOVANTIK 12.5 MG, 25 MG TABLET MO 3 QL(30 per 30 days) \nMYALEPT 5 MG/ML (FINAL CONC.) RECON SOLUTION DL 5 PA,QL(30 per 30 days) \nnizatidine 150 mg, 300 mg CAPSULE GC,MO 2  \nnizatidine 150 mg/10 ml SOLUTION MO 4  \nomeprazole 10 mg CAPSULE, DR/EC GC,MO 1 QL(60 per 30 days) \nomeprazole 20 mg, 40 mg CAPSULE, DR/EC GC,MO 1 QL(60 per 30 days) \npantoprazole 20 mg, 40 mg TABLET, DR/EC GC,MO 1 QL(60 per 30 days) \npantoprazole 40 mg RECON SOLUTION MO 3  \npeg 3350-electrolytes 236-22.74-6.74 -5.86 gram RECON SOLUTION GC,MO 2  \npeg-electrolyte soln 420 gram RECON SOLUTION GC,MO 2  \nPYLERA 140-125-125 MG CAPSULE MO 4 QL(120 per 30 days) \nrabeprazole 20 mg TABLET, DR/EC MO 3 QL(60 per 30 days) \nsucralfate 1 gram TABLET GC,MO 2  \nsucralfate 100 mg/ml SUSPENSION MO 4  \ntrilyte with flavor packets 420 gram RECON SOLUTION GC,MO 2  \nursodiol 250 mg TABLET MO 3  \nursodiol 300 mg CAPSULE MO 4  \nursodiol 500 mg TABLET MO 4  ", "doc_id": "bf70ff21-322b-4115-b60a-8fa480876486", "embedding": null, "doc_hash": "af75becffc991f6787ebbf56412fb35ada4ae33deebdcb0f0647781a9ab94887", "extra_info": {"page_label": "70", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2228, "_node_type": "1"}, "relationships": {"1": "7e7c6386-027a-4849-9ead-0ac46c1082c4"}}, "__type__": "1"}, "d76a66d4-173d-442e-a957-8ff3f85e3c59": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 71DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.XIFAXAN 200 MG TABLET DL 5 PA,QL(9 per 30 days) \nXIFAXAN 550 MG TABLET DL 5 PA,QL(84 per 28 days) \nGENETIC/ENZYME/PROTEIN DISORDER: REPLACEMENT, MODIFIERS, TREATMENT\nbetaine 1 gram/scoop POWDER DL 5  \nCERDELGA 84 MG CAPSULE DL 5 PA \nCEREZYME 400 UNIT RECON SOLUTION DL 5 PA \nCHOLBAM 250 MG, 50 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nCREON 12,000-38,000 -60,000 UNIT, 3,000-9,500- 15,000 UNIT,  \n36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT CAPSULE,  \nDR/EC MO3  \nCREON 24,000-76,000 -120,000 UNIT CAPSULE, DR/EC MO 3  \nCRYSVITA 10 MG/ML, 20 MG/ML SOLUTION DL 5 PA,QL(2 per 28 days) \nCRYSVITA 30 MG/ML SOLUTION DL 5 PA,QL(6 per 28 days) \nCYSTAGON 150 MG, 50 MG CAPSULE MO 4  \nELELYSO 200 UNIT RECON SOLUTION DL 5 PA \njavygtor 100 mg TABLET, SOLUBLE DL 5 PA \njavygtor 100 mg, 500 mg POWDER IN PACKET DL 5 PA \nnitisinone 10 mg, 2 mg, 20 mg, 5 mg CAPSULE DL 5  \nPROLASTIN-C 1,000 MG (+/-)/20 ML SOLUTION DL 5 PA \nPROLASTIN-C 1,000 MG RECON SOLUTION DL 5 PA \nREVCOVI 2.4 MG/1.5 ML (1.6 MG/ML) SOLUTION DL 5  \nsapropterin 100 mg TABLET, SOLUBLE DL 5 PA \nsapropterin 100 mg, 500 mg POWDER IN PACKET DL 5 PA \nsodium phenylbutyrate 0.94 gram/gram POWDER DL 5  \nSTRENSIQ 18 MG/0.45 ML, 28 MG/0.7 ML, 40 MG/ML, 80 MG/0.8 ML  \nSOLUTION DL5 PA \nSUCRAID 8,500 UNIT/ML SOLUTION DL 5  \nVYNDAMAX 61 MG CAPSULE DL 5 PA,QL(30 per 30 days) \nVYNDAQEL 20 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nZENPEP 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT,  \n20,000-63,000- 84,000 UNIT, 3,000-10,000 -14,000-UNIT,  \n40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT CAPSULE,  \nDR/EC MO4  \nZENPEP 25,000-79,000- 105,000 UNIT CAPSULE, DR/EC MO 4  \nZOKINVY 50 MG, 75 MG CAPSULE DL 5 PA,QL(120 per 30 days) \nGENITOURINARY AGENTS\nalfuzosin 10 mg TABLET, ER 24 HR. GC,MO 1  ", "doc_id": "d76a66d4-173d-442e-a957-8ff3f85e3c59", "embedding": null, "doc_hash": "3bf3c200ade3dfc36886ca32b675fa9e1b0a6b08e3e173c2390fe637bdb54d26", "extra_info": {"page_label": "71", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2260, "_node_type": "1"}, "relationships": {"1": "bf29f4ea-5e23-45e4-a4fb-8308f76e4b04"}}, "__type__": "1"}, "b35aa57a-8fbf-4a98-a804-985e332e159e": {"__data__": {"text": "72 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.bethanechol chloride 10 mg, 25 mg, 5 mg, 50 mg TABLET MO 3  \ndarifenacin 15 mg, 7.5 mg TABLET, ER 24 HR. MO 4 ST,QL(30 per 30 days) \ndutasteride 0.5 mg CAPSULE MO 3 QL(30 per 30 days) \ndutasteride-tamsulosin 0.5-0.4 mg CAPSULE ER MULTIPHASE 24 HR. MO 3 QL(30 per 30 days) \nELMIRON 100 MG CAPSULE MO 4 QL(90 per 30 days) \nfesoterodine 4 mg, 8 mg TABLET, ER 24 HR. MO 3 QL(30 per 30 days) \nfinasteride 5 mg TABLET GC,MO 1 QL(30 per 30 days) \nGEMTESA 75 MG TABLET MO 4 QL(30 per 30 days) \nMYRBETRIQ 25 MG, 50 MG TABLET, ER 24 HR. MO 3 QL(30 per 30 days) \nMYRBETRIQ 8 MG/ML SUSPENSION, ER, RECON MO 3 QL(300 per 30 days) \noxybutynin chloride 10 mg, 5 mg TABLET, ER 24 HR. GC,MO 2 QL(60 per 30 days) \noxybutynin chloride 15 mg TABLET, ER 24 HR. GC,MO 2 QL(60 per 30 days) \noxybutynin chloride 2.5 mg TABLET GC,MO 2 QL(90 per 30 days) \noxybutynin chloride 5 mg TABLET GC,MO 2  \noxybutynin chloride 5 mg/5 ml SYRUP GC,MO 2  \nsolifenacin 10 mg, 5 mg TABLET GC,MO 2 QL(30 per 30 days) \ntamsulosin 0.4 mg CAPSULE GC,MO 2  \ntiopronin 100 mg TABLET DL 5  \ntolterodine 1 mg, 2 mg TABLET MO 4 QL(60 per 30 days) \ntolterodine 2 mg, 4 mg CAPSULE, ER 24 HR. MO 4 QL(30 per 30 days) \nHORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)\nbetamethasone acet,sod phos 6 mg/ml SUSPENSION MO 3  \ndexamethasone 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg TABLET \nGC,MO2  \ndexamethasone 0.5 mg/5 ml ELIXIR GC,MO 2  \ndexamethasone 0.5 mg/5 ml SOLUTION GC,MO 2  \ndexamethasone intensol 1 mg/ml DROPS MO 3  \ndexamethasone sodium phos (pf) 10 mg/ml SOLUTION GC,MO 2  \ndexamethasone sodium phos (pf) 10 mg/ml SYRINGE GC,MO 2  \ndexamethasone sodium phosphate 10 mg/ml, 4 mg/ml SOLUTION GC,MO 2  \ndexamethasone sodium phosphate 4 mg/ml SYRINGE GC,MO 2  \nfludrocortisone 0.1 mg TABLET GC,MO 2  \nmethylprednisolone 16 mg, 32 mg, 4 mg, 8 mg TABLET GC,MO 2 BvsD \nmethylprednisolone 4 mg TABLET, DOSE PACK GC,MO 2  \nmethylprednisolone acetate 40 mg/ml, 80 mg/ml SUSPENSION GC,MO 2  ", "doc_id": "b35aa57a-8fbf-4a98-a804-985e332e159e", "embedding": null, "doc_hash": "134be2377e014e1b6ffa0a93432b8b5cb50c7633f11304a99f182516841089e1", "extra_info": {"page_label": "72", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2450, "_node_type": "1"}, "relationships": {"1": "a67a0c69-37d3-4dcf-a851-ba42db79d0ae"}}, "__type__": "1"}, "0deeb4d9-44ae-4069-84ec-355af3e9ae4e": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 73DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.methylprednisolone sodium succ 1,000 mg, 125 mg, 40 mg RECON SOLUTION \nMO4  \nprednisolone 15 mg/5 ml SOLUTION GC,MO 2  \nprednisolone sodium phosphate 15 mg/5 ml (3 mg/ml) SOLUTION GC,MO 2  \nprednisolone sodium phosphate 20 mg/5 ml (4 mg/ml) SOLUTION MO 4  \nprednisolone sodium phosphate 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7  \nmg/5 ml) SOLUTION MO3  \nprednisone 1 mg, 2.5 mg, 50 mg TABLET GC,MO 1 BvsD \nprednisone 10 mg, 20 mg, 5 mg TABLET GC,MO 1 BvsD \nprednisone 10 mg, 5 mg TABLET, DOSE PACK GC,MO 2  \nprednisone 5 mg/5 ml SOLUTION MO 3 BvsD \nprednisone intensol 5 mg/ml CONCENTRATE MO 4 BvsD \nSOLU-MEDROL 2 GRAM RECON SOLUTION MO 4  \nSOLU-MEDROL (PF) 1,000 MG/8 ML, 125 MG/2 ML, 40 MG/ML, 500 MG/4 ML  \nRECON SOLUTION MO4  \ntriamcinolone acetonide 0.025 %, 0.1 % LOTION MO 3  \ntriamcinolone acetonide 0.025 %, 0.1 %, 0.5 % OINTMENT GC,MO 2  \ntriamcinolone acetonide 0.025 %, 0.5 % CREAM GC,MO 2  \ntriamcinolone acetonide 0.1 % CREAM GC,MO 2  \ntriderm 0.1 %, 0.5 % CREAM GC,MO 2  \nVERIPRED 20 20 MG/5 ML (4 MG/ML) SOLUTION MO 4  \nHORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)\nCHORIONIC GONADOTROPIN, HUMAN 10,000 UNIT RECON SOLUTION MO 4 PA \ndesmopressin 0.1 mg TABLET MO 3  \ndesmopressin 0.2 mg TABLET MO 4  \nEGRIFTA SV 2 MG RECON SOLUTION DL 5 PA,QL(30 per 30 days) \nINCRELEX 10 MG/ML SOLUTION DL 5 PA \nOMNITROPE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML)  \nCARTRIDGE DL5 PA \nOMNITROPE 5.8 MG RECON SOLUTION DL 5 PA \nHORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)\nafirmelle 0.1-20 mg-mcg TABLET MO 4  \naltavera (28) 0.15-0.03 mg TABLET MO 4  \nalyacen 1/35 (28) 1-35 mg-mcg TABLET MO 4  \nalyacen 7/7/7 (28) 0.5/0.75/1 mg- 35 mcg TABLET MO 4  \namabelz 0.5-0.1 mg, 1-0.5 mg TABLET MO 4  ", "doc_id": "0deeb4d9-44ae-4069-84ec-355af3e9ae4e", "embedding": null, "doc_hash": "32676be3b03039ed488ab1a14981e4945568399cf4669be5a84176595bc5d460", "extra_info": {"page_label": "73", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2237, "_node_type": "1"}, "relationships": {"1": "da15542e-e229-4442-b1fc-7688c1e7be6b"}}, "__type__": "1"}, "32f1c308-54ac-4256-8c7b-17db572c7f90": {"__data__": {"text": "74 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.amethia 0.15 mg-30 mcg (84)/10 mcg (7) TABLET, DOSE PACK, 3 MONTH MO 4 QL(91 per 90 days) \namethyst (28) 90-20 mcg (28) TABLET MO 4  \napri 0.15-0.03 mg TABLET MO 4  \naranelle (28) 0.5/1/0.5-35 mg-mcg TABLET MO 4  \nashlyna 0.15 mg-30 mcg (84)/10 mcg (7) TABLET, DOSE PACK, 3 MONTH MO 4 QL(91 per 90 days) \naubra 0.1-20 mg-mcg TABLET MO 4  \naubra eq 0.1-20 mg-mcg TABLET MO 4  \naurovela 1.5/30 (21) 1.5-30 mg-mcg TABLET MO 4  \naurovela 1/20 (21) 1-20 mg-mcg TABLET MO 4  \naurovela 24 fe 1 mg-20 mcg (24)/75 mg (4) TABLET MO 4  \naurovela fe 1-20 (28) 1 mg-20 mcg (21)/75 mg (7) TABLET MO 4  \naurovela fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) TABLET MO 4  \naviane 0.1-20 mg-mcg TABLET MO 4  \nayuna 0.15-0.03 mg TABLET MO 4  \nazurette (28) 0.15-0.02 mgx21 /0.01 mg x 5 TABLET MO 4  \nbalziva (28) 0.4-35 mg-mcg TABLET MO 4  \nblisovi 24 fe 1 mg-20 mcg (24)/75 mg (4) TABLET MO 4  \nblisovi fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) TABLET MO 4  \nblisovi fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) TABLET MO 4  \nbriellyn 0.4-35 mg-mcg TABLET MO 4  \ncamila 0.35 mg TABLET MO 4  \ncamrese 0.15 mg-30 mcg (84)/10 mcg (7) TABLET, DOSE PACK, 3 MONTH MO 4 QL(91 per 90 days) \ncamrese lo 0.1 mg-20 mcg (84)/10 mcg (7) TABLET, DOSE PACK, 3 MONTH MO 4 QL(91 per 90 days) \ncaziant (28) 0.1/.125/.15-25 mg-mcg TABLET MO 4  \ncharlotte 24 fe 1 mg-20 mcg(24) /75 mg (4) CHEWABLE TABLET MO 4  \nchateal (28) 0.15-0.03 mg TABLET MO 4  \nchateal eq (28) 0.15-0.03 mg TABLET MO 4  \nCOMBIPATCH 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR PATCH, SEMIWEEKLY \nMO4 QL(8 per 28 days) \ncryselle (28) 0.3-30 mg-mcg TABLET MO 4  \ncyclafem 1/35 (28) 1-35 mg-mcg TABLET MO 4  \ncyclafem 7/7/7 (28) 0.5/0.75/1 mg- 35 mcg TABLET MO 4  \ncyred 0.15-0.03 mg TABLET MO 4  \ncyred eq 0.15-0.03 mg TABLET MO 4  \ndanazol 100", "doc_id": "32f1c308-54ac-4256-8c7b-17db572c7f90", "embedding": null, "doc_hash": "4f405d582baac8a2fbb72c46e8329d430636b5866fa48d24cd34e7e0105da2e7", "extra_info": {"page_label": "74", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2264, "_node_type": "1"}, "relationships": {"1": "02f0cce7-ae60-4d19-a666-ac5e53c94f05", "3": "e658db25-fb30-4c84-a222-af11f367afd4"}}, "__type__": "1"}, "e658db25-fb30-4c84-a222-af11f367afd4": {"__data__": {"text": "mg TABLET MO 4  \ndanazol 100 mg, 200 mg, 50 mg CAPSULE MO 4  \ndasetta 1/35 (28) 1-35 mg-mcg TABLET MO 4  ", "doc_id": "e658db25-fb30-4c84-a222-af11f367afd4", "embedding": null, "doc_hash": "ffd4248030881af43eff999cca96f5ce7c54022bcf9c2e3716aa10c76f8bfc97", "extra_info": {"page_label": "74", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2236, "end": 2341, "_node_type": "1"}, "relationships": {"1": "02f0cce7-ae60-4d19-a666-ac5e53c94f05", "2": "32f1c308-54ac-4256-8c7b-17db572c7f90"}}, "__type__": "1"}, "e95488fe-cdc8-4f3a-9184-c9dba1e556b2": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 75DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.dasetta 7/7/7 (28) 0.5/0.75/1 mg- 35 mcg TABLET MO 4  \ndaysee 0.15 mg-30 mcg (84)/10 mcg (7) TABLET, DOSE PACK, 3 MONTH MO 4 QL(91 per 90 days) \ndeblitane 0.35 mg TABLET MO 4  \nDEPO-ESTRADIOL 5 MG/ML OIL MO 3 QL(5 per 30 days) \nDEPO-SUBQ PROVERA 104 104 MG/0.65 ML SYRINGE MO 4 QL(0.65 per 90 days) \ndesog-e.estradiol/e.estradiol 0.15-0.02 mgx21 /0.01 mg x 5 TABLET MO 4  \ndesogestrel-ethinyl estradiol 0.15-0.03 mg TABLET MO 4  \ndolishale 90-20 mcg (28) TABLET MO 4  \ndotti 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1  \nmg/24 hr PATCH, SEMIWEEKLY MO3 QL(8 per 28 days) \ndrospirenone-ethinyl estradiol 3-0.02 mg, 3-0.03 mg TABLET MO 4  \nDUAVEE 0.45-20 MG TABLET MO 4 PA,QL(30 per 30 days) \nelinest 0.3-30 mg-mcg TABLET MO 4  \nELLA 30 MG TABLET MO 3 QL(1 per 30 days) \neluryng 0.12-0.015 mg/24 hr RING MO 4 QL(1 per 28 days) \nemoquette 0.15-0.03 mg TABLET MO 4  \nENDOMETRIN 100 MG INSERT MO 4  \nenpresse 50-30 (6)/75-40 (5)/125-30(10) TABLET MO 4  \nenskyce 0.15-0.03 mg TABLET MO 4  \nerrin 0.35 mg TABLET MO 4  \nestradiol 0.01 % (0.1 mg/gram) CREAM MO 3  \nestradiol 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr,  \n0.075 mg/24 hr, 0.1 mg/24 hr PATCH, WEEKLY MO3 QL(4 per 28 days) \nestradiol 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1  \nmg/24 hr PATCH, SEMIWEEKLY MO3 QL(8 per 28 days) \nestradiol 0.5 mg, 1 mg, 2 mg TABLET GC,MO 1  \nestradiol 10 mcg TABLET MO 4  \nestradiol valerate 10 mg/ml, 20 mg/ml, 40 mg/ml OIL MO 4  \nestradiol-norethindrone acet 0.5-0.1 mg, 1-0.5 mg TABLET MO 3  \nESTRING 2 MG (7.5 MCG /24 HOUR) RING MO 4 QL(1 per 90 days) \nethynodiol diac-eth estradiol 1-35 mg-mcg, 1-50 mg-mcg TABLET MO 4  \netonogestrel-ethinyl estradiol 0.12-0.015 mg/24 hr RING MO 4 QL(1 per 28 days) \nfalmina (28) 0.1-20 mg-mcg TABLET MO 4  \nfemynor 0.25-35 mg-mcg TABLET MO", "doc_id": "e95488fe-cdc8-4f3a-9184-c9dba1e556b2", "embedding": null, "doc_hash": "73a7a6e318b518886cfad40105d33036df1860d32e4acd152bd1e4ea41b30436", "extra_info": {"page_label": "75", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2328, "_node_type": "1"}, "relationships": {"1": "f7dca085-e477-4667-874f-cb5a5d8faeb2", "3": "5b04157e-cb0b-4993-b122-5f09434fc5ff"}}, "__type__": "1"}, "5b04157e-cb0b-4993-b122-5f09434fc5ff": {"__data__": {"text": "MO 4  \nhailey 1.5-30 mg-mcg TABLET MO 4  \nhailey 24 fe 1 mg-20 mcg (24)/75 mg (4) TABLET MO 4  ", "doc_id": "5b04157e-cb0b-4993-b122-5f09434fc5ff", "embedding": null, "doc_hash": "10c2ac58441fa63d560ec5de0fa971156a09e48f189b8d05e943b643f0e516c8", "extra_info": {"page_label": "75", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2326, "end": 2421, "_node_type": "1"}, "relationships": {"1": "f7dca085-e477-4667-874f-cb5a5d8faeb2", "2": "e95488fe-cdc8-4f3a-9184-c9dba1e556b2"}}, "__type__": "1"}, "2989c3cf-edf6-4f54-847c-9f3294bc8b40": {"__data__": {"text": "76 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.hailey fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) TABLET MO 4  \nhailey fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) TABLET MO 4  \nhaloette 0.12-0.015 mg/24 hr RING MO 4 QL(1 per 28 days) \nheather 0.35 mg TABLET MO 4  \niclevia 0.15 mg-30 mcg (91) TABLET, DOSE PACK, 3 MONTH MO 4 QL(91 per 90 days) \nincassia 0.35 mg TABLET MO 4  \nisibloom 0.15-0.03 mg TABLET MO 4  \njaimiess 0.15 mg-30 mcg (84)/10 mcg (7) TABLET, DOSE PACK, 3 MONTH MO 4 QL(91 per 90 days) \njasmiel (28) 3-0.02 mg TABLET MO 4  \njencycla 0.35 mg TABLET MO 4  \njuleber 0.15-0.03 mg TABLET MO 4  \njunel 1.5/30 (21) 1.5-30 mg-mcg TABLET MO 4  \njunel 1/20 (21) 1-20 mg-mcg TABLET MO 4  \njunel fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) TABLET MO 4  \njunel fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) TABLET MO 4  \njunel fe 24 1 mg-20 mcg (24)/75 mg (4) TABLET MO 4  \nkalliga 0.15-0.03 mg TABLET MO 4  \nkariva (28) 0.15-0.02 mgx21 /0.01 mg x 5 TABLET MO 4  \nkelnor 1-50 (28) 1-50 mg-mcg TABLET MO 4  \nkelnor 1/35 (28) 1-35 mg-mcg TABLET MO 4  \nkurvelo (28) 0.15-0.03 mg TABLET MO 4  \nl norgest/e.estradiol-e.estrad 0.1 mg-20 mcg (84)/10 mcg (7), 0.15 mg-20  \nmcg/ 0.15 mg-25 mcg, 0.15 mg-30 mcg (84)/10 mcg (7) TABLET, DOSE PACK, 3  \nMONTH MO4 QL(91 per 90 days) \nlarin 1.5/30 (21) 1.5-30 mg-mcg TABLET MO 4  \nlarin 1/20 (21) 1-20 mg-mcg TABLET MO 4  \nlarin 24 fe 1 mg-20 mcg (24)/75 mg (4) TABLET MO 4  \nlarin fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) TABLET MO 4  \nlarin fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) TABLET MO 4  \nlarissia 0.1-20 mg-mcg TABLET MO 4  \nleena 28 0.5/1/0.5-35 mg-mcg TABLET MO 4  \nlessina 0.1-20 mg-mcg TABLET MO 4  \nlevonest (28) 50-30 (6)/75-40 (5)/125-30(10) TABLET MO 4  \nlevonorg-eth estrad triphasic 50-30 (6)/75-40 (5)/125-30(10) TABLET MO 4  \nlevonorgestrel-ethinyl", "doc_id": "2989c3cf-edf6-4f54-847c-9f3294bc8b40", "embedding": null, "doc_hash": "027abad7500ffac5638ee037e4e6afcb2bf3bfb33d46c1625921dfb035855d93", "extra_info": {"page_label": "76", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2249, "_node_type": "1"}, "relationships": {"1": "a5679258-9c9f-49ec-8269-040a82fe45c0", "3": "696e25a9-1801-49c2-b4de-77ca20657b83"}}, "__type__": "1"}, "696e25a9-1801-49c2-b4de-77ca20657b83": {"__data__": {"text": "estrad 0.1-20 mg-mcg, 0.15-0.03 mg, 90-20 mcg (28)  \nTABLET MO4  ", "doc_id": "696e25a9-1801-49c2-b4de-77ca20657b83", "embedding": null, "doc_hash": "f7f1f1b9efea1d8ae2566aa7712404f57ee3b7fc1039d4e48bd098f0d4813dd0", "extra_info": {"page_label": "76", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2250, "end": 2315, "_node_type": "1"}, "relationships": {"1": "a5679258-9c9f-49ec-8269-040a82fe45c0", "2": "2989c3cf-edf6-4f54-847c-9f3294bc8b40"}}, "__type__": "1"}, "317ee7fe-3eb3-463e-85b7-5be19faf5582": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 77DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.levonorgestrel-ethinyl estrad 0.15 mg-30 mcg (91) TABLET, DOSE PACK, 3  \nMONTH MO4 QL(91 per 90 days) \nlevora-28 0.15-0.03 mg TABLET MO 4  \nlillow (28) 0.15-0.03 mg TABLET MO 4  \nlo-zumandimine (28) 3-0.02 mg TABLET MO 4  \nLOESTRIN 1.5/30 (21) 1.5-30 MG-MCG TABLET MO 4  \nLOESTRIN 1/20 (21) 1-20 MG-MCG TABLET MO 4  \nLOESTRIN FE 1.5/30 (28-DAY) 1.5 MG-30 MCG (21)/75 MG (7) TABLET MO 4  \nLOESTRIN FE 1/20 (28-DAY) 1 MG-20 MCG (21)/75 MG (7) TABLET MO 4  \nlojaimiess 0.1 mg-20 mcg (84)/10 mcg (7) TABLET, DOSE PACK, 3 MONTH MO 4 QL(91 per 90 days) \nloryna (28) 3-0.02 mg TABLET MO 3  \nlow-ogestrel (28) 0.3-30 mg-mcg TABLET MO 4  \nlutera (28) 0.1-20 mg-mcg TABLET MO 4  \nlyleq 0.35 mg TABLET MO 4  \nlyllana 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1  \nmg/24 hr PATCH, SEMIWEEKLY MO3 QL(8 per 28 days) \nlyza 0.35 mg TABLET MO 4  \nmarlissa (28) 0.15-0.03 mg TABLET MO 4  \nmedroxyprogesterone 10 mg, 2.5 mg, 5 mg TABLET GC,MO 2  \nmedroxyprogesterone 150 mg/ml SUSPENSION GC,MO 2 QL(1 per 90 days) \nmedroxyprogesterone 150 mg/ml SYRINGE GC,MO 2 QL(1 per 90 days) \nmegestrol 20 mg, 40 mg TABLET GC,MO 2  \nmegestrol 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml) SUSPENSION MO 3  \nmegestrol 625 mg/5 ml (125 mg/ml) SUSPENSION MO 4  \nMENEST 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG TABLET MO 4  \nmicrogestin 1.5/30 (21) 1.5-30 mg-mcg TABLET MO 4  \nmicrogestin 1/20 (21) 1-20 mg-mcg TABLET MO 4  \nmicrogestin 24 fe 1 mg-20 mcg (24)/75 mg (4) TABLET MO 4  \nmicrogestin fe 1.5/30 (28) 1.5 mg-30 mcg (21)/75 mg (7) TABLET MO 4  \nmicrogestin fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) TABLET MO 4  \nmili 0.25-35 mg-mcg TABLET MO 4  \nmimvey 1-0.5 mg TABLET MO 4  \nMIRCETTE (28) 0.15-0.02 MGX21 /0.01 MG X 5 TABLET MO 4  \nmono-linyah 0.25-35 mg-mcg TABLET MO 4  \nNATAZIA 3 MG/2 MG-2 MG/ 2 MG-3 MG/1 MG TABLET MO", "doc_id": "317ee7fe-3eb3-463e-85b7-5be19faf5582", "embedding": null, "doc_hash": "f36d9af4b71228a93a8492234d1bc1034e41ae6583f3e7ea33b46f7d5032f001", "extra_info": {"page_label": "77", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2305, "_node_type": "1"}, "relationships": {"1": "a71483fe-0252-40f4-8065-f69cbe55c3ab", "3": "0d015a0e-5c1d-4f7c-a7e4-fcf57217c326"}}, "__type__": "1"}, "0d015a0e-5c1d-4f7c-a7e4-fcf57217c326": {"__data__": {"text": "MG/1 MG TABLET MO 4  \nnecon 0.5/35 (28) 0.5-35 mg-mcg TABLET MO 4  ", "doc_id": "0d015a0e-5c1d-4f7c-a7e4-fcf57217c326", "embedding": null, "doc_hash": "207910963aca3b9d00be1464953e115e9bc5bb203977447a10327ee816ce9b92", "extra_info": {"page_label": "77", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2288, "end": 2355, "_node_type": "1"}, "relationships": {"1": "a71483fe-0252-40f4-8065-f69cbe55c3ab", "2": "317ee7fe-3eb3-463e-85b7-5be19faf5582"}}, "__type__": "1"}, "bd8be6f9-e479-4a92-8a17-87b5e1e434f3": {"__data__": {"text": "78 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.nikki (28) 3-0.02 mg TABLET MO 4  \nnora-be 0.35 mg TABLET MO 4  \nnoreth-ethinyl estradiol-iron 0.4mg-35mcg(21) and 75 mg (7) CHEWABLE  \nTABLET MO4  \nnorethindrone (contraceptive) 0.35 mg TABLET MO 4  \nnorethindrone ac-eth estradiol 1-20 mg-mcg, 1.5-30 mg-mcg TABLET MO 4  \nnorethindrone acetate 5 mg TABLET MO 3  \nnorethindrone-e.estradiol-iron 1 mg-20 mcg (21)/75 mg (7), 1-20(5)/1-30(7)  \n/1mg-35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7) TABLET MO4  \nnorethindrone-e.estradiol-iron 1 mg-20 mcg(24) /75 mg (4) CHEWABLE TABLET \nMO4  \nnorgestimate-ethinyl estradiol 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25  \nmg-35 mcg (28), 0.25-35 mg-mcg TABLET MO4  \nnorlyda 0.35 mg TABLET MO 4  \nnortrel 0.5/35 (28) 0.5-35 mg-mcg TABLET MO 4  \nnortrel 1/35 (21) 1-35 mg-mcg (21) TABLET MO 4  \nnortrel 1/35 (28) 1-35 mg-mcg TABLET MO 4  \nnortrel 7/7/7 (28) 0.5/0.75/1 mg- 35 mcg TABLET MO 4  \nnylia 1/35 (28) 1-35 mg-mcg TABLET MO 4  \nnylia 7/7/7 (28) 0.5/0.75/1 mg- 35 mcg TABLET MO 4  \nnymyo 0.25-35 mg-mcg TABLET MO 4  \nocella 3-0.03 mg TABLET MO 4  \norsythia 0.1-20 mg-mcg TABLET MO 4  \nORTHO-NOVUM 7/7/7 (28) 0.5/0.75/1 MG- 35 MCG TABLET MO 4  \nOSPHENA 60 MG TABLET MO 3 PA \noxandrolone 10 mg TABLET MO 4 PA,QL(60 per 30 days) \noxandrolone 2.5 mg TABLET MO 3 PA,QL(120 per 30 days) \nphilith 0.4-35 mg-mcg TABLET MO 4  \npimtrea (28) 0.15-0.02 mgx21 /0.01 mg x 5 TABLET MO 4  \npirmella 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg TABLET MO 4  \nportia 28 0.15-0.03 mg TABLET MO 4  \nPREMARIN 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG TABLET MO 4  \nPREMARIN 0.625 MG/GRAM CREAM MO 3  \nprevifem 0.25-35 mg-mcg TABLET MO 4  \nprogesterone 50 mg/ml OIL MO 3  \nprogesterone micronized 100 mg, 200 mg CAPSULE MO 3  ", "doc_id": "bd8be6f9-e479-4a92-8a17-87b5e1e434f3", "embedding": null, "doc_hash": "f36d9442e4c67dd1736b9b694627f21e150005b18f69af20ee042f5234c080f2", "extra_info": {"page_label": "78", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2179, "_node_type": "1"}, "relationships": {"1": "d8528268-6b55-43d7-839c-c66d4f012744"}}, "__type__": "1"}, "4701cd83-0d32-4e58-b992-d75ef1ba5ed8": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 79DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.QUARTETTE 0.15 MG-20 MCG/ 0.15 MG-25 MCG TABLET, DOSE PACK, 3  \nMONTH MO4 QL(91 per 90 days) \nraloxifene 60 mg TABLET MO 3 QL(30 per 30 days) \nreclipsen (28) 0.15-0.03 mg TABLET MO 4  \nrivelsa 0.15 mg-20 mcg/ 0.15 mg-25 mcg TABLET, DOSE PACK, 3 MONTH MO 4 QL(91 per 90 days) \nsetlakin 0.15 mg-30 mcg (91) TABLET, DOSE PACK, 3 MONTH MO 4 QL(91 per 90 days) \nsharobel 0.35 mg TABLET MO 4  \nsimliya (28) 0.15-0.02 mgx21 /0.01 mg x 5 TABLET MO 4  \nsimpesse 0.15 mg-30 mcg (84)/10 mcg (7) TABLET, DOSE PACK, 3 MONTH MO 4 QL(91 per 90 days) \nSLYND 4 MG (28) TABLET MO 4  \nsprintec (28) 0.25-35 mg-mcg TABLET MO 4  \nsronyx 0.1-20 mg-mcg TABLET MO 4  \nsyeda 3-0.03 mg TABLET MO 4  \ntarina 24 fe 1 mg-20 mcg (24)/75 mg (4) TABLET MO 4  \ntarina fe 1-20 eq (28) 1 mg-20 mcg (21)/75 mg (7) TABLET MO 4  \ntarina fe 1/20 (28) 1 mg-20 mcg (21)/75 mg (7) TABLET MO 4  \ntestosterone 1.62 % (20.25 mg/1.25 gram) GEL IN PACKET MO 3 PA,QL(37.5 per 30 days) \ntestosterone 1.62 % (40.5 mg/2.5 gram) GEL IN PACKET MO 3 PA,QL(150 per 30 days) \ntestosterone 20.25 mg/1.25 gram (1.62 %) GEL IN METERED DOSE PUMP MO 3 PA,QL(150 per 30 days) \ntestosterone cypionate 100 mg/ml, 200 mg/ml OIL MO 3  \ntestosterone enanthate 200 mg/ml OIL MO 3 QL(24 per 90 days) \ntilia fe 1-20(5)/1-30(7) /1mg-35mcg (9) TABLET MO 4  \ntri femynor 0.18/0.215/0.25 mg-35 mcg (28) TABLET MO 4  \ntri-legest fe 1-20(5)/1-30(7) /1mg-35mcg (9) TABLET MO 4  \ntri-linyah 0.18/0.215/0.25 mg-35 mcg (28) TABLET MO 4  \ntri-lo-estarylla 0.18/0.215/0.25 mg-25 mcg TABLET MO 4  \ntri-lo-marzia 0.18/0.215/0.25 mg-25 mcg TABLET MO 4  \ntri-lo-mili 0.18/0.215/0.25 mg-25 mcg TABLET MO 4  \ntri-lo-sprintec 0.18/0.215/0.25 mg-25 mcg TABLET MO 4  \ntri-mili 0.18/0.215/0.25 mg-35 mcg (28) TABLET MO 4  \ntri-nymyo 0.18/0.215/0.25 mg-35 mcg (28) TABLET MO 4  \ntri-previfem (28) 0.18/0.215/0.25 mg-35", "doc_id": "4701cd83-0d32-4e58-b992-d75ef1ba5ed8", "embedding": null, "doc_hash": "ce19ee60bb55aa6db151bd4bbc7664ead4809d18a8978122088b7b1f27e9969b", "extra_info": {"page_label": "79", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2320, "_node_type": "1"}, "relationships": {"1": "f0597b1e-6389-4e93-b936-4f433d2728a8", "3": "3147f1ad-9d87-4f84-a019-ca00fbeae987"}}, "__type__": "1"}, "3147f1ad-9d87-4f84-a019-ca00fbeae987": {"__data__": {"text": "mg-35 mcg (28) TABLET MO 4  \ntri-sprintec (28) 0.18/0.215/0.25 mg-35 mcg (28) TABLET MO 4  \ntri-vylibra 0.18/0.215/0.25 mg-35 mcg (28) TABLET MO 4  \ntri-vylibra lo 0.18/0.215/0.25 mg-25 mcg TABLET MO 4  \ntrivora (28) 50-30 (6)/75-40 (5)/125-30(10) TABLET MO 4  ", "doc_id": "3147f1ad-9d87-4f84-a019-ca00fbeae987", "embedding": null, "doc_hash": "f9bd8af876cf4ff19750d4793a34db6a498998ac1bfd82abed097c4fea123859", "extra_info": {"page_label": "79", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2315, "end": 2576, "_node_type": "1"}, "relationships": {"1": "f0597b1e-6389-4e93-b936-4f433d2728a8", "2": "4701cd83-0d32-4e58-b992-d75ef1ba5ed8"}}, "__type__": "1"}, "68564dd4-60d4-4be3-b647-9bedd2724a81": {"__data__": {"text": "80 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.tulana 0.35 mg TABLET MO 4  \nTYBLUME 0.1 MG- 20 MCG CHEWABLE TABLET MO 4  \nvelivet triphasic regimen (28) 0.1/.125/.15-25 mg-mcg TABLET MO 4  \nvestura (28) 3-0.02 mg TABLET MO 4  \nvienva 0.1-20 mg-mcg TABLET MO 4  \nviorele (28) 0.15-0.02 mgx21 /0.01 mg x 5 TABLET MO 4  \nvolnea (28) 0.15-0.02 mgx21 /0.01 mg x 5 TABLET MO 4  \nvyfemla (28) 0.4-35 mg-mcg TABLET MO 4  \nvylibra 0.25-35 mg-mcg TABLET MO 4  \nwera (28) 0.5-35 mg-mcg TABLET MO 4  \nwymzya fe 0.4mg-35mcg(21) and 75 mg (7) CHEWABLE TABLET MO 4  \nxulane 150-35 mcg/24 hr PATCH, WEEKLY MO 4 QL(3 per 28 days) \nzafemy 150-35 mcg/24 hr PATCH, WEEKLY MO 4 QL(3 per 28 days) \nzarah 3-0.03 mg TABLET MO 4  \nzovia 1-35 (28) 1-35 mg-mcg TABLET MO 4  \nzovia 1/35e (28) 1-35 mg-mcg TABLET MO 4  \nzumandimine (28) 3-0.03 mg TABLET MO 4  \nHORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)\nARMOUR THYROID 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG,  \n90 MG TABLET MO3  \nEUTHYROX 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200  \nMCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG TABLET GC,MO1  \nLEVO-T 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200  \nMCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG TABLET MO3  \nlevothyroxine 100 mcg RECON SOLUTION MO 4  \nlevothyroxine 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 25 mcg, 50  \nmcg, 75 mcg, 88 mcg TABLET GC,MO1  \nlevothyroxine 175 mcg, 200 mcg, 300 mcg TABLET GC,MO 1  \nlevothyroxine 200 mcg, 500 mcg RECON SOLUTION DL 5  \nLEVOXYL 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200  \nMCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG TABLET MO3  \nliothyronine 10 mcg/ml SOLUTION MO 3  \nliothyronine 25 mcg, 5 mcg, 50 mcg TABLET MO 3  \nSYNTHROID 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200  \nMCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG TABLET MO3  \nUNITHROID 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200  \nMCG, 25 MCG, 300 MCG, 50", "doc_id": "68564dd4-60d4-4be3-b647-9bedd2724a81", "embedding": null, "doc_hash": "29abc6f1dcad0c73e187fb21b3e4365c9f37eabccd9d30bea07b5abeaeff58ff", "extra_info": {"page_label": "80", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2363, "_node_type": "1"}, "relationships": {"1": "982995d7-f964-4e5c-9ea2-a6a296b1168c", "3": "e60d16a9-af1a-4305-8705-99d2e716bf6b"}}, "__type__": "1"}, "e60d16a9-af1a-4305-8705-99d2e716bf6b": {"__data__": {"text": "200  \nMCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG TABLET MO3  ", "doc_id": "e60d16a9-af1a-4305-8705-99d2e716bf6b", "embedding": null, "doc_hash": "ef8ac6ac471ef97903c6ab014b14cc8a62474349a9c706409770e97ab2909ed9", "extra_info": {"page_label": "80", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2333, "end": 2396, "_node_type": "1"}, "relationships": {"1": "982995d7-f964-4e5c-9ea2-a6a296b1168c", "2": "68564dd4-60d4-4be3-b647-9bedd2724a81"}}, "__type__": "1"}, "8d31b1b1-39a2-4ace-baf9-dce0100c425e": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 81DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.HORMONAL AGENTS, SUPPRESSANT (ADRENAL)\nLYSODREN 500 MG TABLET DL 5  \nHORMONAL AGENTS, SUPPRESSANT (PITUITARY)\ncabergoline 0.5 mg TABLET MO 4 QL(16 per 28 days) \nELIGARD 7.5 MG (1 MONTH) SYRINGE MO 4 PA \nELIGARD (3 MONTH) 22.5 MG SYRINGE MO 4 PA \nELIGARD (4 MONTH) 30 MG SYRINGE MO 4 PA \nELIGARD (6 MONTH) 45 MG SYRINGE MO 4 PA \nFIRMAGON 120 MG RECON SOLUTION DL 5 PA \nFIRMAGON KIT W DILUENT SYRINGE 120 MG RECON SOLUTION DL 5 PA \nFIRMAGON KIT W DILUENT SYRINGE 80 MG RECON SOLUTION MO 4 PA \nlanreotide 120 mg/0.5 ml SYRINGE DL 5 PA,QL(0.5 per 28 days) \nleuprolide 1 mg/0.2 ml KIT MO 4  \nleuprolide (3 month) 22.5 mg SUSPENSION FOR RECONSTITUTION MO 4 PA,QL(1 per 90 days) \nLUPRON DEPOT 3.75 MG SYRINGE KIT MO 4 PA,QL(1 per 30 days) \nLUPRON DEPOT 7.5 MG SYRINGE KIT DL 5 PA,QL(1 per 30 days) \nLUPRON DEPOT (3 MONTH) 11.25 MG, 22.5 MG SYRINGE KIT MO 4 PA,QL(1 per 90 days) \nLUPRON DEPOT (4 MONTH) 30 MG SYRINGE KIT MO 4 PA,QL(1 per 112 days) \nLUPRON DEPOT (6 MONTH) 45 MG SYRINGE KIT 5 PA,QL(1 per 168 days) \nLUPRON DEPOT-PED 11.25 MG KIT DL 5 PA,QL(1 per 28 days) \nLUPRON DEPOT-PED 15 MG, 7.5 MG (PED) KIT DL 5 PA,QL(1 per 28 days) \nLUPRON DEPOT-PED 45 MG SYRINGE KIT 5 PA,QL(1 per 168 days) \nLUPRON DEPOT-PED (3 MONTH) 11.25 MG, 30 MG SYRINGE KIT 5 PA,QL(1 per 90 days) \noctreotide acetate 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 500 mcg/ml  \nSOLUTION MO4 PA \noctreotide acetate 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml)  \nSYRINGE MO4 PA \noctreotide acetate 50 mcg/ml SOLUTION MO 3 PA \nORGOVYX 120 MG TABLET DL 5 PA,QL(32 per 30 days) \nSANDOSTATIN LAR DEPOT 10 MG, 20 MG, 30 MG SUSPENSION, ER, RECON DL 5 PA \nSIGNIFOR 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SOLUTION \nDL5 PA,QL(60 per 30 days) \nSOMATULINE DEPOT 120 MG/0.5 ML SYRINGE DL 5 PA,QL(0.5 per 28 days) \nSOMATULINE DEPOT 60 MG/0.2 ML SYRINGE DL 5 PA,QL(0.2 per 28 days) \nSOMATULINE DEPOT 90 MG/0.3 ML SYRINGE DL 5 PA,QL(0.3 per 28 days)", "doc_id": "8d31b1b1-39a2-4ace-baf9-dce0100c425e", "embedding": null, "doc_hash": "a779fb5272e28801c777a0a8e988baa2a53e53f47c4cf0a8c0c0d5de24bd9851", "extra_info": {"page_label": "81", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2414, "_node_type": "1"}, "relationships": {"1": "01d7e509-ce7c-4bfc-b523-13e70dd4e55c", "3": "b749a7e6-ab93-4284-997e-d9c906a05fc3"}}, "__type__": "1"}, "b749a7e6-ab93-4284-997e-d9c906a05fc3": {"__data__": {"text": "per 28 days) \nSOMAVERT 10 MG, 15 MG, 20 MG RECON SOLUTION DL 5 PA,QL(60 per 30 days) ", "doc_id": "b749a7e6-ab93-4284-997e-d9c906a05fc3", "embedding": null, "doc_hash": "4d7a145ffe88d7c5631ffcc22822b45529f45c984c05d72547851013b49b5347", "extra_info": {"page_label": "81", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2402, "end": 2487, "_node_type": "1"}, "relationships": {"1": "01d7e509-ce7c-4bfc-b523-13e70dd4e55c", "2": "8d31b1b1-39a2-4ace-baf9-dce0100c425e"}}, "__type__": "1"}, "472e3e50-ece6-423f-a941-04f1be0ca11f": {"__data__": {"text": "82 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.SOMAVERT 25 MG, 30 MG RECON SOLUTION DL 5 PA,QL(30 per 30 days) \nSYNAREL 2 MG/ML SPRAY, NON-AEROSOL DL 5  \nTRELSTAR 11.25 MG, 22.5 MG SUSPENSION FOR RECONSTITUTION 5 PA \nTRELSTAR 3.75 MG SUSPENSION FOR RECONSTITUTION DL 5 PA \nZOLADEX 10.8 MG IMPLANT MO 4 PA,QL(1 per 84 days) \nZOLADEX 3.6 MG IMPLANT MO 4 PA,QL(1 per 28 days) \nHORMONAL AGENTS, SUPPRESSANT (THYROID)\nmethimazole 10 mg, 5 mg TABLET GC,MO 2  \npropylthiouracil 50 mg TABLET MO 3  \nIMMUNOLOGICAL AGENTS\nACTHIB (PF) 10 MCG/0.5 ML RECON SOLUTION DL,GC 1  \nACTIMMUNE 100 MCG/0.5 ML SOLUTION DL 5 PA \nADACEL(TDAP ADOLESN/ADULT)(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML  \nSUSPENSION DL,GC1  \nADACEL(TDAP ADOLESN/ADULT)(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML  \nSYRINGE DL,GC1  \nARCALYST 220 MG RECON SOLUTION DL 5 PA \nazathioprine 50 mg TABLET GC,MO 2 BvsD \nBCG VACCINE, LIVE (PF) 50 MG SUSPENSION FOR RECONSTITUTION DL,GC 1  \nBENLYSTA 120 MG RECON SOLUTION DL 5 PA,QL(20 per 28 days) \nBENLYSTA 200 MG/ML AUTO-INJECTOR DL 5 PA,QL(8 per 28 days) \nBENLYSTA 200 MG/ML SYRINGE DL 5 PA,QL(8 per 28 days) \nBENLYSTA 400 MG RECON SOLUTION DL 5 PA,QL(6 per 28 days) \nBEXSERO 50-50-50-25 MCG/0.5 ML SYRINGE DL,GC 1  \nBOOSTRIX TDAP 2.5-8-5 LF-MCG-LF/0.5ML SUSPENSION DL,GC 1  \nBOOSTRIX TDAP 2.5-8-5 LF-MCG-LF/0.5ML SYRINGE DL,GC 1  \nCELLCEPT 200 MG/ML SUSPENSION FOR RECONSTITUTION DL 5 BvsD \nCELLCEPT 250 MG CAPSULE DL 5 BvsD \nCELLCEPT 500 MG TABLET DL 5 BvsD \nCELLCEPT INTRAVENOUS 500 MG RECON SOLUTION MO 4 BvsD \nCOSENTYX 150 MG/ML SYRINGE DL 5 PA,QL(8 per 28 days) \nCOSENTYX 75 MG/0.5 ML SYRINGE DL 5 PA,QL(2 per 28 days) \nCOSENTYX (2 SYRINGES) 150 MG/ML SYRINGE DL 5 PA,QL(8 per 28 days) \nCOSENTYX PEN 150 MG/ML PEN INJECTOR DL 5 PA,QL(8 per 28 days) \nCOSENTYX PEN (2 PENS) 150 MG/ML PEN INJECTOR DL 5 PA,QL(8 per 28 days) \ncyclosporine 100 mg, 25 mg CAPSULE MO 4 BvsD ", "doc_id": "472e3e50-ece6-423f-a941-04f1be0ca11f", "embedding": null, "doc_hash": "ca9d31cb8990aa7e8fffd8798330dcac9728b6214bf2e11a8afa3947247e8489", "extra_info": {"page_label": "82", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2306, "_node_type": "1"}, "relationships": {"1": "3d1284ba-742f-4f00-99ba-ba391d2dc05d"}}, "__type__": "1"}, "52d692d4-a8b0-480e-858c-8e64fbb79acc": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 83DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.cyclosporine modified 100 mg, 25 mg, 50 mg CAPSULE MO 4 BvsD \ncyclosporine modified 100 mg/ml SOLUTION MO 4 BvsD \nDAPTACEL (DTAP PEDIATRIC) (PF) 15-10-5 LF-MCG-LF/0.5ML SUSPENSION \nDL,GC1  \nDENGVAXIA (PF) 10EXP4.5-6 CCID50/0.5 ML SUSPENSION FOR  \nRECONSTITUTION GC,MO1  \nDUPIXENT PEN 200 MG/1.14 ML PEN INJECTOR DL 5 PA,QL(3.42 per 28 days) \nDUPIXENT PEN 300 MG/2 ML PEN INJECTOR DL 5 PA,QL(8 per 28 days) \nDUPIXENT SYRINGE 100 MG/0.67 ML SYRINGE DL 5 PA,QL(1.34 per 28 days) \nDUPIXENT SYRINGE 200 MG/1.14 ML SYRINGE DL 5 PA,QL(3.42 per 28 days) \nDUPIXENT SYRINGE 300 MG/2 ML SYRINGE DL 5 PA,QL(8 per 28 days) \nENBREL 25 MG (1 ML) RECON SOLUTION DL 5 PA,QL(8 per 28 days) \nENBREL 25 MG/0.5 ML (0.5), 50 MG/ML (1 ML) SYRINGE DL 5 PA,QL(8 per 28 days) \nENBREL 25 MG/0.5 ML SOLUTION DL 5 PA,QL(8 per 28 days) \nENBREL MINI 50 MG/ML (1 ML) CARTRIDGE DL 5 PA,QL(8 per 28 days) \nENBREL SURECLICK 50 MG/ML (1 ML) PEN INJECTOR DL 5 PA,QL(8 per 28 days) \nENGERIX-B (PF) 20 MCG/ML SUSPENSION DL,GC 1 BvsD \nENGERIX-B (PF) 20 MCG/ML SYRINGE DL,GC 1 BvsD \nENGERIX-B PEDIATRIC (PF) 10 MCG/0.5 ML SYRINGE DL,GC 1 BvsD \nENVARSUS XR 0.75 MG, 1 MG TABLET, ER 24 HR. MO 4 PA \nENVARSUS XR 4 MG TABLET, ER 24 HR. DL 4 PA \neverolimus (immunosuppressive) 0.25 mg TABLET MO 4 BvsD,QL(60 per 30 days) \neverolimus (immunosuppressive) 0.5 mg TABLET DL 5 BvsD,QL(120 per 30 days) \neverolimus (immunosuppressive) 0.75 mg, 1 mg TABLET DL 5 BvsD,QL(60 per 30 days) \nGAMUNEX-C 1 GRAM/10 ML (10 %) SOLUTION DL 5 PA \nGAMUNEX-C 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20  \nGRAM/200 ML (10 %), 40 GRAM/400 ML (10 %), 5 GRAM/50 ML (10 %)  \nSOLUTION DL5 PA \nGARDASIL 9 (PF) 0.5 ML SUSPENSION DL,GC 1  \nGARDASIL 9 (PF) 0.5 ML SYRINGE DL,GC 1  \ngengraf 100 mg, 25 mg CAPSULE MO 4 BvsD \ngengraf 100 mg/ml SOLUTION MO 4 BvsD \nHAEGARDA 2,000 UNIT, 3,000 UNIT RECON SOLUTION DL 5 PA,QL(24 per 28 days) \nHAVRIX (PF) 1,440", "doc_id": "52d692d4-a8b0-480e-858c-8e64fbb79acc", "embedding": null, "doc_hash": "44bbdec367755c658c29ee98df7ee34579a2b486660b3f832b6ecdbd5441cd40", "extra_info": {"page_label": "83", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2376, "_node_type": "1"}, "relationships": {"1": "5689055c-d65e-4c1c-850e-6988767ce179", "3": "dd401094-5e8b-46d5-88b2-0ce9857c54b4"}}, "__type__": "1"}, "dd401094-5e8b-46d5-88b2-0ce9857c54b4": {"__data__": {"text": "\nHAVRIX (PF) 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML SYRINGE DL,GC 1  \nHEPLISAV-B (PF) 20 MCG/0.5 ML SYRINGE DL,GC 1 BvsD \nHIBERIX (PF) 10 MCG/0.5 ML RECON SOLUTION DL,GC 1  \nHUMIRA 40 MG/0.8 ML SYRINGE KIT DL 5 PA,QL(6 per 28 days) ", "doc_id": "dd401094-5e8b-46d5-88b2-0ce9857c54b4", "embedding": null, "doc_hash": "eceb78b598d2583cd37194dc48b8afa302b29e34b0f87bba8236d4da048b5b0f", "extra_info": {"page_label": "83", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2358, "end": 2594, "_node_type": "1"}, "relationships": {"1": "5689055c-d65e-4c1c-850e-6988767ce179", "2": "52d692d4-a8b0-480e-858c-8e64fbb79acc"}}, "__type__": "1"}, "0889fa44-16e9-4800-b2cf-c432fb2744f9": {"__data__": {"text": "84 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.HUMIRA PEN 40 MG/0.8 ML PEN INJECTOR KIT DL 5 PA,QL(6 per 28 days) \nHUMIRA PEN CROHNS-UC-HS START 40 MG/0.8 ML PEN INJECTOR KIT DL 5 PA,QL(6 per 28 days) \nHUMIRA PEN PSOR-UVEITS-ADOL HS 40 MG/0.8 ML PEN INJECTOR KIT DL 5 PA,QL(6 per 28 days) \nHUMIRA(CF) 10 MG/0.1 ML SYRINGE KIT DL 5 PA,QL(2 per 28 days) \nHUMIRA(CF) 20 MG/0.2 ML, 40 MG/0.4 ML SYRINGE KIT DL 5 PA,QL(6 per 28 days) \nHUMIRA(CF) PEDI CROHNS STARTER 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4  \nML SYRINGE KIT DL5 PA,QL(6 per 28 days) \nHUMIRA(CF) PEN 40 MG/0.4 ML, 80 MG/0.8 ML PEN INJECTOR KIT DL 5 PA,QL(6 per 28 days) \nHUMIRA(CF) PEN CROHNS-UC-HS 80 MG/0.8 ML PEN INJECTOR KIT DL 5 PA,QL(6 per 28 days) \nHUMIRA(CF) PEN PEDIATRIC UC 80 MG/0.8 ML PEN INJECTOR KIT DL 5 PA,QL(6 per 28 days) \nHUMIRA(CF) PEN PSOR-UV-ADOL HS 80 MG/0.8 ML-40 MG/0.4 ML PEN  \nINJECTOR KIT DL5 PA,QL(6 per 28 days) \nicatibant 30 mg/3 ml SYRINGE DL 5 PA,QL(18 per 30 days) \nIMOVAX RABIES VACCINE (PF) 2.5 UNIT RECON SOLUTION DL,GC 1 BvsD \nINFANRIX (DTAP) (PF) 25-58-10 LF-MCG-LF/0.5ML SYRINGE DL,GC 1  \nINTRON A 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML) RECON  \nSOLUTION MO4 PA \nINTRON A 10 MILLION UNIT/ML, 6 MILLION UNIT/ML SOLUTION DL 5 PA \nINTRON A 50 MILLION UNIT (1 ML) RECON SOLUTION MO 3 PA \nIPOL 40-8-32 UNIT/0.5 ML SUSPENSION DL,GC 1  \nIXIARO (PF) 6 MCG/0.5 ML SYRINGE DL,GC 1  \nKEVZARA 150 MG/1.14 ML, 200 MG/1.14 ML PEN INJECTOR DL 5 PA,QL(2.28 per 28 days) \nKEVZARA 150 MG/1.14 ML, 200 MG/1.14 ML SYRINGE DL 5 PA,QL(2.28 per 28 days) \nKINRIX (PF) 25 LF-58 MCG-10 LF/0.5 ML SUSPENSION DL,GC 1  \nKINRIX (PF) 25 LF-58 MCG-10 LF/0.5 ML SYRINGE DL,GC 1  \nleflunomide 10 mg, 20 mg TABLET MO 3 QL(30 per 30 days) \nM-M-R II (PF) 1,000-12,500 TCID50/0.5 ML RECON SOLUTION DL,GC 1  \nMENACTRA (PF) 4 MCG/0.5 ML", "doc_id": "0889fa44-16e9-4800-b2cf-c432fb2744f9", "embedding": null, "doc_hash": "82d4f64165c1c3bb3a7dc9851ffca90e5864d09fc134e94f2df3cb1e64df3447", "extra_info": {"page_label": "84", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2247, "_node_type": "1"}, "relationships": {"1": "4e5848ff-1a60-4cce-873f-9661a990882a", "3": "68699bd1-6840-4d04-b460-926d83735e7d"}}, "__type__": "1"}, "68699bd1-6840-4d04-b460-926d83735e7d": {"__data__": {"text": "DL,GC 1  \nMENACTRA (PF) 4 MCG/0.5 ML SOLUTION DL,GC 1  \nMENQUADFI (PF) 10 MCG/0.5 ML SOLUTION GC,MO 1  \nMENVEO A-C-Y-W-135-DIP (PF) 10-5 MCG/0.5 ML KIT DL,GC 1  \nMENVEO A-C-Y-W-135-DIP (PF) 10-5 MCG/0.5 ML SOLUTION DL,GC 1  \nmethotrexate sodium 2.5 mg TABLET GC,MO 2 BvsD \nmethotrexate sodium 25 mg/ml SOLUTION GC,MO 1  \nmethotrexate sodium (pf) 1 gram RECON SOLUTION GC,MO 2  \nmethotrexate sodium (pf) 25 mg/ml SOLUTION GC,MO 1  \nMONJUVI 200 MG RECON SOLUTION DL 5 PA ", "doc_id": "68699bd1-6840-4d04-b460-926d83735e7d", "embedding": null, "doc_hash": "5916d861285fcb70a15b819c29f257b4ec7a693e41ba625312967c0add25806b", "extra_info": {"page_label": "84", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2211, "end": 2680, "_node_type": "1"}, "relationships": {"1": "4e5848ff-1a60-4cce-873f-9661a990882a", "2": "0889fa44-16e9-4800-b2cf-c432fb2744f9"}}, "__type__": "1"}, "f9cc017b-dfdc-4f47-8c03-deff3d646b29": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 85DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.mycophenolate mofetil 200 mg/ml SUSPENSION FOR RECONSTITUTION MO 4 BvsD \nmycophenolate mofetil 250 mg CAPSULE MO 3 BvsD \nmycophenolate mofetil 500 mg TABLET MO 3 BvsD \nmycophenolate mofetil (hcl) 500 mg RECON SOLUTION MO 4 BvsD \nmycophenolate sodium 180 mg, 360 mg TABLET, DR/EC MO 4 BvsD \nMYFORTIC 180 MG TABLET, DR/EC MO 4 BvsD \nMYFORTIC 360 MG TABLET, DR/EC DL 5 BvsD \nPEDIARIX (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML SYRINGE DL,GC 1  \nPEDVAX HIB (PF) 7.5 MCG/0.5 ML SOLUTION DL,GC 1  \nPEGASYS 180 MCG/0.5 ML SYRINGE DL 5 PA,QL(2 per 28 days) \nPEGASYS 180 MCG/ML SOLUTION DL 5 PA,QL(4 per 28 days) \nPENTACEL (PF) 15 LF UNIT-20 MCG-5 LF/0.5 ML, 15LF-48MCG-62DU -10  \nMCG/0.5ML KIT DL,GC1  \nPREHEVBRIO (PF) 10 MCG/ML SUSPENSION DL,GC 1 BvsD \nPRIORIX (PF) 10EXP3.4-4.2- 3.3CCID50/0.5ML SUSPENSION FOR  \nRECONSTITUTION DL,GC1  \nPROGRAF 0.2 MG, 1 MG GRANULES IN PACKET MO 4 BvsD \nPROQUAD (PF) 10EXP3-4.3-3- 3.99 TCID50/0.5 SUSPENSION FOR  \nRECONSTITUTION DL,GC1  \nQUADRACEL (PF) 15 LF-48 MCG- 5 LF UNIT/0.5ML SUSPENSION DL,GC 1  \nQUADRACEL (PF) 15 LF-48 MCG- 5 LF UNIT/0.5ML SYRINGE DL,GC 1  \nRABAVERT (PF) 2.5 UNIT SUSPENSION FOR RECONSTITUTION DL,GC 1 BvsD \nRECOMBIVAX HB (PF) 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML SUSPENSION \nDL,GC1 BvsD \nRECOMBIVAX HB (PF) 10 MCG/ML, 5 MCG/0.5 ML SYRINGE DL,GC 1 BvsD \nREZUROCK 200 MG TABLET DL 5 PA,QL(30 per 30 days) \nRHOPHYLAC 1,500 UNIT (300 MCG)/2 ML SYRINGE MO 4  \nRINVOQ 15 MG, 30 MG TABLET, ER 24 HR. DL 5 PA,QL(30 per 30 days) \nRINVOQ 45 MG TABLET, ER 24 HR. DL 5 PA,QL(56 per 365 days) \nROTARIX 10EXP6 CCID50 /1.5 ML SUSPENSION DL,GC 1  \nROTARIX 10EXP6 CCID50/ML SUSPENSION FOR RECONSTITUTION DL,GC 1  \nROTATEQ VACCINE 2 ML SOLUTION DL,GC 1  \nsajazir 30 mg/3 ml SYRINGE DL 5 PA,QL(18 per 30 days) \nSANDIMMUNE 100 MG/ML SOLUTION MO 4 BvsD \nSHINGRIX (PF) 50", "doc_id": "f9cc017b-dfdc-4f47-8c03-deff3d646b29", "embedding": null, "doc_hash": "11bd817b2282a62bd28aed4f58566a82c7c4af91ace5cfca89911a11b9d81b44", "extra_info": {"page_label": "85", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2289, "_node_type": "1"}, "relationships": {"1": "27d969ee-3116-4ed1-929e-01b46afeaa85", "3": "34829c26-0c6d-4cb2-b035-14c27c0f3d96"}}, "__type__": "1"}, "34829c26-0c6d-4cb2-b035-14c27c0f3d96": {"__data__": {"text": "MG/ML SOLUTION MO 4 BvsD \nSHINGRIX (PF) 50 MCG/0.5 ML SUSPENSION FOR RECONSTITUTION DL,GC 1  \nSIMULECT 10 MG, 20 MG RECON SOLUTION DL 5 BvsD \nsirolimus 0.5 mg, 1 mg, 2 mg TABLET MO 4 BvsD ", "doc_id": "34829c26-0c6d-4cb2-b035-14c27c0f3d96", "embedding": null, "doc_hash": "7e5a174d6fe4d3f50152919c5e682781e1986a9b4350b3390cf6be84bd178626", "extra_info": {"page_label": "85", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2247, "end": 2435, "_node_type": "1"}, "relationships": {"1": "27d969ee-3116-4ed1-929e-01b46afeaa85", "2": "f9cc017b-dfdc-4f47-8c03-deff3d646b29"}}, "__type__": "1"}, "26e931b5-4ec7-4900-86fc-931eff0dbdf4": {"__data__": {"text": "86 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.sirolimus 1 mg/ml SOLUTION MO 4 BvsD \nSKYRIZI 150 MG/ML PEN INJECTOR 5 PA,QL(6 per 365 days) \nSKYRIZI 150 MG/ML SYRINGE 5 PA,QL(6 per 365 days) \nSKYRIZI 150MG/1.66ML(75 MG/0.83 ML X2) SYRINGE KIT 5 PA,QL(6 per 365 days) \nSKYRIZI 180 MG/1.2 ML (150 MG/ML) WEARABLE INJECTOR DL 5 PA,QL(8.4 per 365 days) \nSKYRIZI 360 MG/2.4 ML (150 MG/ML) WEARABLE INJECTOR DL 5 PA,QL(16.8 per 365 days) \nSKYRIZI 75 MG/0.83 ML SYRINGE 5 PA,QL(9.96 per 365 days) \nSTELARA 45 MG/0.5 ML SOLUTION DL 5 PA,QL(1.5 per 84 days) \nSTELARA 45 MG/0.5 ML SYRINGE DL 5 PA,QL(1.5 per 84 days) \nSTELARA 90 MG/ML SYRINGE DL 5 PA,QL(3 per 84 days) \nSYLVANT 100 MG, 400 MG RECON SOLUTION DL 5 PA \ntacrolimus 0.5 mg, 1 mg, 5 mg CAPSULE MO 4 BvsD \nTDVAX 2-2 LF UNIT/0.5 ML SUSPENSION DL,GC 1  \nTENIVAC (PF) 5 LF UNIT- 2 LF UNIT/0.5ML SUSPENSION DL,GC 1  \nTENIVAC (PF) 5-2 LF UNIT/0.5 ML SYRINGE DL,GC 1  \nTETANUS,DIPHTHERIA TOX PED(PF) 5-25 LF UNIT/0.5 ML SUSPENSION DL,GC 1  \nTICOVAC 1.2 MCG/0.25 ML, 2.4 MCG/0.5 ML SYRINGE DL,GC 1  \nTRUMENBA 120 MCG/0.5 ML SYRINGE DL,GC 1  \nTWINRIX (PF) 720 ELISA UNIT- 20 MCG/ML SYRINGE DL,GC 1  \nTYPHIM VI 25 MCG/0.5 ML SOLUTION DL,GC 1  \nTYPHIM VI 25 MCG/0.5 ML SYRINGE DL,GC 1  \nVAQTA (PF) 25 UNIT/0.5 ML, 50 UNIT/ML SUSPENSION DL,GC 1  \nVAQTA (PF) 25 UNIT/0.5 ML, 50 UNIT/ML SYRINGE DL,GC 1  \nVARIVAX (PF) 1,350 UNIT/0.5 ML SUSPENSION FOR RECONSTITUTION DL,GC 1  \nVARIZIG 125 UNIT/1.2 ML SOLUTION DL 5 PA,QL(12 per 30 days) \nWINRHO SDF 1,500 UNIT (300 MCG)/1.3 ML, 15000 UNIT(3000 MCG)/13 ML,  \n2,500 UNIT (500 MCG)/2.2 ML, 5,000 UNIT(1000 MCG)/4.4 ML SOLUTION DL5 BvsD \nXATMEP 2.5 MG/ML SOLUTION MO 4 PA \nXOLAIR 150 MG RECON SOLUTION DL,LA 5 PA,QL(8 per 28 days) \nXOLAIR 150 MG/ML SYRINGE DL,LA 5 PA,QL(8 per 28 days) \nXOLAIR 75 MG/0.5 ML SYRINGE DL,LA 5 PA,QL(4 per 28 days)", "doc_id": "26e931b5-4ec7-4900-86fc-931eff0dbdf4", "embedding": null, "doc_hash": "1f9c70f71259bfe0be7a356d2e5a575a1f2a81929205fc0d3e9d6c64d87376f3", "extra_info": {"page_label": "86", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2273, "_node_type": "1"}, "relationships": {"1": "06a7289a-cc72-43db-8e99-34aba1bbddbf", "3": "0b24766e-aa5c-477a-a3a3-3df909b5867f"}}, "__type__": "1"}, "0b24766e-aa5c-477a-a3a3-3df909b5867f": {"__data__": {"text": "ML SYRINGE DL,LA 5 PA,QL(4 per 28 days) \nYF-VAX (PF) 10 EXP4.74 UNIT/0.5 ML SUSPENSION FOR RECONSTITUTION \nDL,GC1  \nINFLAMMATORY BOWEL DISEASE AGENTS\nbalsalazide 750 mg CAPSULE MO 4  \nbudesonide 3 mg CAPSULE, DR/EC MO 4 PA ", "doc_id": "0b24766e-aa5c-477a-a3a3-3df909b5867f", "embedding": null, "doc_hash": "c915f26a0bd215c6334c894e5ed721245a6ec608aee971fe3ed2f561ef8d33c4", "extra_info": {"page_label": "86", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2234, "end": 2457, "_node_type": "1"}, "relationships": {"1": "06a7289a-cc72-43db-8e99-34aba1bbddbf", "2": "26e931b5-4ec7-4900-86fc-931eff0dbdf4"}}, "__type__": "1"}, "f331b363-fcef-4443-9871-81e664147dcf": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 87DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.budesonide 9 mg TABLET, DR/ER MO 4 PA,QL(30 per 30 days) \nhydrocortisone 100 mg/60 ml ENEMA MO 3  \nmesalamine 0.375 gram CAPSULE, ER 24 HR. MO 4 QL(120 per 30 days) \nmesalamine 4 gram/60 ml ENEMA MO 4 QL(1800 per 30 days) \nsulfasalazine 500 mg TABLET GC,MO 2  \nsulfasalazine 500 mg TABLET, DR/EC GC,MO 2  \nMETABOLIC BONE DISEASE AGENTS\nalendronate 10 mg, 5 mg TABLET GC,MO 1 QL(30 per 30 days) \nalendronate 35 mg TABLET GC,MO 1 QL(4 per 28 days) \nalendronate 70 mg TABLET GC,MO 1 QL(4 per 28 days) \ncalcitonin (salmon) 200 unit/actuation SPRAY, NON-AEROSOL MO 3 QL(3.7 per 28 days) \ncalcitriol 0.25 mcg, 0.5 mcg CAPSULE GC,MO 2  \ncalcitriol 1 mcg/ml SOLUTION MO 4  \ncinacalcet 30 mg, 60 mg TABLET MO 4 QL(60 per 30 days) \ncinacalcet 90 mg TABLET MO 4 QL(120 per 30 days) \ndoxercalciferol 0.5 mcg, 1 mcg, 2.5 mcg CAPSULE MO 4  \ndoxercalciferol 4 mcg/2 ml SOLUTION MO 4  \nFORTEO 20 MCG/DOSE (600MCG/2.4ML) PEN INJECTOR DL 5 PA,QL(2.4 per 28 days) \nHECTOROL 2 MCG/ML SOLUTION MO 3  \nibandronate 150 mg TABLET GC,MO 2 QL(1 per 28 days) \nibandronate 3 mg/3 ml SOLUTION MO 4 PA,QL(3 per 90 days) \nibandronate 3 mg/3 ml SYRINGE MO 4 PA,QL(3 per 90 days) \nNATPARA 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE  \nCARTRIDGE DL,LA5 PA,QL(2 per 28 days) \npamidronate 30 mg/10 ml (3 mg/ml) SOLUTION GC,MO 1 QL(30 per 21 days) \npamidronate 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9 mg/ml) SOLUTION GC,MO 1 QL(10 per 21 days) \nparicalcitol 1 mcg, 2 mcg CAPSULE MO 4 QL(30 per 30 days) \nparicalcitol 2 mcg/ml SOLUTION MO 3 QL(24 per 30 days) \nparicalcitol 4 mcg CAPSULE MO 4 QL(12 per 30 days) \nparicalcitol 5 mcg/ml SOLUTION MO 3 QL(48 per 28 days) \nPROLIA 60 MG/ML SYRINGE MO 4 QL(1 per 180 days) \nRAYALDEE 30 MCG CAPSULE, ER 24 HR. DL 5 QL(60 per 30 days) \nrisedronate 150 mg TABLET MO 3 QL(1 per 30 days) \nrisedronate 30 mg, 5 mg TABLET MO 3 QL(30 per 30 days) \nrisedronate 35 mg TABLET MO 3 QL(4 per 28 days) \nrisedronate 35 mg TABLET, DR/EC MO 4 QL(4 per 28 days) ", "doc_id": "f331b363-fcef-4443-9871-81e664147dcf", "embedding": null, "doc_hash": "86c8341ed63719f1e4643a8570b6a7b580fefe57239afe1b9013b616d5bc0da3", "extra_info": {"page_label": "87", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2451, "_node_type": "1"}, "relationships": {"1": "75383dc2-f1d7-4da0-a723-cbf4ffac5fc3"}}, "__type__": "1"}, "2a06301b-9034-43fe-bba6-0cddf5ef7659": {"__data__": {"text": "88 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.TYMLOS 80 MCG (3,120 MCG/1.56 ML) PEN INJECTOR DL 5 PA,QL(1.56 per 30 days) \nXGEVA 120 MG/1.7 ML (70 MG/ML) SOLUTION DL 5 PA,QL(1.7 per 28 days) \nzoledronic ac-mannitol-0.9nacl 4 mg/100 ml PIGGYBACK MO 4 QL(300 per 21 days) \nzoledronic acid 4 mg RECON SOLUTION MO 4  \nzoledronic acid 4 mg/5 ml SOLUTION MO 4 QL(15 per 21 days) \nzoledronic acid-mannitol-water 5 mg/100 ml PIGGYBACK GC,MO 1 PA,QL(100 per 365 days) \nMISCELLANEOUS THERAPEUTIC AGENTS\n1ST TIER UNIFINE PENTIPS 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31 GAUGE X  \n3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 5/32\" NEEDLE GC,MO1  \n1ST TIER UNIFINE PENTIPS PLUS 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31  \nGAUGE X 3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 5/32\" NEEDLE GC,MO1  \nABOUTTIME PEN NEEDLE 30 GAUGE X 5/16\", 31 GAUGE X 3/16\", 31 GAUGE X  \n5/16\", 32 GAUGE X 5/32\" NEEDLE GC,MO1  \nacetic acid 0.25 % SOLUTION GC,MO 2  \nacetylcysteine 200 mg/ml (20 %) SOLUTION MO 4  \nADVOCATE PEN NEEDLE 29 GAUGE X 1/2\", 31 GAUGE X 3/16\", 31 GAUGE X  \n5/16\", 33 GAUGE X 5/32\" NEEDLE GC,MO1  \nADVOCATE SYRINGES 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30 GAUGE X 5/16\", 0.3  \nML 31 GAUGE X 5/16\", 0.5 ML 29 GAUGE X 1/2\", 0.5 ML 30 GAUGE X 5/16\",  \n0.5 ML 31 GAUGE X 5/16\", 1 ML 29 GAUGE X 1/2\", 1 ML 30 GAUGE X 5/16, 1  \nML 31 GAUGE X 5/16 SYRINGE GC,MO1  \nALCOHOL PADS  PADS, MEDICATED GC,MO 1  \nALCOHOL PREP PADS  PADS, MEDICATED GC,MO 1  \nALCOHOL SWABS  PADS, MEDICATED GC,MO 1  \nALCOHOL WIPES  PADS, MEDICATED GC,MO 1  \nASSURE ID DUO-SHIELD 30 GAUGE X 3/16\", 30 GAUGE X 5/16\" NEEDLE GC,MO 1  \nASSURE ID INSULIN SAFETY 0.5 ML 29 GAUGE X 1/2\", 0.5 ML 31 GAUGE X  \n15/64\", 1 ML 29 GAUGE X 1/2\", 1 ML 31 GAUGE X 15/64\" SYRINGE GC,MO1  \nASSURE ID PEN NEEDLE 30 GAUGE X 3/16\", 30 GAUGE X 5/16\", 31 GAUGE X  \n3/16\" NEEDLE GC,MO1  \nAUTOJECT 2 INJECTION DEVICE  INSULIN PEN GC,MO 1  \nAUTOPEN 1 TO 21 UNITS  INSULIN PEN GC,MO 1  \nAUTOPEN 2 TO 42 UNITS  INSULIN PEN GC,MO 1  \nBAND-AID GAUZE PADS 2 X 2 \"", "doc_id": "2a06301b-9034-43fe-bba6-0cddf5ef7659", "embedding": null, "doc_hash": "0288dbeb111f58e9277a44e41752c70704fa4587dd710db5b01cc3c771843b39", "extra_info": {"page_label": "88", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2404, "_node_type": "1"}, "relationships": {"1": "dcde70ac-d580-4a37-baec-34e5c68ad0a2", "3": "f7af74ad-d187-4e4f-b244-590bf30cf669"}}, "__type__": "1"}, "f7af74ad-d187-4e4f-b244-590bf30cf669": {"__data__": {"text": "GC,MO 1  \nBAND-AID GAUZE PADS 2 X 2 \" BANDAGE GC,MO 1  \nBD ALCOHOL SWABS  PADS, MEDICATED GC,MO 1  \nBD AUTOSHIELD DUO PEN NEEDLE 30 GAUGE X 3/16\" NEEDLE GC,MO 1  \nBD ECLIPSE LUER-LOK 1 ML 30 GAUGE X 1/2\" SYRINGE GC,MO 1  ", "doc_id": "f7af74ad-d187-4e4f-b244-590bf30cf669", "embedding": null, "doc_hash": "b923e0f9ce08e8e3c4272bcce2cf41be9116775a521013f960fa9b55772cedf5", "extra_info": {"page_label": "88", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2367, "end": 2588, "_node_type": "1"}, "relationships": {"1": "dcde70ac-d580-4a37-baec-34e5c68ad0a2", "2": "2a06301b-9034-43fe-bba6-0cddf5ef7659"}}, "__type__": "1"}, "1a94900d-3e19-426e-96bf-9848d9b22f90": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 89DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.BD INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2\", 0.5 ML 29 GAUGE X 1/2\", 1 ML  \n25 GAUGE X 5/8\", 1 ML 25 X 1\", 1 ML 26 X 1/2\", 1 ML 27 GAUGE X 1/2\", 1 ML  \n28 GAUGE X 1/2\", 1 ML 29 GAUGE X 1/2\" SYRINGE GC,MO1  \nBD INSULIN SYRINGE (HALF UNIT) 0.3 ML 31 GAUGE X 5/16\" SYRINGE GC,MO 1  \nBD INSULIN SYRINGE MICRO-FINE 1 ML 28 GAUGE X 1/2\" SYRINGE GC,MO 1  \nBD INSULIN SYRINGE SAFETY-LOK 1 ML 29 GAUGE X 1/2\" SYRINGE GC,MO 1  \nBD INSULIN SYRINGE SLIP TIP 1 ML SYRINGE GC,MO 1  \nBD INSULIN SYRINGE U-500 1/2 ML 31 GAUGE X 15/64\" SYRINGE GC,MO 1  \nBD INSULIN SYRINGE ULTRA-FINE 0.3 ML 30 GAUGE X 1/2\", 0.3 ML 31 GAUGE  \nX 5/16\", 0.5 ML 30 GAUGE X 1/2\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 30 GAUGE  \nX 1/2\", 1 ML 31 GAUGE X 5/16 SYRINGE GC,MO1  \nBD LO-DOSE MICRO-FINE IV 1/2 ML 28 GAUGE X 1/2\" SYRINGE GC,MO 1  \nBD LO-DOSE ULTRA-FINE 0.5 ML 29 GAUGE X 1/2\" SYRINGE GC,MO 1  \nBD NANO 2ND GEN PEN NEEDLE 32 GAUGE X 5/32\" NEEDLE GC,MO 1  \nBD SAFETYGLIDE INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 31  \nGAUGE X 15/64\", 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 29 GAUGE X 1/2\", 0.5 ML  \n30 GAUGE X 5/16\", 0.5 ML 31 GAUGE X 15/64\", 1 ML 29 GAUGE X 1/2\", 1 ML  \n31 GAUGE X 15/64\" SYRINGE GC,MO1  \nBD SAFETYGLIDE SYRINGE 1 ML 27 GAUGE X 5/8\" SYRINGE GC,MO 1  \nBD ULTRA-FINE MICRO PEN NEEDLE 32 GAUGE X 1/4\" NEEDLE GC,MO 1  \nBD ULTRA-FINE MINI PEN NEEDLE 31 GAUGE X 3/16\" NEEDLE GC,MO 1  \nBD ULTRA-FINE NANO PEN NEEDLE 32 GAUGE X 5/32\" NEEDLE GC,MO 1  \nBD ULTRA-FINE ORIG PEN NEEDLE 29 GAUGE X 1/2\" NEEDLE GC,MO 1  \nBD ULTRA-FINE SHORT PEN NEEDLE 31 GAUGE X 5/16\" NEEDLE GC,MO 1  \nBD VEO INSULIN SYR (HALF UNIT) 0.3 ML 31 GAUGE X 15/64\" SYRINGE GC,MO 1  \nBD VEO INSULIN SYRINGE UF 0.3 ML 31 GAUGE X 15/64\", 1 ML 31 GAUGE X  \n15/64\", 1/2 ML 31 GAUGE X 15/64\" SYRINGE GC,MO1  \nBORDERED GAUZE 2 X 2 \" BANDAGE GC,MO 1 ", "doc_id": "1a94900d-3e19-426e-96bf-9848d9b22f90", "embedding": null, "doc_hash": "c8dc03a57dce67687701b7cf6e45091c3f66a3aa1b5ca9b637c0c6f7e9257272", "extra_info": {"page_label": "89", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2276, "_node_type": "1"}, "relationships": {"1": "fbcc267c-32d4-4041-abfb-14e9a2325b76", "3": "ee1286dd-fb20-4dd6-a51e-d693604d4ea6"}}, "__type__": "1"}, "ee1286dd-fb20-4dd6-a51e-d693604d4ea6": {"__data__": {"text": "\nBORDERED GAUZE 2 X 2 \" BANDAGE GC,MO 1  \nbutalbital-acetaminop-caf-cod 50-325-40-30 mg CAPSULE DL 4 QL(360 per 30 days) \nbutalbital-acetaminophen-caff 50-325-40 mg CAPSULE MO 4 QL(180 per 30 days) \nbutalbital-acetaminophen-caff 50-325-40 mg TABLET GC,MO 2 QL(180 per 30 days) \ncaffeine citrate 60 mg/3 ml (20 mg/ml) SOLUTION GC,MO 1  \ncalcium disodium versenate 200 mg/ml SOLUTION GC,MO 1  \nCAREFINE PEN NEEDLE 29 GAUGE X 1/2\", 30 GAUGE X 5/16\", 31 GAUGE X  \n1/4\", 31 GAUGE X 5/16\", 32 GAUGE X 1/4\", 32 GAUGE X 3/16\", 32 GAUGE X  \n5/32\" NEEDLE GC,MO1  \nCARETOUCH ALCOHOL PREP PAD  PADS, MEDICATED GC,MO 1  ", "doc_id": "ee1286dd-fb20-4dd6-a51e-d693604d4ea6", "embedding": null, "doc_hash": "f15acdf2905a86fe786eb128a1c7905f77f0de0521f39beeea65531d1504090f", "extra_info": {"page_label": "89", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2236, "end": 2843, "_node_type": "1"}, "relationships": {"1": "fbcc267c-32d4-4041-abfb-14e9a2325b76", "2": "1a94900d-3e19-426e-96bf-9848d9b22f90"}}, "__type__": "1"}, "6f00b9d0-2613-4d7b-85f0-ba1bda3c561c": {"__data__": {"text": "90 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.CARETOUCH INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 30 GAUGE X  \n5/16\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 28 X 5/16\", 1 ML 29 GAUGE X 5/16, 1  \nML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 SYRINGE GC,MO1  \nCARETOUCH PEN NEEDLE 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31 GAUGE X  \n3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 3/16\", 32 GAUGE X 5/32\" NEEDLE \nGC,MO1  \nCLICKFINE PEN NEEDLE 31 GAUGE X 1/4\", 31 GAUGE X 5/16\", 32 GAUGE X  \n5/32\" NEEDLE GC,MO1  \nCOMFORT EZ INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30 GAUGE X  \n1/2\", 0.3 ML 30 GAUGE X 5/16\", 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 29 GAUGE  \nX 1/2\", 0.5 ML 30 GAUGE X 1/2\", 0.5 ML 30 GAUGE X 5/16\", 0.5 ML 31 GAUGE  \nX 5/16\", 1 ML 28 GAUGE X 1/2\", 1 ML 29 GAUGE X 1/2\", 1 ML 30 GAUGE X  \n1/2\", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2\"  \nSYRINGE GC,MO1  \nCOMFORT EZ PEN NEEDLES 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31 GAUGE X  \n3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 1/4\", 32 GAUGE X 3/16\", 32 GAUGE X  \n5/16\", 32 GAUGE X 5/32\", 33 GAUGE X 1/4\", 33 GAUGE X 3/16\", 33 GAUGE X  \n5/16\", 33 GAUGE X 5/32\" NEEDLE GC,MO1  \nCOMFORT TOUCH PEN NEEDLE 31 GAUGE X 1/4\", 31 GAUGE X 3/16\", 31  \nGAUGE X 5/16\", 31 GAUGE X 5/32\", 32 GAUGE X 1/4\", 32 GAUGE X 3/16\", 32  \nGAUGE X 5/16\", 32 GAUGE X 5/32\", 33 GAUGE X 1/4\", 33 GAUGE X 3/16\", 33  \nGAUGE X 5/32\" NEEDLE GC,MO1  \nCURITY ALCOHOL SWABS  PADS, MEDICATED GC,MO 1  \nCURITY GAUZE 2 X 2 \" BANDAGE GC,MO 1  \nDERMACEA 2 X 2 \" BANDAGE GC,MO 1  \nDOJOLVI 8.3 KCAL/ML LIQUID DL 5 PA \nDROPLET INSULIN SYR(HALF UNIT) 0.5 ML 29 GAUGE X 1/2\", 0.5 ML 30  \nGAUGE X 1/2\", 0.5 ML 30 GAUGE X 5/16\", 0.5 ML 31 GAUGE X 15/64\", 0.5 ML  \n31 GAUGE X 5/16\", 0.5ML 30 GAUGE X 15/64\" SYRINGE GC,MO1  \nDROPLET INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30 GAUGE X  \n1/2\", 0.3 ML 30 GAUGE X 15/64\", 0.3 ML 30 GAUGE X", "doc_id": "6f00b9d0-2613-4d7b-85f0-ba1bda3c561c", "embedding": null, "doc_hash": "a38a565fcb7839a42f2942431824ce4e4de1d97daa1b4fc3214194dc1df318a8", "extra_info": {"page_label": "90", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2290, "_node_type": "1"}, "relationships": {"1": "f0630758-a52e-4b37-bff3-8022ebc61c20", "3": "af822332-d017-4192-b151-4220227d348d"}}, "__type__": "1"}, "af822332-d017-4192-b151-4220227d348d": {"__data__": {"text": "0.3 ML 30 GAUGE X 15/64\", 0.3 ML 30 GAUGE X 5/16\", 0.3 ML 31  \nGAUGE X 15/64\", 0.3 ML 31 GAUGE X 5/16\", 1 ML 29 GAUGE X 1/2\", 1 ML 30  \nGAUGE X 1/2\", 1 ML 30 GAUGE X 15/64\", 1 ML 30 GAUGE X 5/16, 1 ML 31  \nGAUGE X 15/64\", 1 ML 31 GAUGE X 5/16 SYRINGE GC,MO1  \nDROPLET MICRON PEN NEEDLE 34 GAUGE X 9/64\" NEEDLE GC,MO 1  \nDROPLET PEN NEEDLE 29 GAUGE X 1/2\", 29 GAUGE X 3/8\", 30 GAUGE X  \n5/16\", 31 GAUGE X 1/4\", 31 GAUGE X 3/16\", 31 GAUGE X 5/16\", 32 GAUGE X  \n1/4\", 32 GAUGE X 3/16\", 32 GAUGE X 5/16\", 32 GAUGE X 5/32\" NEEDLE GC,MO1  \nDROPSAFE ALCOHOL PREP PADS  PADS, MEDICATED GC,MO 1  ", "doc_id": "af822332-d017-4192-b151-4220227d348d", "embedding": null, "doc_hash": "ad485fb89a200ce5d8bd8898c9833d33edf4bb5a730ad3cd225ecd2a89bdcd6d", "extra_info": {"page_label": "90", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2247, "end": 2834, "_node_type": "1"}, "relationships": {"1": "f0630758-a52e-4b37-bff3-8022ebc61c20", "2": "6f00b9d0-2613-4d7b-85f0-ba1bda3c561c"}}, "__type__": "1"}, "4da48a85-a147-4e03-8ef5-030f1a64760f": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 91DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.DROPSAFE PEN NEEDLE 31 GAUGE X 1/4\", 31 GAUGE X 3/16\", 31 GAUGE X  \n5/16\" NEEDLE GC,MO1  \nDROXIA 200 MG, 300 MG, 400 MG CAPSULE MO 3  \nEASY COMFORT ALCOHOL PAD  PADS, MEDICATED GC,MO 1  \nEASY COMFORT INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16\", 0.5 ML 30  \nGAUGE X 1/2\", 0.5 ML 30 GAUGE X 5/16\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 30  \nGAUGE X 1/2\", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1 ML 32  \nGAUGE X 5/16\", 1/2 ML 32 GAUGE X 5/16\" SYRINGE GC,MO1  \nEASY COMFORT PEN NEEDLES 31 GAUGE X 1/4\", 31 GAUGE X 3/16\", 31  \nGAUGE X 5/16\", 32 GAUGE X 5/32\", 33 GAUGE X 1/4\", 33 GAUGE X 3/16\", 33  \nGAUGE X 5/32\" NEEDLE GC,MO1  \nEASY GLIDE INSULIN SYRINGE 0.3 ML 31 GAUGE X 15/64\", 1 ML 31 GAUGE X  \n15/64\", 1/2 ML 31 GAUGE X 15/64\" SYRINGE GC,MO1  \nEASY GLIDE PEN NEEDLE 33 GAUGE X 5/32\" NEEDLE GC,MO 1  \nEASY TOUCH 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31 GAUGE X 3/16\", 31  \nGAUGE X 5/16\", 32 GAUGE X 1/4\", 32 GAUGE X 3/16\", 32 GAUGE X 5/32\"  \nNEEDLE GC,MO1  \nEASY TOUCH ALCOHOL PREP PADS  PADS, MEDICATED GC,MO 1  \nEASY TOUCH FLIPLOCK INSULIN 1 ML 29 GAUGE X 1/2\", 1 ML 30 GAUGE X  \n1/2\", 1 ML 30 GAUGE X 5/16\", 1 ML 31 GAUGE X 5/16\" SYRINGE GC,MO1  \nEASY TOUCH INSULIN SAFETY SYR 0.5 ML 29 GAUGE X 1/2\", 0.5 ML 30 GAUGE  \nX 5/16\", 1 ML 29 GAUGE X 1/2\", 1 ML 30 GAUGE X 1/2\" SYRINGE GC,MO1  \nEASY TOUCH INSULIN SYRINGE 0.3 ML 30 GAUGE X 1/2\", 0.3 ML 30 GAUGE X  \n5/16\", 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 29 GAUGE X 1/2\", 0.5 ML 30 GAUGE  \nX 1/2\", 0.5 ML 30 GAUGE X 5/16\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 27 GAUGE  \nX 1/2\", 1 ML 27 GAUGE X 5/8\", 1 ML 28 GAUGE X 1/2\", 1 ML 29 GAUGE X 1/2\",  \n1 ML 30 GAUGE X 1/2\", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2  \nML 27 GAUGE X 1/2\", 1/2 ML 28 GAUGE X 1/2\" SYRINGE GC,MO1  \nEASY TOUCH LUER LOCK INSULIN 1 ML SYRINGE GC,MO 1  \nEASY TOUCH PEN NEEDLE 30 GAUGE X 5/16\" NEEDLE GC,MO 1 ", "doc_id": "4da48a85-a147-4e03-8ef5-030f1a64760f", "embedding": null, "doc_hash": "552680be80138b58f2baa5319158e15cca26873916e2feabc986682aab48251a", "extra_info": {"page_label": "91", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2310, "_node_type": "1"}, "relationships": {"1": "34f5f364-de68-412e-956c-54db598213bb", "3": "bdcc64ad-2a26-410f-920f-69ee30fe3d63"}}, "__type__": "1"}, "bdcc64ad-2a26-410f-920f-69ee30fe3d63": {"__data__": {"text": "NEEDLE 30 GAUGE X 5/16\" NEEDLE GC,MO 1  \nEASY TOUCH SAFETY PEN NEEDLE 29 GAUGE X 3/16\", 29 GAUGE X 5/16\", 30  \nGAUGE X 1/4\", 30 GAUGE X 3/16\", 30 GAUGE X 5/16\" NEEDLE GC,MO1  \nEASY TOUCH SHEATHLOCK INSULIN 1 ML 29 GAUGE X 1/2\", 1 ML 30 GAUGE X  \n1/2\", 1 ML 30 GAUGE X 5/16\", 1 ML 31 GAUGE X 5/16\" SYRINGE GC,MO1  \nEASY TOUCH UNI-SLIP 1 ML SYRINGE GC,MO 1  \nEMBRACE PEN NEEDLE 29 GAUGE X 1/2\", 30 GAUGE X 3/16\", 30 GAUGE X  \n5/16\", 31 GAUGE X 1/4\", 31 GAUGE X 3/16\", 31 GAUGE X 5/16\", 32 GAUGE X  \n5/32\" NEEDLE GC,MO1  \nEXEL INSULIN 0.3 ML 29 GAUGE X 1/2\", 0.5 ML 30 GAUGE X 5/16\", 1 ML 30  \nGAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2\" SYRINGE GC,MO1  ", "doc_id": "bdcc64ad-2a26-410f-920f-69ee30fe3d63", "embedding": null, "doc_hash": "2238b787332ac9f73060a1bb4c7ffa4cb53d14d59d456a5fe80f8449ad71cfe8", "extra_info": {"page_label": "91", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2271, "end": 2915, "_node_type": "1"}, "relationships": {"1": "34f5f364-de68-412e-956c-54db598213bb", "2": "4da48a85-a147-4e03-8ef5-030f1a64760f"}}, "__type__": "1"}, "bee95db5-0e83-4aa3-ab01-3f28bb8dccc0": {"__data__": {"text": "92 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.flumazenil 0.1 mg/ml SOLUTION MO 4  \nFREESTYLE PRECISION 0.5 ML 30 GAUGE X 5/16\", 0.5 ML 31 GAUGE X 5/16\", 1  \nML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16 SYRINGE GC,MO1  \nGAUZE BANDAGE 2 X 2 \" BANDAGE GC,MO 1  \nGAUZE PAD 2 X 2 \" BANDAGE GC,MO 1  \nHEALTHWISE INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16\", 0.3 ML 31 GAUGE  \nX 5/16\", 0.5 ML 30 GAUGE X 5/16\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 30 GAUGE  \nX 5/16, 1 ML 31 GAUGE X 5/16 SYRINGE GC,MO1  \nHEALTHWISE PEN NEEDLE 31 GAUGE X 3/16\", 31 GAUGE X 5/16\", 32 GAUGE  \nX 5/32\" NEEDLE GC,MO1  \nHEALTHY ACCENTS UNIFINE PENTIP 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31  \nGAUGE X 3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 5/32\" NEEDLE GC,MO1  \nINCONTROL ALCOHOL PADS  PADS, MEDICATED GC,MO 1  \nINCONTROL PEN NEEDLE 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31 GAUGE X  \n3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 5/32\" NEEDLE GC,MO1  \nINSULIN SYR/NDL U100 HALF MARK 0.3 ML 31 GAUGE X 1/4\" SYRINGE GC,MO 1  \nINSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2\", 1 ML 29 GAUGE X 1/2\" SYRINGE \nGC,MO1  \nINSULIN SYRINGE MICROFINE 1 ML 27 GAUGE X 5/8\", 1/2 ML 28 GAUGE X  \n1/2\" SYRINGE GC,MO1  \nINSULIN SYRINGE NEEDLELESS 1 ML SYRINGE GC,MO 1  \nINSULIN SYRINGE-NEEDLE U-100 0.3 ML 29 GAUGE, 0.3 ML 29 GAUGE X  \n1/2\", 0.3 ML 30, 0.3 ML 30 GAUGE X 1/2\", 0.3 ML 30 GAUGE X 5/16\", 0.3 ML  \n31 GAUGE X 1/4\", 0.3 ML 31 GAUGE X 15/64\", 0.3 ML 31 GAUGE X 5/16\", 0.5  \nML 29 GAUGE X 1/2\", 0.5 ML 30 GAUGE X 1/2\", 0.5 ML 30 GAUGE X 5/16\", 0.5  \nML 31 GAUGE X 5/16\", 1 ML 27 GAUGE X 1/2\", 1 ML 28 GAUGE, 1 ML 28  \nGAUGE X 1/2\", 1 ML 29 GAUGE X 1/2\", 1 ML 29 GAUGE X 7/16\", 1 ML 30  \nGAUGE X 1/2\", 1 ML 30 GAUGE X 3/8\", 1 ML 30 GAUGE X 5/16, 1 ML 30 GAUGE  \nX 7/16\", 1 ML 31 GAUGE X 1/4\", 1 ML 31 GAUGE X 15/64\", 1 ML 31 GAUGE X  \n5/16, 1/2 ML 27 GAUGE X 1/2\", 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X 1/2\",  \n1/2 ML 29, 1/2 ML 30", "doc_id": "bee95db5-0e83-4aa3-ab01-3f28bb8dccc0", "embedding": null, "doc_hash": "d11da6ea2db98abb02b9079740b94d0974162a2d95777fa56075a8f70de733f4", "extra_info": {"page_label": "92", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2294, "_node_type": "1"}, "relationships": {"1": "feebbea2-1e93-43b9-949f-69b6b6d210f8", "3": "0a3d38c0-ea0f-4145-9615-3b82d549f6d8"}}, "__type__": "1"}, "0a3d38c0-ea0f-4145-9615-3b82d549f6d8": {"__data__": {"text": "GAUGE X 1/2\",  \n1/2 ML 29, 1/2 ML 30 GAUGE, 1/2 ML 31 GAUGE X 1/4\", 1/2 ML 31 GAUGE X  \n15/64\" SYRINGE GC,MO1  \nINSUPEN PEN NEEDLE 29 GAUGE X 1/2\", 30 GAUGE X 5/16\", 31 GAUGE X  \n1/4\", 31 GAUGE X 3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 1/4\", 32 GAUGE X  \n5/16\", 32 GAUGE X 5/32\", 33 GAUGE X 5/32\" NEEDLE GC,MO1  \nIV PREP WIPES  PADS, MEDICATED GC,MO 1  \nKORLYM 300 MG TABLET DL 5 PA,QL(120 per 30 days) \nlactated ringers  SOLUTION GC,MO 2  \nLAGEVRIO (EUA) 200 MG CAPSULE MO 4 QL(40 per 5 days) ", "doc_id": "0a3d38c0-ea0f-4145-9615-3b82d549f6d8", "embedding": null, "doc_hash": "ca4a608ad960f0745f1927788556bb5b749f9fbb097534f816752a89db390969", "extra_info": {"page_label": "92", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2258, "end": 2748, "_node_type": "1"}, "relationships": {"1": "feebbea2-1e93-43b9-949f-69b6b6d210f8", "2": "bee95db5-0e83-4aa3-ab01-3f28bb8dccc0"}}, "__type__": "1"}, "51f96d84-1330-46b6-b069-3653d9fc708d": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 93DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.LITE TOUCH INSULIN PEN NEEDLES 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31  \nGAUGE X 3/16\", 31 GAUGE X 5/16\" NEEDLE GC,MO1  \nLITE TOUCH INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30 GAUGE X  \n5/16\", 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 29 GAUGE X 1/2\", 0.5 ML 30 GAUGE  \nX 5/16\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 28 GAUGE, 1 ML 28 GAUGE X 1/2\", 1  \nML 29 GAUGE, 1 ML 29 GAUGE X 1/2\", 1 ML 30 GAUGE X 5/16, 1 ML 30 GAUGE  \nX 7/16\", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE, 1/2 ML 28 GAUGE X 1/2\",  \n1/2 ML 29, 1/2 ML 30 GAUGE SYRINGE GC,MO1  \nLITHOSTAT 250 MG TABLET DL 5  \nMAGELLAN INSULIN SAFETY SYRNG 0.3 ML 29 GAUGE X 1/2\", 0.5 ML 29  \nGAUGE X 1/2\", 1 ML 29 GAUGE X 1/2\", 1 ML 30 GAUGE X 5/16\" SYRINGE GC,MO1  \nMAGELLAN SYRINGE 0.3 ML 30 X 5/16\", 0.5 ML 30 GAUGE X 5/16\" SYRINGE \nGC,MO1  \nMAXI-COMFORT INSULIN SYRINGE 1 ML 28 GAUGE X 1/2\", 1/2 ML 28 GAUGE  \nX 1/2\" SYRINGE GC,MO1  \nMAXICOMFORT II PEN NEEDLE 31 GAUGE X 1/4\" NEEDLE GC,MO 1  \nMAXICOMFORT INSULIN SYRINGE 1 ML 27 GAUGE X 1/2\", 1/2 ML 27 GAUGE X  \n1/2\" SYRINGE GC,MO1  \nMAXICOMFORT SAFETY PEN NEEDLE 29 GAUGE X 3/16\", 29 GAUGE X 5/16\"  \nNEEDLE GC,MO1  \nMICRODOT INSULIN PEN NEEDLE 31 GAUGE X 1/4\", 32 GAUGE X 5/32\", 33  \nGAUGE X 5/32\" NEEDLE GC,MO1  \nMINI ULTRA-THIN II 31 GAUGE X 3/16\" NEEDLE GC,MO 1  \nMONOJECT INSULIN SAFETY SYRING 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30  \nGAUGE X 5/16\", 0.5 ML 29 GAUGE X 1/2\", 0.5 ML 30 GAUGE X 5/16\", 29  \nGAUGE X 1/2\" SYRINGE GC,MO1  \nMONOJECT INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30 GAUGE X  \n5/16\", 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 29 GAUGE X 1/2\", 0.5 ML 30 GAUGE  \nX 5/16\", 0.5 ML 31 GAUGE X 5/16\", 1 ML, 1 ML 25 GAUGE X 5/8\", 1 ML 27  \nGAUGE X 1/2\", 1 ML 28 GAUGE X 1/2\", 1 ML 29 GAUGE X 1/2\", 1 ML 30 GAUGE  \nX 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2\" SYRINGE GC,MO1 ", "doc_id": "51f96d84-1330-46b6-b069-3653d9fc708d", "embedding": null, "doc_hash": "66b2c93d86c56a417884dc20d8947e24dc2d1a2f25fd8111572950767f0e47c7", "extra_info": {"page_label": "93", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2275, "_node_type": "1"}, "relationships": {"1": "e0bbe570-7182-45f1-94af-0aa5cd71c9ea", "3": "63eff1f2-a97f-4003-958a-cb4f29a2d877"}}, "__type__": "1"}, "63eff1f2-a97f-4003-958a-cb4f29a2d877": {"__data__": {"text": "ML 28 GAUGE X 1/2\" SYRINGE GC,MO1  \nMONOJECT SYRINGE 1/2 ML 28 GAUGE SYRINGE GC,MO 1  \nMONOJECT ULTRA COMFORT INSULIN 1/2 ML 28 GAUGE SYRINGE GC,MO 1  \nNOVOFINE 32 32 GAUGE X 1/4\" NEEDLE GC,MO 1  \nNOVOFINE AUTOCOVER 30 GAUGE X 1/3\" NEEDLE GC,MO 1  \nNOVOFINE PLUS 32 GAUGE X 1/6\" NEEDLE GC,MO 1  \nNOVOPEN ECHO  INSULIN PEN GC,MO 1  \nNOVOTWIST 32 GAUGE X 1/5\" NEEDLE GC,MO 1  \nOMNIPOD 5 G6 INTRO KIT (GEN 5)  CARTRIDGE MO 3  ", "doc_id": "63eff1f2-a97f-4003-958a-cb4f29a2d877", "embedding": null, "doc_hash": "21e47f7d53e4cb3f092ed62c792e1eae4946e7a363c602367da92c14c7cc69dd", "extra_info": {"page_label": "93", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2241, "end": 2664, "_node_type": "1"}, "relationships": {"1": "e0bbe570-7182-45f1-94af-0aa5cd71c9ea", "2": "51f96d84-1330-46b6-b069-3653d9fc708d"}}, "__type__": "1"}, "1d871056-f983-4c8b-93b8-e43c1a334410": {"__data__": {"text": "94 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.OMNIPOD 5 G6 PODS (GEN 5)  CARTRIDGE MO 3  \nOMNIPOD CLASSIC PODS (GEN 3)  CARTRIDGE MO 3  \nOMNIPOD DASH INTRO KIT (GEN 4)  CARTRIDGE MO 3  \nOMNIPOD DASH PODS (GEN 4)  CARTRIDGE MO 3  \nOMNIPOD GO PODS  CARTRIDGE MO 3  \nOMNIPOD GO PODS 10 UNITS/DAY  CARTRIDGE MO 3  \nOMNIPOD GO PODS 15 UNITS/DAY  CARTRIDGE MO 3  \nOMNIPOD GO PODS 20 UNITS/DAY  CARTRIDGE MO 3  \nOMNIPOD GO PODS 25 UNITS/DAY  CARTRIDGE MO 3  \nOMNIPOD GO PODS 30 UNITS/DAY  CARTRIDGE MO 3  \nOMNIPOD GO PODS 40 UNITS/DAY  CARTRIDGE MO 3  \nPAXLOVID 150-100 MG TABLET, DOSE PACK MO 4 QL(40 per 10 days) \nPAXLOVID 300 MG (150 MG X 2)-100 MG TABLET, DOSE PACK MO 4 QL(60 per 10 days) \nPEN NEEDLE 29 GAUGE X 1/2\", 30 GAUGE X 5/16\", 31 GAUGE X 1/4\", 31  \nGAUGE X 3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 5/32\" NEEDLE GC,MO1  \nPEN NEEDLE, DIABETIC 29 GAUGE X 1/2\", 29 GAUGE X 15/32\", 30 GAUGE X  \n3/16\", 30 GAUGE X 5/16\", 31 GAUGE X 1/3\", 31 GAUGE X 1/4\", 31 GAUGE X  \n1/6\", 31 GAUGE X 13/64\", 31 GAUGE X 15/64\", 31 GAUGE X 3/16\", 31 GAUGE  \nX 5/16\", 31 GAUGE X 5/32\", 32 GAUGE X 1/4\", 32 GAUGE X 3/16\", 32 GAUGE  \nX 5/16\", 32 GAUGE X 5/32\", 33 GAUGE X 1/4\", 33 GAUGE X 3/16\", 33 GAUGE  \nX 5/32\" NEEDLE GC,MO1  \nPEN NEEDLE, DIABETIC, SAFETY 31 GAUGE X 3/16\", 31 GAUGE X 5/32\"  \nNEEDLE GC,MO1  \nPENTIPS 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31 GAUGE X 3/16\", 31 GAUGE X  \n5/16\", 32 GAUGE X 1/4\", 32 GAUGE X 5/32\" NEEDLE GC,MO1  \nPHYSIOLYTE 140-5-3-98 MEQ/L SOLUTION GC,MO 1  \nPHYSIOSOL IRRIGATION 140-5-3-98 MEQ/L SOLUTION GC,MO 1  \nPIP PEN NEEDLE 31 GAUGE X 3/16\", 32 GAUGE X 5/32\" NEEDLE GC,MO 1  \nPREVENT DROPSAFE PEN NEEDLE 31 GAUGE X 1/4\", 31 GAUGE X 5/16\"  \nNEEDLE GC,MO1  \nPRO COMFORT ALCOHOL PADS  PADS, MEDICATED GC,MO 1  \nPRO COMFORT INSULIN SYRINGE 0.5 ML 30 GAUGE X 1/2\", 0.5 ML 30 GAUGE  \nX 5/16\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 30 GAUGE X 1/2\", 1 ML 30 GAUGE X  \n5/16, 1 ML 31", "doc_id": "1d871056-f983-4c8b-93b8-e43c1a334410", "embedding": null, "doc_hash": "5f3e9dc46603190d40ac94515a8b6e6bc87bdcc1b38eb89361427fa258c2d22e", "extra_info": {"page_label": "94", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2328, "_node_type": "1"}, "relationships": {"1": "bfd9a388-f0b2-4ee5-a53a-344444954295", "3": "2cf6efad-df50-465f-8d82-c491f955a233"}}, "__type__": "1"}, "2cf6efad-df50-465f-8d82-c491f955a233": {"__data__": {"text": "X 1/2\", 1 ML 30 GAUGE X  \n5/16, 1 ML 31 GAUGE X 5/16 SYRINGE GC,MO1  \nPRO COMFORT PEN NEEDLE 31 GAUGE X 5/16\", 32 GAUGE X 1/4\", 32 GAUGE X  \n3/16\", 32 GAUGE X 5/32\" NEEDLE GC,MO1  \nPRODIGY INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 31 GAUGE X  \n5/16\", 1 ML 28 GAUGE X 1/2\" SYRINGE GC,MO1  ", "doc_id": "2cf6efad-df50-465f-8d82-c491f955a233", "embedding": null, "doc_hash": "0ec6c63e50575ee3d3ce62bbdba6dc1aad01d268e79f40a3deb90f62b9d4911c", "extra_info": {"page_label": "94", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2289, "end": 2583, "_node_type": "1"}, "relationships": {"1": "bfd9a388-f0b2-4ee5-a53a-344444954295", "2": "1d871056-f983-4c8b-93b8-e43c1a334410"}}, "__type__": "1"}, "2cf246df-ce82-4ccb-81db-3c1cbf29f64a": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 95DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.protamine 10 mg/ml SOLUTION GC,MO 1  \nPURE COMFORT ALCOHOL PADS  PADS, MEDICATED GC,MO 1  \nPURE COMFORT PEN NEEDLE 32 GAUGE X 1/4\", 32 GAUGE X 3/16\", 32 GAUGE  \nX 5/16\", 32 GAUGE X 5/32\" NEEDLE GC,MO1  \nRECTIV 0.4 % (W/W) OINTMENT MO 4 QL(30 per 30 days) \nribavirin 6 gram RECON SOLUTION DL 5 BvsD \nringer's  SOLUTION GC,MO 1  \nSAFESNAP INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16\", 0.5 ML 29 GAUGE X  \n1/2\", 0.5 ML 30 GAUGE X 5/16\", 1 ML 28 GAUGE X 1/2\", 1 ML 29 GAUGE X  \n1/2\" SYRINGE GC,MO1  \nSAFETY PEN NEEDLE 31 GAUGE X 3/16\" NEEDLE GC,MO 1  \nSECURESAFE INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2\", 1 ML 29 GAUGE X  \n1/2\" SYRINGE GC,MO1  \nSECURESAFE PEN NEEDLE 30 GAUGE X 5/16\" NEEDLE GC,MO 1  \nSKY SAFETY PEN NEEDLE 30 GAUGE X 3/16\", 30 GAUGE X 5/16\" NEEDLE GC,MO 1  \nsodium benzoate-sod phenylacet 10-10 % SOLUTION DL 5  \nsodium chloride 0.9 % SOLUTION GC,MO 2  \nsorbitol-mannitol 2.7-0.54 gram/100 ml SOLUTION GC,MO 1  \nSURE COMFORT ALCOHOL PREP PADS  PADS, MEDICATED GC,MO 1  \nSURE COMFORT INS. SYR. U-100 0.5 ML 29 GAUGE X 1/2\" SYRINGE GC,MO 1  \nSURE COMFORT INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30 GAUGE  \nX 1/2\", 0.3 ML 30 GAUGE X 5/16\", 0.3 ML 31 GAUGE X 1/4\", 0.3 ML 31 GAUGE  \nX 5/16\", 0.5 ML 30 GAUGE X 1/2\", 0.5 ML 30 GAUGE X 5/16\", 0.5 ML 31  \nGAUGE X 5/16\", 1 ML 28 GAUGE X 1/2\", 1 ML 29 GAUGE X 1/2\", 1 ML 30  \nGAUGE X 1/2\", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 1/4\", 1 ML 31 GAUGE  \nX 5/16, 1/2 ML 28 GAUGE X 1/2\", 1/2 ML 31 GAUGE X 1/4\" SYRINGE GC,MO1  \nSURE COMFORT PEN NEEDLE 29 GAUGE X 1/2\", 30 GAUGE X 5/16\", 31 GAUGE  \nX 3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 1/4\", 32 GAUGE X 5/32\" NEEDLE \nGC,MO1  \nSURE COMFORT SAFETY PEN NEEDLE 31 GAUGE X 1/4\", 32 GAUGE X 5/32\"  \nNEEDLE GC,MO1  \nSURE-FINE PEN NEEDLES 29 GAUGE X 1/2\", 31 GAUGE X 3/16\", 31 GAUGE X  \n5/16\" NEEDLE GC,MO1  \nSURE-JECT INSULIN SYRINGE 0.3 ML 29", "doc_id": "2cf246df-ce82-4ccb-81db-3c1cbf29f64a", "embedding": null, "doc_hash": "64bec98604e75870b45902e9f6a0392ba7885bd0780a6809fa1821ef4bb5e993", "extra_info": {"page_label": "95", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2330, "_node_type": "1"}, "relationships": {"1": "8804de4d-927f-42cf-8886-5e678eb52072", "3": "e3ecc5eb-6da5-48dc-ad96-10412191e3b6"}}, "__type__": "1"}, "e3ecc5eb-6da5-48dc-ad96-10412191e3b6": {"__data__": {"text": " \nSURE-JECT INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30 GAUGE X  \n5/16\", 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 29 GAUGE X 1/2\", 0.5 ML 30 GAUGE  \nX 5/16\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 28 GAUGE X 1/2\", 1 ML 29 GAUGE X  \n1/2\", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2\"  \nSYRINGE GC,MO1  \nSURE-PREP ALCOHOL PREP PADS  PADS, MEDICATED GC,MO 1  ", "doc_id": "e3ecc5eb-6da5-48dc-ad96-10412191e3b6", "embedding": null, "doc_hash": "0c12d1dd82dac57da7bfc4c8d75252ee3a4d7d9d55e3350338007736728494b7", "extra_info": {"page_label": "95", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2293, "end": 2659, "_node_type": "1"}, "relationships": {"1": "8804de4d-927f-42cf-8886-5e678eb52072", "2": "2cf246df-ce82-4ccb-81db-3c1cbf29f64a"}}, "__type__": "1"}, "801b2a31-eafa-4271-852a-5cebbd3af022": {"__data__": {"text": "96 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.TECHLITE INSULIN SYRINGE 1 ML 29 GAUGE X 1/2\", 1 ML 30 GAUGE X 1/2\", 1  \nML 31 GAUGE X 15/64\", 1 ML 31 GAUGE X 5/16 SYRINGE GC,MO1  \nTECHLITE INSULN SYR(HALF UNIT) 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30  \nGAUGE X 5/16\", 0.3 ML 31 GAUGE X 15/64\", 0.3 ML 31 GAUGE X 5/16\", 0.5  \nML 30 GAUGE X 1/2\", 0.5 ML 30 GAUGE X 5/16\", 0.5 ML 31 GAUGE X 15/64\",  \n0.5 ML 31 GAUGE X 5/16\" SYRINGE GC,MO1  \nTECHLITE PEN NEEDLE 29 GAUGE X 1/2\", 29 GAUGE X 3/8\", 31 GAUGE X 1/4\",  \n31 GAUGE X 3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 1/4\", 32 GAUGE X 5/16\",  \n32 GAUGE X 5/32\" NEEDLE GC,MO1  \nTERUMO INSULIN SYRINGE 0.3 ML 30 X 3/8\", 0.5 ML 29 GAUGE X 1/2\", 1 ML  \n27 GAUGE X 1/2\", 1 ML 28 GAUGE X 1/2\", 1 ML 29 GAUGE X 1/2\", 1/2 ML 27  \nGAUGE X 1/2\", 1/2 ML 28 GAUGE X 1/2\", 1/2 ML 30 X 3/8\" SYRINGE GC,MO1  \nTHINPRO INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30 X 3/8\", 0.3  \nML 31 X 3/8\", 0.5 ML 29 GAUGE X 1/2\", 0.5 ML 31 X 3/8\", 1 ML 28 GAUGE X  \n1/2\", 1 ML 29 GAUGE X 1/2\", 1 ML 30 GAUGE X 3/8\", 1 ML 31 X 3/8\", 1/2 ML  \n28 GAUGE X 1/2\", 1/2 ML 30 X 3/8\" SYRINGE GC,MO1  \nTOPCARE CLICKFINE 31 GAUGE X 1/4\", 31 GAUGE X 5/16\" NEEDLE GC,MO 1  \nTOPCARE ULTRA COMFORT 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30 GAUGE X  \n5/16\", 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 29 GAUGE X 1/2\", 0.5 ML 30 GAUGE  \nX 5/16\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 29 GAUGE X 1/2\", 1 ML 30 GAUGE X  \n5/16, 1 ML 31 GAUGE X 5/16 SYRINGE GC,MO1  \nTRUE COMFORT ALCOHOL PADS  PADS, MEDICATED GC,MO 1  \nTRUE COMFORT INSULIN SYRINGE 0.5 ML 31 GAUGE X 5/16\", 1 ML 31 GAUGE  \nX 5/16 SYRINGE GC,MO1  \nTRUE COMFORT PEN NEEDLE 31 GAUGE X 1/4\", 31 GAUGE X 3/16\", 31 GAUGE  \nX 5/16\", 32 GAUGE X 1/4\", 32 GAUGE X 3/16\", 32 GAUGE X 5/32\", 33 GAUGE  \nX 1/4\", 33 GAUGE X 3/16\", 33 GAUGE X 5/32\" NEEDLE GC,MO1  \nTRUE COMFORT PRO ALCOHOL PADS  PADS, MEDICATED GC,MO 1 ", "doc_id": "801b2a31-eafa-4271-852a-5cebbd3af022", "embedding": null, "doc_hash": "f99f11a10d7278b7bd4f36ed14c4c5853112572fef033b864d652efd5524cc1c", "extra_info": {"page_label": "96", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2280, "_node_type": "1"}, "relationships": {"1": "3ea0f5cd-f5d8-4a53-a1b7-c251792bc30a", "3": "8b47db3b-e8ef-4889-a9ea-8da27020524f"}}, "__type__": "1"}, "8b47db3b-e8ef-4889-a9ea-8da27020524f": {"__data__": {"text": "PRO ALCOHOL PADS  PADS, MEDICATED GC,MO 1  \nTRUE COMFORT PRO INS SYRINGE 0.5 ML 30 GAUGE X 1/2\", 0.5 ML 30 GAUGE  \nX 5/16\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 30 GAUGE X 1/2\", 1 ML 30 GAUGE X  \n5/16, 1 ML 31 GAUGE X 5/16, 1 ML 32 GAUGE X 5/16\", 1/2 ML 32 GAUGE X  \n5/16\" SYRINGE GC,MO1  \nTRUE COMFORT SAFETY PEN NEEDLE 31 GAUGE X 1/4\", 31 GAUGE X 3/16\", 32  \nGAUGE X 5/32\" NEEDLE GC,MO1  \nTRUEPLUS INSULIN 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30 GAUGE X 5/16\", 0.3  \nML 31 GAUGE X 5/16\", 0.5 ML 29 GAUGE X 1/2\", 0.5 ML 30 GAUGE X 5/16\",  \n0.5 ML 31 GAUGE X 5/16\", 1 ML 28 GAUGE X 1/2\", 1 ML 29 GAUGE X 1/2\", 1  \nML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE X 1/2\"  \nSYRINGE GC,MO1  \nTRUEPLUS PEN NEEDLE 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31 GAUGE X  \n3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 5/32\" NEEDLE GC,MO1  ", "doc_id": "8b47db3b-e8ef-4889-a9ea-8da27020524f", "embedding": null, "doc_hash": "f7cf7b6ad3fc1806456300a53f4467f1266a01524cc911ac13a61c2227ce2a9d", "extra_info": {"page_label": "96", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2238, "end": 3047, "_node_type": "1"}, "relationships": {"1": "3ea0f5cd-f5d8-4a53-a1b7-c251792bc30a", "2": "801b2a31-eafa-4271-852a-5cebbd3af022"}}, "__type__": "1"}, "2317efbd-e9a3-422d-b664-9d92ed5ed9af": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 97DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.UBRELVY 100 MG, 50 MG TABLET DL 5 PA,QL(16 per 30 days) \nULTICARE 0.3 ML 30 GAUGE X 1/2\", 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 30  \nGAUGE X 1/2\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 30 GAUGE X 1/2\", 1 ML 31  \nGAUGE X 5/16 SYRINGE GC,MO1  \nULTICARE INSULIN SYRINGE 0.3 ML 31 GAUGE X 1/4\", 1 ML 31 GAUGE X 1/4\",  \n1/2 ML 31 GAUGE X 1/4\" SYRINGE GC,MO1  \nULTICARE INSULN SYR(HALF UNIT) 0.3 ML 31 GAUGE X 1/4\" SYRINGE GC,MO 1  \nULTICARE PEN NEEDLE 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31 GAUGE X  \n3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 1/4\", 32 GAUGE X 5/32\" NEEDLE GC,MO1  \nULTICARE SAFETY PEN NEEDLE 30 GAUGE X 3/16\", 30 GAUGE X 5/16\" NEEDLE \nGC,MO1  \nULTIGUARD SAFEPACK-INSULIN SYR 0.3 ML 30 X 1/2\", 0.3 ML 31 X 5/16\", 1  \nML 30 X 1/2\", 1 ML 31 X 5/16\", 1/2 ML 30 X 1/2\", 1/2 ML 31 X 5/16\" SYRINGE \nGC,MO1  \nULTIGUARD SAFEPACK-PEN NEEDLE 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31  \nGAUGE X 3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 1/4\", 32 GAUGE X 5/32\"  \nNEEDLE GC,MO1  \nULTILET ALCOHOL SWAB  PADS, MEDICATED GC,MO 1  \nULTILET INSULIN SYRINGE 0.3 ML 29 GAUGE, 0.3 ML 29 GAUGE X 1/2\", 0.3  \nML 30 GAUGE X 5/16\", 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 29 GAUGE X 1/2\",  \n0.5 ML 30 GAUGE X 5/16\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 29 GAUGE, 1 ML  \n29 GAUGE X 1/2\", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X 5/16, 1/2 ML 29  \nSYRINGE GC,MO1  \nULTILET PEN NEEDLE 29 GAUGE, 32 GAUGE X 5/32\" NEEDLE GC,MO 1  \nULTRA CMFT INS SYR (HALF UNIT) 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 31 GAUGE  \nX 5/16\" SYRINGE GC,MO1  \nULTRA COMFORT INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30, 0.3  \nML 30 GAUGE X 5/16\", 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 29 GAUGE X 1/2\",  \n0.5 ML 30 GAUGE X 5/16\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 28 GAUGE, 1 ML  \n28 GAUGE X 1/2\", 1 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2\", 1 ML 30 GAUGE X  \n5/16, 1 ML 30 GAUGE X 7/16\", 1 ML 31 GAUGE X", "doc_id": "2317efbd-e9a3-422d-b664-9d92ed5ed9af", "embedding": null, "doc_hash": "42d5aa3fac0d6f52e964b33d25fa417ca4db4518b858fd00eff36d84db0c329c", "extra_info": {"page_label": "97", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2285, "_node_type": "1"}, "relationships": {"1": "9ebaf473-8dd2-4c77-acb3-efde7aacea92", "3": "9bb90168-2063-4620-9e9a-55c3fea55e28"}}, "__type__": "1"}, "9bb90168-2063-4620-9e9a-55c3fea55e28": {"__data__": {"text": "1 ML 30 GAUGE X 7/16\", 1 ML 31 GAUGE X 5/16, 1/2 ML 28 GAUGE, 1/2  \nML 28 GAUGE X 1/2\", 1/2 ML 29, 1/2 ML 30 GAUGE SYRINGE GC,MO1  \nULTRA FLO INSUL SYR(HALF UNIT) 0.3 ML 30 GAUGE X 1/2\", 0.3 ML 30 GAUGE  \nX 5/16\", 0.3 ML 31 GAUGE X 5/16\" SYRINGE GC,MO1  \nULTRA FLO INSULIN SYRINGE 0.3 ML 29 GAUGE X 1/2\", 0.3 ML 30 GAUGE X  \n5/16\", 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 29 GAUGE X 1/2\" SYRINGE GC,MO1  \nULTRA FLO PEN NEEDLE 29 GAUGE X 1/2\", 31 GAUGE X 3/16\", 31 GAUGE X  \n5/16\", 32 GAUGE X 5/32\", 33 GAUGE X 5/32\" NEEDLE GC,MO1  \nULTRA THIN PEN NEEDLE 32 GAUGE X 5/32\" NEEDLE GC,MO 1  ", "doc_id": "9bb90168-2063-4620-9e9a-55c3fea55e28", "embedding": null, "doc_hash": "919d05be14a48ee226407bea6df7fde9ce578c118dd25b56542e4489f7e1b2cf", "extra_info": {"page_label": "97", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2247, "end": 2826, "_node_type": "1"}, "relationships": {"1": "9ebaf473-8dd2-4c77-acb3-efde7aacea92", "2": "2317efbd-e9a3-422d-b664-9d92ed5ed9af"}}, "__type__": "1"}, "ef4c1c90-64d0-47d3-9a32-26a8e7ed95c0": {"__data__": {"text": "98 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.ULTRA-THIN II (SHORT) INS SYR 0.3 ML 30 GAUGE X 5/16\", 0.3 ML 31 GAUGE  \nX 5/16\", 0.5 ML 30 GAUGE X 5/16\", 0.5 ML 31 GAUGE X 5/16\", 1 ML 30 GAUGE  \nX 5/16, 1 ML 31 GAUGE X 5/16 SYRINGE GC,MO1  \nULTRA-THIN II (SHORT) PEN NDL 31 GAUGE X 5/16\" NEEDLE GC,MO 1  \nULTRA-THIN II INS PEN NEEDLES 29 GAUGE X 1/2\" NEEDLE GC,MO 1  \nULTRA-THIN II INSULIN SYRINGE 0.5 ML 29 GAUGE X 1/2\", 1 ML 29 GAUGE X  \n1/2\" SYRINGE GC,MO1  \nULTRACARE INSULIN SYRINGE 0.3 ML 30 GAUGE X 5/16\", 0.3 ML 31 GAUGE X  \n5/16\", 0.5 ML 30 GAUGE X 1/2\", 0.5 ML 30 GAUGE X 5/16\", 0.5 ML 31 GAUGE  \nX 5/16\", 1 ML 30 GAUGE X 1/2\", 1 ML 30 GAUGE X 5/16, 1 ML 31 GAUGE X  \n5/16 SYRINGE GC,MO1  \nULTRACARE PEN NEEDLE 31 GAUGE X 1/4\", 31 GAUGE X 3/16\", 31 GAUGE X  \n5/16\", 32 GAUGE X 1/4\", 32 GAUGE X 3/16\", 32 GAUGE X 5/32\", 33 GAUGE X  \n5/32\" NEEDLE GC,MO1  \nUNIFINE PEN NEEDLE 32 GAUGE X 5/32\" NEEDLE GC,MO 1  \nUNIFINE PENTIPS 29 GAUGE, 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31 GAUGE  \nX 3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 1/4\", 32 GAUGE X 5/32\", 33 GAUGE  \nX 5/32\" NEEDLE GC,MO1  \nUNIFINE PENTIPS MAXFLOW 30 GAUGE X 3/16\" NEEDLE GC,MO 1  \nUNIFINE PENTIPS PLUS 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31 GAUGE X  \n3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 5/32\", 33 GAUGE X 5/32\" NEEDLE \nGC,MO1  \nUNIFINE PENTIPS PLUS MAXFLOW 30 GAUGE X 3/16\" NEEDLE GC,MO 1  \nUNIFINE SAFECONTROL 30 GAUGE X 3/16\", 30 GAUGE X 5/16\", 32 GAUGE X  \n5/32\" NEEDLE GC,MO1  \nUNIFINE ULTRA PEN NEEDLE 31 GAUGE X 1/4\", 31 GAUGE X 3/16\", 31 GAUGE  \nX 5/16\", 32 GAUGE X 5/32\" NEEDLE GC,MO1  \nV-GO 20  DEVICE MO 3  \nV-GO 30  DEVICE MO 3  \nV-GO 40  DEVICE MO 3  \nVANISHPOINT INSULIN SYRINGE 1 ML 30 GAUGE X 3/16\" SYRINGE GC,MO 1  \nVANISHPOINT SYRINGE 0.5 ML 30 GAUGE X 1/2\", 1 ML 29 GAUGE X 1/2\"  \nSYRINGE GC,MO1  \nVERIFINE INSULIN SYRINGE 0.3 ML 31 GAUGE X 5/16\", 0.5 ML 31 GAUGE X  \n5/16\", 1 ML 29 GAUGE X", "doc_id": "ef4c1c90-64d0-47d3-9a32-26a8e7ed95c0", "embedding": null, "doc_hash": "224c4619e922c0b9b75c2ac885310b43c6ca4dfd4b5153dc258ab3400b4e9206", "extra_info": {"page_label": "98", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2316, "_node_type": "1"}, "relationships": {"1": "b38b8103-9ad4-4a8a-bb82-aa128a7386e8", "3": "0ab7c261-fb8d-40ae-9048-e3efe1b044c3"}}, "__type__": "1"}, "0ab7c261-fb8d-40ae-9048-e3efe1b044c3": {"__data__": {"text": "0.5 ML 31 GAUGE X  \n5/16\", 1 ML 29 GAUGE X 1/2\", 1 ML 31 GAUGE X 5/16 SYRINGE GC,MO1  \nVERIFINE PEN NEEDLE 29 GAUGE X 1/2\", 31 GAUGE X 1/4\", 31 GAUGE X  \n3/16\", 31 GAUGE X 5/16\", 32 GAUGE X 1/4\", 32 GAUGE X 3/16\", 32 GAUGE X  \n5/32\" NEEDLE GC,MO1  ", "doc_id": "0ab7c261-fb8d-40ae-9048-e3efe1b044c3", "embedding": null, "doc_hash": "08bd78e602ef640a807b4872bccf73223c35ccd8d2b4c8f37574dd187cf9b56b", "extra_info": {"page_label": "98", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2274, "end": 2522, "_node_type": "1"}, "relationships": {"1": "b38b8103-9ad4-4a8a-bb82-aa128a7386e8", "2": "ef4c1c90-64d0-47d3-9a32-26a8e7ed95c0"}}, "__type__": "1"}, "9b4f2a56-e040-4aee-a9df-ab91e4361aa8": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 99DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.water for irrigation, sterile  SOLUTION GC,MO 2  \nWEBCOL  PADS, MEDICATED GC,MO 1  \nOPHTHALMIC AGENTS\nak-poly-bac 500-10,000 unit/gram OINTMENT GC,MO 2  \nALCAINE 0.5 % DROPS GC,MO 2  \nALPHAGAN P 0.1 % DROPS MO 3  \napraclonidine 0.5 % DROPS MO 3  \natropine 1 % DROPS MO 3  \nazelastine 0.05 % DROPS MO 3  \nbacitracin 500 unit/gram OINTMENT MO 4  \nbacitracin-polymyxin b 500-10,000 unit/gram OINTMENT GC,MO 2  \nBETADINE OPHTHALMIC PREP 5 % SOLUTION MO 4  \nbetaxolol 0.5 % DROPS MO 3  \nbrimonidine 0.15 % DROPS MO 4  \nbrimonidine 0.2 % DROPS GC,MO 1  \ncarteolol 1 % DROPS GC,MO 1  \nCILOXAN 0.3 % OINTMENT MO 4  \nciprofloxacin hcl 0.3 % DROPS GC,MO 1  \nCOMBIGAN 0.2-0.5 % DROPS MO 3 QL(5 per 25 days) \ncromolyn 4 % DROPS GC,MO 1  \nCYSTARAN 0.44 % DROPS DL 5 PA,QL(60 per 28 days) \ndexamethasone sodium phosphate 0.1 % DROPS GC,MO 2  \ndiclofenac sodium 0.1 % DROPS GC,MO 2  \ndifluprednate 0.05 % DROPS MO 3  \ndorzolamide 2 % DROPS GC,MO 1  \ndorzolamide-timolol 22.3-6.8 mg/ml DROPS GC,MO 1  \nDUREZOL 0.05 % DROPS MO 3  \nerythromycin 5 mg/gram (0.5 %) OINTMENT GC,MO 2 QL(3.5 per 28 days) \nEYSUVIS 0.25 % DROPS, SUSPENSION MO 3 QL(16.6 per 30 days) \nfluorometholone 0.1 % DROPS, SUSPENSION MO 3  \nflurbiprofen sodium 0.03 % DROPS GC,MO 2  \ngatifloxacin 0.5 % DROPS MO 4 QL(2.5 per 25 days) \ngentak 0.3 % (3 mg/gram) OINTMENT GC,MO 2  \ngentamicin 0.3 % DROPS GC,MO 2  \nILEVRO 0.3 % DROPS, SUSPENSION MO 3 QL(3 per 30 days) \nketorolac 0.4 % DROPS GC,MO 2 QL(10 per 30 days) ", "doc_id": "9b4f2a56-e040-4aee-a9df-ab91e4361aa8", "embedding": null, "doc_hash": "942211f09a5e86fcf37bd74606a6df367092b85f37af956908a56d1f9b628943", "extra_info": {"page_label": "99", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 1960, "_node_type": "1"}, "relationships": {"1": "74bd25f0-59c3-4442-8315-10ffd2c17113"}}, "__type__": "1"}, "04ff110a-e221-4369-bfd0-5b62217dd734": {"__data__": {"text": "100 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.ketorolac 0.5 % DROPS GC,MO 2 QL(10 per 30 days) \nlatanoprost 0.005 % DROPS GC,MO 1 QL(5 per 25 days) \nlevobunolol 0.5 % DROPS GC,MO 1  \nLOTEMAX SM 0.38 % DROPS, GEL MO 4  \nLUMIGAN 0.01 % DROPS MO 3 QL(2.5 per 25 days) \nmetipranolol 0.3 % DROPS GC,MO 2  \nmoxifloxacin 0.5 % DROPS MO 3  \nNATACYN 5 % DROPS, SUSPENSION MO 4  \nneo-polycin 3.5-400-10,000 mg-unit-unit/g OINTMENT MO 3  \nneo-polycin hc 3.5-400-10,000 mg-unit/g-1% OINTMENT MO 3  \nneomycin-bacitracin-poly-hc 3.5-400-10,000 mg-unit/g-1% OINTMENT MO 3  \nneomycin-bacitracin-polymyxin 3.5-400-10,000 mg-unit-unit/g OINTMENT MO 3  \nneomycin-polymyxin b-dexameth 3.5 mg/g-10,000 unit/g-0.1 % OINTMENT \nGC,MO2  \nneomycin-polymyxin b-dexameth 3.5mg/ml-10,000 unit/ml-0.1 % DROPS,  \nSUSPENSION GC,MO2  \nneomycin-polymyxin-gramicidin 1.75 mg-10,000 unit-0.025mg/ml DROPS MO 3  \nneomycin-polymyxin-hc 3.5-10,000-10 mg-unit-mg/ml DROPS, SUSPENSION MO 4  \nofloxacin 0.3 % DROPS GC,MO 2  \nolopatadine 0.1 % DROPS MO 3 ST \nolopatadine 0.2 % DROPS GC,MO 2  \nPHOSPHOLINE IODIDE 0.125 % DROPS MO 4  \npilocarpine hcl 1 %, 2 %, 4 % DROPS MO 3  \npolycin 500-10,000 unit/gram OINTMENT GC,MO 2  \npolymyxin b sulf-trimethoprim 10,000 unit- 1 mg/ml DROPS GC,MO 1  \nPRED-G 0.3-1 % DROPS, SUSPENSION MO 4  \nprednisolone acetate 1 % DROPS, SUSPENSION MO 3  \nprednisolone sodium phosphate 1 % DROPS MO 3  \nproparacaine 0.5 % DROPS GC,MO 2  \nRESTASIS 0.05 % DROPPERETTE MO 3 QL(60 per 30 days) \nRESTASIS MULTIDOSE 0.05 % DROPS MO 3 QL(5.5 per 25 days) \nRHOPRESSA 0.02 % DROPS MO 3 ST,QL(2.5 per 25 days) \nROCKLATAN 0.02-0.005 % DROPS MO 3 ST,QL(2.5 per 25 days) \nSIMBRINZA 1-0.2 % DROPS, SUSPENSION MO 4 QL(16 per 30 days) \nsulfacetamide sodium 10 % DROPS GC,MO 2  \nsulfacetamide-prednisolone 10 %-0.23 % (0.25 %) DROPS GC,MO 2  ", "doc_id": "04ff110a-e221-4369-bfd0-5b62217dd734", "embedding": null, "doc_hash": "94cdaa860aac8fc00441ffe09528060d5cb8f49f9c509534ce7e280b048158e2", "extra_info": {"page_label": "100", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2257, "_node_type": "1"}, "relationships": {"1": "f2992f20-4a85-4ea9-b87f-d73c3abe30f6"}}, "__type__": "1"}, "80c740ed-1697-42f9-ad11-6c30c4b06b77": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 101DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.timolol maleate 0.25 % DROPS GC,MO 1  \ntimolol maleate 0.25 %, 0.5 % GEL FORMING SOLUTION MO 4  \ntimolol maleate 0.5 % DROPS GC,MO 1  \ntimolol maleate 0.5 % DROPS, ONCE DAILY MO 4  \ntimolol maleate (pf) 0.25 % DROPPERETTE GC,MO 1  \ntimolol maleate (pf) 0.5 % DROPPERETTE MO 4  \ntobramycin 0.3 % DROPS GC,MO 2  \ntobramycin-dexamethasone 0.3-0.1 % DROPS, SUSPENSION MO 4  \ntravoprost 0.004 % DROPS MO 3 QL(2.5 per 25 days) \ntrifluridine 1 % DROPS MO 4  \nVYZULTA 0.024 % DROPS MO 4 QL(5 per 30 days) \nZERVIATE 0.24 % DROPPERETTE MO 4 QL(60 per 30 days) \nOTIC AGENTS\nciprofloxacin hcl 0.2 % DROPPERETTE MO 4  \nfluocinolone acetonide oil 0.01 % DROPS MO 3  \nhydrocortisone-acetic acid 1-2 % DROPS MO 4  \nneomycin-polymyxin-hc 3.5-10,000-1 mg/ml-unit/ml-% DROPS, SUSPENSION \nMO3  \nneomycin-polymyxin-hc 3.5-10,000-1 mg/ml-unit/ml-% SOLUTION MO 3  \nofloxacin 0.3 % DROPS MO 3  \nRESPIRATORY TRACT/PULMONARY AGENTS\nacetylcysteine 100 mg/ml (10 %), 200 mg/ml (20 %) SOLUTION MO 4 BvsD \nADEMPAS 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG TABLET DL,LA 5 PA,QL(90 per 30 days) \nADVAIR DISKUS 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE  \nBLISTER WITH DEVICE MO3 QL(60 per 30 days) \nADVAIR HFA 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21  \nMCG/ACTUATION HFA AEROSOL INHALER MO3 QL(12 per 30 days) \nalbuterol sulfate 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5  \nmg/0.5 ml, 5 mg/ml SOLUTION FOR NEBULIZATION GC,MO2 BvsD \nalbuterol sulfate 2 mg, 4 mg TABLET MO 4  \nalbuterol sulfate 2 mg/5 ml SYRUP GC,MO 2  \nalbuterol sulfate 4 mg, 8 mg TABLET, ER 12 HR. MO 4  \nalbuterol sulfate 90 mcg/actuation HFA AEROSOL INHALER MO 3 QL(36 per 30 days) \nalyq 20 mg TABLET MO 4 PA,QL(60 per 30 days) \nambrisentan 10 mg, 5 mg TABLET DL 5 PA,QL(30 per 30 days) \naminophylline 250 mg/10 ml, 500 mg/20 ml SOLUTION GC,MO 2  ", "doc_id": "80c740ed-1697-42f9-ad11-6c30c4b06b77", "embedding": null, "doc_hash": "0a7bfe9ab73134bab558bde804904dd8780004026353470c3677c6b155a233b9", "extra_info": {"page_label": "101", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2303, "_node_type": "1"}, "relationships": {"1": "6171c80e-32c4-4cfa-9d9d-21c6008eebee"}}, "__type__": "1"}, "74851931-da80-4837-8177-f594448a38e5": {"__data__": {"text": "102 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.arformoterol 15 mcg/2 ml SOLUTION FOR NEBULIZATION MO 4 PA,QL(120 per 30 days) \nARNUITY ELLIPTA 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50  \nMCG/ACTUATION BLISTER WITH DEVICE MO3 QL(30 per 30 days) \nATROVENT HFA 17 MCG/ACTUATION HFA AEROSOL INHALER MO 4 QL(25.8 per 30 days) \nAUVI-Q 0.1 MG/0.1 ML AUTO-INJECTOR MO 3  \nAUVI-Q 0.15 MG/0.15 ML, 0.3 MG/0.3 ML AUTO-INJECTOR MO 3 QL(4 per 30 days) \nazelastine 137 mcg (0.1 %) AEROSOL SPRAY MO 3 QL(30 per 25 days) \nazelastine 205.5 mcg (0.15 %) SPRAY, NON-AEROSOL MO 4 QL(30 per 25 days) \nBEVESPI AEROSPHERE 9-4.8 MCG HFA AEROSOL INHALER MO 4 QL(10.7 per 30 days) \nBREO ELLIPTA 100-25 MCG/DOSE, 200-25 MCG/DOSE BLISTER WITH DEVICE \nMO3 QL(60 per 30 days) \nBREZTRI AEROSPHERE 160-9-4.8 MCG/ACTUATION HFA AEROSOL INHALER \nMO3 QL(10.7 per 30 days) \nBROVANA 15 MCG/2 ML SOLUTION FOR NEBULIZATION DL 5 PA,QL(120 per 30 days) \nbudesonide 0.25 mg/2 ml, 0.5 mg/2 ml SUSPENSION FOR NEBULIZATION MO 4 BvsD \nCAYSTON 75 MG/ML SOLUTION FOR NEBULIZATION DL 5 PA,QL(84 per 28 days) \ncetirizine 1 mg/ml SOLUTION GC,MO 2 QL(300 per 30 days) \nCOMBIVENT RESPIMAT 20-100 MCG/ACTUATION MIST MO 4 QL(4 per 20 days) \ncromolyn 100 mg/5 ml CONCENTRATE MO 4  \ncromolyn 20 mg/2 ml SOLUTION FOR NEBULIZATION DL 5 BvsD \ncyproheptadine 4 mg TABLET MO 4  \nDALIRESP 250 MCG TABLET MO 3 QL(28 per 365 days) \nDALIRESP 500 MCG TABLET MO 3 QL(30 per 30 days) \ndesloratadine 5 mg TABLET MO 3 QL(30 per 30 days) \ndiphenhydramine hcl 50 mg/ml SOLUTION MO 4  \nepinephrine 0.15 mg/0.15 ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml AUTO-INJECTOR \nMO3 QL(4 per 30 days) \nepoprostenol (glycine) 0.5 mg, 1.5 mg RECON SOLUTION DL 5 PA \nFASENRA PEN 30 MG/ML AUTO-INJECTOR DL 5 PA,QL(1 per 28 days) \nFLOVENT DISKUS 100 MCG/ACTUATION BLISTER WITH DEVICE MO 3 QL(60 per 30 days) \nFLOVENT DISKUS 250 MCG/ACTUATION, 50 MCG/ACTUATION BLISTER WITH  \nDEVICE MO3 QL(60 per 30 days) \nFLOVENT HFA 110 MCG/ACTUATION HFA AEROSOL INHALER MO 3 QL(24 per 30 days) \nFLOVENT HFA 220 MCG/ACTUATION", "doc_id": "74851931-da80-4837-8177-f594448a38e5", "embedding": null, "doc_hash": "43ad18348c5d0f7111d24a0daabfe837053e846b1ea7451e565432585b30e2df", "extra_info": {"page_label": "102", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2459, "_node_type": "1"}, "relationships": {"1": "0c983c27-a24e-428e-8b01-7ee379b826e4", "3": "40e53e01-2cb4-4d99-8ab8-75b331c01e14"}}, "__type__": "1"}, "40e53e01-2cb4-4d99-8ab8-75b331c01e14": {"__data__": {"text": "HFA AEROSOL INHALER MO 3 QL(24 per 30 days) \nFLOVENT HFA 44 MCG/ACTUATION HFA AEROSOL INHALER MO 3 QL(10.6 per 30 days) \nflunisolide 25 mcg (0.025 %) SPRAY, NON-AEROSOL MO 3 QL(50 per 30 days) ", "doc_id": "40e53e01-2cb4-4d99-8ab8-75b331c01e14", "embedding": null, "doc_hash": "1a77afb0ea0398ce7b1ed22e6d3bb6c636a7ffa9c4308d6081dcc187efa64b81", "extra_info": {"page_label": "102", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2460, "end": 2653, "_node_type": "1"}, "relationships": {"1": "0c983c27-a24e-428e-8b01-7ee379b826e4", "2": "74851931-da80-4837-8177-f594448a38e5"}}, "__type__": "1"}, "f645b972-019d-4ca5-9b92-96df346a9d79": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 103DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.fluticasone propion-salmeterol 100-50 mcg/dose, 500-50 mcg/dose BLISTER  \nWITH DEVICE MO3 QL(60 per 30 days) \nfluticasone propion-salmeterol 113-14 mcg/actuation, 232-14 mcg/actuation,  \n55-14 mcg/actuation AEROSOL POWDER BREATH ACTIV. MO3 QL(1 per 30 days) \nfluticasone propion-salmeterol 250-50 mcg/dose BLISTER WITH DEVICE MO 3 QL(60 per 30 days) \nfluticasone propionate 50 mcg/actuation SPRAY, SUSPENSION GC,MO 2 QL(16 per 30 days) \nformoterol fumarate 20 mcg/2 ml SOLUTION FOR NEBULIZATION MO 4 PA,QL(120 per 30 days) \nhydroxyzine pamoate 100 mg, 50 mg CAPSULE MO 3  \nhydroxyzine pamoate 25 mg CAPSULE MO 3  \nipratropium bromide 0.02 % SOLUTION GC,MO 2 BvsD \nipratropium bromide 21 mcg (0.03 %) SPRAY, NON-AEROSOL GC,MO 2 QL(30 per 30 days) \nipratropium bromide 42 mcg (0.06 %) SPRAY, NON-AEROSOL GC,MO 2 QL(45 per 30 days) \nipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 ml SOLUTION FOR  \nNEBULIZATION GC,MO2 BvsD \nKALYDECO 13.4 MG, 25 MG, 5.8 MG, 50 MG, 75 MG GRANULES IN PACKET DL 5 PA,QL(56 per 28 days) \nKALYDECO 150 MG TABLET DL 5 PA,QL(60 per 30 days) \nlevalbuterol tartrate 45 mcg/actuation HFA AEROSOL INHALER MO 4 ST,QL(30 per 30 days) \nlevocetirizine 5 mg TABLET GC,MO 1 QL(30 per 30 days) \nmometasone 50 mcg/actuation SPRAY, NON-AEROSOL MO 4 QL(34 per 30 days) \nmontelukast 10 mg TABLET GC,MO 1 QL(30 per 30 days) \nmontelukast 4 mg GRANULES IN PACKET MO 4 QL(30 per 30 days) \nmontelukast 4 mg, 5 mg CHEWABLE TABLET GC,MO 1 QL(30 per 30 days) \nNUCALA 100 MG/ML AUTO-INJECTOR DL 5 PA,QL(3 per 28 days) \nNUCALA 100 MG/ML SYRINGE DL 5 PA,QL(3 per 28 days) \nNUCALA 40 MG/0.4 ML SYRINGE DL 5 PA,QL(0.4 per 28 days) \nOFEV 100 MG, 150 MG CAPSULE DL,LA 5 PA,QL(60 per 30 days) \nOPSUMIT 10 MG TABLET DL,LA 5 PA,QL(30 per 30 days) \nORKAMBI 100-125 MG, 150-188 MG, 75-94 MG GRANULES IN PACKET DL 5 PA,QL(56 per 28 days) \nORKAMBI 100-125 MG, 200-125 MG TABLET DL 5 PA,QL(112 per 28 days) \nPERFOROMIST 20 MCG/2 ML SOLUTION FOR NEBULIZATION DL 5 PA,QL(120 per 30 days) \npirfenidone 267 mg TABLET DL 5 PA,QL(270 per 30 days) \npirfenidone 534 mg, 801 mg TABLET DL 5 PA,QL(90 per", "doc_id": "f645b972-019d-4ca5-9b92-96df346a9d79", "embedding": null, "doc_hash": "323d0485fca8ac713f29d66ed88db5a01e129a220eb6a751567afb9458169753", "extra_info": {"page_label": "103", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2576, "_node_type": "1"}, "relationships": {"1": "6bf221cb-5621-4db3-a60c-c365a5f117ab", "3": "ace4100e-f1f5-4775-8de9-11c8a33d857b"}}, "__type__": "1"}, "ace4100e-f1f5-4775-8de9-11c8a33d857b": {"__data__": {"text": "DL 5 PA,QL(90 per 30 days) \nPULMOZYME 1 MG/ML SOLUTION DL 5 BvsD \nroflumilast 250 mcg TABLET MO 3 QL(28 per 365 days) \nroflumilast 500 mcg TABLET MO 3 QL(30 per 30 days) \nsildenafil (pulm.hypertension) 10 mg/ml SUSPENSION FOR RECONSTITUTION DL 5 PA,QL(180 per 30 days) ", "doc_id": "ace4100e-f1f5-4775-8de9-11c8a33d857b", "embedding": null, "doc_hash": "ed54835dd0bc4add28f06c30881b3efaa57debb3ad441e471a3c8337635931fd", "extra_info": {"page_label": "103", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2559, "end": 2828, "_node_type": "1"}, "relationships": {"1": "6bf221cb-5621-4db3-a60c-c365a5f117ab", "2": "f645b972-019d-4ca5-9b92-96df346a9d79"}}, "__type__": "1"}, "055708d8-7f94-477d-bae1-f5fd3ff7f397": {"__data__": {"text": "104 - 2023 HUMANA FORMULARY UPDATED 06/2023DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.sildenafil (pulm.hypertension) 20 mg TABLET MO 3 PA,QL(90 per 30 days) \nSPIRIVA RESPIMAT 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION MIST MO 3 QL(4 per 28 days) \nSPIRIVA WITH HANDIHALER 18 MCG CAPSULE, W/INHALATION DEVICE MO 3 QL(30 per 30 days) \nSTIOLTO RESPIMAT 2.5-2.5 MCG/ACTUATION MIST MO 3 QL(4 per 28 days) \nSTRIVERDI RESPIMAT 2.5 MCG/ACTUATION MIST MO 3 QL(4 per 30 days) \nSYMBICORT 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION HFA  \nAEROSOL INHALER MO3 QL(10.2 per 30 days) \nSYMDEKO 100-150 MG (D)/ 150 MG (N), 50-75 MG (D)/ 75 MG (N) TABLET,  \nSEQUENTIAL DL5 PA,QL(56 per 28 days) \nSYMJEPI 0.15 MG/0.3 ML, 0.3 MG/0.3 ML SYRINGE MO 3 QL(4 per 30 days) \ntadalafil (pulm. hypertension) 20 mg TABLET MO 4 PA,QL(60 per 30 days) \ntheophylline 300 mg, 450 mg TABLET, ER 12 HR. MO 4  \ntheophylline 400 mg, 600 mg TABLET, ER 24 HR. MO 4  \ntheophylline in dextrose 5 % 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml,  \n800 mg/250 ml PARENTERAL SOLUTION MO4  \nTRELEGY ELLIPTA 100-62.5-25 MCG, 200-62.5-25 MCG BLISTER WITH  \nDEVICE MO3 QL(60 per 30 days) \nTRIKAFTA 100-50-75 MG(D) /150 MG (N), 50-25-37.5 MG (D)/75 MG (N)  \nTABLET, SEQUENTIAL DL5 PA,QL(84 per 28 days) \nTRIKAFTA 100-50-75MG (D) /75 MG (N), 80-40-60 MG (D) /59.5 MG (N)  \nGRANULES IN PACKET, SEQUENTIAL DL5 PA,QL(56 per 28 days) \nVENTAVIS 10 MCG/ML SOLUTION FOR NEBULIZATION DL 5 PA,QL(150 per 30 days) \nVENTAVIS 20 MCG/ML SOLUTION FOR NEBULIZATION DL 5 PA,QL(90 per 30 days) \nVENTOLIN HFA 90 MCG/ACTUATION HFA AEROSOL INHALER MO 3 QL(36 per 30 days) \nwixela inhub 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose BLISTER  \nWITH DEVICE MO3 QL(60 per 30 days) \nzafirlukast 10 mg TABLET MO 4 QL(60 per 30 days) \nzafirlukast 20 mg TABLET MO 4 QL(60 per 30 days) \nSKELETAL MUSCLE RELAXANTS\ncarisoprodol 350 mg TABLET MO 4 QL(120 per 30 days) \ncyclobenzaprine 10 mg, 5 mg TABLET GC,MO 2  \nmethocarbamol 500 mg, 750 mg TABLET GC,MO 2  \nvanadom 350 mg TABLET MO 4 QL(120 per 30 days) \nSLEEP DISORDER AGENTS\nBELSOMRA 10 MG TABLET MO 3", "doc_id": "055708d8-7f94-477d-bae1-f5fd3ff7f397", "embedding": null, "doc_hash": "5e2ccf434861b91555046eb38fda31610a0213725a8d66cd167afe6419dee7b6", "extra_info": {"page_label": "104", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2476, "_node_type": "1"}, "relationships": {"1": "e619bff8-4340-48dc-b342-850f2ad65828", "3": "e0d330c3-c7a2-451c-b207-e0cf59e0569c"}}, "__type__": "1"}, "e0d330c3-c7a2-451c-b207-e0cf59e0569c": {"__data__": {"text": "AGENTS\nBELSOMRA 10 MG TABLET MO 3 QL(60 per 30 days) \nBELSOMRA 15 MG, 20 MG TABLET MO 3 QL(30 per 30 days) \nBELSOMRA 5 MG TABLET MO 3 QL(120 per 30 days) ", "doc_id": "e0d330c3-c7a2-451c-b207-e0cf59e0569c", "embedding": null, "doc_hash": "b7a40278daa567d13f66f1d207fca034ba85363f6a10ba8269649980813b7f59", "extra_info": {"page_label": "104", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 2443, "end": 2597, "_node_type": "1"}, "relationships": {"1": "e619bff8-4340-48dc-b342-850f2ad65828", "2": "055708d8-7f94-477d-bae1-f5fd3ff7f397"}}, "__type__": "1"}, "6e8dd6d2-da80-477d-8854-47a10378b4f0": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 105DRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Need more information about the indicators displayed by the drug names? Please go to page 10. Need more \ninformation about the utilization management requirements?  Please go to page 5.HETLIOZ 20 MG CAPSULE DL 5 PA,QL(30 per 30 days) \nHETLIOZ LQ 4 MG/ML SUSPENSION DL 5 PA,QL(158 per 30 days) \nmodafinil 100 mg, 200 mg TABLET MO 3 PA,QL(60 per 30 days) \nsodium oxybate 500 mg/ml SOLUTION DL,LA 5 PA,QL(540 per 30 days) \ntasimelteon 20 mg CAPSULE DL 5 PA,QL(30 per 30 days) \ntemazepam 15 mg, 30 mg CAPSULE DL 4 QL(30 per 30 days) \nXYREM 500 MG/ML SOLUTION DL,LA 5 PA,QL(540 per 30 days) \nzolpidem 10 mg, 5 mg TABLET GC,MO 2 QL(30 per 30 days) ", "doc_id": "6e8dd6d2-da80-477d-8854-47a10378b4f0", "embedding": null, "doc_hash": "3cacc878c1e4da6a33c19f019ccac33ff1ec8927861e3473e191d89adaeeff65", "extra_info": {"page_label": "105", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 953, "_node_type": "1"}, "relationships": {"1": "e5df9d7c-adbf-4f14-a3cb-0900f21db8e1"}}, "__type__": "1"}, "a339e548-1962-4b3e-ad80-47d72f1b85b5": {"__data__": {"text": "106 - 2023 HUMANA FORMULARY UPDATED 06/2023Formulary Start Cross Reference \nHumana Coverage of Additional Prescription Drugs\nDRUG NAME TIER UTILIZATION  \nMANAGEMENT  \nREQUIREMENTS\nYour Humana plan has additional coverage of some drugs.  These drugs are not normally covered under Medicare Part  \nD. These drugs are not subject to the Medicare appeals process. The amount you pay when you fill a prescription for  \nthese drugs does not count toward your total drug costs (in other words, the amount you pay does not help you qualify  \nfor catastrophic coverage).\nB vs D - Part B vs Part D \u2022 MO \u2013 Mail Order \u2022 PA - Prior Authorization \u2022 QL - Quantity Limit \u2022 ST - Step Therapy \n  \u2022 DL \u2013 Dispensing Limit \u2022 GC- Gap Coverage \u2022 ISP \u2013 Insulin Savings Program \u2022 LA \u2013 Limited Access Erectile Dysfunction \nsildenafil 100 mg, 25 mg, 50 mg TABLET  1 QL(6 per 30 days)\nWeight Loss \nCONTRAVE 8-90 MG TABLET ER  2 PA,QL(120 per 30 days)", "doc_id": "a339e548-1962-4b3e-ad80-47d72f1b85b5", "embedding": null, "doc_hash": "481cd1e2cfffd39fc94f4433ceccca0522da2d8142569724e059b9bc4e903863", "extra_info": {"page_label": "106", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 922, "_node_type": "1"}, "relationships": {"1": "127f760f-e743-47ef-9aa9-8d1623aa0b1c"}}, "__type__": "1"}, "295ab6af-6dc3-4f28-ac96-6a3d2b013fef": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 107Index\nA\nabacavir... 43 \nabacavir-lamivudine... 43 \nabacavir-lamivudine-zidovudine...  \n43 \nABELCET... 26 \nABILIFY ASIMTUFII... 40 \nABILIFY MAINTENA... 40 \nabiraterone... 28 \nABOUTTIME PEN NEEDLE... 88 \nABRAXANE... 28 \nacamprosate... 14 \nacarbose... 48 \naccutane... 62 \nacebutolol... 52 \nacetaminophen-codeine... 11 \nacetazolamide sodium... 53 \nacetazolamide... 52, 53 \nacetic acid... 14, 88 \nacetylcysteine... 88, 101 \nacitretin... 62 \nACTHIB (PF)... 82 \nACTIMMUNE... 82 \nacyclovir sodium... 43 \nacyclovir... 43 \nADACEL(TDAP  \nADOLESN/ADULT)(PF)... 82 \nadapalene... 62 \nADCETRIS... 28 \nadefovir... 43 \nADEMPAS... 101adenosine... 53\nadriamycin... 29\nADVAIR DISKUS... 101\nADVAIR HFA... 101\nADVOCATE PEN NEEDLE... 88\nADVOCATE SYRINGES... 88\nafirmelle... 73\nAIMOVIG AUTOINJECTOR... 27\nak-poly-bac... 99\nalbendazole... 39\nalbuterol sulfate... 101\nALCAINE... 99\nALCOHOL PADS... 88\nALCOHOL PREP PADS... 88\nALCOHOL SWABS... 88\nALCOHOL WIPES... 88\nALECENSA... 29\nalendronate... 87\nalfuzosin... 71\nALIMTA... 29\nALIQOPA... 29\naliskiren... 53\nallopurinol... 27\nALPHAGAN P... 99\nalprazolam... 47\naltavera (28)... 73\nALUNBRIG... 29\nalyacen 1/35 (28)... 73\nalyacen 7/7/7 (28)... 73\nalyq... 101\namabelz... 73amantadine hcl... 39\nAMBISOME... 26\nambrisentan... 101\namethia... 74\namethyst (28)... 74\namikacin... 14\namiloride... 53\namiloride-hydrochlorothiazide... 53\naminocaproic acid... 51\naminophylline... 101\nAMINOSYN II 10 %... 64\nAMINOSYN II 15 %... 64\nAMINOSYN II 7 %... 65\nAMINOSYN II 8.5 %... 65\nAMINOSYN II 8.5 %-ELECTROLYTES...  \n65\nAMINOSYN M 3.5 %... 65\nAMINOSYN 10 %... 64\nAMINOSYN 7 % WITH  \nELECTROLYTES... 64\nAMINOSYN 8.5 %... 64\nAMINOSYN 8.5 %-ELECTROLYTES...  \n64\nAMINOSYN-HBC 7%... 65\nAMINOSYN-PF 10 %... 65\nAMINOSYN-PF 7 % (SULFITE-FREE)...  \n65\nAMINOSYN-RF 5.2 %... 65\namiodarone... 53\namitriptyline... 23\namlodipine... 53\namlodipine-atorvastatin... 53", "doc_id": "295ab6af-6dc3-4f28-ac96-6a3d2b013fef", "embedding": null, "doc_hash": "00887410bd90064f2ce9d316d17e73caff4ef075cc20ec1867f994581dcad513", "extra_info": {"page_label": "107", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 1897, "_node_type": "1"}, "relationships": {"1": "b7fa1cd8-08cc-443a-b536-3d004397a1ef"}}, "__type__": "1"}, "10c47816-8de9-4aa1-9c26-4dd07e7b144b": {"__data__": {"text": "108 - 2023 HUMANA FORMULARY UPDATED 06/2023amlodipine-benazepril... 53\namlodipine-olmesartan... 53\namlodipine-valsartan... 53\nammonium lactate... 62\namnesteem... 62\namoxapine... 23\namoxicil-clarithromy-lansopraz...  \n69\namoxicillin... 14\namoxicillin-pot clavulanate... 14, 15\namphotericin b liposome... 26\namphotericin b... 26\nampicillin sodium... 15\nampicillin... 15\nampicillin-sulbactam... 15\nanagrelide... 51\nanastrozole... 29\napraclonidine... 99\naprepitant... 25\nAPRETUDE... 43\napri... 74\nAPTIOM... 19\nAPTIVUS (WITH VITAMIN E)... 43\nAPTIVUS... 43\naranelle (28)... 74\nARCALYST... 82\narformoterol... 102\naripiprazole... 40\nARISTADA INITIO... 40\nARISTADA... 40\nARMOUR THYROID... 80\nARNUITY ELLIPTA... 102\nARRANON... 29arsenic trioxide... 29\nasenapine maleate... 40\nashlyna... 74\nASPARLAS... 29\naspirin-dipyridamole... 51\nASSURE ID DUO-SHIELD... 88\nASSURE ID INSULIN SAFETY... 88\nASSURE ID PEN NEEDLE... 88\natazanavir... 43, 44\natenolol... 53\natenolol-chlorthalidone... 53\natomoxetine... 60\natorvastatin... 53\natovaquone... 39\natovaquone-proguanil... 39\natropine... 99\nATROVENT HFA... 102\naubra eq... 74\naubra... 74\nAUGMENTIN... 15\naurovela fe 1.5/30 (28)... 74\naurovela fe 1-20 (28)... 74\naurovela 1.5/30 (21)... 74\naurovela 1/20 (21)... 74\naurovela 24 fe... 74\nAUSTEDO XR... 60\nAUSTEDO... 60\nAUTOJECT 2 INJECTION DEVICE... 88\nAUTOPEN 1 TO 21 UNITS... 88\nAUTOPEN 2 TO 42 UNITS... 88\nAUVELITY... 23\nAUVI-Q... 102\naviane... 74ayuna... 74\nAYVAKIT... 29\nazacitidine... 29\nazathioprine... 82\nazelaic acid... 62\nazelastine... 99, 102\nazithromycin... 15\naztreonam... 15\nazurette (28)... 74\nB\nbacitracin... 15, 99\nbacitracin-polymyxin b... 99\nbaclofen... 43\nbal-care dha... 65\nbalsalazide... 86\nBALVERSA... 29\nbalziva (28)... 74\nBAND-AID GAUZE PADS... 88\nBAQSIMI... 48\nBARACLUDE... 44\nBAVENCIO... 29\nBCG VACCINE, LIVE (PF)... 82\nBD ALCOHOL SWABS... 88\nBD AUTOSHIELD DUO PEN NEEDLE...  \n88\nBD ECLIPSE LUER-LOK... 88\nBD INSULIN SYRINGE (HALF UNIT)...  \n89\nBD INSULIN SYRINGE MICRO-FINE...  \n89\nBD INSULIN SYRINGE SAFETY-LOK...  \n89\nBD INSULIN SYRINGE SLIP TIP... 89\nBD INSULIN SYRINGE U-500... 89", "doc_id": "10c47816-8de9-4aa1-9c26-4dd07e7b144b", "embedding": null, "doc_hash": "64084bc8dbf741cb85efbb52d5e03643438161736e660b130c3a7056cd7be94d", "extra_info": {"page_label": "108", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2087, "_node_type": "1"}, "relationships": {"1": "e5dc3e5e-b274-4c5c-8390-ac6c9645e0bd"}}, "__type__": "1"}, "0982f878-f68f-4a5b-87fd-b365e2ed36b5": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 109BD INSULIN SYRINGE ULTRA-FINE...  \n89\nBD INSULIN SYRINGE... 89\nBD LO-DOSE MICRO-FINE IV... 89\nBD LO-DOSE ULTRA-FINE... 89\nBD NANO 2ND GEN PEN NEEDLE... 89\nBD SAFETYGLIDE INSULIN SYRINGE...  \n89\nBD SAFETYGLIDE SYRINGE... 89\nBD ULTRA-FINE MICRO PEN  \nNEEDLE... 89\nBD ULTRA-FINE MINI PEN NEEDLE...  \n89\nBD ULTRA-FINE NANO PEN NEEDLE...  \n89\nBD ULTRA-FINE ORIG PEN NEEDLE...  \n89\nBD ULTRA-FINE SHORT PEN  \nNEEDLE... 89\nBD VEO INSULIN SYR (HALF UNIT)...  \n89\nBD VEO INSULIN SYRINGE UF... 89\nBELBUCA... 11\nBELEODAQ... 29\nBELSOMRA... 104\nbenazepril... 53\nbenazepril-hydrochlorothiazide... 53\nbendamustine... 29\nBENDEKA... 29\nBENLYSTA... 82\nbenztropine... 39\nBESPONSA... 29\nBETADINE OPHTHALMIC PREP... 99\nbetaine... 71\nbetamethasone acet,sod phos... 72\nbetamethasone dipropionate... 62betamethasone valerate... 62\nbetamethasone, augmented... 62\nBETASERON... 60\nbetaxolol... 99\nbethanechol chloride... 72\nBEVESPI AEROSPHERE... 102\nbexarotene... 29\nBEXSERO... 82\nbicalutamide... 29\nBICILLIN C-R... 15\nBICILLIN L-A... 15\nBICNU... 29\nBIKTARVY... 44\nbismuth subcit k-metronidz-tcn...  \n69\nbisoprolol fumarate... 53\nbisoprolol-hydrochlorothiazide... 53\nBLENREP... 29\nbleomycin... 29\nblisovi fe 1.5/30 (28)... 74\nblisovi fe 1/20 (28)... 74\nblisovi 24 fe... 74\nBOOSTRIX TDAP... 82\nBORDERED GAUZE... 89\nBORTEZOMIB... 29\nBOSULIF... 29\nBRAFTOVI... 29\nBREO ELLIPTA... 102\nBREZTRI AEROSPHERE... 102\nbriellyn... 74\nBRILINTA... 51\nbrimonidine... 99\nBRIVIACT... 19bromocriptine... 39\nBROVANA... 102\nBRUKINSA... 29\nbudesonide... 86, 87, 102\nbumetanide... 53\nbupivacaine (pf)... 13\nbupivacaine hcl... 13\nbuprenorphine hcl... 14\nbuprenorphine... 11\nbuprenorphine-naloxone... 14\nbupropion hcl (smoking deter)... 14\nbupropion hcl... 23\nbuspirone... 47\nbusulfan... 29\nBUSULFEX... 30\nbutalbital-acetaminop-caf-cod... 89\nbutalbital-acetaminophen-caff... 89\nBYDUREON BCISE... 48\nC\nc-nate dha... 65\nCABENUVA... 44\ncabergoline... 81\nCABLIVI... 51\nCABOMETYX... 30\ncaffeine citrate... 89\ncalcipotriene... 62\ncalcitonin (salmon)... 87\ncalcitriol... 87\ncalcium acetate(phosphat bind)...  \n65\ncalcium chloride... 65\ncalcium disodium versenate... 89\ncalcium gluconate... 65", "doc_id": "0982f878-f68f-4a5b-87fd-b365e2ed36b5", "embedding": null, "doc_hash": "45325e682b51a602c8489a851af4f0069ced59df2aa2f9001a25e9b5544a9af4", "extra_info": {"page_label": "109", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2175, "_node_type": "1"}, "relationships": {"1": "3a532330-5add-4d57-8822-8eaa8566d70c"}}, "__type__": "1"}, "813bb6e6-a453-40a3-8250-5a86af88b2f2": {"__data__": {"text": "110 - 2023 HUMANA FORMULARY UPDATED 06/2023CALQUENCE (ACALABRUTINIB  \nMAL)... 30\nCALQUENCE... 30\ncamila... 74\ncamrese lo... 74\ncamrese... 74\nCAMZYOS... 53\ncandesartan... 53\ncandesartan-hydrochlorothiazid...  \n54\nCAPLYTA... 40\nCAPRELSA... 30\ncaptopril... 54\ncaptopril-hydrochlorothiazide... 54\ncarbamazepine... 19, 20\ncarbidopa-levodopa... 39, 40\ncarbidopa-levodopa-entacapone...  \n40\ncarboplatin... 30\nCAREFINE PEN NEEDLE... 89\nCARETOUCH ALCOHOL PREP PAD...  \n89\nCARETOUCH INSULIN SYRINGE... 90\nCARETOUCH PEN NEEDLE... 90\ncarglumic acid... 65\ncarisoprodol... 104\ncarmustine... 30\ncarteolol... 99\ncartia xt... 54\ncarvedilol phosphate... 54\ncarvedilol... 54\ncaspofungin... 26\nCAYSTON... 102\ncaziant (28)... 74cefaclor... 15\ncefadroxil... 15\ncefazolin in dextrose (iso-os)... 15\ncefazolin... 15\ncefdinir... 15\ncefepime in dextrose 5 %... 15\ncefepime in dextrose,iso-osm... 15\ncefepime... 15\ncefixime... 15\ncefotaxime... 15\ncefotetan... 15\ncefoxitin in dextrose, iso-osm... 15\ncefoxitin... 15\ncefpodoxime... 15\ncefprozil... 16\nceftazidime in d5w... 16\nceftazidime... 16\nceftriaxone in dextrose,iso-os... 16\nceftriaxone... 16\ncefuroxime axetil... 16\ncefuroxime sodium... 16\ncelecoxib... 11\nCELLCEPT INTRAVENOUS... 82\nCELLCEPT... 82\nCELONTIN... 20\ncephalexin... 16\nCERDELGA... 71\nCEREZYME... 71\ncetirizine... 102\ncevimeline... 61\ncharlotte 24 fe... 74\nchateal (28)... 74\nchateal eq (28)... 74CHEMET... 65\nCHENODAL... 69\nchloramphenicol sod succinate... 16\nchlorhexidine gluconate... 61\nchloroquine phosphate... 39\nchlorothiazide sodium... 54\nchlorpromazine... 40, 41\nchlorthalidone... 54\nCHOLBAM... 71\ncholestyramine (with sugar)... 54\ncholestyramine light... 54\ncholestyramine-aspartame... 54\nCHORIONIC GONADOTROPIN,  \nHUMAN... 73\nciclodan... 26\nciclopirox... 26\ncidofovir... 44\ncilostazol... 51\nCILOXAN... 99\nCIMDUO... 44\ncimetidine hcl... 69\ncimetidine... 69\ncinacalcet... 87\nciprofloxacin hcl... 16, 99, 101\nciprofloxacin in 5 % dextrose... 16\ncisplatin... 30\ncitalopram... 23\ncladribine... 30\nclaravis... 62\nclarithromycin... 16\nCLENPIQ... 69\nCLEOCIN... 16\nCLICKFINE PEN NEEDLE... 90", "doc_id": "813bb6e6-a453-40a3-8250-5a86af88b2f2", "embedding": null, "doc_hash": "29f8563642a2cecaf99ab58d80cea3683c3ea1976d33c57c30ba6c16e5079427", "extra_info": {"page_label": "110", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2082, "_node_type": "1"}, "relationships": {"1": "8d790f7b-da26-438b-9610-cedebbe3167c"}}, "__type__": "1"}, "6d89c1d0-2fa8-4201-be3a-dfcf45ad37d8": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 111clindamycin hcl... 16\nclindamycin in 0.9 % sod chlor... 16\nclindamycin in 5 % dextrose... 16\nclindamycin pediatric... 16\nclindamycin phosphate... 16, 62\nCLINIMIX E 2.75%/D5W SULF FREE...  \n65\nCLINIMIX E 4.25%/D10W SUL  \nFREE... 65\nCLINIMIX E 4.25%/D5W SULF FREE...  \n65\nCLINIMIX E 5%/D15W SULFIT FREE...  \n65\nCLINIMIX E 5%/D20W SULFIT FREE...  \n65\nCLINIMIX E 8%-D10W  \nSULFITEFREE... 65\nCLINIMIX E 8%-D14W  \nSULFITEFREE... 65\nCLINIMIX 4.25%/D10W SULF FREE...  \n65\nCLINIMIX 4.25%/D5W SULFIT  \nFREE... 65\nCLINIMIX  \n5%-D20W(SULFITE-FREE)... 65\nCLINIMIX  5%/D15W SULFITE FREE...  \n65\nCLINIMIX 6%-D5W  \n(SULFITE-FREE)... 65\nCLINIMIX  \n8%-D10W(SULFITE-FREE)... 65\nCLINIMIX  \n8%-D14W(SULFITE-FREE)... 65\nCLINISOL SF 15 %... 65\nCLINOLIPID... 65\nclobazam... 20\nclobetasol... 62, 63\nclobetasol-emollient... 63clofarabine... 30\nCLOLAR... 30\nclomipramine... 23\nclonazepam... 47\nclonidine hcl... 54\nclonidine... 54\nclopidogrel... 51\nclorazepate dipotassium... 47\nclotrimazole... 26\nclotrimazole-betamethasone... 26\nclovique... 65\nclozapine... 41\nCOARTEM... 39\ncolchicine... 27\ncolestipol... 54\ncolistin (colistimethate na)... 16\nCOMBIGAN... 99\nCOMBIPATCH... 74\nCOMBIVENT RESPIMAT... 102\nCOMETRIQ... 30\nCOMFORT EZ INSULIN SYRINGE... 90\nCOMFORT EZ PEN NEEDLES... 90\nCOMFORT TOUCH PEN NEEDLE... 90\nCOMPLERA... 44\ncomplete natal dha... 65\ncompro... 25\nconstulose... 69\nCONTRAVE... 106\nCOPAXONE... 60\nCOPIKTRA... 30\nCORLANOR... 54\nCORLOPAM... 54\nCOSENTYX (2 SYRINGES)... 82COSENTYX PEN (2 PENS)... 82\nCOSENTYX PEN... 82\nCOSENTYX... 82\nCOSMEGEN... 30\nCOTELLIC... 30\nCREON... 71\ncromolyn... 99, 102\ncryselle (28)... 74\nCRYSVITA... 71\nCURITY ALCOHOL SWABS... 90\nCURITY GAUZE... 90\ncyclafem 1/35 (28)... 74\ncyclafem 7/7/7 (28)... 74\ncyclobenzaprine... 104\ncyclophosphamide... 30\ncycloserine... 28\ncyclosporine modified... 83\ncyclosporine... 82\ncyproheptadine... 102\nCYRAMZA... 30\ncyred eq... 74\ncyred... 74\nCYSTAGON... 71\nCYSTARAN... 99\ncytarabine (pf)... 30\ncytarabine... 30\nD\ndabigatran etexilate... 51\ndacarbazine... 30\ndactinomycin... 30\ndalfampridine... 60\nDALIRESP... 102\ndanazol... 74", "doc_id": "6d89c1d0-2fa8-4201-be3a-dfcf45ad37d8", "embedding": null, "doc_hash": "f752e9f39dd3f1beb7e8a842d5cd64d83db8d86b68446e024aaf2b38db34e89f", "extra_info": {"page_label": "111", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2113, "_node_type": "1"}, "relationships": {"1": "93c62739-724d-4b84-a894-4d1829915335"}}, "__type__": "1"}, "234b3a34-b16b-415a-8461-517de762eede": {"__data__": {"text": "112 - 2023 HUMANA FORMULARY UPDATED 06/2023dantrolene... 43\nDANYELZA... 30\ndapsone... 28\nDAPTACEL (DTAP PEDIATRIC) (PF)...  \n83\ndaptomycin... 16\ndarifenacin... 72\nDARZALEX FASPRO... 30\nDARZALEX... 30\ndasetta 1/35 (28)... 74\ndasetta 7/7/7 (28)... 75\ndaunorubicin... 30\nDAURISMO... 30\ndaysee... 75\ndeblitane... 75\ndecitabine... 30\ndeferasirox... 66\nDELSTRIGO... 44\ndemeclocycline... 16\nDEMSER... 54\nDENGVAXIA (PF)... 83\nDEPO-ESTRADIOL... 75\nDEPO-SUBQ PROVERA 104... 75\nDERMACEA... 90\nDESCOVY... 44\ndesipramine... 23\ndesloratadine... 102\ndesmopressin... 73\ndesog-e.estradiol/e.estradiol... 75\ndesogestrel-ethinyl estradiol... 75\ndesvenlafaxine succinate... 23\ndexamethasone intensol... 72\ndexamethasone sodium phos (pf)...  \n72dexamethasone sodium  \nphosphate... 72, 99\ndexamethasone... 72\ndexmethylphenidate... 60\ndexrazoxane hcl... 31\ndextroamphetamine sulfate... 60\ndextroamphetamine-amphetamine...  \n60\ndextrose 10 % and 0.2 % nacl... 66\ndextrose 10 % in water (d10w)... 66\ndextrose 20 % in water (d20w)... 66\ndextrose 25 % in water (d25w)... 66\ndextrose 30 % in water (d30w)... 66\ndextrose 40 % in water (d40w)... 66\ndextrose 5 % in water (d5w)... 66\ndextrose 5 %-lactated ringers... 66\ndextrose 5%-0.2 % sod chloride...  \n66\ndextrose 5%-0.3 % sod.chloride...  \n66\ndextrose 50 % in water (d50w)... 66\ndextrose 70 % in water (d70w)... 66\nDIACOMIT... 20\ndiazepam intensol... 47\ndiazepam... 20, 47\ndiazoxide... 48\ndiclofenac epolamine... 11\ndiclofenac sodium... 11, 63, 99\ndiclofenac-misoprostol... 11\ndicloxacillin... 16\ndicyclomine... 69\ndidanosine... 44\nDIFICID... 17\ndifluprednate... 99digitek... 54\ndigox... 54\ndigoxin... 54\ndihydroergotamine... 27\nDILANTIN INFATABS... 20\nDILANTIN-125... 20\ndilt-xr... 54\ndiltiazem hcl... 54, 55\ndimethyl fumarate... 60, 61\ndiphenhydramine hcl... 102\ndiphenoxylate-atropine... 69\ndipyridamole... 51\ndisulfiram... 14\nDIURIL... 55\ndivalproex... 20\nDOCEFREZ... 31\ndocetaxel... 31\ndofetilide... 55\nDOJOLVI... 90\ndolishale... 75\ndonepezil... 22\ndorzolamide... 99\ndorzolamide-timolol... 99\ndotti... 75\nDOVATO... 44\ndoxazosin... 55\ndoxepin... 47\ndoxercalciferol... 87\ndoxorubicin... 31\ndoxorubicin, peg-liposomal... 31\ndoxy-100... 17\ndoxycycline hyclate... 17\ndoxycycline monohydrate... 17", "doc_id": "234b3a34-b16b-415a-8461-517de762eede", "embedding": null, "doc_hash": "de990b3b00e9c05e873b545069fbb37137547fcea0d957a211445f89b1053118", "extra_info": {"page_label": "112", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2220, "_node_type": "1"}, "relationships": {"1": "b8c07ae1-7531-4f59-a33a-7aecc604952c"}}, "__type__": "1"}, "604655b7-0d62-4221-b227-0de177954e6d": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 113DRIZALMA SPRINKLE... 23\ndronabinol... 25\ndroperidol... 41\nDROPLET INSULIN SYR(HALF UNIT)...  \n90\nDROPLET INSULIN SYRINGE... 90\nDROPLET MICRON PEN NEEDLE... 90\nDROPLET PEN NEEDLE... 90\nDROPSAFE ALCOHOL PREP PADS... 90\nDROPSAFE PEN NEEDLE... 91\ndrospirenone-ethinyl estradiol... 75\nDROXIA... 91\nDUAVEE... 75\nduloxetine... 23\nDUPIXENT PEN... 83\nDUPIXENT SYRINGE... 83\nDUREZOL... 99\ndutasteride... 72\ndutasteride-tamsulosin... 72\nd10 %-0.45 % sodium chloride... 65\nd2.5 %-0.45 % sodium chloride... 66\nd5 % and 0.9 % sodium chloride...  \n66\nd5 %-0.45 % sodium chloride... 66\nE\nEASY COMFORT ALCOHOL PAD... 91\nEASY COMFORT INSULIN SYRINGE...  \n91\nEASY COMFORT PEN NEEDLES... 91\nEASY GLIDE INSULIN SYRINGE... 91\nEASY GLIDE PEN NEEDLE... 91\nEASY TOUCH ALCOHOL PREP PADS...  \n91\nEASY TOUCH FLIPLOCK INSULIN... 91EASY TOUCH INSULIN SAFETY SYR...  \n91\nEASY TOUCH INSULIN SYRINGE... 91\nEASY TOUCH LUER LOCK INSULIN...  \n91\nEASY TOUCH PEN NEEDLE... 91\nEASY TOUCH SAFETY PEN NEEDLE...  \n91\nEASY TOUCH SHEATHLOCK  \nINSULIN... 91\nEASY TOUCH UNI-SLIP... 91\nEASY TOUCH... 91\nec-naproxen... 11\neconazole... 26\nEDURANT... 44\nefavirenz... 44\nefavirenz-emtricitabin-tenofov... 44\nefavirenz-lamivu-tenofov disop... 44\nEGRIFTA SV... 73\nelectrolyte-48 in d5w... 66\nELELYSO... 71\nELIGARD (3 MONTH)... 81\nELIGARD (4 MONTH)... 81\nELIGARD (6 MONTH)... 81\nELIGARD... 81\nelinest... 75\nELIQUIS DVT-PE TREAT 30D START...  \n51\nELIQUIS... 51\nELLA... 75\nELMIRON... 72\neluryng... 75\nELZONRIS... 31\nEMBRACE PEN NEEDLE... 91EMCYT... 31\nEMGALITY PEN... 27\nEMGALITY SYRINGE... 27\nemoquette... 75\nEMPLICITI... 31\nEMSAM... 23\nemtricitabine... 44\nemtricitabine-tenofovir (tdf)... 44\nEMTRIVA... 44\nenalapril maleate... 55\nenalapril-hydrochlorothiazide... 55\nenalaprilat... 55\nENBREL MINI... 83\nENBREL SURECLICK... 83\nENBREL... 83\nendocet... 11\nENDOMETRIN... 75\nENGERIX-B (PF)... 83\nENGERIX-B PEDIATRIC (PF)... 83\nENHERTU... 31\nenoxaparin... 51\nenpresse... 75\nenskyce... 75\nENSTILAR... 63\nentacapone... 40\nentecavir... 44\nENTRESTO... 55\nenulose... 69\nENVARSUS XR... 83\nEPCLUSA... 44\nEPIDIOLEX... 20\nepinephrine... 102\nepirubicin... 31", "doc_id": "604655b7-0d62-4221-b227-0de177954e6d", "embedding": null, "doc_hash": "2d8561ab2909e0ffcf1da9621279cf09dc717f929680a5f84452761b2cfeb6de", "extra_info": {"page_label": "113", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2130, "_node_type": "1"}, "relationships": {"1": "4edd867b-07ef-4a38-87a3-ecbd0fc17685"}}, "__type__": "1"}, "06e46a1a-005a-48aa-a3dd-4d26f27bb302": {"__data__": {"text": "114 - 2023 HUMANA FORMULARY UPDATED 06/2023epitol... 20\nEPIVIR HBV... 44\nEPKINLY... 31\nepoprostenol (glycine)... 102\nEPRONTIA... 27\nERBITUX... 31\nergotamine-caffeine... 27\nERIVEDGE... 31\nERLEADA... 31\nerlotinib... 31\nerrin... 75\nertapenem... 17\nERWINAZE... 31\nery pads... 63\nERYTHROCIN... 17\nerythromycin lactobionate... 17\nerythromycin with ethanol... 63\nerythromycin... 17, 99\nescitalopram oxalate... 23, 24\nesomeprazole magnesium... 69\nestradiol valerate... 75\nestradiol... 75\nestradiol-norethindrone acet... 75\nESTRING... 75\nethacrynate sodium... 55\nethambutol... 28\nethosuximide... 20\nethynodiol diac-eth estradiol... 75\netodolac... 11\netonogestrel-ethinyl estradiol... 75\nETOPOPHOS... 31\netoposide... 31\netravirine... 44EULEXIN... 31\nEUTHYROX... 80\neverolimus (antineoplastic)... 31\neverolimus (immunosuppressive)...  \n83\nEVOMELA... 31\nEVOTAZ... 44\nEXEL INSULIN... 91\nexemestane... 31\nEXKIVITY... 31\nEYSUVIS... 99\nezetimibe... 55\nezetimibe-simvastatin... 55\nF\nfalmina (28)... 75\nfamciclovir... 44\nfamotidine (pf)... 69\nfamotidine (pf)-nacl  (iso-os)... 70\nfamotidine... 69\nFANAPT... 41\nFARXIGA... 48\nFASENRA PEN... 102\nfelbamate... 20\nfelodipine... 55\nfemynor... 75\nfenofibrate micronized... 55\nfenofibrate nanocrystallized... 55\nfenofibrate... 55\nfenofibric acid... 55\nfentanyl citrate (pf)... 11\nfentanyl citrate... 11\nfentanyl... 11\nfesoterodine... 72FETZIMA... 24\nFIASP FLEXTOUCH U-100 INSULIN...  \n48\nFIASP PENFILL U-100 INSULIN... 48\nFIASP U-100 INSULIN... 48\nfinasteride... 72\nfingolimod... 61\nFINTEPLA... 20\nFIRDAPSE... 61\nFIRMAGON KIT W DILUENT  \nSYRINGE... 81\nFIRMAGON... 81\nflecainide... 55\nFLOVENT DISKUS... 102\nFLOVENT HFA... 102\nfloxuridine... 31\nfluconazole in nacl (iso-osm)... 26\nfluconazole... 26\nflucytosine... 26\nfludarabine... 31\nfludrocortisone... 72\nflumazenil... 92\nflunisolide... 102\nfluocinolone acetonide oil... 101\nfluocinolone and shower cap... 63\nfluocinolone... 63\nfluocinonide... 63\nfluocinonide-e... 63\nfluocinonide-emollient... 63\nfluorometholone... 99\nfluorouracil... 31, 63\nfluoxetine... 24\nfluphenazine decanoate... 41", "doc_id": "06e46a1a-005a-48aa-a3dd-4d26f27bb302", "embedding": null, "doc_hash": "141ff60c4732fef99c17c432bf4c484a81bdcc69624bb974c2f003c164ae4a77", "extra_info": {"page_label": "114", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2061, "_node_type": "1"}, "relationships": {"1": "c2bc3153-203f-42a6-8202-fca086edafa1"}}, "__type__": "1"}, "5b11a152-14b4-4c01-a345-bfd97e311ad3": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 115fluphenazine hcl... 41\nflurbiprofen sodium... 99\nflurbiprofen... 11\nflutamide... 32\nfluticasone propion-salmeterol...  \n103\nfluticasone propionate... 63, 103\nfluvastatin... 55\nfluvoxamine... 24\nFOLOTYN... 32\nformoterol fumarate... 103\nFORTEO... 87\nfosamprenavir... 44\nfosinopril... 55\nfosinopril-hydrochlorothiazide... 55\nfosphenytoin... 20\nFOTIVDA... 32\nFREAMINE III 10 %... 66\nFREESTYLE PRECISION... 92\nFULPHILA... 51\nfulvestrant... 32\nfurosemide... 55\nFUZEON... 44\nFYARRO... 32\nFYCOMPA... 20\nG\ngabapentin... 20\ngalantamine... 22, 23\nGAMUNEX-C... 83\nGARDASIL 9 (PF)... 83\ngatifloxacin... 99\nGATTEX ONE-VIAL... 70\nGATTEX 30-VIAL... 70GAUZE BANDAGE... 92\nGAUZE PAD... 92\ngavilyte-c... 70\ngavilyte-g... 70\ngavilyte-n... 70\nGAVRETO... 32\nGAZYVA... 32\ngefitinib... 32\ngemcitabine... 32\ngemfibrozil... 55\nGEMTESA... 72\ngenerlac... 70\ngengraf... 83\ngentak... 99\ngentamicin in nacl (iso-osm)... 17\ngentamicin sulfate (ped) (pf)... 17\ngentamicin sulfate (pf)... 17\ngentamicin... 17, 99\nGENVOYA... 44\nGILENYA... 61\nGILOTRIF... 32\nglatiramer... 61\nglatopa... 61\nGLEOSTINE... 32\nglimepiride... 48\nglipizide... 48\nglipizide-metformin... 48\nGLUCAGEN HYPOKIT... 48\nglyburide micronized... 48\nglyburide... 48\nglyburide-metformin... 48\nGLYCOPHOS... 66\nglycopyrrolate... 70GLYXAMBI... 48\ngranisetron (pf)... 25\ngranisetron hcl... 25\ngriseofulvin microsize... 26\ngriseofulvin ultramicrosize... 26\nguanfacine... 55, 61\nGVOKE HYPOPEN 1-PACK... 48\nGVOKE HYPOPEN 2-PACK... 48\nGVOKE PFS 1-PACK SYRINGE... 49\nGVOKE PFS 2-PACK SYRINGE... 49\nGVOKE... 48\nH\nHAEGARDA... 83\nhailey fe 1.5/30 (28)... 76\nhailey fe 1/20 (28)... 76\nhailey 24 fe... 75\nhailey... 75\nHALAVEN... 32\nhaloette... 76\nhaloperidol decanoate... 41\nhaloperidol lactate... 41\nhaloperidol... 41\nHARVONI... 45\nHAVRIX (PF)... 83\nHEALTHWISE INSULIN SYRINGE... 92\nHEALTHWISE PEN NEEDLE... 92\nHEALTHY ACCENTS UNIFINE  \nPENTIP... 92\nheather... 76\nHECTOROL... 87\nheparin (porcine)... 51\nheparin, porcine (pf)... 51\nHEPLISAV-B (PF)... 83", "doc_id": "5b11a152-14b4-4c01-a345-bfd97e311ad3", "embedding": null, "doc_hash": "ee175f7a2ddd93062d6cade822d19e52b9dc80cde3ab995844cfe826575d8a01", "extra_info": {"page_label": "115", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2010, "_node_type": "1"}, "relationships": {"1": "dbe65b41-b652-42a1-b66f-80d2f8df2bea"}}, "__type__": "1"}, "1d0bfbda-8793-46af-89ed-49365740d75c": {"__data__": {"text": "116 - 2023 HUMANA FORMULARY UPDATED 06/2023HETLIOZ LQ... 105\nHETLIOZ... 105\nHIBERIX (PF)... 83\nHUMIRA PEN CROHNS-UC-HS  \nSTART... 84\nHUMIRA PEN PSOR-UVEITS-ADOL  \nHS... 84\nHUMIRA PEN... 84\nHUMIRA... 83\nHUMIRA(CF) PEDI CROHNS  \nSTARTER... 84\nHUMIRA(CF) PEN CROHNS-UC-HS...  \n84\nHUMIRA(CF) PEN PEDIATRIC UC... 84\nHUMIRA(CF) PEN PSOR-UV-ADOL  \nHS... 84\nHUMIRA(CF) PEN... 84\nHUMIRA(CF)... 84\nHUMULIN R U-500 (CONC)  \nINSULIN... 49\nHUMULIN R U-500 (CONC)  \nKWIKPEN... 49\nhydralazine... 56\nhydrochlorothiazide... 56\nhydrocodone-acetaminophen... 11\nhydrocodone-ibuprofen... 12\nhydrocortisone... 63, 87\nhydrocortisone-acetic acid... 101\nhydromorphone... 12\nhydroxychloroquine... 39\nhydroxyurea... 32\nhydroxyzine hcl... 48\nhydroxyzine pamoate... 103\nHYFTOR... 63\nIibandronate... 87\nIBRANCE... 32\nibu... 12\nibuprofen... 12\nibutilide fumarate... 56\nicatibant... 84\niclevia... 76\nICLUSIG... 32\nidarubicin... 32\nIDHIFA... 32\nifosfamide... 32\nILEVRO... 99\nimatinib... 32\nIMBRUVICA... 32\nIMFINZI... 32\nimipenem-cilastatin... 17\nimipramine hcl... 24\nimipramine pamoate... 24\nimiquimod... 63\nIMJUDO... 32\nIMLYGIC... 32\nIMOVAX RABIES VACCINE (PF)... 84\nincassia... 76\nINCONTROL ALCOHOL PADS... 92\nINCONTROL PEN NEEDLE... 92\nINCRELEX... 73\nindapamide... 56\nindomethacin... 12\nINFANRIX (DTAP) (PF)... 84\nINGREZZA INITIATION PACK... 61\nINGREZZA... 61\nINLYTA... 32\nINQOVI... 33INREBIC... 33\nINSULIN SYR/NDL U100 HALF  \nMARK... 92\nINSULIN SYRINGE MICROFINE... 92\nINSULIN SYRINGE NEEDLELESS... 92\nINSULIN SYRINGE... 92\nINSULIN SYRINGE-NEEDLE U-100...  \n92\nINSUPEN PEN NEEDLE... 92\nINTELENCE... 45\nINTRALIPID... 66\nINTRON A... 84\nINVEGA HAFYERA... 41\nINVEGA SUSTENNA... 41\nINVEGA TRINZA... 41\nINVIRASE... 45\nINVOKAMET XR... 49\nINVOKAMET... 49\nINVOKANA... 49\nIONOSOL-B IN D5W... 66\nIONOSOL-MB IN D5W... 66\nIPOL... 84\nipratropium bromide... 103\nipratropium-albuterol... 103\nirbesartan... 56\nirbesartan-hydrochlorothiazide... 56\nIRESSA... 33\nirinotecan... 33\nISENTRESS HD... 45\nISENTRESS... 45\nisibloom... 76\nISOLYTE S PH 7.4... 66\nISOLYTE-P IN 5 % DEXTROSE... 66", "doc_id": "1d0bfbda-8793-46af-89ed-49365740d75c", "embedding": null, "doc_hash": "697509a1f043a77777edd9d090fba4447bf3f195a65d4aca2a5095c8fa376481", "extra_info": {"page_label": "116", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2035, "_node_type": "1"}, "relationships": {"1": "03dcbde7-5230-4348-b9cc-d12d81a2c869"}}, "__type__": "1"}, "c6fe0850-3b74-4552-9f9a-7de5d4825168": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 117ISOLYTE-S... 66\nisoniazid... 28\nisosorbide dinitrate... 56\nisosorbide mononitrate... 56\nisotretinoin... 63\nisradipine... 56\nISTODAX... 33\nISUPREL... 56\nitraconazole... 26\nIV PREP WIPES... 92\nivermectin... 39\nIXEMPRA... 33\nIXIARO (PF)... 84\nJ\njaimiess... 76\nJAKAFI... 33\njantoven... 51\nJANUMET XR... 49\nJANUMET... 49\nJANUVIA... 49\nJARDIANCE... 49\njasmiel (28)... 76\njavygtor... 71\nJAYPIRCA... 33\nJEMPERLI... 33\njencycla... 76\nJENTADUETO XR... 49\nJENTADUETO... 49\nJEVTANA... 33\njuleber... 76\nJULUCA... 45\njunel fe 1.5/30 (28)... 76\njunel fe 1/20 (28)... 76junel fe 24... 76\njunel 1.5/30 (21)... 76\njunel 1/20 (21)... 76\nK\nK-TAB... 66\nKABIVEN... 66\nKADCYLA... 33\nkalliga... 76\nKALYDECO... 103\nKANJINTI... 33\nkariva (28)... 76\nkelnor 1-50 (28)... 76\nkelnor 1/35 (28)... 76\nKERENDIA... 56\nKESIMPTA PEN... 61\nketoconazole... 26\nketorolac... 12, 99, 100\nKEVZARA... 84\nKEYTRUDA... 33\nKIMMTRAK... 33\nKINRIX (PF)... 84\nKISQALI FEMARA CO-PACK... 33\nKISQALI... 33\nklor-con m10... 66\nKLOR-CON M15... 66\nklor-con m20... 66\nKLOR-CON 10... 66\nKLOR-CON 8... 66\nKOMBIGLYZE XR... 49\nKORLYM... 92\nKOSELUGO... 33\nKRAZATI... 33\nKRINTAFEL... 39kurvelo (28)... 76\nKYNMOBI... 40\nKYPROLIS... 33\nL\nl norgest/e.estradiol-e.estrad... 76\nlabetalol... 56\nlacosamide... 20\nlactated ringers... 66, 92\nlactulose... 70\nLAGEVRIO (EUA)... 92\nlamivudine... 45\nlamivudine-zidovudine... 45\nlamotrigine... 20, 21\nLAMPIT... 39\nlanreotide... 81\nlansoprazole... 70\nLANTUS SOLOSTAR U-100 INSULIN...  \n49\nLANTUS U-100 INSULIN... 49\nlapatinib... 33\nlarin fe 1.5/30 (28)... 76\nlarin fe 1/20 (28)... 76\nlarin 1.5/30 (21)... 76\nlarin 1/20 (21)... 76\nlarin 24 fe... 76\nlarissia... 76\nlatanoprost... 100\nLATUDA... 41, 42\nledipasvir-sofosbuvir... 45\nleena 28... 76\nleflunomide... 84\nlenalidomide... 33\nLENVIMA... 33", "doc_id": "c6fe0850-3b74-4552-9f9a-7de5d4825168", "embedding": null, "doc_hash": "aac31eb4309d2b3842a361c95fd11a00bafce0e35e8f644b9de663749a3ef2b3", "extra_info": {"page_label": "117", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 1805, "_node_type": "1"}, "relationships": {"1": "a9c12691-0f49-4d17-b40f-a8efcdbb586c"}}, "__type__": "1"}, "c50edbac-8c36-4ea9-8a81-dd288b1d4422": {"__data__": {"text": "118 - 2023 HUMANA FORMULARY UPDATED 06/2023lessina... 76\nletrozole... 33\nleucovorin calcium... 33, 34\nLEUKERAN... 34\nleuprolide (3 month)... 81\nleuprolide... 81\nlevalbuterol tartrate... 103\nLEVEMIR FLEXPEN... 49\nLEVEMIR FLEXTOUCH U100  \nINSULIN... 49\nLEVEMIR U-100 INSULIN... 49\nlevetiracetam in nacl (iso-os)... 21\nlevetiracetam... 21\nLEVO-T... 80\nlevobunolol... 100\nlevocarnitine (with sugar)... 67\nlevocarnitine... 66\nlevocetirizine... 103\nlevofloxacin in d5w... 17\nlevofloxacin... 17\nlevoleucovorin calcium... 34\nlevonest (28)... 76\nlevonorg-eth estrad triphasic... 76\nlevonorgestrel-ethinyl estrad... 76,  \n77\nlevora-28... 77\nlevothyroxine... 80\nLEVOXYL... 80\nLEVULAN... 34\nLEXIVA... 45\nLIBTAYO... 34\nlidocaine  (pf) in d7.5w... 13\nlidocaine (pf)... 56\nlidocaine hcl... 13lidocaine in 5 % dextrose (pf)... 56\nlidocaine viscous... 13\nlidocaine... 13\nlidocaine-epinephrine... 13\nlidocaine-prilocaine... 13\nlillow (28)... 77\nlincomycin... 17\nlindane... 63\nlinezolid in dextrose 5%... 17\nlinezolid... 17\nlinezolid-0.9% sodium chloride... 17\nLINZESS... 70\nliothyronine... 80\nLIPOFEN... 56\nlisinopril... 56\nlisinopril-hydrochlorothiazide... 56\nLITE TOUCH INSULIN PEN NEEDLES...  \n93\nLITE TOUCH INSULIN SYRINGE... 93\nlithium carbonate... 48\nLITHOSTAT... 93\nlo-zumandimine (28)... 77\nLOCOID LIPOCREAM... 63\nLOESTRIN FE 1.5/30 (28-DAY)... 77\nLOESTRIN FE 1/20 (28-DAY)... 77\nLOESTRIN 1.5/30 (21)... 77\nLOESTRIN 1/20 (21)... 77\nlojaimiess... 77\nLONSURF... 34\nloperamide... 70\nlopinavir-ritonavir... 45\nlorazepam intensol... 48\nlorazepam... 48LORBRENA... 34\nloryna (28)... 77\nlosartan... 56\nlosartan-hydrochlorothiazide... 56\nLOTEMAX SM... 100\nlovastatin... 56\nlow-ogestrel (28)... 77\nloxapine succinate... 42\nLUMAKRAS... 34\nLUMIGAN... 100\nLUMOXITI... 34\nLUNSUMIO... 34\nLUPRON DEPOT (3 MONTH)... 81\nLUPRON DEPOT (4 MONTH)... 81\nLUPRON DEPOT (6 MONTH)... 81\nLUPRON DEPOT... 81\nLUPRON DEPOT-PED (3 MONTH)... 81\nLUPRON DEPOT-PED... 81\nlurasidone... 42\nlutera (28)... 77\nLYBALVI... 42\nlyleq... 77\nlyllana... 77\nLYNPARZA... 34\nLYSODREN... 81\nLYTGOBI... 34\nlyza... 77\nM\nM-M-R II (PF)... 84\nm-natal plus... 67\nMAGELLAN INSULIN SAFETY  \nSYRNG... 93\nMAGELLAN SYRINGE... 93", "doc_id": "c50edbac-8c36-4ea9-8a81-dd288b1d4422", "embedding": null, "doc_hash": "aaa3716edb4bfea81bdd847d692622d4c85aa52f2ba5e00893a0864e2f9fb8c4", "extra_info": {"page_label": "118", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2156, "_node_type": "1"}, "relationships": {"1": "b3760952-ea5a-4bb5-be63-bdd7ade742ec"}}, "__type__": "1"}, "5e2a3730-bd5f-4011-a5d9-32fc82184426": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 119magnesium sulfate in d5w... 67\nmagnesium sulfate in water... 67\nmagnesium sulfate... 67\nmalathion... 63\nmannitol 10 %... 56\nmannitol 20 %... 56\nmannitol 25 %... 57\nmannitol 5 %... 57\nmaraviroc... 45\nMARGENZA... 34\nmarlissa (28)... 77\nMARPLAN... 24\nMATULANE... 34\nMAXI-COMFORT INSULIN SYRINGE...  \n93\nMAXICOMFORT II PEN NEEDLE... 93\nMAXICOMFORT INSULIN SYRINGE...  \n93\nMAXICOMFORT SAFETY PEN  \nNEEDLE... 93\nmeclizine... 25\nmedroxyprogesterone... 77\nmefloquine... 39\nmegestrol... 77\nMEKINIST... 34\nMEKTOVI... 34\nmeloxicam... 12\nmelphalan hcl... 34\nmelphalan... 34\nmemantine... 23\nMENACTRA (PF)... 84\nMENEST... 77\nMENQUADFI (PF)... 84\nMENVEO A-C-Y-W-135-DIP (PF)... 84mercaptopurine... 34\nmeropenem... 17\nmeropenem-0.9% sodium  \nchloride... 17\nmesalamine... 87\nMESNEX... 34\nmetformin... 49\nmethadone intensol... 12\nmethadone... 12\nmethazolamide... 57\nmethenamine hippurate... 17\nmethimazole... 82\nmethocarbamol... 104\nmethotrexate sodium (pf)... 84\nmethotrexate sodium... 84\nmethoxsalen... 64\nmethscopolamine... 70\nmethsuximide... 21\nmethyldopa... 57\nmethyldopa-hydrochlorothiazide...  \n57\nmethylphenidate hcl... 61\nmethylprednisolone acetate... 72\nmethylprednisolone sodium succ...  \n73\nmethylprednisolone... 72\nmetipranolol... 100\nmetoclopramide hcl... 25\nmetolazone... 57\nmetoprolol succinate... 57\nmetoprolol ta-hydrochlorothiaz...  \n57\nmetoprolol tartrate... 57\nmetronidazole in nacl (iso-os)... 18metronidazole... 18\nmetyrosine... 57\nmicafungin... 26\nmiconazole-3... 26\nMICRODOT INSULIN PEN NEEDLE...  \n93\nmicrogestin fe 1.5/30 (28)... 77\nmicrogestin fe 1/20 (28)... 77\nmicrogestin 1.5/30 (21)... 77\nmicrogestin 1/20 (21)... 77\nmicrogestin 24 fe... 77\nmidodrine... 57\nmili... 77\nmimvey... 77\nMINI ULTRA-THIN II... 93\nminocycline... 18\nminoxidil... 57\nMIRCETTE (28)... 77\nmirtazapine... 24\nmisoprostol... 70\nMITIGARE... 27\nmitomycin... 34\nmitoxantrone... 34\nmodafinil... 105\nmoexipril... 57\nmolindone... 42\nmometasone... 64, 103\nmondoxyne nl... 18\nMONJUVI... 84\nmono-linyah... 77\nMONOJECT INSULIN SAFETY  \nSYRING... 93\nMONOJECT INSULIN SYRINGE... 93", "doc_id": "5e2a3730-bd5f-4011-a5d9-32fc82184426", "embedding": null, "doc_hash": "6cf25fe40e893ca250196f888f8d5e62603ba14cd5f45ce4309031ec0588f230", "extra_info": {"page_label": "119", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2094, "_node_type": "1"}, "relationships": {"1": "7370cdec-6d94-46a0-85f0-fc81472b53f2"}}, "__type__": "1"}, "3ee580ab-4408-4249-8840-4b9dedc31146": {"__data__": {"text": "120 - 2023 HUMANA FORMULARY UPDATED 06/2023MONOJECT SYRINGE... 93\nMONOJECT ULTRA COMFORT  \nINSULIN... 93\nmontelukast... 103\nmorphine concentrate... 12\nmorphine... 12\nMOUNJARO... 49\nMOVANTIK... 70\nmoxifloxacin... 18, 100\nMOZOBIL... 51\nMULTAQ... 57\nmupirocin... 64\nMUTAMYCIN... 34\nMVASI... 34\nMYALEPT... 70\nmycophenolate mofetil (hcl)... 85\nmycophenolate mofetil... 85\nmycophenolate sodium... 85\nMYFORTIC... 85\nMYLOTARG... 34\nmyorisan... 64\nMYRBETRIQ... 72\nN\nnabumetone... 12\nnadolol... 57\nnafcillin in dextrose iso-osm... 18\nnafcillin... 18\nnalmefene... 14\nnaloxone... 14\nnaltrexone... 14\nNAMZARIC... 23\nnaproxen sodium... 12, 13\nnaproxen... 12naratriptan... 27\nNATACYN... 100\nNATAZIA... 77\nnateglinide... 49\nNATPARA... 87\nNAYZILAM... 21\nnebivolol... 57\nNEBUPENT... 39\nnecon 0.5/35 (28)... 77\nnefazodone... 24\nnelarabine... 34\nneo-polycin hc... 100\nneo-polycin... 100\nneomycin... 18\nneomycin-bacitracin-poly-hc... 100\nneomycin-bacitracin-polymyxin...  \n100\nneomycin-polymyxin b-dexameth...  \n100\nneomycin-polymyxin-gramicidin...  \n100\nneomycin-polymyxin-hc... 100, 101\nNEONATAL COMPLETE... 67\nNEONATAL PLUS VITAMIN... 67\nNEONATAL-DHA... 67\nNERLYNX... 34\nNEULASTA ONPRO... 52\nNEULASTA... 52\nnevirapine... 45\nNEXLETOL... 57\nNEXLIZET... 57\nNEXTERONE... 57\nniacin... 57\nniacor... 57NICOTROL NS... 14\nnifedipine... 57\nnikki (28)... 78\nnilutamide... 34\nnimodipine... 57\nNINLARO... 35\nNIPENT... 35\nnisoldipine... 57\nnitazoxanide... 39\nnitisinone... 71\nnitrofurantoin macrocrystal... 18\nnitrofurantoin monohyd/m-cryst...  \n18\nnitroglycerin in 5 % dextrose... 58\nnitroglycerin... 57, 58\nNITROSTAT... 58\nNIVESTYM... 52\nnizatidine... 70\nnora-be... 78\nnorepinephrine bitartrate... 58\nnoreth-ethinyl estradiol-iron... 78\nnorethindrone (contraceptive)... 78\nnorethindrone ac-eth estradiol... 78\nnorethindrone acetate... 78\nnorethindrone-e.estradiol-iron... 78\nnorgestimate-ethinyl estradiol... 78\nnorlyda... 78\nNORMOSOL-M IN 5 % DEXTROSE...  \n67\nNORMOSOL-R IN 5 % DEXTROSE... 67\nNORMOSOL-R PH 7.4... 67\nNORMOSOL-R... 67\nnortrel 0.5/35 (28)... 78", "doc_id": "3ee580ab-4408-4249-8840-4b9dedc31146", "embedding": null, "doc_hash": "0a89a79ce0be5b66e5b9c48a0485938e7d98e5f39d2d253dee2ae065560e96bf", "extra_info": {"page_label": "120", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2030, "_node_type": "1"}, "relationships": {"1": "1f20a2be-1257-4db8-939c-e0438e0a8452"}}, "__type__": "1"}, "349027d5-7bf3-4277-a3e4-d7b66eaeebb2": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 121nortrel 1/35 (21)... 78\nnortrel 1/35 (28)... 78\nnortrel 7/7/7 (28)... 78\nnortriptyline... 24\nNORVIR... 45\nNOVOFINE AUTOCOVER... 93\nNOVOFINE PLUS... 93\nNOVOFINE 32... 93\nNOVOLIN N FLEXPEN... 50\nNOVOLIN N NPH U-100 INSULIN...  \n50\nNOVOLIN R FLEXPEN... 50\nNOVOLIN R REGULAR U-100  \nINSULN... 50\nNOVOLIN 70-30 FLEXPEN U-100...  \n49\nNOVOLIN 70/30 U-100 INSULIN...  \n49\nNOVOLOG FLEXPEN U-100  \nINSULIN... 50\nNOVOLOG MIX 70-30 U-100  \nINSULN... 50\nNOVOLOG MIX 70-30FLEXPEN  \nU-100... 50\nNOVOLOG PENFILL U-100 INSULIN...  \n50\nNOVOLOG U-100 INSULIN ASPART...  \n50\nNOVOPEN ECHO... 93\nNOVOTWIST... 93\nNOXAFIL... 26, 27\nNUBEQA... 35\nNUCALA... 103\nNUEDEXTA... 61\nNUPLAZID... 42\nNUTRILIPID... 67NUZYRA... 18\nnyamyc... 27\nnylia 1/35 (28)... 78\nnylia 7/7/7 (28)... 78\nnymyo... 78\nnystatin... 27\nnystatin-triamcinolone... 27\nnystop... 27\nO\nO-CAL PRENATAL... 67\nocella... 78\noctreotide acetate... 81\nODEFSEY... 45\nODOMZO... 35\nOFEV... 103\nofloxacin... 18, 100, 101\nolanzapine... 42\nolmesartan... 58\nolmesartan-amlodipin-hcthiazid...  \n58\nolmesartan-hydrochlorothiazide...  \n58\nolopatadine... 100\nomega-3 acid ethyl esters... 58\nomeprazole... 70\nOMNIPOD CLASSIC PODS (GEN 3)...  \n94\nOMNIPOD DASH INTRO KIT (GEN 4)...  \n94\nOMNIPOD DASH PODS (GEN 4)... 94\nOMNIPOD GO PODS 10 UNITS/DAY...  \n94\nOMNIPOD GO PODS 15 UNITS/DAY...  \n94OMNIPOD GO PODS 20 UNITS/DAY...  \n94\nOMNIPOD GO PODS 25 UNITS/DAY...  \n94\nOMNIPOD GO PODS 30 UNITS/DAY...  \n94\nOMNIPOD GO PODS 40 UNITS/DAY...  \n94\nOMNIPOD GO PODS... 94\nOMNIPOD 5 G6 INTRO KIT (GEN 5)...  \n93\nOMNIPOD 5 G6 PODS (GEN 5)... 94\nOMNITROPE... 73\nONCASPAR... 35\nondansetron hcl (pf)... 25\nondansetron hcl... 25\nondansetron... 25\nONGLYZA... 50\nONIVYDE... 35\nONUREG... 35\nOPDIVO... 35\nOPDUALAG... 35\nOPSUMIT... 103\noralone... 61\nORBACTIV... 18\nORGOVYX... 81\nORKAMBI... 103\nORSERDU... 35\norsythia... 78\nORTHO-NOVUM 7/7/7 (28)... 78\noseltamivir... 45\nOSMITROL 10 %... 58\nOSMITROL 15 %... 58\nOSMITROL 20 %... 58", "doc_id": "349027d5-7bf3-4277-a3e4-d7b66eaeebb2", "embedding": null, "doc_hash": "90a231f47090a50f12d73e1b5331428dc1f7623d232b2c4537c61e96e1c0f780", "extra_info": {"page_label": "121", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 1967, "_node_type": "1"}, "relationships": {"1": "086aee2b-5764-459f-86c5-ca72ef3a6dc5"}}, "__type__": "1"}, "1ac83e14-53c6-41c4-81da-2b5b86053aa9": {"__data__": {"text": "122 - 2023 HUMANA FORMULARY UPDATED 06/2023OSMITROL 5 %... 58\nOSPHENA... 78\nOTEZLA STARTER... 64\nOTEZLA... 64\noxacillin in dextrose(iso-osm)... 18\noxacillin... 18\noxaliplatin... 35\noxandrolone... 78\noxazepam... 48\noxcarbazepine... 21\noxybutynin chloride... 72\noxycodone... 13\noxycodone-acetaminophen... 13\noxycodone-aspirin... 13\nOZEMPIC... 50\nP\nPACERONE... 58\npaclitaxel protein-bound... 35\npaclitaxel... 35\nPADCEV... 35\npaliperidone... 42\npamidronate... 87\nPANRETIN... 35\npantoprazole... 70\nparaplatin... 35\nparicalcitol... 87\nparoex oral rinse... 61\nparomomycin... 18\nparoxetine hcl... 24\nPASER... 28\nPAXIL... 24\nPAXLOVID... 94\nPEDIARIX (PF)... 85PEDVAX HIB (PF)... 85\npeg 3350-electrolytes... 70\npeg-electrolyte soln... 70\nPEGASYS... 85\nPEMAZYRE... 35\npemetrexed disodium... 35\npemetrexed... 35\nPEN NEEDLE... 94\nPEN NEEDLE, DIABETIC... 94\nPEN NEEDLE, DIABETIC, SAFETY... 94\npenicillamine... 67\npenicillin g pot in dextrose... 18\npenicillin g potassium... 18\npenicillin g procaine... 18\npenicillin g sodium... 18\npenicillin v potassium... 18\nPENTACEL (PF)... 85\nPENTAM... 39\npentamidine... 39\nPENTIPS... 94\npentoxifylline... 58\nPERFOROMIST... 103\nPERIKABIVEN... 67\nperindopril erbumine... 58\nperiogard... 61\nPERJETA... 35\npermethrin... 64\nperphenazine... 42\nperphenazine-amitriptyline... 24\nPERSERIS... 42\npfizerpen-g... 18\nphenelzine... 24\nphenobarbital... 21PHENYTEK... 21\nphenytoin sodium extended... 21\nphenytoin sodium... 21\nphenytoin... 21\nphilith... 78\nPHOSPHOLINE IODIDE... 100\nPHYSIOLYTE... 94\nPHYSIOSOL IRRIGATION... 94\nPIFELTRO... 45\npilocarpine hcl... 62, 100\npimecrolimus... 64\npimozide... 42\npimtrea (28)... 78\npioglitazone... 50\npioglitazone-metformin... 50\nPIP PEN NEEDLE... 94\npiperacillin-tazobactam... 18\nPIQRAY... 35\npirfenidone... 103\npirmella... 78\npiroxicam... 13\nPLASMA-LYTE A... 67\nPLASMA-LYTE 148... 67\nPLENAMINE... 67\npodofilox... 64\nPOLIVY... 35\npolocaine... 13\npolocaine-mpf... 14\npolycin... 100\npolymyxin b sulf-trimethoprim...  \n100\npolymyxin b sulfate... 18\nPOMALYST... 35", "doc_id": "1ac83e14-53c6-41c4-81da-2b5b86053aa9", "embedding": null, "doc_hash": "777d89d8b57757921df916afa2580e13a9766af56b63bccf59ff318c7e9e361a", "extra_info": {"page_label": "122", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2007, "_node_type": "1"}, "relationships": {"1": "5738874c-275f-4dc2-b1bf-29b05a8e6e86"}}, "__type__": "1"}, "e2185805-90e5-41d5-937c-67aa9bdc48b1": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 123portia 28... 78\nPORTRAZZA... 35\nposaconazole... 27\npotassium acetate... 67\npotassium chlorid-d5-0.45%nacl...  \n67\npotassium chloride in lr-d5... 68\npotassium chloride in water... 68\npotassium chloride in 0.9%nacl... 67\npotassium chloride in 5 % dex... 68\npotassium chloride... 67\npotassium chloride-d5-0.2%nacl...  \n68\npotassium chloride-d5-0.3%nacl...  \n68\npotassium chloride-d5-0.9%nacl...  \n68\npotassium chloride-0.45 % nacl...  \n68\npotassium citrate... 68\nPOTELIGEO... 35\npr natal 400 ec... 68\npr natal 400... 68\npr natal 430 ec... 68\npr natal 430... 68\nPRADAXA... 52\npramipexole... 40\nprasugrel... 52\npravastatin... 58\npraziquantel... 39\nprazosin... 58\nPRED-G... 100\nprednisolone acetate... 100\nprednisolone sodium phosphate...  \n73, 100prednisolone... 73\nprednisone intensol... 73\nprednisone... 73\npregabalin... 61\nPREHEVBRIO (PF)... 85\nPREMARIN... 78\nPREMASOL 10 %... 68\nPRENATA... 68\nPRENATABS FA... 68\nprenatal plus (calcium carb)... 68\nprenatal plus vitamin-mineral... 68\nPRENATE ELITE... 68\npreplus... 68\nprevalite... 58\nPREVENT DROPSAFE PEN NEEDLE...  \n94\nprevifem... 78\nPREVYMIS... 46\nPREZCOBIX... 46\nPREZISTA... 46\nPRIFTIN... 28\nprimaquine... 39\nprimidone... 21\nPRIMSOL... 18\nPRIORIX (PF)... 85\nPRO COMFORT ALCOHOL PADS... 94\nPRO COMFORT INSULIN SYRINGE...  \n94\nPRO COMFORT PEN NEEDLE... 94\nprobenecid... 27\nprobenecid-colchicine... 27\nprocainamide... 58\nPROCALAMINE 3%... 68prochlorperazine edisylate... 25\nprochlorperazine maleate... 25\nprochlorperazine... 25\nPROCRIT... 52\nprocto-med hc... 64\nproctosol hc... 64\nproctozone-hc... 64\nPRODIGY INSULIN SYRINGE... 94\nprogesterone micronized... 78\nprogesterone... 78\nPROGRAF... 85\nPROLASTIN-C... 71\nPROLEUKIN... 35\nPROLIA... 87\nPROMACTA... 52\npromethazine... 25\npropafenone... 58\nproparacaine... 100\npropranolol... 58\npropranolol-hydrochlorothiazid... 59\npropylthiouracil... 82\nPROQUAD (PF)... 85\nPROSOL 20 %... 68\nprotamine... 95\nprotriptyline... 24\nPULMOZYME... 103\nPURE COMFORT ALCOHOL PADS... 95\nPURE COMFORT PEN NEEDLE... 95\nPURIXAN... 36\nPYLERA... 70\npyrazinamide... 28\npyridostigmine bromide... 28\npyrimethamine... 39", "doc_id": "e2185805-90e5-41d5-937c-67aa9bdc48b1", "embedding": null, "doc_hash": "afad27d5be999e13926e31aba4d6e3f83ed807f168bb6ff6a0971a3bb4d8b971", "extra_info": {"page_label": "123", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2128, "_node_type": "1"}, "relationships": {"1": "035495cf-4948-4143-b4b6-d03afb4f6144"}}, "__type__": "1"}, "1ce7acb2-9e33-4740-9ae0-67558380cd12": {"__data__": {"text": "124 - 2023 HUMANA FORMULARY UPDATED 06/2023PYRUKYND... 52\nQ\nQINLOCK... 36\nQUADRACEL (PF)... 85\nQUARTETTE... 79\nquetiapine... 42\nquinapril... 59\nquinapril-hydrochlorothiazide... 59\nquinidine sulfate... 59\nquinine sulfate... 39\nQULIPTA... 27\nR\nRABAVERT (PF)... 85\nrabeprazole... 70\nraloxifene... 79\nramipril... 59\nranolazine... 59\nrasagiline... 40\nRAYALDEE... 87\nreclipsen (28)... 79\nRECOMBIVAX HB (PF)... 85\nRECTIV... 95\nREGRANEX... 64\nRELENZA DISKHALER... 46\nrepaglinide... 50\nREPATHA PUSHTRONEX... 59\nREPATHA SURECLICK... 59\nREPATHA SYRINGE... 59\nRESTASIS MULTIDOSE... 100\nRESTASIS... 100\nRETACRIT... 52\nRETEVMO... 36\nRETROVIR... 46REVCOVI... 71\nREXULTI... 42\nREYATAZ... 46\nREZLIDHIA... 36\nREZUROCK... 85\nRHOPHYLAC... 85\nRHOPRESSA... 100\nRIABNI... 36\nribavirin... 46, 95\nrifabutin... 28\nrifampin... 28\nriluzole... 61\nrimantadine... 46\nringer's... 68, 95\nRINVOQ... 85\nrisedronate... 87\nRISPERDAL CONSTA... 42\nrisperidone... 42\nritonavir... 46\nrivastigmine tartrate... 23\nrivastigmine... 23\nrivelsa... 79\nrizatriptan... 28\nROCKLATAN... 100\nroflumilast... 103\nromidepsin... 36\nropinirole... 40\nropivacaine (pf)... 14\nrosuvastatin... 59\nROTARIX... 85\nROTATEQ VACCINE... 85\nroweepra xr... 21\nroweepra... 21ROZLYTREK... 36\nRUBRACA... 36\nrufinamide... 21, 22\nRUKOBIA... 46\nRUXIENCE... 36\nRUZURGI... 61\nRYBELSUS... 50\nRYBREVANT... 36\nRYDAPT... 36\nRYLAZE... 36\nRYTARY... 40\nS\nSAFESNAP INSULIN SYRINGE... 95\nSAFETY PEN NEEDLE... 95\nsajazir... 85\nSANCUSO... 25\nSANDIMMUNE... 85\nSANDOSTATIN LAR DEPOT... 81\nSANTYL... 64\nsapropterin... 71\nSARCLISA... 36\nSAVELLA... 61\nSCEMBLIX... 36\nscopolamine base... 25\nse-natal 19 chewable... 68\nSECUADO... 43\nSECURESAFE INSULIN SYRINGE... 95\nSECURESAFE PEN NEEDLE... 95\nselegiline hcl... 40\nselenium sulfide... 64\nSELZENTRY... 46\nsertraline... 24\nsetlakin... 79", "doc_id": "1ce7acb2-9e33-4740-9ae0-67558380cd12", "embedding": null, "doc_hash": "e0a3f97869136bd82d8dce110cedc72671c63877002a920b71641f99e80365f8", "extra_info": {"page_label": "124", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 1787, "_node_type": "1"}, "relationships": {"1": "ae47c3c5-bc95-4cac-b1dc-7a8bf0ff9fce"}}, "__type__": "1"}, "79a3745e-1d78-4ded-996d-b09971c14d6b": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 125sevelamer carbonate... 68\nsharobel... 79\nSHINGRIX (PF)... 85\nSIGNIFOR... 81\nsildenafil (pulm.hypertension)...  \n103, 104\nsildenafil... 106\nsilver sulfadiazine... 64\nSIMBRINZA... 100\nsimliya (28)... 79\nsimpesse... 79\nSIMULECT... 85\nsimvastatin... 59\nsirolimus... 85, 86\nSIRTURO... 28\nSIVEXTRO... 18\nSKY SAFETY PEN NEEDLE... 95\nSKYRIZI... 86\nSLYND... 79\nSMOFLIPID... 68\nsodium benzoate-sod phenylacet...  \n95\nsodium bicarbonate... 68\nsodium chloride 0.45 %... 68\nsodium chloride 0.9 %... 68\nsodium chloride 3 % hypertonic...  \n69\nsodium chloride 5 % hypertonic...  \n69\nsodium chloride... 68, 95\nsodium oxybate... 105\nsodium phenylbutyrate... 71\nsodium phosphate... 69\nsodium polystyrene sulfonate... 69solifenacin... 72\nSOLIQUA 100/33... 50\nSOLTAMOX... 36\nSOLU-MEDROL (PF)... 73\nSOLU-MEDROL... 73\nSOMATULINE DEPOT... 81\nSOMAVERT... 81, 82\nsorafenib... 36\nsorbitol-mannitol... 95\nsorine... 59\nsotalol af... 59\nsotalol... 59\nSPIRIVA RESPIMAT... 104\nSPIRIVA WITH HANDIHALER... 104\nspironolacton-hydrochlorothiaz...  \n59\nspironolactone... 59\nsprintec (28)... 79\nSPRITAM... 22\nSPRYCEL... 36\nSPS (WITH SORBITOL)... 69\nsronyx... 79\nSSD... 64\nstavudine... 46\nSTELARA... 86\nSTIOLTO RESPIMAT... 104\nSTIVARGA... 36\nSTRENSIQ... 71\nstreptomycin... 18\nSTRIBILD... 46\nSTRIVERDI RESPIMAT... 104\nsubvenite starter (blue) kit... 22\nsubvenite starter (green) kit... 22subvenite starter (orange) kit... 22\nsubvenite... 22\nSUCRAID... 71\nsucralfate... 70\nsulfacetamide sodium (acne)... 19\nsulfacetamide sodium... 19, 100\nsulfacetamide-prednisolone... 100\nsulfadiazine... 19\nsulfamethoxazole-trimethoprim...  \n19\nsulfasalazine... 87\nsulindac... 13\nsumatriptan succinate... 28\nsumatriptan... 28\nsunitinib malate... 36\nSUNLENCA... 46\nSUPRAX... 19\nSURE COMFORT ALCOHOL PREP  \nPADS... 95\nSURE COMFORT INS. SYR. U-100... 95\nSURE COMFORT INSULIN SYRINGE...  \n95\nSURE COMFORT PEN NEEDLE... 95\nSURE COMFORT SAFETY PEN  \nNEEDLE... 95\nSURE-FINE PEN NEEDLES... 95\nSURE-JECT INSULIN SYRINGE... 95\nSURE-PREP ALCOHOL PREP PADS...  \n95\nsyeda... 79\nSYLVANT... 86\nSYMBICORT... 104\nSYMDEKO... 104\nSYMFI LO... 46", "doc_id": "79a3745e-1d78-4ded-996d-b09971c14d6b", "embedding": null, "doc_hash": "f814c5ce4dacbe4c3d54b6bbcc235a1ccd6fe629075106397d8b411a0619422a", "extra_info": {"page_label": "125", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2111, "_node_type": "1"}, "relationships": {"1": "f832ec61-b897-4745-b835-5158abc4b7c7"}}, "__type__": "1"}, "e1c8753d-fee9-4101-ae7e-8c251770d409": {"__data__": {"text": "126 - 2023 HUMANA FORMULARY UPDATED 06/2023SYMFI... 46\nSYMJEPI... 104\nSYMLINPEN 120... 50\nSYMLINPEN 60... 50\nSYMPAZAN... 22\nSYMTUZA... 46\nSYNAREL... 82\nSYNERCID... 19\nSYNJARDY XR... 50\nSYNJARDY... 50\nSYNRIBO... 36\nSYNTHROID... 80\nT\nTABLOID... 36\nTABRECTA... 36\ntacrolimus... 64, 86\ntadalafil (pulm. hypertension)... 104\nTAFINLAR... 36\nTAGRISSO... 36\nTALZENNA... 36\ntamoxifen... 36\ntamsulosin... 72\nTARGRETIN... 36\ntarina fe 1-20 eq (28)... 79\ntarina fe 1/20 (28)... 79\ntarina 24 fe... 79\nTASIGNA... 37\ntasimelteon... 105\ntazarotene... 64\ntaztia xt... 59\nTAZVERIK... 37\nTDVAX... 86\nTECENTRIQ... 37TECHLITE INSULIN SYRINGE... 96\nTECHLITE INSULN SYR(HALF UNIT)...  \n96\nTECHLITE PEN NEEDLE... 96\nTECVAYLI... 37\nTEFLARO... 19\ntelmisartan... 59\ntelmisartan-amlodipine... 59\ntelmisartan-hydrochlorothiazid... 59\ntemazepam... 105\nTEMIXYS... 46\ntemsirolimus... 37\nteniposide... 37\nTENIVAC (PF)... 86\ntenofovir disoproxil fumarate... 46\nTEPMETKO... 37\nterazosin... 59\nterbinafine hcl... 27\nterconazole... 27\nteriflunomide... 61\nTERUMO INSULIN SYRINGE... 96\ntestosterone cypionate... 79\ntestosterone enanthate... 79\ntestosterone... 79\nTETANUS,DIPHTHERIA TOX PED(PF)...  \n86\ntetrabenazine... 61\nTHALOMID... 37\ntheophylline in dextrose 5 %... 104\ntheophylline... 104\nTHINPRO INSULIN SYRINGE... 96\nthioridazine... 43\nthiotepa... 37thiothixene... 43\ntiadylt er... 59\ntiagabine... 22\nTIBSOVO... 37\nTICOVAC... 86\ntigecycline... 19\ntilia fe... 79\ntimolol maleate (pf)... 101\ntimolol maleate... 59, 101\ntinidazole... 19\ntiopronin... 72\nTIVDAK... 37\nTIVICAY PD... 46\nTIVICAY... 46\ntizanidine... 43\ntobramycin sulfate... 19\ntobramycin with nebulizer... 19\ntobramycin... 19, 101\ntobramycin-dexamethasone... 101\ntolterodine... 72\nTOPCARE CLICKFINE... 96\nTOPCARE ULTRA COMFORT... 96\ntopiramate... 28\ntopotecan... 37\ntoremifene... 37\ntorsemide... 59\nTOUJEO MAX U-300 SOLOSTAR... 50\nTOUJEO SOLOSTAR U-300 INSULIN...  \n50\nTPN ELECTROLYTES... 69\nTRADJENTA... 50\ntramadol... 13\ntramadol-acetaminophen... 13", "doc_id": "e1c8753d-fee9-4101-ae7e-8c251770d409", "embedding": null, "doc_hash": "54201a8ed1c04f2c37d7302454eb3d2c1489c972d846b3039ed2ab3978ff7261", "extra_info": {"page_label": "126", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 1977, "_node_type": "1"}, "relationships": {"1": "e3cc393d-f9c3-4d3c-9f6b-1f118edcd88b"}}, "__type__": "1"}, "85610445-3361-4556-921c-50e92adf755f": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 127trandolapril... 59\ntrandolapril-verapamil... 59\ntranexamic acid... 52\ntranylcypromine... 24\nTRAVASOL 10 %... 69\ntravoprost... 101\nTRAZIMERA... 37\ntrazodone... 24\nTREANDA... 37\nTRECATOR... 28\nTRELEGY ELLIPTA... 104\nTRELSTAR... 82\nTRESIBA FLEXTOUCH U-100... 50\nTRESIBA FLEXTOUCH U-200... 50\nTRESIBA U-100 INSULIN... 50\ntretinoin (antineoplastic)... 37\ntretinoin... 64\ntri femynor... 79\ntri-legest fe... 79\ntri-linyah... 79\ntri-lo-estarylla... 79\ntri-lo-marzia... 79\ntri-lo-mili... 79\ntri-lo-sprintec... 79\ntri-mili... 79\ntri-nymyo... 79\ntri-previfem (28)... 79\ntri-sprintec (28)... 79\ntri-vylibra lo... 79\ntri-vylibra... 79\ntriamcinolone acetonide... 62, 73\ntriamterene-hydrochlorothiazid...  \n59, 60triderm... 73\ntrientine... 69\ntrifluoperazine... 43\ntrifluridine... 101\ntrihexyphenidyl... 40\nTRIJARDY XR... 50\nTRIKAFTA... 104\ntrilyte with flavor packets... 70\ntrimethobenzamide... 25\ntrimethoprim... 19\ntrimipramine... 25\ntrinatal rx 1... 69\nTRINTELLIX... 25\nTRISENOX... 37\nTRIUMEQ PD... 46\nTRIUMEQ... 46\ntriveen-duo dha... 69\ntrivora (28)... 79\nTRIZIVIR... 46\nTRODELVY... 37\nTROGARZO... 46\nTROPHAMINE 10 %... 69\nTRUE COMFORT ALCOHOL PADS... 96\nTRUE COMFORT INSULIN SYRINGE...  \n96\nTRUE COMFORT PEN NEEDLE... 96\nTRUE COMFORT PRO ALCOHOL  \nPADS... 96\nTRUE COMFORT PRO INS SYRINGE...  \n96\nTRUE COMFORT SAFETY PEN  \nNEEDLE... 96\nTRUEPLUS INSULIN... 96\nTRUEPLUS PEN NEEDLE... 96TRULICITY... 50\nTRUMENBA... 86\nTRUSELTIQ... 37\nTUKYSA... 37\ntulana... 80\nTURALIO... 37\nTWINRIX (PF)... 86\nTYBLUME... 80\nTYBOST... 47\nTYMLOS... 88\nTYPHIM VI... 86\nU\nUBRELVY... 97\nUDENYCA AUTOINJECTOR... 52\nUDENYCA... 52\nULTICARE INSULIN SYRINGE... 97\nULTICARE INSULN SYR(HALF UNIT)...  \n97\nULTICARE PEN NEEDLE... 97\nULTICARE SAFETY PEN NEEDLE... 97\nULTICARE... 97\nULTIGUARD SAFEPACK-INSULIN  \nSYR... 97\nULTIGUARD SAFEPACK-PEN  \nNEEDLE... 97\nULTILET ALCOHOL SWAB... 97\nULTILET INSULIN SYRINGE... 97\nULTILET PEN NEEDLE... 97\nULTRA CMFT INS SYR (HALF UNIT)...  \n97\nULTRA COMFORT INSULIN SYRINGE...  \n97\nULTRA FLO INSUL SYR(HALF UNIT)...  \n97\nULTRA FLO INSULIN SYRINGE... 97", "doc_id": "85610445-3361-4556-921c-50e92adf755f", "embedding": null, "doc_hash": "5d624b0c1531aa2ed1fd8442d774b573d8f7d2bbd05aaa8fbf2cbf0b777594c3", "extra_info": {"page_label": "127", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 2086, "_node_type": "1"}, "relationships": {"1": "088db272-8b0d-4e3d-a324-7d4bf233517e"}}, "__type__": "1"}, "c509f7d7-14d5-4f06-9bc2-0689e259509f": {"__data__": {"text": "128 - 2023 HUMANA FORMULARY UPDATED 06/2023ULTRA FLO PEN NEEDLE... 97\nULTRA THIN PEN NEEDLE... 97\nULTRA-THIN II (SHORT) INS SYR... 98\nULTRA-THIN II (SHORT) PEN NDL...  \n98\nULTRA-THIN II INS PEN NEEDLES...  \n98\nULTRA-THIN II INSULIN SYRINGE...  \n98\nULTRACARE INSULIN SYRINGE... 98\nULTRACARE PEN NEEDLE... 98\nUNIFINE PEN NEEDLE... 98\nUNIFINE PENTIPS MAXFLOW... 98\nUNIFINE PENTIPS PLUS MAXFLOW...  \n98\nUNIFINE PENTIPS PLUS... 98\nUNIFINE PENTIPS... 98\nUNIFINE SAFECONTROL... 98\nUNIFINE ULTRA PEN NEEDLE... 98\nUNITHROID... 80\nUNITUXIN... 37\nursodiol... 70\nUVADEX... 64\nV\nV-GO 20... 98\nV-GO 30... 98\nV-GO 40... 98\nvalacyclovir... 47\nVALCHLOR... 37\nvalganciclovir... 47\nvalproate sodium... 22\nvalproic acid (as sodium salt)... 22\nvalproic acid... 22\nvalrubicin... 37valsartan... 60\nvalsartan-hydrochlorothiazide... 60\nVALSTAR... 37\nVALTOCO... 22\nvanadom... 104\nvancomycin in dextrose 5 %... 19\nvancomycin in 0.9 % sodium chl...  \n19\nvancomycin... 19\nvancomycin-diluent combo no.1...  \n19\nVANISHPOINT INSULIN SYRINGE...  \n98\nVANISHPOINT SYRINGE... 98\nVAQTA (PF)... 86\nvarenicline... 14\nVARIVAX (PF)... 86\nVARIZIG... 86\nVASCEPA... 60\nVECTIBIX... 37\nvelivet triphasic regimen (28)... 80\nVELTASSA... 69\nVEMLIDY... 47\nVENCLEXTA STARTING PACK... 38\nVENCLEXTA... 37, 38\nvenlafaxine... 25\nVENTAVIS... 104\nVENTOLIN HFA... 104\nverapamil... 60\nVERIFINE INSULIN SYRINGE... 98\nVERIFINE PEN NEEDLE... 98\nVERIPRED 20... 73\nVERSACLOZ... 43\nVERZENIO... 38vestura (28)... 80\nVICTOZA 2-PAK... 51\nVICTOZA 3-PAK... 51\nvienva... 80\nvigabatrin... 22\nvigadrone... 22\nVIIBRYD... 25\nvilazodone... 25\nvinblastine... 38\nvincasar pfs... 38\nvincristine... 38\nvinorelbine... 38\nviorele (28)... 80\nVIRACEPT... 47\nVIREAD... 47\nvirt-c dha... 69\nvirt-nate dha... 69\nVISTOGARD... 38\nVITRAKVI... 38\nVIVITROL... 14\nVIZIMPRO... 38\nVOCABRIA... 47\nvolnea (28)... 80\nVONJO... 38\nvoriconazole... 27\nVOSEVI... 47\nVOTRIENT... 38\nVRAYLAR... 43\nVUMERITY... 61\nvyfemla (28)... 80\nvylibra... 80\nVYNDAMAX... 71\nVYNDAQEL... 71", "doc_id": "c509f7d7-14d5-4f06-9bc2-0689e259509f", "embedding": null, "doc_hash": "8ea2996bd114769f4804c43391b4abb883dfc6ba68ff296526e955be025d3118", "extra_info": {"page_label": "128", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 1968, "_node_type": "1"}, "relationships": {"1": "8faf3c04-6f49-4e02-aa35-14919129f4cd"}}, "__type__": "1"}, "25ce4d90-ff5e-4074-8da6-bd1bf136b636": {"__data__": {"text": "2023 HUMANA FORMULARY UPDATED 06/2023 - 129VYXEOS... 38\nVYZULTA... 101\nW\nwarfarin... 52\nwater for irrigation, sterile... 99\nWEBCOL... 99\nWELIREG... 38\nwera (28)... 80\nwesnate dha... 69\nwestab plus... 69\nWINRHO SDF... 86\nwixela inhub... 104\nwymzya fe... 80\nX\nXALKORI... 38\nXARELTO DVT-PE TREAT 30D START...  \n52\nXARELTO... 52\nXATMEP... 86\nXCOPRI MAINTENANCE PACK... 22\nXCOPRI TITRATION PACK... 22\nXCOPRI... 22\nXGEVA... 88\nXIFAXAN... 71\nXIGDUO XR... 51\nXOFLUZA... 47\nXOLAIR... 86\nXOSPATA... 38\nXPOVIO... 38\nXTAMPZA ER... 13\nXTANDI... 38\nxulane... 80\nXULTOPHY 100/3.6... 51XYREM... 105\nY\nYERVOY... 38\nYF-VAX (PF)... 86\nYONDELIS... 38\nZ\nzafemy... 80\nzafirlukast... 104\nZALTRAP... 38\nZANOSAR... 38\nzarah... 80\nZARXIO... 52\nZEGALOGUE AUTOINJECTOR... 51\nZEGALOGUE SYRINGE... 51\nZEJULA... 38\nZELBORAF... 38\nzenatane... 64\nZENPEP... 71\nZEPZELCA... 39\nZERBAXA... 19\nZERVIATE... 101\nzidovudine... 47\nziprasidone hcl... 43\nziprasidone mesylate... 43\nZIRABEV... 39\nZIRGAN... 47\nZOKINVY... 71\nZOLADEX... 82\nzoledronic ac-mannitol-0.9nacl...  \n88\nzoledronic acid... 88\nzoledronic acid-mannitol-water...  \n88ZOLINZA... 39\nzolpidem... 105\nZONISADE... 22\nzonisamide... 22\nzovia 1-35 (28)... 80\nzovia 1/35e (28)... 80\nZTALMY... 22\nZUBSOLV... 14\nzumandimine (28)... 80\nZYDELIG... 39\nZYKADIA... 39\nZYNLONTA... 39\nZYNYZ... 39\nZYPITAMAG... 60\nZYPREXA RELPREVV... 43\n1ST TIER UNIFINE PENTIPS PLUS...  \n88\n1ST TIER UNIFINE PENTIPS... 88", "doc_id": "25ce4d90-ff5e-4074-8da6-bd1bf136b636", "embedding": null, "doc_hash": "d8a50b545c2a0d8d9fc0d31f194cf58c6bc2c44c62682be44193a2d57d1087a7", "extra_info": {"page_label": "129", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 1411, "_node_type": "1"}, "relationships": {"1": "129ef60f-c486-4c05-beb1-5130b9e7be24"}}, "__type__": "1"}, "b28404ab-736e-485c-ba80-479395cdb79b": {"__data__": {"text": "GHHLNNXEN 0522Important! ____________________________________________________________________\nAt Humana, it is important you are treated fairly.\nHumana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color, national  \norigin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, ethnicity, marital status,  \nreligion, or language. Discrimination is against the law. Humana and its subsidiaries comply with applicable  \nfederal civil rights laws. If you believe that you have been discriminated against by Humana or its subsidiaries,  \nthere are ways to get help.\n\u2022You may file a complaint, also known as a grievance:\nDiscrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618\nIf you need help filing a grievance, call 1-877-320-1235 or if you use a TTY,.\ncall 711.\n\u2022You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for  \nCivil Rights electronically through the Office for Civil Rights Complaint Portal, available at \nhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at U.S. Department of Health and Human Services, 200  \nIndependence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019,  \n800-537-7697 (TDD).\n\u2022California residents: You may also call the California Department of Insurance toll-free hotline  \nnumber: 1-800-927-HELP (4357), to file a grievance.\nComplaint forms are available at https://www.hhs.gov/ocr/office/file/index.html.\nAuxiliary aids and services, free of charge, are available to you. 1-877-320-1235 (TTY:  \n711)\nHumana provides free auxiliary aids and services, such as qualified sign language interpreters, video remote  \ninterpretation, and written information in other formats to people with disabilities when such auxiliary aids  \nand services are necessary to ensure an equal opportunity to participate.", "doc_id": "b28404ab-736e-485c-ba80-479395cdb79b", "embedding": null, "doc_hash": "428350f22b23dbd81ca96ee26c2e077003471a597b3306aa7f95b698b5fa33f3", "extra_info": {"page_label": "130", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 1885, "_node_type": "1"}, "relationships": {"1": "de73d03d-7c87-41f1-a992-b4fa980f8cfe"}}, "__type__": "1"}, "8bd3fddc-19b3-4748-a1ee-231454b0d538": {"__data__": {"text": "Notes\n\u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 ", "doc_id": "8bd3fddc-19b3-4748-a1ee-231454b0d538", "embedding": null, "doc_hash": "7b204f7cb4527bee0a522967d2f3b6b33bc1747d25aa35710110484bf6d2b61b", "extra_info": {"page_label": "133", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 238, "_node_type": "1"}, "relationships": {"1": "d18df3cb-bef8-4889-a804-415e03ab7086"}}, "__type__": "1"}, "efd7971e-40b7-4dff-915b-f94f40e27c0f": {"__data__": {"text": "Notes\n\u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 \u2022 ", "doc_id": "efd7971e-40b7-4dff-915b-f94f40e27c0f", "embedding": null, "doc_hash": "06fa10ce6ce4ecf873cc72d28beaba8b1f217072edca911faec207ce7b6166fe", "extra_info": {"page_label": "134", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 238, "_node_type": "1"}, "relationships": {"1": "81a22fd6-5773-4146-bc1e-c0cac30d8514"}}, "__type__": "1"}, "5ad08e7e-53df-4765-8201-0b580a04f964": {"__data__": {"text": "Blank Page", "doc_id": "5ad08e7e-53df-4765-8201-0b580a04f964", "embedding": null, "doc_hash": "2f522b87ee9d0b289ed7d9fc813d683cd21386fb5ee4ee8293f7a397b6f036a6", "extra_info": {"page_label": "135", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 10, "_node_type": "1"}, "relationships": {"1": "b5910d2b-ac7c-48bd-a526-aabff5029769"}}, "__type__": "1"}, "e9fa399d-4add-4ef2-8fb9-31153ac4cae6": {"__data__": {"text": "20230043PDG2349423C_v13\nY0040_PDG23_FINAL_43C_C 20230043PDG2349423C_v13Humana.comThis formulary was updated on 06/05/2023. For more recent information or other questions, please  \ncontact Humana with any questions at 1-800-457-4708 or, for TTY users, 711, five days a week April 1 \u2013  \nSeptember 30 or seven days a week October 1\u2013 March 31 from 8 a.m. - 8 p.m. Our automated phone  \nsystem is available after hours, weekends, and holidays. Our website is also available 24 hours a day 7  \ndays a week, by visiting Humana.com.\n \nH0028-014, 019, 024, 025, 029, 030, 046, 052, 053, 054; H2463-003; H4141-015, 017; H4623-001, 002;  \nH5619-111, 152; H6622-032, 033\n \n  \n ", "doc_id": "e9fa399d-4add-4ef2-8fb9-31153ac4cae6", "embedding": null, "doc_hash": "5e3df868dfd78a4a807e6a8b8d94d4ad67c9bd5983173bf99280b880d6a5300b", "extra_info": {"page_label": "136", "file_name": "covered-drugs.pdf"}, "node_info": {"start": 0, "end": 665, "_node_type": "1"}, "relationships": {"1": "877cd254-b969-4020-818f-1d78ca2c953b"}}, "__type__": "1"}, "356c1e4a-1a5c-4f8c-bfd0-39369d18619f": {"__data__": {"text": "abiraterone\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers with severe hepatic impairment (Child-Pugh Class C). \nMembers that have experienced disease progression while on \nabiraterone acetate.Concomitant use with Erleada, Xtandi, Provenge, \nTaxotere or Jevtana.\n2023 Super National-5 MAPD\nFormulary ID 23493\nVersion 13\nFormulary ID 23494\nVersion 13\nFormulary ID 23496\nVersion 13\nFormulary ID 23492\nVersion 13\nFormulary ID 23497\nVersion 13\nYou can contact Humana for the most recent list of drugs by calling \n1-800-281-\n6918\n or, for TTY users, \n711\n, five days a week April \n1\n - September \n30\n or seven \ndays a week October \n1\n - March \n31\n from \n8\n a.m. - \n8\n p.m. Our automated phone \nsystem is available after hours, weekends, and holidays. Our website is also \navailable \n24\n hours a day \n7\n days a week, by visiting Humana.com.\nPrior Authorization Criteria\nEffective 06/01/2023\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 1 of 497\n", "doc_id": "356c1e4a-1a5c-4f8c-bfd0-39369d18619f", "embedding": null, "doc_hash": "71e82b6b6a5193cc27b0bb5017a635cdd7a8191d05e12f3d39a59fc6812c15b5", "extra_info": {"page_label": "1", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 961, "_node_type": "1"}, "relationships": {"1": "a847fb2f-95d6-4c67-8699-a2df88305780"}}, "__type__": "1"}, "7777690d-cb9c-4f4f-ae04-62c5f2aaf994": {"__data__": {"text": "abiraterone\nRequired\nMedical\nInformation\nProstate Cancer (mCRPC). The member has metastatic (stage IV) \ncastration-resistant prostate cancer (CRPC). The member will be using \nabiraterone acetate in combination with prednisone. Prostate Cancer \n(mCSPC). The member has diagnosis of castration-sensitive prostate \ncancer plus one of the following scenarios: metastatic (stage IV) disease \nAND is high risk (e.g. Gleason score of 8 or more, at least three bone \nlesions, or presence of measurable visceral metastases) OR Node-\npositive (any T, N1) OR localized disease with high risk features (e.g. a \nPSA level greater than 4 ng per milliliter with a doubling time of less than \n6 months, a PSA level greater than 20 ng per milliliter, nodal or \nmetastatic relapse, or adjuvant or neoadjuvant therapy lasting less than \n12 months of total ADT and completed at least 12 months previously) \nthat is persistent or recurrent after prior radical prostatectomy and/or \nradiation therapy.  Member will be using  abiraterone acetate in \ncombination with prednisone and one of the following applies: in \ncombination with LHRH analog (e.g, Lupron, Trelstar) OR has previous \nbilateral orchiectomy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 2 of 497\n", "doc_id": "7777690d-cb9c-4f4f-ae04-62c5f2aaf994", "embedding": null, "doc_hash": "703987d3593f485aece182e2a272ca2f114498b5ec30d71cffa88bdfba03ef1e", "extra_info": {"page_label": "2", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1376, "_node_type": "1"}, "relationships": {"1": "07808233-38ae-4ea0-97f4-ed949647387f"}}, "__type__": "1"}, "2e5e0bf6-f699-4bee-b90c-8f3784f9f104": {"__data__": {"text": "ABRAXANE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nBreast Cancer. The member has a diagnosis of metastatic (Stage IV) or \nrecurrent breast cancer. The member received prior therapy that \nincluded an anthracycline (unless contraindicated). The member has \ndocumented hypersensitivity reaction to conventional Taxol or Taxotere \nor the member has a documented contraindication to standard \nhypersensitivity premedications. Non-small Cell Lung Cancer (NSCLC). \nThe member has a diagnosis of locally advanced, recurrent or metastatic \nNSCLC. Member has documented hypersensitivity reaction to \nconventional Taxol or Taxotere or the member has a documented \ncontraindication to standard hypersensitivity premedications AND \nmember has squamous histology where Abraxane will be given in combo \nwith Keytruda and carboplatin as first line therapy OR member will be \nusing Abraxane as monotherapy or in combo with carboplatin AND One \nof the following apply: will be using for first line therapy OR member will \nbe using as subsequent therapy for EGFR mutation-positive tumors after \nprior therapy OR The member will be using as subsequent therapy for \nALK-positive tumors after prior therapy  OR  member will be using as \nsubsequent therapy for ROS-1 positive disease after prior therapy OR \nmember will be using as subsequent therapy for BRAF V600E positive \ndisease  OR The member will be using as subsequent therapy after \npembrolizumab and EGFR, ALK, BRAF V600E, and ROS-1 negative \ndisease OR member has metastatic NSCLC, non- squamous histology \nwith no EGFR or ALK genomic tumor aberrations AND Abraxane will be \ngiven combo with Tecentriq and carboplatin as first line therapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 3 of 497\n", "doc_id": "2e5e0bf6-f699-4bee-b90c-8f3784f9f104", "embedding": null, "doc_hash": "5afe4b22fe3ebb778af3d2d02b52fd0e412240ee596ad387b50697db2e9c2f02", "extra_info": {"page_label": "3", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1875, "_node_type": "1"}, "relationships": {"1": "c8dcdac5-e757-4371-b2b1-45f4f2092cac"}}, "__type__": "1"}, "81da3871-0a12-4cca-974f-28b014f3c001": {"__data__": {"text": "ABRAXANE\nOther Criteria\nOvarian Cancer. The member has a diagnosis of epithelial ovarian \ncancer, fallopian tube cancer or primary peritoneal cancer. The member \nmeets one of the following criteria: Progressive, stable or persistent \ndisease on primary chemotherapy OR Recurrent disease. The member \nhas documented hypersensitivity reaction to conventional Taxol \n(paclitaxel) or Taxotere (docetaxol) or the member has a documented \ncontraindication to standard hypersensitivity premedications. Pancreatic \nCancer: The member has a diagnosis of pancreatic cancer and \nAbraxane is being used in combination with gemcitabine as neoadjuvant \ntherapy or The member has a diagnosis of metastatic pancreatic cancer \nAND The member will be using Abraxane in combination with \ngemcitabine. Melanoma: The member has a diagnosis of unresectable \nor metastatic melanoma AND The member will be using Abraxane (nab-\npaclitaxel) as monotherapy AND The member will be using Abraxane \n(nab-paclitaxel) as second-line or subsequent therapy after progression \non BRAF targeted therapy AND The member has documented \nhypersensitivity reaction to conventional Taxol (paclitaxel) or Taxotere \n(docetaxol) or the member has a documented contraindication to \nstandard hypersensitivity premedications.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 4 of 497\n", "doc_id": "81da3871-0a12-4cca-974f-28b014f3c001", "embedding": null, "doc_hash": "6049defa34bbc4df9aea12d0b903c0faa58e0e1f75421301bb85aeea94005cd8", "extra_info": {"page_label": "4", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1350, "_node_type": "1"}, "relationships": {"1": "708561cb-b946-468a-8062-011d26bd70ab"}}, "__type__": "1"}, "8f925daa-77e9-4e49-9354-decd2e4043ef": {"__data__": {"text": "acitretin\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nPregnant or breastfeeding members, members with severe renal \nimpairment or failure, members with severe hepatic dysfunction.\nRequired\nMedical\nInformation\nMember must have a diagnosis of severe cutaneous psoriasis including \nplaque, guttate, erythrodermic, palmar-plantar, and pustular types AND \nthe member has had previous treatment, contraindication, or intolerance \nto methotrexate or cyclosporine.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 5 of 497\n", "doc_id": "8f925daa-77e9-4e49-9354-decd2e4043ef", "embedding": null, "doc_hash": "b54b80f7566f2316f2d0de54d5f4ea752d54e9dae41f347926124011af52ecf1", "extra_info": {"page_label": "5", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 661, "_node_type": "1"}, "relationships": {"1": "81aa97fb-da37-4c36-ba3a-15058dd657ca"}}, "__type__": "1"}, "e93b2350-d67c-4721-92e7-0f9a07393779": {"__data__": {"text": "ACTIMMUNE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nChronic Granulomatous Disease (CGD): The member has chronic \ngranulomatous disease (CGD). The member is using Actimmune to \nreduce the frequency and severity of infections. Severe Malignant \nOsteopetrosis: The member has severe malignant osteopetrosis \nconfirmed by biopsy. The member is using Actimmune to delay time to \ndisease progression.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 6 of 497\n", "doc_id": "e93b2350-d67c-4721-92e7-0f9a07393779", "embedding": null, "doc_hash": "a09a692ebdbe527654068ca63f989d5d3b97b74b654adf1a711d3c5f8c78d1ae", "extra_info": {"page_label": "6", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 630, "_node_type": "1"}, "relationships": {"1": "fcb0bb9b-e43a-46b3-bfdd-64b1fd009dce"}}, "__type__": "1"}, "49ccbc19-8c14-4113-9366-f6e10390bf82": {"__data__": {"text": "acyclovir\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nThe member must have a diagnosis of genital herpes OR member has a \ndiagnosis of non-life-threatening mucocutaneous Herpes Simplex Virus \n(HSV) infection and is immunocompromised. The member has had \nprevious treatment, contraindication, or intolerance with two of the \nfollowing: oral acyclovir, valacyclovir or famciclovir.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 7 of 497\n", "doc_id": "49ccbc19-8c14-4113-9366-f6e10390bf82", "embedding": null, "doc_hash": "868c03e2d0f7cc55eb941b8b742f4141f675d4faf63473cca9e5b8790584aca4", "extra_info": {"page_label": "7", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 613, "_node_type": "1"}, "relationships": {"1": "34c077aa-02f6-488b-8c08-e64a26a7b253"}}, "__type__": "1"}, "16eb342f-da23-4729-b10e-54893821a438": {"__data__": {"text": "ADCETRIS\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers that have experienced disease progression while on Adcetris.\nRequired\nMedical\nInformation\nHodgkin lymphoma. Diagnosis of relapsed or refractory Hodgkin \nlymphoma. The member has documented evidence of progression \nfollowing an autologous stem cell transplant OR is not a candidate for an \nautologous stem cell transplant but documented evidence of progression \non at least two previous multi-agent chemotherapy regimens OR the \nmember will be using Adcetris (brentuximab) as palliative therapy for \nolder adults (age greater than 60). The member will be using Adcetris as \nmonotherapy or in combination with bendamustine. Systemic Anaplastic \nLarge Cell Lymphoma (sALCL). Diagnosis of relapsed or refractory \nsystemic anaplastic large cell lymphoma. The member has documented \nevidence of progression on at least one prior multi-agent chemotherapy \nregimen The member will be using Adcetris (brentuximab vedotin) as \nmonotherapy.Disease has confirmed CD30 positivity. Hodgkin \nLymphoma Post-auto-HSCT Consolidation: The member has a \ndiagnosis of classical Hodgkin lymphoma AND The member will be using \nAdcetris (brentuximab vedotin) as post-autologous hematopoietic stem \ncell transplant (HSCT) consolidation AND The member is at high risk of \npost-autologous HSCT relapse or progression (must meet at least one of \nthe following criteria): Refractory disease to front-line therapy, Relapsed \ndisease within 12 months to front-line therapy, Relapsed disease with \nextranodal disease to front-line therapy. Previously untreated Hodgkin \nlymphoma. The member has a diagnosis of stage III or IV classical \nHodgkin lymphoma AND The member has previously untreated disease \nAND The member will be using Adcetris (brentuximab vedotin) in \ncombination with doxorubicin, vinblastine, and dacarbazine.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPrimary Cutaneous Anaplastic Large Cell Lymphoma (pcALCL) or CD30\n-expressing Mycosis Fungoides (MF). The member has a diagnosis of \nprimary cutaneous anaplastic large cell lymphoma (pcALCL) or CD30-\nexpressing mycosis fungoides (MF) AND The member has received at \nleast one prior systemic therapy AND The member will be using Adcetris \n(brentuximab vedotin) as monotherapy.\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 8 of 497\n", "doc_id": "16eb342f-da23-4729-b10e-54893821a438", "embedding": null, "doc_hash": "76630bf7925ba13281a7fb7d82ad397bb1335dec8738304a635db1b19adc97cc", "extra_info": {"page_label": "8", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2418, "_node_type": "1"}, "relationships": {"1": "b77112c0-c576-49dd-b52a-1f5646326e8d"}}, "__type__": "1"}, "f29d0ab4-df7b-45fe-ad39-a726f18b3a30": {"__data__": {"text": "ADCETRIS\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 9 of 497\n", "doc_id": "f29d0ab4-df7b-45fe-ad39-a726f18b3a30", "embedding": null, "doc_hash": "0b34238c3851bc88d0a700b53c1fb4a81a2c3f9bd9db35810ed0c6f4af896eec", "extra_info": {"page_label": "9", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 81, "_node_type": "1"}, "relationships": {"1": "1f9ddaa1-3f03-4773-9443-27bb153195b8"}}, "__type__": "1"}, "2b72a8db-8d7e-419f-bbf4-43b072cbef30": {"__data__": {"text": "ADEMPAS\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nChronic Thromboembolic Pulmonary Hypertension (CTEPH). The \nmember must have a diagnosis of Chronic Thromboembolic Pulmonary \nHypertension (CTEPH) (WHO Group 4) AND The member must have \nCTEPH classified as inoperable or persistent/recurrent after surgical \ntreatment (i.e. pulmonary endarterectomy). Pulmonary Arterial \nHypertension (PAH). The member must have a diagnosis of pulmonary \narterial hypertension (WHO Group 1) confirmed by right heart \ncatheterization.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 10 of 497\n", "doc_id": "2b72a8db-8d7e-419f-bbf4-43b072cbef30", "embedding": null, "doc_hash": "9acce6b27570cf4ff622c816d5580656f6a864002e9e72700cb24228d462cfff", "extra_info": {"page_label": "10", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 765, "_node_type": "1"}, "relationships": {"1": "a7ab9171-09f1-4033-ab67-c42d6c0522b2"}}, "__type__": "1"}, "36674254-95ee-4613-8471-541055e283aa": {"__data__": {"text": "AIMOVIG AUTOINJECTOR\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nEpisodic or Chronic Migraine.  Initial therapy: The member has \ndocumented history of greater than or equal to 4 migraine days per \nmonth AND the member has been unable to achieve at least a 2 day \nreduction in migraine headache days per month after previous treatment \n(of at least 2 months) with one of the following oral preventative \nmedications:  Divalproex, Topiramate, Metoprolol, Propranolol, or \nTimolol.  Reauthorization: The member has experienced a positive \nclinical response (e.g. sustained decrease in migraine days per month).\nAge Restriction\nThe member is 18 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial auth: 3 months.  Reauth: Plan Year Duration.\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 11 of 497\n", "doc_id": "36674254-95ee-4613-8471-541055e283aa", "embedding": null, "doc_hash": "d35c27e69e8f7e606cf241b963d7a89d0f373b1d038277557eba03a284843b02", "extra_info": {"page_label": "11", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 925, "_node_type": "1"}, "relationships": {"1": "aa36d483-733c-4b70-8f29-cd0dc0064d2e"}}, "__type__": "1"}, "4b55be42-c577-4a54-acc7-5cb026667660": {"__data__": {"text": "ALECENSA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member has experienced disease progression while on Alecensa \n(alectinib).\nRequired\nMedical\nInformation\nNon-small Cell Lung Cancer:The member has recurrent or metastatic \nnon-small cell lung cancer AND The member has documented \nanaplastic lymphoma kinase (ALK)-positive disease AND The member \nwill be using Alecensa (alectinib) as monotherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 12 of 497\n", "doc_id": "4b55be42-c577-4a54-acc7-5cb026667660", "embedding": null, "doc_hash": "387e829360125568ec6f697679892f3c4544748d7f0e8782721f66e56ca74b8e", "extra_info": {"page_label": "12", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 616, "_node_type": "1"}, "relationships": {"1": "ddfe4c8f-3803-494a-98fc-9d391355d06e"}}, "__type__": "1"}, "e2555100-60b2-45a9-bc13-3dc8042638a4": {"__data__": {"text": "ALIMTA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nSquamous cell non-small cell lung cancer. Creatinine clearance (CrCl) \nless than 45 ml/minute.\nRequired\nMedical\nInformation\nNon-Small Cell Lung Cancer (Nonsquamous). Diagnosis of \nnonsquamous NSCLC that is locally advanced or metastatic AND EGFR, \nALK, ROS1 BRAF negative and PD-L1 less than 1% AND one of the \nfollowing applies: Alimta is being used in combination with cisplatin or \ncarboplatin therapy for the initial treatment in members with a \nperformance status (PS) 0-2 or Alimta is being used in cisplatin or \ncarboplatin-based regimens in combination with bevacizumab product in \nmembers with PS 0-1 and no history of hemoptysis or as a single agent \nin PS 2 OR If EGFR, ALK, ROS1, BRAF positive and PD-L1 greater than \nor equal to 1% and after prior therapy AND one of the following applies: \nAlimta is being used in combination with cisplatin or carboplatin therapy \nfor the subsequent therapy in members with a performance status (PS) 0\n-2 or Alimta is being used in cisplatin or carboplatin-based regimens in \ncombination with bevacizumab product in members with PS 0-1 and no \nhistory of hemoptysis as subsequent therapy or as a single agent in PS 2 \nas subsequent therapy. OR Alimta is being used as a single agent after \nprior chemotherapy. Alimta is being used as a single agent for the \nmaintenance treatment of members whose disease has not progressed \nafter four cycles of platinum-based first-line chemotherapy OR As a \nsingle agent for recurrence or metastasis in members who achieved \ntumor response or stable disease following first-line chemotherapy with \nAlimta OR in combination with Keytruda and carboplatin or cisplatin as \nfirst line therapy for nonsquamous metastatic NSCLC followed by \nmaintenance Keytruda in combination with pemetrexed OR in \ncombination with cisplatin used as neoadjuvant or adjuvant \nchemotherapy OR Concurrent chemoradiation in combination with \ncarboplatin or cisplatin.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 13 of 497\n", "doc_id": "e2555100-60b2-45a9-bc13-3dc8042638a4", "embedding": null, "doc_hash": "127a980bb6339ba26cd6dd0ab51e82d35688256e4bd2dbaecc65afac7b1d046e", "extra_info": {"page_label": "13", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2144, "_node_type": "1"}, "relationships": {"1": "f021f8ac-a087-45b2-a6dc-5d220082d90d"}}, "__type__": "1"}, "aa25a05a-cc3d-4bcb-ad66-ef3c7b68d46d": {"__data__": {"text": "ALIMTA\nOther Criteria\nMalignant Pleural Mesothelioma. Diagnosis of malignant pleural \nmesothelioma AND must be using pemetrexed as induction therapy in \ncombination with cisplatin or carboplatin for medically operable clinical \nstage I-III OR must be using pemetrexed as a single agent or in \ncombination with cisplatin or carboplatin OR is using pemetrexed as \nsecond-line as a single agent if not administered first-line. OR \npemetrexed is being used in combination with bevacizumab product and \ncisplatin. Bladder Cancer: The member must have a diagnosis of \nmetastatic bladder cancer AND pemetrexed is being used as second-line \nor subsequent therapy as a single agent for metastatic disease.  Cervical \nCancer. Diagnosis of cervical cancer AND pemetrexed is being used as \na second-line or subsequent therapy as a single agent for local/regional \nrecurrence or distant metastases. Ovarian Cancer. Diagnosis of Ovarian \nCancer, or Epithelial Ovarian Cancer/Fallopian Tube Cancer/Primary \nPeritoneal Cancer AND pemetrexed is being used as a single agent for \npersistent disease or recurrence therapy. Thymic Malignancy. Diagnosis \nof thymic malignancy AND pemetrexed is being used as second-line \ntherapy as a single agent.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 14 of 497\n", "doc_id": "aa25a05a-cc3d-4bcb-ad66-ef3c7b68d46d", "embedding": null, "doc_hash": "ec818ef7a47f4d5495b156154c35069d9eba1a2208f01a63cd04e92b6991e79c", "extra_info": {"page_label": "14", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1300, "_node_type": "1"}, "relationships": {"1": "5b6581eb-2f5b-4061-b17b-e1956bba6754"}}, "__type__": "1"}, "1108eab3-c0eb-4d6e-b2a2-b394f2c51cec": {"__data__": {"text": "ALIQOPA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on or following \na PI3K inhibitor (e.g. idelalisib, copanlisib)\nRequired\nMedical\nInformation\nFollicular Lymphoma: The member has a diagnosis of follicular \nlymphoma AND The member has relapsed, refractory, or progressive \ndisease AND The member has received at least two prior systemic \ntherapies AND The member will be using Aliqopa as monotherapy\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 15 of 497\n", "doc_id": "1108eab3-c0eb-4d6e-b2a2-b394f2c51cec", "embedding": null, "doc_hash": "02da3632e6453fb79d921a926fe3ad499cd108d6d6b935c61fc0b54334c0b58c", "extra_info": {"page_label": "15", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 663, "_node_type": "1"}, "relationships": {"1": "24975b92-7a26-4eb5-a145-c17d069fb815"}}, "__type__": "1"}, "6525a768-43c3-4936-9b7e-0756cb4ecc69": {"__data__": {"text": "ALUNBRIG\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers experience disease progression on Alunbrig (brigatinib).\nRequired\nMedical\nInformation\nNon-Small cell lung cancer: The member has a diagnosis of advanced or \nmetastatic NSCLC with documented anaplastic lymphoma kinase (ALK) \npositivity AND Alunbrig will be given as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 16 of 497\n", "doc_id": "6525a768-43c3-4936-9b7e-0756cb4ecc69", "embedding": null, "doc_hash": "7157883f01e7dd6a7eff7e33bcde5d98a28b76b0850767fa1a79f4a6e00a9a57", "extra_info": {"page_label": "16", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 544, "_node_type": "1"}, "relationships": {"1": "31c0b408-3b8a-4d91-9664-6162d180fa9f"}}, "__type__": "1"}, "25b69f63-b54e-4faa-89de-708574a74935": {"__data__": {"text": "alyq\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nPulmonary Arterial Hypertension (PAH). The member must have a \ndiagnosis of pulmonary arterial hypertension (WHO Group I) confirmed \nby right heart catheterization.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 17 of 497\n", "doc_id": "25b69f63-b54e-4faa-89de-708574a74935", "embedding": null, "doc_hash": "9a4d164b08537564099a5df0e58a175bac3f3c9d31a5d4c0317d000dcf88c3d2", "extra_info": {"page_label": "17", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 460, "_node_type": "1"}, "relationships": {"1": "d404ec4c-c113-42e7-a270-6da65b31ea8e"}}, "__type__": "1"}, "a29262a0-0c93-457f-9f78-e2b792f87d79": {"__data__": {"text": "ambrisentan\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMember has a diagnosis of idiopathic pulmonary fibrosis.\nRequired\nMedical\nInformation\nPulmonary Arterial Hypertension (PAH). The member has a diagnosis of \npulmonary arterial hypertension (WHO Group I) confirmed by right heart \ncatheterization.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 18 of 497\n", "doc_id": "a29262a0-0c93-457f-9f78-e2b792f87d79", "embedding": null, "doc_hash": "416e9ca7ed68f720ba6f195d24030f4e98e75fd7b978855d748d5f30842197d6", "extra_info": {"page_label": "18", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 515, "_node_type": "1"}, "relationships": {"1": "a6a18a04-116e-44da-93bd-067b695befb9"}}, "__type__": "1"}, "1e1263b7-4f81-414a-a712-033484814215": {"__data__": {"text": "APTIOM\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nUse of oxcarbazepine\nRequired\nMedical\nInformation\nPartial-Onset Seizures. Diagnosis of partial-onset seizures. Prior therapy \nwith, contraindication, or intolerance to at least two other drugs for \ncontrolling partial-onset seizures (e.g. carbamazepine, lamotrigine, \nlevetiracetam, topiramate). Inadequately controlled seizures.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 19 of 497\n", "doc_id": "1e1263b7-4f81-414a-a712-033484814215", "embedding": null, "doc_hash": "07cc13018abdac0bcf87582a783987b22b1312176b5f9c7970383f26362592df", "extra_info": {"page_label": "19", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 592, "_node_type": "1"}, "relationships": {"1": "e07ff4ae-9985-4891-ac52-9b3d5ea0997f"}}, "__type__": "1"}, "81e1fe4e-e413-4662-b18a-3f3ccb03aa1b": {"__data__": {"text": "ARCALYST\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nFamilial Cold Autoinflammatory Syndrome or Muckle-Wells Syndrome:  \nThe member has a diagnosis of Cryopryin-Associated Periodic \nSyndrome (CAPS), including Familial Cold Autoinflammatory Syndrome \n(FCAS) and Muckle-Wells Syndrome (MWS).  Recurrent Pericarditis:  \nMember has a diagnosis of recurrent pericarditis defined by: \npresentation of symptoms of acute pericarditis after a symptom-free \ninterval of at least 4 weeks.  Deficiency of Interleukin-1 Receptor \nAntagonist (DIRA) The member has a diagnosis of deficiency of \ninterleukin-1 receptor antagonist (DIRA).\nAge Restriction\nMember must be 12 years of age or older for Familial Cold \nAutoinflammatory Syndrome, Muckle-Wells Syndrome, and Recurrent \nPericarditis indications.  Age restriction does not apply to DIRA.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 20 of 497\n", "doc_id": "81e1fe4e-e413-4662-b18a-3f3ccb03aa1b", "embedding": null, "doc_hash": "1a1deb9cb44f13117deb44ddf1509af37084cc9d92bf3ceaaf846aa91347a8af", "extra_info": {"page_label": "20", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1047, "_node_type": "1"}, "relationships": {"1": "9481fc18-7bec-4141-9ed2-9115c5ff6f90"}}, "__type__": "1"}, "e0522904-5bf0-4d20-a40a-59f674d3c525": {"__data__": {"text": "arformoterol\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nAsthma, in the absence of concurrent medication containing inhaled \ncorticosteroid and comorbid COPD diagnosis.\nRequired\nMedical\nInformation\nChronic Obstructive Pulmonary Disease (COPD).Diagnosis of Chronic \nObstructive Pulmonary Disease (COPD), including chronic bronchitis \nand emphysema, requiring maintenance treatment of \nbronchoconstriction.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 21 of 497\n", "doc_id": "e0522904-5bf0-4d20-a40a-59f674d3c525", "embedding": null, "doc_hash": "a0f7ca157b64e3782affab65f0e610695b7655f618bcb54be5472e683ec5afac", "extra_info": {"page_label": "21", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 610, "_node_type": "1"}, "relationships": {"1": "9baf27eb-4f98-480a-a62a-30bbd33b2c36"}}, "__type__": "1"}, "8424883b-7390-4784-bfd3-6b9f1630ebb5": {"__data__": {"text": "arsenic trioxide\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nAcute Promyelocytic Leukemia (APL). The member has a diagnosis of \nacute promyelocytic leukemia AND the member will be using Trisenox \n(arsenic trioxide) for induction therapy, consolidation therapy, or relapsed \ndisease.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 22 of 497\n", "doc_id": "8424883b-7390-4784-bfd3-6b9f1630ebb5", "embedding": null, "doc_hash": "e96840fb47c35eb879aa471066aebc2dcaebfae58dcdaa8620167166cc5821d8", "extra_info": {"page_label": "22", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 525, "_node_type": "1"}, "relationships": {"1": "f3646be8-5fe8-4bdb-acb0-f4f35e7cf6df"}}, "__type__": "1"}, "d6237a1d-5ad5-4c21-a054-614b89d98b6f": {"__data__": {"text": "asenapine maleate\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDementia-related psychosis (in the absence of an approvable diagnosis), \nfor member 65 years of age or older.\nRequired\nMedical\nInformation\nSchizophrenia/Bipolar I Disorder, manic or mixed episodes. The member \nmust be utilizing asenapine for treatment of schizophrenia or bipolar I \ndisorder. The member must have prior therapy or intolerance or \ncontraindication to at least two of the following: risperidone or olanzapine \nor quetiapine or ziprasidone or aripiprazole.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 23 of 497\n", "doc_id": "d6237a1d-5ad5-4c21-a054-614b89d98b6f", "embedding": null, "doc_hash": "8aeae2e60070a2f02af82f163d07e6a59aa41fd21b53361cc1b3898b5e519724", "extra_info": {"page_label": "23", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 738, "_node_type": "1"}, "relationships": {"1": "9dffd154-6c4c-473d-a8f0-f8f7a6ea7ec1"}}, "__type__": "1"}, "81501a0e-addd-4a42-bb9f-d1749de4aeb2": {"__data__": {"text": "ASPARLAS\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers that have experienced disease progression while on or \nfollowing Asparlas (calaspargase pegol-mknl). Members with a history of \nserious thrombosis with prior asparaginase therapy. Members with a \nhistory of pancreatitis with prior asparaginase therapy. Members with a \nhistory of serious hemorrhagic events with prior asparaginase therapy. \nMembers with total bilirubin more than 10 times the upper limit of normal.\nRequired\nMedical\nInformation\nAcute Lymphoblastic Leukemia (ALL):  The member has a diagnosis of \nacute lymphoblastic leukemia (ALL) AND The member will be using \nAsparlas (calaspargase pegol-mknl) as a component of a multi-agent \nchemotherapy regimen.\nAge Restriction\nThe age of the member is less than or equal to \n21\n years.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 24 of 497\n", "doc_id": "81501a0e-addd-4a42-bb9f-d1749de4aeb2", "embedding": null, "doc_hash": "53350d516b3d2985a737b7051fadc5838a95b77653f56e3c5536571c2c3f6ac3", "extra_info": {"page_label": "24", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 998, "_node_type": "1"}, "relationships": {"1": "94fdbb72-5d7e-4c6a-8341-74f3eaa9e40f"}}, "__type__": "1"}, "5105b182-ea99-400d-a52f-68d568ee2f0a": {"__data__": {"text": "AUGMENTIN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nMember must have a previous treatment, intolerance or contraindication \nto an AB-rated generic equivalent product.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 25 of 497\n", "doc_id": "5105b182-ea99-400d-a52f-68d568ee2f0a", "embedding": null, "doc_hash": "167b7e1d647fc69841f1654ce26056864a88a0e4d42965827b2b5ab0f341c537", "extra_info": {"page_label": "25", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 403, "_node_type": "1"}, "relationships": {"1": "1eea301e-a3d6-4853-b491-e21b2f9ec598"}}, "__type__": "1"}, "b10aa813-49d0-4a2e-9194-1a0430c7e8cc": {"__data__": {"text": "AUSTEDO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nInitial Therapy - TD: The member is utilizing Austedo (deutetrabenazine) \nfor the treatment of tardive dyskinesia that is associated with the use of \ndopamine receptor blocking agents AND Symptoms persist despite one \nof the following: Discontinuation or reduction in dose of dopamine \nblocking agent(s) OR Discontinuation or reduction in dose of dopamine \nblocking agent(s) is not possible.  OR the member is utilizing Austedo \n(deutetrabenazine) for the treatment of TD that is not associated with \nother medication therapies (e.g. dopamine receptor-blocking agents). \nAND The provider attests that the risk versus benefit of depression and \nsuicidality has been considered, and the benefits of treatment outweigh \nthe risks.  Continuation- TD: The member has a documented \nimprovement or maintenance of symptoms while on Austedo \n(deutetrabenazine) (e.g. reduction in Abnormal Involuntary Movement \nScale [AIMS] score or Dyskinesia Identification System: Condensed User \nScale [DISCUS] from baseline) AND the provider attests that the risk \nversus benefit of depression and suicidality has been considered, and \nthe benefits of treatment outweigh the risks.  Initial Therapy - Chorea \nwith HD: Diagnosis of chorea associated with Huntington's disease AND \nInadequate symptom control (e.g. no improvement in total maximal \nchorea [TMC] score, no improvement in overall motor function) on \nprevious treatment with tetrabenazine therapy or intolerance to \ntetrabenazine AND The provider attests that the risk versus benefit of \ndepression and suicidality has been considered, and the benefits of \ntreatment outweigh the risks.  Continuation - Chorea with HD: The \nmember has a documented improvement or maintenance of symptoms \n(e.g. reduction in total maximal chorea [TMC] score, improvement in \noverall motor function) with Austedo (deutetrabenazine) AND the \nprovider attests that the risk versus benefit of depression and suicidality \nhas been considered, and the benefits of treatment outweigh the risks.\nAge Restriction\nMember is 18 years of age or older (Tardive Dyskinesia).\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial auth: 3 months, Reauthorization: Plan Year Duration\nOther Criteria\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 26 of 497\n", "doc_id": "b10aa813-49d0-4a2e-9194-1a0430c7e8cc", "embedding": null, "doc_hash": "29e841b96bc1e37f310cf9b84a38856958c2956124342afc760ffe2e77b0ddf0", "extra_info": {"page_label": "26", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2371, "_node_type": "1"}, "relationships": {"1": "218eb4d2-cb26-49a7-91f4-1eb905f6d371"}}, "__type__": "1"}, "ac624d69-7811-41bf-b881-f4e2ed01d9cf": {"__data__": {"text": "AUSTEDO\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 27 of 497\n", "doc_id": "ac624d69-7811-41bf-b881-f4e2ed01d9cf", "embedding": null, "doc_hash": "e4676cf6fe1e657a8d1626804803757e780cef4064743d0809a1cd0e6a94be4f", "extra_info": {"page_label": "27", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 81, "_node_type": "1"}, "relationships": {"1": "98885822-5de3-4fd4-8504-ff15ac4f1c59"}}, "__type__": "1"}, "cc17dc9b-0355-449e-8ed7-2572286979d6": {"__data__": {"text": "AUSTEDO XR\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nInitial Therapy - TD: The member is utilizing Austedo (deutetrabenazine) \nfor the treatment of tardive dyskinesia that is associated with the use of \ndopamine receptor blocking agents AND Symptoms persist despite one \nof the following: Discontinuation or reduction in dose of dopamine \nblocking agent(s) OR Discontinuation or reduction in dose of dopamine \nblocking agent(s) is not possible.  OR the member is utilizing Austedo \n(deutetrabenazine) for the treatment of TD that is not associated with \nother medication therapies (e.g. dopamine receptor-blocking agents). \nAND The provider attests that the risk versus benefit of depression and \nsuicidality has been considered, and the benefits of treatment outweigh \nthe risks.  Continuation- TD: The member has a documented \nimprovement or maintenance of symptoms while on Austedo \n(deutetrabenazine) (e.g. reduction in Abnormal Involuntary Movement \nScale [AIMS] score or Dyskinesia Identification System: Condensed User \nScale [DISCUS] from baseline) AND the provider attests that the risk \nversus benefit of depression and suicidality has been considered, and \nthe benefits of treatment outweigh the risks.  Initial Therapy - Chorea \nwith HD: Diagnosis of chorea associated with Huntington's disease AND \nInadequate symptom control (e.g. no improvement in total maximal \nchorea [TMC] score, no improvement in overall motor function) on \nprevious treatment with tetrabenazine therapy or intolerance to \ntetrabenazine AND The provider attests that the risk versus benefit of \ndepression and suicidality has been considered, and the benefits of \ntreatment outweigh the risks.  Continuation - Chorea with HD: The \nmember has a documented improvement or maintenance of symptoms \n(e.g. reduction in total maximal chorea [TMC] score, improvement in \noverall motor function) with Austedo (deutetrabenazine) AND the \nprovider attests that the risk versus benefit of depression and suicidality \nhas been considered, and the benefits of treatment outweigh the risks.\nAge Restriction\nMember is 18 years of age or older (Tardive Dyskinesia).\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial auth: 3 months, Reauthorization: Plan Year Duration\nOther Criteria\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 28 of 497\n", "doc_id": "cc17dc9b-0355-449e-8ed7-2572286979d6", "embedding": null, "doc_hash": "6c625788b14c1c8b8a8f84630ce13692e33b3de435c41308b1a30d0f836e2de7", "extra_info": {"page_label": "28", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2374, "_node_type": "1"}, "relationships": {"1": "c0d6aae9-1a7b-49f7-be52-feb6710ae610"}}, "__type__": "1"}, "42dcd03c-fcd1-42a5-812b-0265ab79c43c": {"__data__": {"text": "AUSTEDO XR\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 29 of 497\n", "doc_id": "42dcd03c-fcd1-42a5-812b-0265ab79c43c", "embedding": null, "doc_hash": "647ad84d917e5cc990c31becc0d98fd74783702fc577680ea84acaaaa8541695", "extra_info": {"page_label": "29", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 84, "_node_type": "1"}, "relationships": {"1": "c23944e8-5179-416d-a8a7-8fd8827379dc"}}, "__type__": "1"}, "1d5d79c5-ad65-4b56-a432-f8b7b103baaf": {"__data__": {"text": "AUVELITY\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nMajor Depressive Disorder: The member does not have a seizure \ndisorder AND the member does not have a current or prior diagnosis of \nbulimia or anorexia nervosa AND the member does not have bipolar \ndisorder, panic disorder, OCD, substance use disorder within the past \nyear, or clinically significant risk of suicide AND the member has a \nclinical diagnosis of major depressive disorder (MDD) as defined by \nDSM-5 criteria and/or appropriate depression rating scale (e.g. PHQ-9, \nClinically Useful Depression Outcome Scale, Quick Inventory of \nDepressive Symptomatology-Self Report 16 Item, MADRS, HAM-D) \nAND the member has had previous treatment, contraindication, or \nintolerance to at least two different antidepressants of adequate dose \n(i.e. as determined by the treating provider based on individual patient \ncharacteristics) and duration (i.e. at least 8 weeks for each \nantidepressant) from the following: generic SSRI (e.g., citalopram, \nfluoxetine, paroxetine, or sertraline), SNRI (e.g., venlafaxine or \nduloxetine), bupropion OR mirtazapine.\nAge Restriction\nThe member is 18 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 30 of 497\n", "doc_id": "1d5d79c5-ad65-4b56-a432-f8b7b103baaf", "embedding": null, "doc_hash": "23b907bd4ee11f33b27784516558801ca8c13f08c1e66e277f5ab8f029b1c304", "extra_info": {"page_label": "30", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1385, "_node_type": "1"}, "relationships": {"1": "aa35d115-5cd2-450a-a03d-f40f487655dc"}}, "__type__": "1"}, "45eda351-709d-43c8-b8ee-9c01a4cc1828": {"__data__": {"text": "AYVAKIT\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experiences disease progression on Ayvakit (avapritinib).\nRequired\nMedical\nInformation\nGastrointestinal Stromal tumor. The member has documented PDGFRA \nexon 18 mutation-positive unresectable or metastatic gastrointestinal \nstromal tumor (including PDGFRA D842V) AND Ayvakit (avapritinib) will \nbe given as monotherapy.  Advanced systemic mastocytosis:  The \nmember has a diagnosis of advanced systemic mastocytosis (AdvSM), \nincluding systemic mastocytosis with an associated hematological \nneoplasm and mast cell leukemia AND Avyakit is not recommended for \nthe treatment of members with AdvSM with platelet counts of less than \n50 X 109 /L AND Ayvakit (avapritinib) is administered as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 31 of 497\n", "doc_id": "45eda351-709d-43c8-b8ee-9c01a4cc1828", "embedding": null, "doc_hash": "6283e185e4b1c5110b4c39afc7243a96debf1d035fc90389c2b78c6ff1f42459", "extra_info": {"page_label": "31", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 965, "_node_type": "1"}, "relationships": {"1": "9053d7a5-bbc9-4ee5-b436-1c52ca084d85"}}, "__type__": "1"}, "f9917544-b17e-4dad-93f1-5f30d226d5fe": {"__data__": {"text": "azacitidine\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant use with hypomethylators (e.g. azacitidine, decitabine) . \nApplies to azacitidine only: the member must not have a diagnosis of \nadvanced malignant hepatic tumors.\nRequired\nMedical\nInformation\nMyelodysplastic Syndromes. The member has a diagnosis of \nmyelodysplastic syndrome AND one of the following scenarios apply: \nThe member has a Revised International Prognostic Scoring System \n(IPSS-R) of higher risk disease (i.e. intermediate, high, very high) OR \nThe member has a Revised International Prognostic Scoring System \n(IPSS-R) of lower risk disease (i.e. very low, low, or intermediate) AND \none of the following sets of criteria applies: Clinically relevant \nthrombocytopenia, neutropenia, or increased marrow blasts OR Member \nhas symptomatic anemia AND No 5q deletion AND Serum erythropoietin \nlevels greater than 500 mU/mL AND An inadequate response or \nintolerance or contraindication to immunosuppressive therapy OR \nMember has Symptomatic anemia AND Serum erythropoietin levels less \nthan or equal to 500 mU/mL AND An inadequate response to \nerythropoietins alone or in combination with Revlimid (lenalidomide) \nAND An inadequate response or intolerance or contraindication to \nimmunosuppressive therapy OR Member has Symptomatic anemia AND \n5q deletion AND  An inadequate response or intolerance to Revlimid \n(lenalidomide) AND Serum erythropoietin levels greater than 500 mU/mL \nAND An inadequate response or intolerance or contraindication to \nimmunosuppressive therapy. Myeloproliferative Neoplasms: The \nmember has a diagnosis of myelofibrosis (MF)-accelerated phase or MF-\nblast phase/acute myeloid leukemia. Acute Myelogenous Leukemia \n(AML). The member has a diagnosis of AML.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 32 of 497\n", "doc_id": "f9917544-b17e-4dad-93f1-5f30d226d5fe", "embedding": null, "doc_hash": "760fe6def9f1d7e31fb17acffc0775a1aa25e3ad3cf713bcc82b22957152455c", "extra_info": {"page_label": "32", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1970, "_node_type": "1"}, "relationships": {"1": "667caa6c-a289-40bd-9c0a-8c8612232c24"}}, "__type__": "1"}, "3025f9eb-0959-4e8a-9ed1-038827e44300": {"__data__": {"text": "BALVERSA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nUrothelial Cancer: The member has a diagnosis of locally advanced or \nmetastatic urothelial carcinoma AND the member has identification of a \nsusceptible FGFR3 or FGFR2 genetic alteration documented in the \nmedical record [e.g., FGFR3 gene mutations (R284C, S249C, G370C, \nY373C), FGFR gene fusions (FGFR3-TACC3, FGFR3-BAIAP2L1, \nFGFR2-BICC1, FGFR2-CASP7) AND the member will be using Balversa \n(erdafitinib) as a single agent for subsequent therapy after disease \nprogression during or following at least one prior line of platinum-\ncontaining systemic chemotherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 33 of 497\n", "doc_id": "3025f9eb-0959-4e8a-9ed1-038827e44300", "embedding": null, "doc_hash": "fc9b3350901433d34b5591e0b1db81b68f3394d3e3a4319b205e604203610798", "extra_info": {"page_label": "33", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 866, "_node_type": "1"}, "relationships": {"1": "be48bce9-d730-42cc-82c5-2c4aa2696055"}}, "__type__": "1"}, "243a18c1-dd8a-4cc5-8df1-8d95dbaf951d": {"__data__": {"text": "BAVENCIO\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member has experienced disease progression on Bavencio \n(avelumab). The member has experienced disease progression while on \nor following PD-1/PD-L1 therapy (e.g Keytruda, Opdivo, Tecentriq, \nImfinzi). The member has experienced disease progression while on or \nfollowing Yervoy.\nRequired\nMedical\nInformation\nMerkel Cell Carcinoma (Adults). The member has a diagnosis of \nmetastatic Merkel cell carcinoma AND Member will be using Bavencio as \nmonotherapy. Merkel Cell Carcinoma (Pediatrics). The member has a \ndiagnosis of metastatic Merkel cell carcinoma AND Member will be using \nBavencio as monotherapy. Urothelial Cancer. The member has a \ndiagnosis of locally advanced or metastatic urothelial cancer AND the \nmember will be using Bavencio (avelumab) as monotherapy AND One of \nthe following apply: The member will be using Bavencio (avelumab) as \nsecond or subsequent line systemic therapy OR the member has had \ndisease progression within 12 months of neoadjuvant or adjuvant \nchemotherapy OR The member will be using Bavencio (avelumab) as \nmaintenance treatment if there is no disease progression with first-line \nplatinum-containing chemotherapy. Renal Cell Carcinoma. The member \nhas a diagnosis of advanced or metastatic renal cell carcinoma AND \nBavencio (avelumab) will be given in combination with Inlyta (axitinib) as \nfirst-line therapy.\nAge Restriction\nPediatric Merkel Cell Carcinoma \n\u2013 \nmember must be 12 years of age or \nolder.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 34 of 497\n", "doc_id": "243a18c1-dd8a-4cc5-8df1-8d95dbaf951d", "embedding": null, "doc_hash": "e16e876f34219054f445c3cfa45364d4fe5cff35ee7d159052446ce4e2c3eaa9", "extra_info": {"page_label": "34", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1700, "_node_type": "1"}, "relationships": {"1": "a7792b4f-5209-475c-b165-803325c2bc5a"}}, "__type__": "1"}, "a133ecfd-c511-4137-8298-79897353e39b": {"__data__": {"text": "BELEODAQ\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on Beleodaq \n(belinostat). Members on concomitant Istodax (romidepsin), Zolinza \n(vorinostat), or Folotyn (pralatrexate) therapy.\nRequired\nMedical\nInformation\nPeripheral T-Cell Lymphoma (PTCL). The member must have a \ndiagnosis of relapsed OR refractory peripheral T-cell lymphoma (PTCL).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nsix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 35 of 497\n", "doc_id": "a133ecfd-c511-4137-8298-79897353e39b", "embedding": null, "doc_hash": "867486288e80d928069aa1c29e667cacc3de4401f693407bd288139e979db0e3", "extra_info": {"page_label": "35", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 609, "_node_type": "1"}, "relationships": {"1": "cd064d91-ac45-4600-a902-cd0bb1b5b3e2"}}, "__type__": "1"}, "f9a45f8d-66b3-4b24-960e-e9239f9b1b9c": {"__data__": {"text": "bendamustine\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers who experience disease progression on bendamustine \ncontaining regimens.\nRequired\nMedical\nInformation\nChronic Lymphocytic Leukemia (CLL). The member has a diagnosis of \nCLL AND bendamustine is being used for relapsed or refractory disease \nor as first line therapy. Multiple Myeloma (MM). The member has a \ndiagnosis of MM AND bendamustine is being used for disease relapse or \nfor progressive or refractory disease. Non-Hodgkin\n\u2019\ns Lymphoma: The \nmember has a diagnosis of follicular lymphoma, gastric MALT lymphoma \nor nongastric MALT lymphoma and is using Bendamustine. The member \nhas a diagnosis of mantle cell lymphoma and bendamustine is being \nused as one of the following: Less aggressive induction therapy OR \nSecond-line therapy for relapsed, refractory or progressive disease. The \nmember has a diagnosis of primary cutaneous B-cell lymphoma (primary \ncutaneous marginal zone or follicle center B-cell lymphoma) and \nbendamustine is being used as a single agent or in combination with a \nrituximab product in one of the following: Refractory generalized \ncutaneous disease OR generalized extracutaneous disease as initial \ntherapy or for relapse. The member has a diagnosis of splenic marginal \nzone lymphoma and bendamustine is being used as one of the following: \nFirst-line therapy for disease progression following initial treatment for \nsplenomegaly OR Second-line or subsequent therapy for progressive \ndisease. The member has a diagnosis of diffuse large B-cell lymphoma \nand bendamustine is being used as second-line therapy or subsequent \ntherapy .The member has a diagnosis of AIDS-related B-cell lymphoma \nand bendamustine is being used as second-line therapy or subsequent \ntherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration.\nOther Criteria\nWaldenstroms Macroglobulinemia:The member has Waldenstroms \nmacroglobulinemia or lymphoplasmacytic lymphoma and bendamustine \nis being used as one of the following: Primary therapy OR Progressive or \nrelapsed disease. Hodgkin Lymphoma: The member has a diagnosis of \nclassical Hodgkin lymphoma AND bendamustine will be used as \nsubsequent therapy for relapsed or refractory disease.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 36 of 497\n", "doc_id": "f9a45f8d-66b3-4b24-960e-e9239f9b1b9c", "embedding": null, "doc_hash": "a5f78ec2d9460b66b303ddd4fc911f101b24564aa048f0b82413ecc5d9ae505a", "extra_info": {"page_label": "36", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2360, "_node_type": "1"}, "relationships": {"1": "114a59ab-728c-49b2-853a-cbba213b6ff8"}}, "__type__": "1"}, "d48e1d12-27b2-4812-8815-666c63648495": {"__data__": {"text": "BENDEKA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers who experience disease progression on bendamustine \ncontaining regimens.\nRequired\nMedical\nInformation\nChronic Lymphocytic Leukemia (CLL). The member has a diagnosis of \nCLL AND bendamustine is being used for relapsed or refractory disease \nor as first line therapy. Multiple Myeloma (MM). The member has a \ndiagnosis of MM AND bendamustine is being used for disease relapse or \nfor progressive or refractory disease. Non-Hodgkin\n\u2019\ns Lymphoma: The \nmember has a diagnosis of follicular lymphoma, gastric MALT lymphoma \nor nongastric MALT lymphoma and is using Bendamustine. The member \nhas a diagnosis of mantle cell lymphoma and bendamustine is being \nused as one of the following: Less aggressive induction therapy OR \nSecond-line therapy for relapsed, refractory or progressive disease. The \nmember has a diagnosis of primary cutaneous B-cell lymphoma (primary \ncutaneous marginal zone or follicle center B-cell lymphoma) and \nbendamustine is being used as a single agent or in combination with a \nrituximab product in one of the following: Refractory generalized \ncutaneous disease OR generalized extracutaneous disease as initial \ntherapy or for relapse. The member has a diagnosis of splenic marginal \nzone lymphoma and bendamustine is being used as one of the following: \nFirst-line therapy for disease progression following initial treatment for \nsplenomegaly OR Second-line or subsequent therapy for progressive \ndisease. The member has a diagnosis of diffuse large B-cell lymphoma \nand bendamustine is being used as second-line therapy or subsequent \ntherapy .The member has a diagnosis of AIDS-related B-cell lymphoma \nand bendamustine is being used as second-line therapy or subsequent \ntherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration.\nOther Criteria\nWaldenstroms Macroglobulinemia:The member has Waldenstroms \nmacroglobulinemia or lymphoplasmacytic lymphoma and bendamustine \nis being used as one of the following: Primary therapy OR Progressive or \nrelapsed disease. Hodgkin Lymphoma: The member has a diagnosis of \nclassical Hodgkin lymphoma AND bendamustine will be used as \nsubsequent therapy for relapsed or refractory disease.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 37 of 497\n", "doc_id": "d48e1d12-27b2-4812-8815-666c63648495", "embedding": null, "doc_hash": "8db4cda2828df05ecdeeee5b72005acb00d322c6978bf53c789cf9512acec9a0", "extra_info": {"page_label": "37", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2355, "_node_type": "1"}, "relationships": {"1": "5db0336f-7694-408d-b1d3-eea1107c8799"}}, "__type__": "1"}, "b8bd003b-61e9-4713-b19a-4a1bdea38ac9": {"__data__": {"text": "BENLYSTA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nSevere active central nervous system lupus.\nRequired\nMedical\nInformation\nSystemic Lupus Erythematosus (SLE). The member must have a \ndiagnosis of active systemic lupus erythematosus (SLE).The member \nmust be auto-antibody positive in the absence of any drugs for SLE \ndefined as: ANA titer greater than or equal 1:80 or anti-dsDNA level \ngreater than or equal 30 I/mL.  The member must be utilizing Benlysta \n(belimumab) in combination with standard treatment regimens for SLE \nwhich may include: corticosteroids (e.g. prednisone), \nhydroxychloroquine, azathioprine.  Lupus Nephritis:  The member must \nhave a diagnosis of active lupus nephritis AND the member must be \nutilizing Benlysta in combination with standard therapy (e.g. \ncorticosteroids with mycophenolate or cyclophosphamide).\nAge Restriction\nLupus Nephritis: The member is 5 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 38 of 497\n", "doc_id": "b8bd003b-61e9-4713-b19a-4a1bdea38ac9", "embedding": null, "doc_hash": "8bfa4c18b3147fbdbb479b9ffeb62d6e369b05b6f773a6b900e59b1766a56d82", "extra_info": {"page_label": "38", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1104, "_node_type": "1"}, "relationships": {"1": "23251ee2-03d8-40da-b2a5-925018444725"}}, "__type__": "1"}, "0b0dbdaa-e8ca-4866-91e7-c7adced2904b": {"__data__": {"text": "BESPONSA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember has experienced disease progression while on or following \nBesponsa (inotuzumab ozogamicin)\nRequired\nMedical\nInformation\nAcute Lymphoblastic Leukemia: The member has a diagnosis of B-cell \nprecursor acute lymphoblastic leukemia (ALL)AND The member has \nrelapsed or refractory disease AND The member has documented CD22 \nblasts found in bone marrow or peripheral blood AND The member will \nbe using Besponsa (inotuzumab ozogamicin) as monotherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner.\nCoverage\nDuration\nSix month durations (up to a maximum of 6 cycles)\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 39 of 497\n", "doc_id": "0b0dbdaa-e8ca-4866-91e7-c7adced2904b", "embedding": null, "doc_hash": "b7c21a6360383aa4cbde9ae446b989497e375ec7051922c6eb0160c9409c6c14", "extra_info": {"page_label": "39", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 750, "_node_type": "1"}, "relationships": {"1": "e06c63fe-2a3a-4c7c-830e-b6b3bbd855fb"}}, "__type__": "1"}, "b38cdebe-b5a9-48d0-b99f-deeae0cbcfdc": {"__data__": {"text": "BETASERON\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nThe member has a diagnosis of a relapsing form of multiple sclerosis, to \ninclude relapsing-remitting or active secondary progressive disease OR \nthe member has a diagnosis of a clinically isolated syndrome (CIS).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 40 of 497\n", "doc_id": "b38cdebe-b5a9-48d0-b99f-deeae0cbcfdc", "embedding": null, "doc_hash": "675368912eabacaf9eb517e054b2649c9b2371d8a5ad93e18285f06b18a10590", "extra_info": {"page_label": "40", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 514, "_node_type": "1"}, "relationships": {"1": "6f29e41a-f812-4162-ad45-37ac3cab1afd"}}, "__type__": "1"}, "261d514a-785e-4fbd-811e-059580094b87": {"__data__": {"text": "bexarotene\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers that are pregnant. Members on concomitant retinoid therapy.\nRequired\nMedical\nInformation\nCutaneous T-cell Lymphoma (CTCL). Targretin (bexarotene) capsules). \nThe member will be using Targretin as primary treatment  OR Member \nhas experienced disease progression, contraindication, or intolerance to \nat least one prior systemic therapy for cutaneous manifestations of \ncutaneous T-cell lymphoma. Cutaneous T-cell Lymphoma. Targretin \n(bexarotene) 1% topical gel/jelly). The member will be using Targretin as \nprimary treatment OR Member has experienced disease progression, \ncontraindications, or intolerance to at least one prior CTCL therapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 41 of 497\n", "doc_id": "261d514a-785e-4fbd-811e-059580094b87", "embedding": null, "doc_hash": "b275e3a4c4a84e6340d9c888c895ae0b18dafbc08a9536647af95762932c4792", "extra_info": {"page_label": "41", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 922, "_node_type": "1"}, "relationships": {"1": "51e07d18-ef1a-4228-a1b3-6fe7aa7ac4d5"}}, "__type__": "1"}, "36e450af-fd4d-426f-8443-9d19151ec92e": {"__data__": {"text": "BLENREP\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member has experienced disease progression on anti-BCMA-\ndirected therapy.\nRequired\nMedical\nInformation\nMultiple Myeloma:  The member has a diagnosis of multiple myeloma \nAND The member has relapsed/refractory disease AND The member \nhas received at least four prior therapies, including an anti-CD38 \nmonoclonal antibody (e.g. daratumumab), a proteasome inhibitor (e.g. \nbortezomib), and an immunomodulatory agent (e.g. lenalidomide) AND \nThe member is using Blenrep (belantamab mafodotin-blmf) as a single \nagent.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 42 of 497\n", "doc_id": "36e450af-fd4d-426f-8443-9d19151ec92e", "embedding": null, "doc_hash": "a0868de885ffc34dd6a35eac3fc96fb98d447e7ef249f8d7cb816bc67cc4eeec", "extra_info": {"page_label": "42", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 785, "_node_type": "1"}, "relationships": {"1": "3ae4e3a1-2dfe-4ab0-93f2-ea1c34c6f108"}}, "__type__": "1"}, "d7e162e0-54ba-4234-94a1-5d053ddfaeab": {"__data__": {"text": "bortezomib\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on bortezomib.\nRequired\nMedical\nInformation\nMantle Cell Lymphoma (MCL): The member has a diagnosis of Mantle \nCell Lymphoma(MCL).  Multiple Myeloma. The member has a diagnosis \nof Multiple Myeloma.  Waldenstr\u00f6m\n\u2019\ns Macroglobulinemia. The member \nhas a diagnosis of Waldenstr\u00f6m\n\u2019\ns macroglobulinemia AND Velcade \n(bortezomib) is being used for primary therapy, progressive or relapsed \ndisease or salvage therapy for disease that does not respond to primary \ntherapy AND Velcade (bortezomib) is being used as monotherapy, in \ncombination with Dexamethasone, or in combination with a rituximab \nproduct.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 43 of 497\n", "doc_id": "d7e162e0-54ba-4234-94a1-5d053ddfaeab", "embedding": null, "doc_hash": "5a8719a1d1b5e75c92d8f45a0e6d75262d5328eaee7bc0b70c2a554828f04b27", "extra_info": {"page_label": "43", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 915, "_node_type": "1"}, "relationships": {"1": "e974b134-6145-4383-bd70-dc312ac48902"}}, "__type__": "1"}, "1f55c7b5-30df-41fa-bdea-c7893b9c181b": {"__data__": {"text": "BOSULIF\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors. Members that have \nexperienced disease progression while on Bosulif (bosutinib). The \nmember has one of the following mutations: T315I, V299L, G250E, or \nF317L.\nRequired\nMedical\nInformation\nChronic Myelogenous Leukemia. The member has a diagnosis of \nPhiladelphia chromosome positive chronic myeloid leukemia (CML) AND \nOne of the following applies: The member has accelerated or blast \nphase CML OR The member has a diagnosis of chronic phase CML that \nhas not been previously treated and one of the following applies: \nIntermediate- or high-risk score for disease progression OR Low risk \nscore for disease progression and has contraindication to, intolerance to, \nor unable to achieve treatment goals with imatinib OR The member has \na diagnosis of chronic phase CML that has received previous treatment \nAND Low-, intermediate-, or high-risk score for disease progression.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 44 of 497\n", "doc_id": "1f55c7b5-30df-41fa-bdea-c7893b9c181b", "embedding": null, "doc_hash": "3f594d260c7e515acd7085860f34411cd0fdcaba0739fec06dfd0aa6f36933c1", "extra_info": {"page_label": "44", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1194, "_node_type": "1"}, "relationships": {"1": "65cf492d-d45d-4d2f-bd7c-47b5daa06f00"}}, "__type__": "1"}, "bd072fe1-c636-407d-b2b8-3629cd723a77": {"__data__": {"text": "BRAFTOVI\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers on concomitant Yervoy (ipilimumab), Opdivo (nivolumab), \nKeytruda (pembrolizumab), Zelboraf (vemurafenib), Cotellic\n(cobimetinib), Tafinlar (dabrafenib), or Mekinist (trametinib) OR Members \nthat have experienced disease progression while on prior anti-\nBRAF/MEK combination therapy [e.g. Cotellic (cobimetinib) with Zelboraf \n(vemurafenib) or Tafinlar (dabrafenib) with Mekinist (trametinib)].\nRequired\nMedical\nInformation\nMelanoma - Unresectable or metastatic. The member has a diagnosis of \nunresectable or stage IV metastatic melanoma AND The member has a \ndocumented BRAF V600 activating mutation AND The member will be \nusing Braftovi (encorafenib) in combination with Mektovi (binimetinib). \nColorectal Cancer - [Braftovi (encorafenib) requests only]:  The member \nhas documented BRAFV600E metastatic metastatic colorectal cancer \nand progressive disease on prior therapy AND Braftovi (encorafenib) is \ngiven in combination with Erbitux (cetuximab).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month durations or as determined through clinical review\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 45 of 497\n", "doc_id": "bd072fe1-c636-407d-b2b8-3629cd723a77", "embedding": null, "doc_hash": "808f166e5d516f80f1977dea7de901680994be1d1216bde1c447f7d8b8c768a2", "extra_info": {"page_label": "45", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1274, "_node_type": "1"}, "relationships": {"1": "cc9c178a-c197-4331-8fa4-4fda3d5dad89"}}, "__type__": "1"}, "0cd01362-f17a-4f91-8608-4943028c4e08": {"__data__": {"text": "BRIVIACT\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nPartial-onset seizures. Member must have a diagnosis of partial-onset \nseizures. Member has had prior therapy with levetiracetam AND one of \nthe following: topiramate, carbamazepine, gabapentin, divalproex, or \nlamotrigine.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 46 of 497\n", "doc_id": "0cd01362-f17a-4f91-8608-4943028c4e08", "embedding": null, "doc_hash": "563283266a255037b1c585eacb201fc6d31924de7761edb99d0c6af28901a226", "extra_info": {"page_label": "46", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 511, "_node_type": "1"}, "relationships": {"1": "3e99586e-a37c-46c0-900d-d26fbae4bec0"}}, "__type__": "1"}, "3a1ba42b-8b87-48e2-9f86-d7b3a478a6cd": {"__data__": {"text": "BROVANA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nAsthma, in the absence of concurrent medication containing inhaled \ncorticosteroid and comorbid COPD diagnosis.\nRequired\nMedical\nInformation\nChronic Obstructive Pulmonary Disease (COPD).Diagnosis of Chronic \nObstructive Pulmonary Disease (COPD), including chronic bronchitis \nand emphysema, requiring maintenance treatment of \nbronchoconstriction.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 47 of 497\n", "doc_id": "3a1ba42b-8b87-48e2-9f86-d7b3a478a6cd", "embedding": null, "doc_hash": "a559142c99d5456787913df86ad07673aecdbbcafb2714fcc85f70dd5585950e", "extra_info": {"page_label": "47", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 605, "_node_type": "1"}, "relationships": {"1": "1d140eaf-ccd8-41c0-be6d-4eb279622c7b"}}, "__type__": "1"}, "feed908e-f583-4be7-b350-f9204d833002": {"__data__": {"text": "BRUKINSA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on or following \nBrukinsa (zanubrutinib).\nRequired\nMedical\nInformation\nMantle cell lymphoma. The member has a diagnosis of mantle cell \nlymphoma AND The member has received at least one prior therapy \nAND The member will be using Brukinsa (zanubrutinib) as monotherapy. \nMarginal Zone Lymphoma: The member has a diagnosis of marginal \nzone lymphoma (MZL) AND The member is using Brukinsa \n(zanubrutinib) as second line or subsequent for refractory or progressive \ndisease AND The member has received at least one regimen containing \nanti-CD20 product (e.g. rituximab product) AND The member will be \nusing Brukinsa (zanubrutinib) as monotherapy. Waldenstroms \nMacroglobulinemia: The member has a diagnosis of Waldenstroms \nmacroglobulinemia (WM) AND the member will be using Brukinsa \n(zanubrutinib) as monotherapy. Chronic Lymphocytic Leukemia \n(CLL)/Small Lymphocytic Lymphoma (SLL). The member has a \ndiagnosis of Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic \nLymphoma (SLL).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 48 of 497\n", "doc_id": "feed908e-f583-4be7-b350-f9204d833002", "embedding": null, "doc_hash": "45677a501089581a3ee957a9194674e32c62c2175c95f879d5d5f8be6eb7b2b5", "extra_info": {"page_label": "48", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1298, "_node_type": "1"}, "relationships": {"1": "10ca498d-155d-4986-8436-798a86a0e22e"}}, "__type__": "1"}, "dbdb9e72-01c9-4912-a90a-976a13858cd8": {"__data__": {"text": "budesonide\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nMild to moderate active Crohn's disease:  The member must have a \ndiagnosis of mild to moderate active Crohn's disease. Autoimmune \nhepatitis: Member must have a diagnosis of autoimmune hepatitis.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 49 of 497\n", "doc_id": "dbdb9e72-01c9-4912-a90a-976a13858cd8", "embedding": null, "doc_hash": "2a01186d9debe5600cf11a2fdeea42a65c3c6f46f783b2bfaf9a8982f1e8c99b", "extra_info": {"page_label": "49", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 498, "_node_type": "1"}, "relationships": {"1": "00129353-93d9-4192-8c8e-57f16ed22367"}}, "__type__": "1"}, "c854a73b-ade2-4c22-a68d-fb62d116b52e": {"__data__": {"text": "CABLIVI\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nAcquired Thrombotic Thrombocytopenic Purpura: Member has a \ndiagnosis of acquired thrombotic thrombocytopenic purpura (aTTP) AND \nmember has achieved a normalized platelet count following plasma \nexchange (PEX) in combination with Cablivi (caplacizumab-yhdp) and \nimmunosuppresive therapy (e.g. rituximab) during inpatient treatment of \nTTP.  Reauthorization: member continues to have evidence of ongoing \ndisease (e.g. suppressed or unstable ADAMTS13 levels) AND member \nis still currently receiving therapy AND member has had 2 or fewer \nrecurrences while actively receiving Cablivi.\nAge Restriction\nMember must be 18 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n3 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 50 of 497\n", "doc_id": "c854a73b-ade2-4c22-a68d-fb62d116b52e", "embedding": null, "doc_hash": "a82c8ffe2dd002dd636dc82eb8af09c76f3836c4255768d7d257facaa184daca", "extra_info": {"page_label": "50", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 921, "_node_type": "1"}, "relationships": {"1": "7323d7d5-95ec-4636-af5a-2bfa7f54d943"}}, "__type__": "1"}, "1fc3fb3f-693c-48b6-91f6-db679d5f0bf5": {"__data__": {"text": "CABOMETYX\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experiences disease progression on cabozantinib.\nRequired\nMedical\nInformation\nRenal cell carcinoma: The member has advanced renal cell carcinoma \nAND one of the following applies:  the member will be using Cabometyx \n(cabozanitinib) as monotherapy OR the member will be using \nCabometyx (cabozanitinib) in combination with Opdivo (nivolumab) as \nfirst line therapy. Hepatocellular carcinoma. The member has a \ndiagnosis of hepatocellular carcinoma AND The member has been \npreviously treated with a first line therapy (e.g., sorafenib) AND \nCabometyx (cabozantinib) will be given as monotherapy.  Thyroid \nCancer:  The member has a diagnosis of locally advanced or metastatic \ndifferentiated thyroid cancer AND Member has experienced disease \nprogression following prior anti-VEGF targeted therapy AND Member is \nradioactive iodine refractory or ineligible AND Cabometyx (cabozantinib) \nwill be administered as monotherapy.\nAge Restriction\nThyroid Cancer: Member is 12 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 51 of 497\n", "doc_id": "1fc3fb3f-693c-48b6-91f6-db679d5f0bf5", "embedding": null, "doc_hash": "8bc2c21aeb3ce988fe34ebc554f9dd9bb071ff9bab34568836a1fcca74d2d967", "extra_info": {"page_label": "51", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1243, "_node_type": "1"}, "relationships": {"1": "cd8f94f6-d520-411f-8640-9b9da389ad01"}}, "__type__": "1"}, "bc47bc62-bdbb-4bc6-82da-57f7bb750019": {"__data__": {"text": "calcipotriene\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nPsoriasis: The member must have a diagnosis of plaque psoriasis AND \nhas had previous treatment, contraindication or intolerance with topical \ntriamcinolone 0.5% AND topical betamethasone dipropionate.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 52 of 497\n", "doc_id": "bc47bc62-bdbb-4bc6-82da-57f7bb750019", "embedding": null, "doc_hash": "7ad36c76e55a8a0eea87ec895457b1efe1b4d7770298e3ffdf6e5977d9d7ded1", "extra_info": {"page_label": "52", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 506, "_node_type": "1"}, "relationships": {"1": "104302c0-1d43-4ae0-a1ce-0a98ce6b9a54"}}, "__type__": "1"}, "6c53b6c1-8c40-491d-85d3-b8f5d3d86de9": {"__data__": {"text": "CALQUENCE\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member has experienced disease progression while on or following \nCalquence (acalabrutinib).\nRequired\nMedical\nInformation\nMantle Cell Lymphoma:  The member had a diagnosis of mantle cell \nlymphoma AND the member has received at least one prior therapy AND \nthe member will be using Calquence (acalabrutinib) as monotherapy.  \nChronic lymphocytic leukemia (CLL) / Small lymphocytic lymphoma \n(SLL):  member has a diagnosis of chronic lymphocytic leukemia (CLL) \nor small lymphocytic lymphoma (SLL).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 53 of 497\n", "doc_id": "6c53b6c1-8c40-491d-85d3-b8f5d3d86de9", "embedding": null, "doc_hash": "b05123e9330d5b160b9e521f9c01218ba6ed306943970a0fe4f607bf5f66d884", "extra_info": {"page_label": "53", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 770, "_node_type": "1"}, "relationships": {"1": "41c723a6-31b3-47ec-80c7-e805195c82e4"}}, "__type__": "1"}, "e5c104f2-8850-428e-9e0e-53e0cce18c24": {"__data__": {"text": "CALQUENCE (ACALABRUTINIB MAL)\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member has experienced disease progression while on or following \nCalquence (acalabrutinib).\nRequired\nMedical\nInformation\nMantle Cell Lymphoma:  The member had a diagnosis of mantle cell \nlymphoma AND the member has received at least one prior therapy AND \nthe member will be using Calquence (acalabrutinib) as monotherapy.  \nChronic lymphocytic leukemia (CLL) / Small lymphocytic lymphoma \n(SLL):  member has a diagnosis of chronic lymphocytic leukemia (CLL) \nor small lymphocytic lymphoma (SLL).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 54 of 497\n", "doc_id": "e5c104f2-8850-428e-9e0e-53e0cce18c24", "embedding": null, "doc_hash": "1dd8588181982b3f6917033871f526b115a0c4ec20bf4a64e4d950698c3bd9a0", "extra_info": {"page_label": "54", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 790, "_node_type": "1"}, "relationships": {"1": "d9b00aeb-bbda-4a5c-87b6-4dea7d13fc5b"}}, "__type__": "1"}, "37a6620b-4114-47c8-b597-1ebab602c11e": {"__data__": {"text": "CAMZYOS\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nObstructive Hypertonic Cardiomyopathy:  member must have diagnosis \nof hypertrophic cardiomyopathy AND the member must have \nconfirmation of an obstruction (e.g. cardiac MRI, echocardiogram, or \ncardiac catheterization) AND the member must have NYHA Class II-III \nsymptoms AND the member must have a left ventricular ejection fraction \n(LVEF) of greater than or equal to 55% AND the member has had \nprevious treatment, intolerance or contraindication to beta-blockers (e.g. \natenolol, metoprolol, bisoprolol) or non-dihydropyridine calcium channel \nblockers (e.g. verapamil, diltiazem) at doses appropriate for obstructive \nhypertrophic cardiomyopathy.  Reauthorization criteria:  the member \nmust meet all of the following criteria:  the member must have a LVEF \ngreater than or equal to 50% AND the member has had clinically \nsignificant improvement of symptoms (e.g. improvement in NT-proBNP, \ndecreased shortness of breath, improvement in patient reported \noutcomes assessment) AND provider attestation that the patient has not \nand will not receive septal reduction therapy (SRT) while on mavacamten \ntherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial Duration: 6 Months. Reauthorization: Plan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 55 of 497\n", "doc_id": "37a6620b-4114-47c8-b597-1ebab602c11e", "embedding": null, "doc_hash": "03fddd40af85dd1f0046a76b8866af3af308285ec51e048c8832a29ce28fa5c7", "extra_info": {"page_label": "55", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1446, "_node_type": "1"}, "relationships": {"1": "9a1538c1-2492-44a5-81aa-c63c94caa618"}}, "__type__": "1"}, "5197d6ae-05b2-44cb-84a6-0930e4d7a673": {"__data__": {"text": "CAPLYTA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDementia-related psychosis (in the absence of an approvable diagnosis), \nfor member 65 years of age or older.\nRequired\nMedical\nInformation\nSchizophrenia. The member must have a diagnosis of schizophrenia \nAND The member must have documentation of prior therapy, \nintolerance, or contraindication to at least two of the following: \nrisperidone or olanzapine or quetiapine or ziprasidone or aripiprazole.  \nBipolar I or II Disorder (Dipolar Depression):  The member must have a \ndiagnosis of bipolar I or II disorder (bipolar depression) AND the member \nmust have documentation of prior therapy, intolerance, or \ncontraindication to quetiapine and at least one of the following:  \nrisperidone, olanzapine, ziprasidone, or aripiprazole.\nAge Restriction\nThe member must be 18 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 56 of 497\n", "doc_id": "5197d6ae-05b2-44cb-84a6-0930e4d7a673", "embedding": null, "doc_hash": "4e1d6c723c76e05e0718a75dbd9c82163e5822fef7c629f0be34c11cc90be395", "extra_info": {"page_label": "56", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1036, "_node_type": "1"}, "relationships": {"1": "9c19605c-cd7f-4416-8ce1-2b44d0ae735e"}}, "__type__": "1"}, "58a1df65-3a98-452e-9047-6790b58aad76": {"__data__": {"text": "CAPRELSA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors. Members that have \nexperienced disease progression while on Vandetanib.\nRequired\nMedical\nInformation\nThyroid Cancer. The member has a diagnosis of locally advanced or \nmetastatic medullary thyroid cancer AND The member has symptomatic \nor progressive disease OR the member has a diagnosis of symptomatic \niodine refractory follicular carcinoma or Hurthle cell carcinoma or \npapillary carcinoma AND  unresectable recurrent or persistent \nlocoregional disease or metastatic disease.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n3 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 57 of 497\n", "doc_id": "58a1df65-3a98-452e-9047-6790b58aad76", "embedding": null, "doc_hash": "d82eb233928afa3e8fe24d671cba0ba0a29816a1a675ef6f02429b7d98a61e0e", "extra_info": {"page_label": "57", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 798, "_node_type": "1"}, "relationships": {"1": "7b9aaa04-641b-489a-9445-d3af27f4c1df"}}, "__type__": "1"}, "51f336cd-2feb-4b27-8151-e715ebbb5949": {"__data__": {"text": "carglumic acid\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nThe member has acute or chronic hyperammonemia due to deficiency of \nhepatic enzyme N-acetylglutamate synthase (NAGS).  Acute \nhyperammonemia due to PAA or MMA deficiency: the member has acute \nhyperammonemia due to propionic acidemia (PA) or methylmalonic \nacidemia (MMA).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 58 of 497\n", "doc_id": "51f336cd-2feb-4b27-8151-e715ebbb5949", "embedding": null, "doc_hash": "d6d70617e90cef9e2172ed586444b93c0dca9db31871141a0fa8cd5d60790cc5", "extra_info": {"page_label": "58", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 567, "_node_type": "1"}, "relationships": {"1": "df1fa265-80be-4603-9628-88c9597d0ad0"}}, "__type__": "1"}, "1feb12bc-6744-4ce1-9b04-0676fd2a9b4a": {"__data__": {"text": "CAYSTON\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nPatients with a forced expiratory volume in one second (FEV1) less than \n25% or greater than 75% predicted. Patients colonized with Burkholderia \ncepacia.\nRequired\nMedical\nInformation\nCystic Fibrosis. The member must have a diagnosis of cystic fibrosis \n(CF). The member is colonized with Pseudomonas aeruginosa. The \nmember must have a short or long-acting beta-agonist bronchodilator \n(e.g. albuterol or formoterol), and will be utilized prior to Cayston.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 59 of 497\n", "doc_id": "1feb12bc-6744-4ce1-9b04-0676fd2a9b4a", "embedding": null, "doc_hash": "6ec999acdd417853599de6660710a64c3b17768679d50f9e92a2fe28605309f2", "extra_info": {"page_label": "59", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 715, "_node_type": "1"}, "relationships": {"1": "7c61def2-3c1c-4c01-b76e-ce02f91404e1"}}, "__type__": "1"}, "4ce04832-7d92-4d98-b75c-b0362623ff41": {"__data__": {"text": "CERDELGA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcurrent use of a strong or moderate CYP2D6 inhibitor (eg. \nparoxetine, terbinafine) and a strong or moderate CYP3A inhibitor (eg. \nketoconazole, fluconazole) in patients who are EMs or IMs.Concurrent \nuse of a strong CYP3A inhibitor in patients who are IMs or PMs  (eg. \nketoconazole).\nRequired\nMedical\nInformation\nType 1 Gaucher's disease:The member has a diagnosis of type 1 \nGaucher's disease AND Member is a CYP2D6 poor metabolizer (PM), \nextensive metabolizer (EM), or intermediate metabolizer (IM) as \nconfirmed by an FDA-approved genetic test.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 60 of 497\n", "doc_id": "4ce04832-7d92-4d98-b75c-b0362623ff41", "embedding": null, "doc_hash": "a7beba160f6075f10e8e203dfb4a4867e85b800b2e1f6174c7fd15fa60de5fc3", "extra_info": {"page_label": "60", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 812, "_node_type": "1"}, "relationships": {"1": "aec0f15b-e05e-46b6-99ce-375434716ff2"}}, "__type__": "1"}, "ec91d208-9eb3-4ef5-943f-3d220a402eea": {"__data__": {"text": "CEREZYME\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nCerezyme (imiglucerase) will require prior authorization. These agents \nmay be considered medically necessary when the following criteria are \nmet: Confirmed diagnosis of Type 1 Gaucher disease, resulting in one or \nmore of the following conditions: Anemia, Thrombocytopenia, Bone \ndisease, Hepatomegaly, Splenomegaly.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 61 of 497\n", "doc_id": "ec91d208-9eb3-4ef5-943f-3d220a402eea", "embedding": null, "doc_hash": "bcda75f2111332e9fafefc2933c8f77752f28e7f79cde19d4548269fb72589e3", "extra_info": {"page_label": "61", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 615, "_node_type": "1"}, "relationships": {"1": "2a909028-dc81-4412-8241-d944dbb5d3d8"}}, "__type__": "1"}, "989fcb88-a4cf-4fb9-aab9-8f3ec29981a3": {"__data__": {"text": "CHENODAL\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nA nonvisualizing gallbladder confirmed by two consecutive single doses \nof dye OR Radiopaque (calcified) stones OR Pregnancy OR Patients \nwith known hepatocyte dysfunction OR Patients with biliary tract disease \nincluding bile ductal abnormalities such as inrahepatic cholestasis, \nprimary biliary cirrhosis, or sclerosing cholangitis OR Patients with \ngallstone complications or gallbladder disease necessitating surgery due \nto unremitting acute cholecystitis, cholangitis, biliary obstruction, \ngallstone pancreatitis, or biliary-GI fistula.\nRequired\nMedical\nInformation\nThe member has a diagnosis of radiolucent gallstones in well-opacifying \ngallbladders AND the member is not a candidate for laparoscopic \ncholecystectomy AND the member must have had previous treatment \nwith, contraindication, or intolerance to ursodiol.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 62 of 497\n", "doc_id": "989fcb88-a4cf-4fb9-aab9-8f3ec29981a3", "embedding": null, "doc_hash": "56feacd641ed1ff108bec28cae92b6c1d59f196a2b809df760cb48b0551982f5", "extra_info": {"page_label": "62", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1093, "_node_type": "1"}, "relationships": {"1": "327b3dfa-5bfe-455d-af15-bca96e695756"}}, "__type__": "1"}, "03144f58-a22b-44ae-8fef-f6cb3fda2d81": {"__data__": {"text": "CHOLBAM\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nBile acid synthesis disorders due to single enzyme defects initial review: \nThe member must have a diagnosis of bile acid synthesis disorders \n(BASDs) due to single enzyme defects confirmed by Fast Atom \nBombardment Ionization analysis (FAB-MS) (e.g. 3beta-hydroxy- delta5-\nC27-steroid oxidoreductase (3beta-HSD) deficiency, delta4-3-oxosteroid \n5beta-reductase (AKR1D1) deficiency, cerebrotendinous xanthomatosis \n(CTX), or 2-[or alpha-] methylacyl-CoA racemase (AMACR) deficiency). \nAdjunctive treatment of peroxisomal disorders: The member must have a \ndiagnosis of a peroxisomal disorder (PD) confirmed by Fast Atom \nBombardment Ionization analysis (FAB-MS), including: Zellweger \nSyndrome or Neonatal Adrenoleukodystrophy or Generalized \nPeroxisomal Disorder or Refsum Disease or Peroxisomal disorder of \nunknown type) AND The member must have signs and symptoms of liver \ndisease (e.g. jaundice, hepatomegaly, dark urine, discolored stools), \nsteatorrhea or complications from decreased fat soluble vitamin \nabsorption.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 63 of 497\n", "doc_id": "03144f58-a22b-44ae-8fef-f6cb3fda2d81", "embedding": null, "doc_hash": "ddca61fab0bc0fcc6f641557194c0968a6343837011cbb9e266bbb1ada54f785", "extra_info": {"page_label": "63", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1312, "_node_type": "1"}, "relationships": {"1": "3e363369-24d7-49f8-8a28-fa580b125227"}}, "__type__": "1"}, "59dd00c0-ab06-4060-87a6-4843e83a07ea": {"__data__": {"text": "CHORIONIC GONADOTROPIN, HUMAN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nObesity, Female or male infertility, Erectile Dysfunction, Precocious \npuberty, Prostatic carcinoma or other androgen-dependent neoplasm.\nRequired\nMedical\nInformation\nNA\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 64 of 497\n", "doc_id": "59dd00c0-ab06-4060-87a6-4843e83a07ea", "embedding": null, "doc_hash": "8ff8ea846fcf584431f843be26c79f480c30a5f3a6ca9c7c3bba83ee712553a6", "extra_info": {"page_label": "64", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 455, "_node_type": "1"}, "relationships": {"1": "be853f4f-973a-4ce9-8a3d-06c3ae902409"}}, "__type__": "1"}, "ed9d357b-eef7-40cf-b1b8-9cc9fb8e5772": {"__data__": {"text": "clobazam\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nLennox-Gastaut Syndrome. Member has diagnosis of seizures \nassociated with LGS.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 65 of 497\n", "doc_id": "ed9d357b-eef7-40cf-b1b8-9cc9fb8e5772", "embedding": null, "doc_hash": "389d4677061b96c695da9d7c2a372102730cee490d4207d3de3c90edcc9b0d62", "extra_info": {"page_label": "65", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 379, "_node_type": "1"}, "relationships": {"1": "e6418e2f-e5e8-4474-ab55-88b33fc95a88"}}, "__type__": "1"}, "0cb4bfd2-811d-4591-83f6-c03f4068615c": {"__data__": {"text": "clozapine\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDementia-related psychosis (in the absence of an approvable diagnosis), \nfor member 65 years of age or older.\nRequired\nMedical\nInformation\nThe member must be using clozapine orally disintegrating tablet for \ntreatment-resistant schizophrenia.The member must have had prior \ntherapy or intolerance to generic clozapine.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 66 of 497\n", "doc_id": "0cb4bfd2-811d-4591-83f6-c03f4068615c", "embedding": null, "doc_hash": "0ce140e3f9b63888b5da4a723a1cd054f9cda0ba0874e4f61855758c8b5e35d0", "extra_info": {"page_label": "66", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 584, "_node_type": "1"}, "relationships": {"1": "0dee2c1b-aba4-489f-8ffa-0167f405ec19"}}, "__type__": "1"}, "be8c18a5-785e-46d0-88bc-e7567f899220": {"__data__": {"text": "COMETRIQ\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on Cometriq \n(cabozantinib). Members on concomitant tyrosine kinase inhibitors.\nRequired\nMedical\nInformation\nMetastatic Medullary Thyroid Carcinoma. The member has a diagnosis \nof progressive, metastatic medullary thyroid carcinoma MTC.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nsix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 67 of 497\n", "doc_id": "be8c18a5-785e-46d0-88bc-e7567f899220", "embedding": null, "doc_hash": "584755f0114acb790c3a0e809ed532d7996b98b0e4f44fea49a946867436e727", "extra_info": {"page_label": "67", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 554, "_node_type": "1"}, "relationships": {"1": "cce2af5b-4ebd-406c-b08f-8815a64e8ea9"}}, "__type__": "1"}, "4bd75d11-54a9-459c-bb61-f0bb033fa1fd": {"__data__": {"text": "CONTRAVE\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nWeight Management:Upon initiation of treatment with obesity \nmedication, Body Mass Index (BMI) is at Least 30 kg/m2 (obese) OR 27 \nkg/m2 (overweight) in the presence of at least one weight-related \ncomorbid condition (e.g., hypertension, dyslipidemia, type 2 diabetes). \nMember will be evaluated by prescribing physician to determine if at \nleast 5% of baseline body weight has been lost at 12 weeks and at least \nevery 6 months thereafter for continued treatment with obesity \nmedication.\nAge Restriction\n18 years or older\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 68 of 497\n", "doc_id": "4bd75d11-54a9-459c-bb61-f0bb033fa1fd", "embedding": null, "doc_hash": "30401b378d2a0754f4f2d8c19b24ac5b8d9d718a7ad036f0f41981b102af0a38", "extra_info": {"page_label": "68", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 804, "_node_type": "1"}, "relationships": {"1": "c778080a-e532-40ac-ab93-8ef6ff0b3547"}}, "__type__": "1"}, "9df86eb3-6b77-428c-a518-da2e357e9826": {"__data__": {"text": "COPAXONE\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nThe member has a diagnosis of a relapsing form of multiple sclerosis, to \ninclude relapsing-remitting or active secondary progressive disease OR \nthe member has a diagnosis of a clinically isolated syndrome (CIS).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 69 of 497\n", "doc_id": "9df86eb3-6b77-428c-a518-da2e357e9826", "embedding": null, "doc_hash": "068ab0e5047e7552fe662711acfd2190fe133de85e02071d7274427065e11d72", "extra_info": {"page_label": "69", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 513, "_node_type": "1"}, "relationships": {"1": "fa329130-0130-4069-b191-9558e903c569"}}, "__type__": "1"}, "d614dc29-5315-4670-9714-84cf74769c5b": {"__data__": {"text": "COPIKTRA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on or following \na PI3K inhibitor (e.g. idelalisib, copanlisib, duvelisib).\nRequired\nMedical\nInformation\nChronic lymphocytic leukemia. The member has a diagnosis of chronic \nlymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) AND \nthe member has relapsed or refractory disease AND The member will be \nusing Copiktra (duvelisib) as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 70 of 497\n", "doc_id": "d614dc29-5315-4670-9714-84cf74769c5b", "embedding": null, "doc_hash": "acae851c2d1f51183a9de87d94e3e2e63e56588f5668aec1d4bd9e1abeb5fbf2", "extra_info": {"page_label": "70", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 665, "_node_type": "1"}, "relationships": {"1": "3c20feac-bd91-4960-bd4b-34988cf58921"}}, "__type__": "1"}, "5ce62330-7800-43a3-ae5d-e60b62bb43b0": {"__data__": {"text": "CORLANOR\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nHeart rate maintained exclusively by pacemaker.\nRequired\nMedical\nInformation\nHeart Failure (Adult Patients): The member must meet ALL of the \nfollowing criteria: have a diagnosis of NYHA Class II, III, or IV heart \nfailure AND Documentation of left ventricular ejection fraction less than \nor equal to 35% AND The member must be in sinus rhythm with a resting \nheart rate greater than or equal to 70 beats per minute AND \nDocumentation of blood pressure greater than or equal to 90/50 mmHg \nAND Documentation of previous treatment, intolerance, or \ncontraindication to maximally tolerated doses of at least one beta-blocker \n(e.g., carvedilol 50 mg daily, metoprolol 200 mg daily, or bisoprolol 10 \nmg daily) AND In patients with Severe Hepatic Impairment (Child-Pugh \nClass C) -  Provider attests that the risk versus benefit of severe \nhypotension has been considered, and the benefits of treatment \noutweigh the risks. Heart Failure (Pediatric Patients) The member must \nmeet ALL of the following criteria: The member must have a diagnosis of \nNYHA Class II, III, or IV heart failure AND Documentation of left \nventricular ejection fraction less than or equal to 45% AND The member \nhas been clinically stable for at least 4 weeks and on optimized medical \ntherapy AND The member is in sinus rhythm AND In patients with \nSevere Hepatic Impairment (Child-Pugh Class C) -  Provider attests that \nthe risk versus benefit of severe hypotension has been considered, and \nthe benefits of treatment outweigh the risks AND One of the following: \nThe member is 6 to 12 months of age and has a resting heart rate of \ngreater than or equal to 105 beats per minute OR The member is 1 to \nless than 3 years of age and has a resting heart rate of greater than or \nequal to 95 beats per minute OR The member is 3 to less than 5 years of \nage and has a resting heart rate of greater than or equal to 75 beats per \nminute OR The member is greater than 5 years of age and has a resting \nheart rate of greater than or equal to 70 beats per minute.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nReauthorization Criteria (Adult and Pediatric Patients): Member has \ncontinued clinical benefit from Corlanor (ivabradine) as defined by \nmaintenance of decreased Heart rate compared to initiation of Corlanor \ntreatment.\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 71 of 497\n", "doc_id": "5ce62330-7800-43a3-ae5d-e60b62bb43b0", "embedding": null, "doc_hash": "9b9a45e5f82ec24f8cc9a5eeaae2192e0014bca6b0da200c78bdb76b48e0f040", "extra_info": {"page_label": "71", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2488, "_node_type": "1"}, "relationships": {"1": "e21afb07-9822-445a-833e-013f46bc321f"}}, "__type__": "1"}, "b6c5ed46-d393-4eb1-a875-022e4e7e7b81": {"__data__": {"text": "CORLANOR\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 72 of 497\n", "doc_id": "b6c5ed46-d393-4eb1-a875-022e4e7e7b81", "embedding": null, "doc_hash": "3c98efd4a72757d97ae0eb90f2cc5e2db2342a306352f88262c295a0aa9d2ad3", "extra_info": {"page_label": "72", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 82, "_node_type": "1"}, "relationships": {"1": "415b75ea-3f7d-483c-8a8a-f25984f59781"}}, "__type__": "1"}, "ce90e5c3-d282-440b-ba95-2a7d678b071a": {"__data__": {"text": "COSENTYX\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nModerate to severe chronic plaque psoriasis: The member has a \ndiagnosis of moderate to severe plaque psoriasis AND The member has \nhad prior therapy with or intolerance to a single conventional oral \nsystemic treatment (e.g. methotrexate, cyclosporine), or contraindication \nto all conventional oral systemic treatments. Psoriatic Arthritis: The \nmember has a diagnosis of active psoriatic arthritis AND The member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine,leflunomide) or contraindication to all \nDMARDs. Active ankylosing spondylitis: The member has a diagnosis of \nactive ankylosing spondylitis AND the member has had prior therapy, \ncontraindication, or intolerance with a non-steroidal anti-inflammatory \ndrug (NSAID) (e.g. ibuprofen, meloxicam, naproxen).  Non-radiographic \nAxial Spondyloarthritis:  The member has a diagnosis of non-\nradiographic axial spondyloarthritis with signs of inflammation AND the \nmember has had prior therapy, contraindication, or intolerance with a \nnonsteroidal anti-inflammatory drug (NSAID) (e.g. ibuprofen, meloxicam, \nnaproxen). Active Enthesitis-related Juvenile Idiopathic Arthritis:  The \nmember has a diagnosis of active enthesitis-related arthritis (ERA) AND \nthe member has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drugs (NSAID) (e.g. ibuprofen, \nmeloxicam, naproxen).\nAge Restriction\nPlaque Psoriasis: Member must be 6 years of age or older.  Ankylosing \nSpondylitis, and Non-radiographic axial spondyloarthritis: Member must \nbe 18 years of age or older. Psoriatic Arthritis: member must be 2 years \nof age or older. Active Enthesitis-related Juvenile Idiopathic Arthritis: \nmember must be 4 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 73 of 497\n", "doc_id": "ce90e5c3-d282-440b-ba95-2a7d678b071a", "embedding": null, "doc_hash": "1b00dc05dba925d5c761b06452cc940e71779479cfae9a77991142dd13c3dafd", "extra_info": {"page_label": "73", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2041, "_node_type": "1"}, "relationships": {"1": "181f480d-f1b4-49df-a446-5acf992efdb0"}}, "__type__": "1"}, "62dbd8e3-0420-45f2-be5b-49c9bf68e4fa": {"__data__": {"text": "COSENTYX (2 SYRINGES)\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nModerate to severe chronic plaque psoriasis: The member has a \ndiagnosis of moderate to severe plaque psoriasis AND The member has \nhad prior therapy with or intolerance to a single conventional oral \nsystemic treatment (e.g. methotrexate, cyclosporine), or contraindication \nto all conventional oral systemic treatments. Psoriatic Arthritis: The \nmember has a diagnosis of active psoriatic arthritis AND The member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine,leflunomide) or contraindication to all \nDMARDs. Active ankylosing spondylitis: The member has a diagnosis of \nactive ankylosing spondylitis AND the member has had prior therapy, \ncontraindication, or intolerance with a non-steroidal anti-inflammatory \ndrug (NSAID) (e.g. ibuprofen, meloxicam, naproxen).  Non-radiographic \nAxial Spondyloarthritis:  The member has a diagnosis of non-\nradiographic axial spondyloarthritis with signs of inflammation AND the \nmember has had prior therapy, contraindication, or intolerance with a \nnonsteroidal anti-inflammatory drug (NSAID) (e.g. ibuprofen, meloxicam, \nnaproxen). Active Enthesitis-related Juvenile Idiopathic Arthritis:  The \nmember has a diagnosis of active enthesitis-related arthritis (ERA) AND \nthe member has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drugs (NSAID) (e.g. ibuprofen, \nmeloxicam, naproxen).\nAge Restriction\nPlaque Psoriasis: Member must be 6 years of age or older.  Ankylosing \nSpondylitis, and Non-radiographic axial spondyloarthritis: Member must \nbe 18 years of age or older. Psoriatic Arthritis: member must be 2 years \nof age or older. Active Enthesitis-related Juvenile Idiopathic Arthritis: \nmember must be 4 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 74 of 497\n", "doc_id": "62dbd8e3-0420-45f2-be5b-49c9bf68e4fa", "embedding": null, "doc_hash": "11d45beab1abe071cfcdd57943aa8b8c99342d59e2aaa8e86c5c7fe7530b3588", "extra_info": {"page_label": "74", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2054, "_node_type": "1"}, "relationships": {"1": "69307d73-8208-4075-aa9e-60c12357ba3f"}}, "__type__": "1"}, "799d9c18-626c-4e20-b34a-a53b9658b9ae": {"__data__": {"text": "COSENTYX PEN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nModerate to severe chronic plaque psoriasis: The member has a \ndiagnosis of moderate to severe plaque psoriasis AND The member has \nhad prior therapy with or intolerance to a single conventional oral \nsystemic treatment (e.g. methotrexate, cyclosporine), or contraindication \nto all conventional oral systemic treatments. Psoriatic Arthritis: The \nmember has a diagnosis of active psoriatic arthritis AND The member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine,leflunomide) or contraindication to all \nDMARDs. Active ankylosing spondylitis: The member has a diagnosis of \nactive ankylosing spondylitis AND the member has had prior therapy, \ncontraindication, or intolerance with a non-steroidal anti-inflammatory \ndrug (NSAID) (e.g. ibuprofen, meloxicam, naproxen).  Non-radiographic \nAxial Spondyloarthritis:  The member has a diagnosis of non-\nradiographic axial spondyloarthritis with signs of inflammation AND the \nmember has had prior therapy, contraindication, or intolerance with a \nnonsteroidal anti-inflammatory drug (NSAID) (e.g. ibuprofen, meloxicam, \nnaproxen). Active Enthesitis-related Juvenile Idiopathic Arthritis:  The \nmember has a diagnosis of active enthesitis-related arthritis (ERA) AND \nthe member has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drugs (NSAID) (e.g. ibuprofen, \nmeloxicam, naproxen).\nAge Restriction\nPlaque Psoriasis: Member must be 6 years of age or older.  Ankylosing \nSpondylitis, and Non-radiographic axial spondyloarthritis: Member must \nbe 18 years of age or older. Psoriatic Arthritis: member must be 2 years \nof age or older. Active Enthesitis-related Juvenile Idiopathic Arthritis: \nmember must be 4 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 75 of 497\n", "doc_id": "799d9c18-626c-4e20-b34a-a53b9658b9ae", "embedding": null, "doc_hash": "b5a181d842c8eb6f51c5dff5b6d7a2035d22bdba2ed74d5a2df9f2f1015ceede", "extra_info": {"page_label": "75", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2045, "_node_type": "1"}, "relationships": {"1": "b86bf61a-9c54-41e3-b493-710dcbec0ed8"}}, "__type__": "1"}, "c4890488-911f-4da0-b7d0-5d5feb8a4649": {"__data__": {"text": "COSENTYX PEN (2 PENS)\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nModerate to severe chronic plaque psoriasis: The member has a \ndiagnosis of moderate to severe plaque psoriasis AND The member has \nhad prior therapy with or intolerance to a single conventional oral \nsystemic treatment (e.g. methotrexate, cyclosporine), or contraindication \nto all conventional oral systemic treatments. Psoriatic Arthritis: The \nmember has a diagnosis of active psoriatic arthritis AND The member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine,leflunomide) or contraindication to all \nDMARDs. Active ankylosing spondylitis: The member has a diagnosis of \nactive ankylosing spondylitis AND the member has had prior therapy, \ncontraindication, or intolerance with a non-steroidal anti-inflammatory \ndrug (NSAID) (e.g. ibuprofen, meloxicam, naproxen).  Non-radiographic \nAxial Spondyloarthritis:  The member has a diagnosis of non-\nradiographic axial spondyloarthritis with signs of inflammation AND the \nmember has had prior therapy, contraindication, or intolerance with a \nnonsteroidal anti-inflammatory drug (NSAID) (e.g. ibuprofen, meloxicam, \nnaproxen). Active Enthesitis-related Juvenile Idiopathic Arthritis:  The \nmember has a diagnosis of active enthesitis-related arthritis (ERA) AND \nthe member has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drugs (NSAID) (e.g. ibuprofen, \nmeloxicam, naproxen).\nAge Restriction\nPlaque Psoriasis: Member must be 6 years of age or older.  Ankylosing \nSpondylitis, and Non-radiographic axial spondyloarthritis: Member must \nbe 18 years of age or older. Psoriatic Arthritis: member must be 2 years \nof age or older. Active Enthesitis-related Juvenile Idiopathic Arthritis: \nmember must be 4 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 76 of 497\n", "doc_id": "c4890488-911f-4da0-b7d0-5d5feb8a4649", "embedding": null, "doc_hash": "9b4fe3d6d346595f6efcec2987ae2f5b679f5007f2d3700abc8585d83b81193c", "extra_info": {"page_label": "76", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2054, "_node_type": "1"}, "relationships": {"1": "5323634e-566c-4b34-859f-9cf4a80e5122"}}, "__type__": "1"}, "1b9a4a62-2e8a-4759-bec9-119d2c8a0513": {"__data__": {"text": "COTELLIC\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMelanoma indication only:  Members on Cotellic as a single agent. \nMembers on concomitant Yervoy (ipilimumab), Opdivo (nivolumab), \nKeytruda(pembrolizumab), Tafinlar (dabrafenib), Mekinist (trametinib), \nBraftovi (encorafenib), or Mektovi (binimetinib). Members that have \nexperienced disease progression while on Cotellic. Members that have \nexperienced disease progression while on prior anti-BRAF/MEK \ncombination therapy [e.g. Cotellic (cobimetinib) with Zelboraf \n(vemurafenib) or  Tafinlar (dabrafenib) with Mekinist (trametinib)].\nRequired\nMedical\nInformation\nMelanoma: The member has a diagnosis of unresectable or stage IV \nmetastatic melanoma AND The member has a documented BRAF V600 \nactivating mutation AND The member will be using Cotellic (cobimetinib) \nin combination with Zelboraf(vemurafenib).  Histiocytic Neoplasms: the \nmember has a diagnosis of histiocytic neoplasms AND the member will \nbe using Cotellic (cobimetinib) as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 77 of 497\n", "doc_id": "1b9a4a62-2e8a-4759-bec9-119d2c8a0513", "embedding": null, "doc_hash": "e49ea0389a9d20154386f6021a1d9eac61877e35c4af9643f0c9afbe768cd9d4", "extra_info": {"page_label": "77", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1215, "_node_type": "1"}, "relationships": {"1": "cc51f16f-94bd-424c-90e9-9cee2d881414"}}, "__type__": "1"}, "478cd9a0-e867-48d0-b27b-d55fae8db294": {"__data__": {"text": "CRYSVITA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nOral phospate within one week of starting Crysvita (burosumab) therapy. \nVitamin D analogs within one week or starting Crysvita therapy.\nRequired\nMedical\nInformation\nX-Linked Hypophosphatemia (XLH) \u00e2?? Initial approval: Member must \nhave diagnosis of XLH supported by both of the following:  Serum \nfibroblast growth factor 23 (FGF23) level greater than 30 pg/mL OR a \npositive PHEX test AND a reduction in the ratio of the maximum rate of \ntubular phosphate reabsorption to the glomerular filtration rate \n(TmP/GFR).  Member must have clinical signs and symptoms of XLH \n(e.g. rickets, growth impairment, musculoskeletal pain, fractures).  \nContinuation of therapy: Member must have been previously treated with \nCrysvita (burosumab). Member has experienced improvement in serum \nphosphorous concentrations while on Crysvita therapy. Member has \nexperienced a positive clinical response (e.g. reduction in \nmusculoskeletal pain, improvement in skeletal deformities, reduction in \nfractures, linear growth).  Tumor-Induced Osteomalacia (TIO) - Initial \nApproval:  The member must have a diagnosis of FGF23-related \nhypophosphatemia in tumor-induced osteomalacia supported by BOTH \nof the following: Serum fibroblast growth factor 23 (FGF23) level of \ngreater than 30 pg/mL AND A reduction in the ratio of the maximum rate \nof tubular phosphate reabsorption to the glomerular filtration rate \n(TmP/GFR) AND The disease must be associated with phosphaturic \nmesenchymal tumors AND The disease cannot be curatively resected or \nlocalized AND The member must have clinical signs and symptoms of \nTIO (muscle weakness, skeletal weakness, muscle pain, fatigue, \nhypophosphatemia Tumor-Induced Osteomalacia (TIO) - Continuation of \nTherapy:  The member must have been previously treated with Crysvita \n(burosumab) AND The member has experienced an increase in serum \nphosphorus from baseline while on Crysvita (burosumab) AND The \nmember has experienced a positive clinical response (e.g. reduction in \nmuscle weakness, muscle pain, fatigue, etc).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner \nCoverage\nDuration\nInitial auth: 4 months duration. Continuation of therapy: Plan Year \nDuration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 78 of 497\n", "doc_id": "478cd9a0-e867-48d0-b27b-d55fae8db294", "embedding": null, "doc_hash": "042efd1612fb9440c7087d0b6bacc998043a72ab3a8186ae4c3b68554b883558", "extra_info": {"page_label": "78", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2359, "_node_type": "1"}, "relationships": {"1": "184dcff1-db72-4450-a6d3-e6eef2544683"}}, "__type__": "1"}, "508dc4bd-20b4-4505-8d40-ec48a99ead71": {"__data__": {"text": "CYRAMZA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers that have experienced disease progression while on Cyramza \n(ramuciruma).\nRequired\nMedical\nInformation\nGastric Cancer: member has a diagnosis of advanced or metastatic \ngastric cancer or gastro-esophageal adenocarcinoma AND the member \nhas disease progression or intolerance on or after prior therapy with \nplatinum-based and/or fluoropyrimidine-based chemotherapy AND \nCyramza (ramucirumab) will be used as subsequent therapy AND will be \nused as monotherapy or in combination with paclitaxel. Non-Small Cell \nLung Cancer: The member has a diagnosis of metastatic non-small cell \nlung cancer AND The member has disease progression or intolerance on \nor following platinum-based chemotherapy AND For members with \nEGFR or ALK genomic aberrations, the member has disease \nprogression on FDA-approved therapy for these aberrations and \nCyramza will be used in combination with Docetaxel OR member has \ndocumented epidermal growth factor receptor (EGFR) exon 19 deletions \nor exon 21 (L858R) mutations AND is given in combo with erlotinib as \nfirst line therapy.  Colorectal Cancer: The member has a diagnosis of \nunresectable or metastatic colorectal cancer AND Primary treatment in \ncombination with irinotecan or FOLFIRI (fluorouracil, leucovorin calcium, \nand irinotecan) for unresectable metachronuous metastases and \nprevious treatment with FOLFOX (fluorouracil, leucovorin calcium, and \noxaliplatin) or CapeOX (capecitabine, oxaliplatin) as adjuvant therapy \nhas been given OR The member has disease progression on or after \nprior therapy with a bevacizumab product, oxaliplatin, and a \nfluoropyrimidine (e.g. 5-fluorouracil, capecitabine) AND Cyramza is given \nin combination with FOLFIRI (irinotecan, folinic acid,and 5-fluorouracil) or \nirinotecan as therapy after first progression of disease if irinotecan was \nnot previously given. Esophageal Cancer: The member has a diagnosis \nof unresectable locally advanced or metastatic or recurrent esophageal \nadenocarcinoma with an Eastern Cooperative Oncology Group (ECOG) \nperformance status 0-2 AND Cyramza will be used as second line \ntherapy with or without paclitaxel.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 79 of 497\n", "doc_id": "508dc4bd-20b4-4505-8d40-ec48a99ead71", "embedding": null, "doc_hash": "6cc61ef2e848ab6a412fbd6c8379d0da7c6a69837ee0210f2688a9a74e468aad", "extra_info": {"page_label": "79", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2359, "_node_type": "1"}, "relationships": {"1": "345062ea-55e7-4e49-9fc5-31a71d6a5f01"}}, "__type__": "1"}, "4903a4b6-b6fb-451f-9863-61fab0731588": {"__data__": {"text": "CYRAMZA\nOther Criteria\nHepatocellular Carcinoma: The member has a diagnosis of metastatic or \nunresectable hepatocellular carcinoma AND the member has received \nprior treatment with a first line therapy (e.g.,sorafenib) AND the member \nhas alpha feta protein greater than or equal to 400 ng/ml AND Cyramza \n(ramucirumab) will be given as a single agent as subsequent therapy.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 80 of 497\n", "doc_id": "4903a4b6-b6fb-451f-9863-61fab0731588", "embedding": null, "doc_hash": "b2635055d3939878c0fb2949a2447a3556a64e08b77b80a63d7cf23f7c96a27c", "extra_info": {"page_label": "80", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 449, "_node_type": "1"}, "relationships": {"1": "6c83953b-d084-4a50-9b87-b10dfef61d4f"}}, "__type__": "1"}, "d21efa2b-1ab0-40c2-9603-ac25de701b30": {"__data__": {"text": "CYSTARAN\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nCystinosis: The member has a diagnosis of cystinosis AND The member \nis using cysteamine ophthalmic solution in the treatment of corneal \ncystine crystal accumulation.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 81 of 497\n", "doc_id": "d21efa2b-1ab0-40c2-9603-ac25de701b30", "embedding": null, "doc_hash": "5c6501841c7f65469b0fc89a531d80b5508bb302bebc1417b11beffe9553efa3", "extra_info": {"page_label": "81", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 467, "_node_type": "1"}, "relationships": {"1": "f1c27dbc-867b-4700-b3e0-7f6ecae1af29"}}, "__type__": "1"}, "b8f7c502-99ab-45d2-9887-307685d11f56": {"__data__": {"text": "dalfampridine\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nHistory of seizure disorder. Moderate to severe renal impairment (CrCl \nless 50ml/min).\nRequired\nMedical\nInformation\nMultiple Sclerosis. Member must have a diagnosis of one of the four \ntypes of multiple sclerosis: Relapse Remitting or Primary Progressive or \nSecondary Progressive or Progressive Relapsing. Patient must be \nambulatory. Initial timed 25-foot walk T25W test or another objective \nmeasure of gait that provides evidence of significant walking impairment \nrelated to multiple sclerosis. Reauthorization Criteria. Documentation of \nimprovement in walking using the T25W test or another objective \nmeasure of gait.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial Auth: 6 months. Reauth: Plan Year Duration.\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 82 of 497\n", "doc_id": "b8f7c502-99ab-45d2-9887-307685d11f56", "embedding": null, "doc_hash": "306d3bd4a36ec2f3fb9fbdfe9491f87acd1e358c9dc6082ee4c53475c0f89b18", "extra_info": {"page_label": "82", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 932, "_node_type": "1"}, "relationships": {"1": "860c32f8-1fae-491a-a3be-b76f4d5a2a25"}}, "__type__": "1"}, "d51ac964-a70c-4c43-933b-b4586212aa5b": {"__data__": {"text": "DANYELZA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers receiving Danyelza (naxitamab) as monotherapy.  Members \nthat have experienced disease progression while on Danyelza \n(naxitamabgqgk).\nRequired\nMedical\nInformation\nRelapsed or Refractory Neuroblastoma:  The member has a diagnosis of \nrelapsed or refractory high-risk neuroblastoma AND The disease is in the \nbone or bone marrow AND The member has achieved a partial or minor \nresponse or stable disease to prior therapy AND Danyelza (naxitamab-\ngqgk) will be used in combination with Leukine (sargramostim).\nAge Restriction\nThe member is 1 year of age and older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 83 of 497\n", "doc_id": "d51ac964-a70c-4c43-933b-b4586212aa5b", "embedding": null, "doc_hash": "6aa4a96b26da104531cc1957c1404be15a272f961d35bee03269946bd7bc249c", "extra_info": {"page_label": "83", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 818, "_node_type": "1"}, "relationships": {"1": "2331cf5d-be9c-436c-8e36-aefa20d2401c"}}, "__type__": "1"}, "46642ad1-f56e-46eb-ba38-152d33eb857c": {"__data__": {"text": "DARZALEX\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDisease progression while taking Darzalex (daratumumab).\nRequired\nMedical\nInformation\nMultiple Myeloma:The member has a diagnosis of multiple myeloma  \nAND The member will be using Darzalex (daratumumab) for newly \ndiagnosed disease AND the member is ineligible for autologous stem \ncell transplant AND the member will be using Darzalex (daratumumab) in \ncombination with bortezomib, melphalan, and prednisone OR the \nmember will be using Darzalex in combination with lenalidomide and \ndexamethasone OR the member is eligible for autologous stem cell \ntransplant AND the member will be using Darzalex in combination with \nbortezomib, thalidomide, and dexamethasone OR the member will be \nusing Darzalex (daratumumab) for relapsed, progressive, or refractory \ndisease in one of the following scenarios:  The member will be using \nDarzalex (daratumumab) in combination with Pomalyst (pomalidomide) \nand dexamethasone AND the member has received at least two prior \ntherapies, including lenalidomide and a proteasome inhibitor (e.g. \nbortezomib, carfilzomib, or ixazomib) OR The member will be using \nDarzalex (daratumumab) in combination with Velcade (bortezomib) and \ndexamethasone OR The member will be using Darzalex (daratumumab) \nin combination with Revlimid (lenalidomide) and dexamethasone OR the \nmember will be using Darzalex (daratumumab) in combination with \nKyprolis (carfilzomib) OR The member will be using Darzalex \n(daratumumab) as monotherapy and one of the following applies: The \nmember has received at least three prior lines of therapy, which must \nhave included a proteasome inhibitor (e.g. bortezomib or carfilzomib) \nand an immunomodulatory drug (e.g. thalidomide, lenalidomide, or \npomalidomide) OR The member is double-refractory to a proteasome \ninhibitor (e.g. bortezomib or carfilzomib) and an immunomodulatory drug \n(e.g. thalidomide, lenalidomide, or pomalidomide).  Omission of \ncorticosteroid from regimen is allowed if intolerance/contraindication.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 84 of 497\n", "doc_id": "46642ad1-f56e-46eb-ba38-152d33eb857c", "embedding": null, "doc_hash": "1550cf0913dc7e43cc301083415a0db3432b975e0ece0679889cd40c395eaff3", "extra_info": {"page_label": "84", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2238, "_node_type": "1"}, "relationships": {"1": "04602e06-6925-4b8f-bfcb-2c9aa163acf8"}}, "__type__": "1"}, "7c56c090-44e5-4227-b65f-126130d5709c": {"__data__": {"text": "DARZALEX FASPRO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDisease progression while taking daratumumab.  Members who have \nNYHA Class IIIB or Class IV cardiac disease or Mayo Stage IIIB \n(Applicable to Light chain (AL) amyloidosis indication only).\nRequired\nMedical\nInformation\nMultiple Myeloma: The member has a diagnosis of multiple myeloma  \nAND The member will be using Darzalex (daratumumab) Faspro for \nnewly diagnosed disease AND the member is ineligible for autologous \nstem cell transplant AND the member will be using Darzalex Faspro in \ncombination with bortezomib, melphalan, and prednisone OR the \nmember will be using Darzalex Faspro in combination with lenalidomide \nand dexamethasone OR the member will be using Darzalex Faspro for \nrelapsed or progressive disease in one of the following scenarios:  in \ncombination with Velcade (bortezomib) and dexamethasone OR in \ncombination with Kyprolis (carfilzomib) and dexamethasone OR in \ncombination with Revlimid (lenalidomide) and dexamethasone OR in \ncombination with Pomalyst (pomalidomide) and dexamethasone OR as \nmonotherapy and one of the following applies:  The member has \nreceived at least three prior lines of therapy, which must have included a \nproteasome inhibitor (e.g. bortezomib or carfilzomib) and an \nimmunomodulatory drug (e.g. thalidomide, lenalidomide, or \npomalidomide) OR The member is double-refractory to a proteasome \ninhibitor (e.g. bortezomib or carfilzomib) and an immunomodulatory drug \n(e.g. thalidomide, lenalidomide, or pomalidomide).  Omission of \ncorticosteroid from regimen is allowed if intolerance/contraindication.  \nLight Chain Amyloidosis:  The member has a diagnosis of light chain \namyloidosis AND The member will be using Darzalex Faspro for newly \ndiagnosed disease AND The member will be using in combination with \nbortezomib, cyclophosphamide, and dexamethasone.  Omission of \ncorticosteroid from regimen is allowed if intolerance/contraindication.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 85 of 497\n", "doc_id": "7c56c090-44e5-4227-b65f-126130d5709c", "embedding": null, "doc_hash": "c588cf4d5e57188827d7316a8c45d9ff6abcc05a6749a02ec3dfac1e23068d9d", "extra_info": {"page_label": "85", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2165, "_node_type": "1"}, "relationships": {"1": "19621c4a-6e17-4cc7-8158-ae43b4172ab6"}}, "__type__": "1"}, "b4db25a5-6f7b-4db6-b56d-ba74f312ce6d": {"__data__": {"text": "DAURISMO\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member has experienced disease progression while on Daurismo \n(glasdegib).\nRequired\nMedical\nInformation\nAcute Myeloid Leukemia. The member has a diagnosis of newly-\ndiagnosed acute myeloid leukemia (AML) AND One of the following \napplies: The member is age 75 years or older OR The member has \ncomorbidities that preclude the use of intensive induction chemotherapy \n(e.g. severe cardiac disease, baseline Eastern Cooperative Oncology \nGroup (ECOG) performance status of 2, or baseline serum creatinine \ngreater than 1.3 mg/dL) AND The member will be using Daurismo \n(glasdegib) in combination with low-dose Cytarabine.  Acute Myeloid \nLeukemia - Relapsed/Refractory:  The member has a diagnosis of acute \nmyeloid leukemia (AML) AND The member has relapsed or refractory \ndisease AND The member will be using Daurismo (glasdegib) as a \ncomponent of repeating the initial successful induction regimen, if late \nrelapse (relapse occurring later than 12 months) AND Daurismo \n(glasdegib) has not been administered continuously AND Daurismo \n(glasdegib) was not stopped due to the development of clinical \nresistance.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 86 of 497\n", "doc_id": "b4db25a5-6f7b-4db6-b56d-ba74f312ce6d", "embedding": null, "doc_hash": "d44fe206aa4a98e4bdd254227b212b64f622b727d183181aad158c7a108183a7", "extra_info": {"page_label": "86", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1385, "_node_type": "1"}, "relationships": {"1": "055b9306-2ad0-4afa-befb-9e7ea22b2270"}}, "__type__": "1"}, "2845c38d-1caa-4daf-98b7-1c6fd5ac4cea": {"__data__": {"text": "decitabine\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant use with hypomethylators (e.g. azacitidine, decitabine) . \nApplies to azacitidine only: the member must not have a diagnosis of \nadvanced malignant hepatic tumors.\nRequired\nMedical\nInformation\nMyelodysplastic Syndromes. The member has a diagnosis of \nmyelodysplastic syndrome AND one of the following scenarios apply: \nThe member has a Revised International Prognostic Scoring System \n(IPSS-R) of higher risk disease (i.e. intermediate, high, very high) OR \nThe member has a Revised International Prognostic Scoring System \n(IPSS-R) of lower risk disease (i.e. very low, low, or intermediate) AND \none of the following sets of criteria applies: Clinically relevant \nthrombocytopenia, neutropenia, or increased marrow blasts OR Member \nhas symptomatic anemia AND No 5q deletion AND Serum erythropoietin \nlevels greater than 500 mU/mL AND An inadequate response or \nintolerance or contraindication to immunosuppressive therapy OR \nMember has Symptomatic anemia AND Serum erythropoietin levels less \nthan or equal to 500 mU/mL AND An inadequate response to \nerythropoietins alone or in combination with Revlimid (lenalidomide) \nAND An inadequate response or intolerance or contraindication to \nimmunosuppressive therapy OR Member has Symptomatic anemia AND \n5q deletion AND  An inadequate response or intolerance to Revlimid \n(lenalidomide) AND Serum erythropoietin levels greater than 500 mU/mL \nAND An inadequate response or intolerance or contraindication to \nimmunosuppressive therapy. Myeloproliferative Neoplasms: The \nmember has a diagnosis of myelofibrosis (MF)-accelerated phase or MF-\nblast phase/acute myeloid leukemia. Acute Myelogenous Leukemia \n(AML). The member has a diagnosis of AML.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 87 of 497\n", "doc_id": "2845c38d-1caa-4daf-98b7-1c6fd5ac4cea", "embedding": null, "doc_hash": "05c1109bd0cd9d8abc9833c28f2ce70026db160998d601cb452be60bd2160301", "extra_info": {"page_label": "87", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1969, "_node_type": "1"}, "relationships": {"1": "f81610f1-fcc6-4290-9084-b7b7a2e2c5a6"}}, "__type__": "1"}, "f1d1c9ac-e182-4e49-88be-d9cec680dcba": {"__data__": {"text": "deferasirox\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has platelet counts less 50,000.\nRequired\nMedical\nInformation\nChronic Iron Toxicity (hemosiderosis) Secondary to Transfusional Iron \nOverload. Initial Request: The Member must meet ALL of the following \ncriteria: Diagnosis of chronic iron overload (hemosiderosis) secondary to \nmultiple RBC transfusions AND Ferritin level greater than 1000 mcg/L \n(ferritin should consistently be above 1000 mcg/L to necessitate \ntreatment). Continuation of Therapy Request: The Member must meet \nALL of the following criteria: Ferritin level must be consistently above \n500mcg/L (deferasirox should be stopped if Ferritin level is consistently \nbelow 500 mcg/L.). Chronic iron overload in patients with non-transfusion \ndependent thalassemia (NTDT) syndromes: The member must meet ALL \nof the following criteria: The member has a diagnosis of chronic iron \noverload with non-transfusion dependent thalassemia (NTDT) syndrome \nAND The member has liver iron (Fe) concentration of at least 5mg/gm of \nliver dry weight AND The member has a serum ferritin greater than 300 \nmcg/L.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 88 of 497\n", "doc_id": "f1d1c9ac-e182-4e49-88be-d9cec680dcba", "embedding": null, "doc_hash": "2615ddea2dc2b7898e0cf1452eef79fa5d7a4f8dfe083b5e4c81b0a21c7e668e", "extra_info": {"page_label": "88", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1333, "_node_type": "1"}, "relationships": {"1": "42a483a4-f04c-4faf-8341-84e58ad68e79"}}, "__type__": "1"}, "21d74570-c9e9-413b-81be-2c3dc3a864c7": {"__data__": {"text": "DIACOMIT\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nThe member has a diagnosis of seizures associated with Dravet \nsyndrome AND Diacomit is prescribed by or in consultation with a \nspecialist (i.e. neurologist, epileptologist) AND The member is refractory \non current therapy (e.g experiencing generalized tonicclonic or clonic \nseizures within the past 28 days) AND The member is taking \nconcomitant clobazam therapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 89 of 497\n", "doc_id": "21d74570-c9e9-413b-81be-2c3dc3a864c7", "embedding": null, "doc_hash": "e62f1edaeb4c8c8ef17d37bd4a6c9a114f27eb29d85fac4f5d70f167692ed4eb", "extra_info": {"page_label": "89", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 654, "_node_type": "1"}, "relationships": {"1": "48f71035-c751-4f8e-b0d4-c3c041aecf6c"}}, "__type__": "1"}, "fa64e6d9-aff4-424f-9b86-8f8918f5f36e": {"__data__": {"text": "diclofenac epolamine\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nTopical treatment of acute pain due to minor strains, sprains, and \ncontusions. The patient has a documented symptomatic acute pain \ncondition.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 90 of 497\n", "doc_id": "fa64e6d9-aff4-424f-9b86-8f8918f5f36e", "embedding": null, "doc_hash": "561ec0c54206d0f5662b0f91314b65d939171e53655a5d5157a3109a1b160a00", "extra_info": {"page_label": "90", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 455, "_node_type": "1"}, "relationships": {"1": "a0976932-6ddd-4223-843d-a905386fa3ce"}}, "__type__": "1"}, "ed1c2ecb-3d7a-48e6-88f8-090d2d84e9f8": {"__data__": {"text": "diclofenac sodium\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nActinic Keratosis: The member has a diagnosis of actinic keratosis. The \nmember has trial, intolerance, or contraindication to generic imiquimod \n5% cream or topical fluorouracil.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 91 of 497\n", "doc_id": "ed1c2ecb-3d7a-48e6-88f8-090d2d84e9f8", "embedding": null, "doc_hash": "9f274ca1f6cb2e38782d2478b7f9acd0e59f3872a6928c69edd5cf6f8a3651ba", "extra_info": {"page_label": "91", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 488, "_node_type": "1"}, "relationships": {"1": "412a7fab-c1c1-4b27-8c07-21da1fd9a9e4"}}, "__type__": "1"}, "363d7670-73a6-4e25-a6c9-fca1d5f12986": {"__data__": {"text": "dihydroergotamine\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAcute treatment of moderate to severe migraine headaches with or \nwithout aura AND has had previous treatment, intolerance, or \ncontraindication to two of the following: naproxen tablet, naratriptan \ntablet, rizatriptan tablet, sumatriptan tablet.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 92 of 497\n", "doc_id": "363d7670-73a6-4e25-a6c9-fca1d5f12986", "embedding": null, "doc_hash": "d49de5b1443b8c50a48b4e5d145c6e61e691e13756db7e12ebf89dace8992f6e", "extra_info": {"page_label": "92", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 544, "_node_type": "1"}, "relationships": {"1": "f178d07d-0e0c-4f1a-9aca-ca2633b50468"}}, "__type__": "1"}, "7909aab6-3932-4fcb-9a33-84218320352f": {"__data__": {"text": "dimethyl fumarate\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nThe member has a diagnosis of a relapsing form of multiple sclerosis, to \ninclude relapsing-remitting or active secondary progressive disease OR \nthe member has a diagnosis of a clinically isolated syndrome (CIS).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 93 of 497\n", "doc_id": "7909aab6-3932-4fcb-9a33-84218320352f", "embedding": null, "doc_hash": "3bffa17a75a55bb5417233fd0214edc2a25b010af7c83c530b9b521055182cfe", "extra_info": {"page_label": "93", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 522, "_node_type": "1"}, "relationships": {"1": "eaff1146-4d22-4bd1-9846-6b0eb75ea74a"}}, "__type__": "1"}, "8ef7b1e5-1e54-4b0d-948c-f8bfafa92767": {"__data__": {"text": "DOJOLVI\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nLong-Chain Fatty Acid Oxidation Disorders:  The member has a \ndiagnosis of long-chain fatty acid disorders (e.g. Very Long-chain \nacylCoA Dehydrogenase [VLCAD] deficiency, Carnitine \nPalmitoyltransferase 2 [CPT2] deficiency, Mitochondrial Trifunctional \nProtein [TFP] Deficiency, Long-chain 3 hydroxyacylCoA Dehydrogenase \n[LCHAD] deficiency) AND Genetic and/or molecular testing has been \nperformed to confirm diagnosis (e.g. positive for pathogenic mutations in \nCPT2, ACADVL, HADHA, or HADHB).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 94 of 497\n", "doc_id": "8ef7b1e5-1e54-4b0d-948c-f8bfafa92767", "embedding": null, "doc_hash": "91dcc1e72dd43941f3b2f648c5506ee5de55242034eae4303fd0158fcc1ec181", "extra_info": {"page_label": "94", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 795, "_node_type": "1"}, "relationships": {"1": "3c21cbd0-94d2-403c-a8ea-44ca9ff87655"}}, "__type__": "1"}, "137cd0f4-6b7f-4990-9077-ffadc3c67f36": {"__data__": {"text": "doxorubicin, peg-liposomal\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nOvarian Cancer: The member has a diagnosis of persistent or recurrent \novarian cancer and one of the following applies: if platinum sensitive, in \ncombination with carboplatin OR if platinum resistant, as a single agent \nor in combination with bevacizumab product OR The member has a \ndiagnosis ovarian cancer and Liposomal doxorubicin will be used in \ncombination with carboplatin and one of the following applies: \nperioperative treatment in members who are poor surgical candidates or \nlow likelihood of optimal cytoreduction or adjuvant treatment or primary \ntreatment in members with incomplete previous surgery or staging. \nBreast Cancer: The member has a diagnosis of recurrent or metastatic \nHER-2-negative breast cancer. Hodgkin Lymphoma: The member has a \ndiagnosis of relapsed or refractory Hodgkins Lymphoma AND The \nmember will be using liposomal doxorubicin as second-line or \nsubsequent therapy. Kaposi's Sarcoma: The member has a diagnosis of \nAIDS-related Kaposi\n\u2019\ns sarcoma AND One of the following criteria \napplies: The member has had prior treatment, intolerance, or \ncontraindication to prior systemic chemotherapy, or the member is using \nLiposomal doxorubicin as first line therapy. Multiple Myeloma: The \nmember has a diagnosis of relapsed or refractory multiple myeloma AND \nThe member will be using liposomal doxorubicin in combination with \nVelcade (bortezomib).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 95 of 497\n", "doc_id": "137cd0f4-6b7f-4990-9077-ffadc3c67f36", "embedding": null, "doc_hash": "a8a3a9fbd9010ec8a74656563f058c26b6d2fea4d60dcd7d829cdeb5286edddc", "extra_info": {"page_label": "95", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1657, "_node_type": "1"}, "relationships": {"1": "0d230ac9-76b7-4810-9fe1-f23a94e80c69"}}, "__type__": "1"}, "e410cc59-d085-44cf-8a2b-7908a609685d": {"__data__": {"text": "doxorubicin, peg-liposomal\nOther Criteria\nNon-Hodgkin's lymphoma: The member has a diagnosis of T-Cell \nLeukemia or Lymphoma AND Liposomal doxorubicin is given in \ncombination with gemcitabine and vinorelbine and one of the following: \nfor non-responders as first  line therapy or for refractory disease after two \nprimary treatment prior to proceeding to transplant OR The member has \ndiagnosis of diffuse large B cell lymphoma AND Liposomal doxorubicin is \ngiven in combination with RCDOP (rituximab product, \ncyclophosphamide, vincristine and prednisone) in members with \ndocumented poor ventricular or very frail OR The member has a \ndiagnosis of Mycosis Fungoides (MF)/Sezary Syndrome (SS) and \nliposomal doxorubicin is given and one of the following: primary \ntreatment OR as combination therapy with gemcitabine and vinorelbine \nprior to proceeding to transplant OR The member has a diagnosis of \nrelapsed or refractory peripheral T-cell lymphoma (not otherwise \nspecified or enteropathy associated Tcell lymphoma) AND Liposomal \ndoxorubicin is given as subsequent therapy in combination therapy with \ngemcitabine and vinorelbine prior to proceeding to transplant.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 96 of 497\n", "doc_id": "e410cc59-d085-44cf-8a2b-7908a609685d", "embedding": null, "doc_hash": "c11526a37641f17599038dcb5831cb467667f18404a4b2e7e21c741bc17eb9d0", "extra_info": {"page_label": "96", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1245, "_node_type": "1"}, "relationships": {"1": "42d817af-cc03-4cce-92c3-2a59092f883a"}}, "__type__": "1"}, "e0b55df1-ec6c-4398-8622-85405068e0b5": {"__data__": {"text": "DRIZALMA SPRINKLE\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nMajor Depressive Disorder, Generalized Anxiety Disorder, or Diabetic \nPeripheral Neuropathic Pain:  The member has a diagnosis of Major \nDepressive Disorder (MDD), Generalized Anxiety Disorder (GAD), or \nDiabetic Peripheral Neuropathic Pain (DPNP).  The member has prior \ntherapy, intolerance, or contraindication with venlafaxine (IR or ER) AND \nduloxetine.  Chronic Musculoskeletal Pain, Fibromyalgia:  The member \nhas a diagnosis of Chronic Musculoskeletal Pain or Fibromyalgia (FM). \nThe member has prior therapy, intolerance, or contraindication with \nduloxetine.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 97 of 497\n", "doc_id": "e0b55df1-ec6c-4398-8622-85405068e0b5", "embedding": null, "doc_hash": "60502e71c7688efad5a179ff3a13c120c61ecc36dbb38eb76e19d8587145b219", "extra_info": {"page_label": "97", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 877, "_node_type": "1"}, "relationships": {"1": "f4559326-88f3-4138-92e8-01c25fef7abb"}}, "__type__": "1"}, "dac7318e-6c74-4b88-b04d-c317e11339ff": {"__data__": {"text": "DUAVEE\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nAbnormal uterine bleeding. Known or past history of breast cancer. \nActive or past history of venous thromboembolism (e.g. pulmonary \nembolism, deep vein thrombosis). Known estrogen-dependent \nneoplasia. Active or past history of arterial thromboembolism (e.g. stroke \nand myocardial infarction). Duavee should not be used in members who \nare pregnant or lactating.  Known hepatic impairment or liver disease. \nKnown protein C, protein S, or antithrombin deficiency or other known \nthrombophilic disorders. Concurrent use with estrogens, progestins, or \nestrogen agonists/antagonists.\nRequired\nMedical\nInformation\nTreatment of moderate to severe vasomotor symptoms associated with \nmenopause:Diagnosis of moderate to severe vasomotor symptoms \nassociated with menopause AND The member must have had previous \ntreatment, intolerance or contraindication to a SSRI [e.g. citalopram, \nfluoxetine, paroxetine hydrochloride] or venlafaxine. Prevention of \nosteoporosis: For the prevention of osteoporosis in a member who is \npostmenopausal AND the member must have had previous treatment, \nintolerance, or contraindication to either alendronate or Evista \n(raloxifene).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 98 of 497\n", "doc_id": "dac7318e-6c74-4b88-b04d-c317e11339ff", "embedding": null, "doc_hash": "ec61350e51e9f4d32e558a8fc1508c54074db260f65ef8babe09c341e167a11c", "extra_info": {"page_label": "98", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1429, "_node_type": "1"}, "relationships": {"1": "6b434d38-2ac3-42ea-a541-910fa4b66e78"}}, "__type__": "1"}, "8ffb72cc-e0f5-473c-9e12-4742cea7dfa1": {"__data__": {"text": "DUPIXENT PEN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nFor asthma indication only: Not for the relief of acute bronchospasm or \nstatus asthmaticus.\nRequired\nMedical\nInformation\nAtopic Dermatitis. Initial Review: The member has a diagnosis of \nmoderate to severe Atopic Dermatitis (e.g. erythema that is pink-red to \ndeep or bright red, moderate to severe induration/population, frequent to \nincessant itching, frequent to nightly loss of sleep) AND The member has \nhad previous treatment, intolerance to, or contraindication to one high \npotency topical corticosteroid (e.g. augmented betamethasone \ndipropionate 0.05%, clobetasol cream/gel/ointment, triamcinolone \nacetonide 0.5%) OR one topical calcineurin inhibitor (e.g. tacrolimus)  \nReauthorization: The member has had an improvement in atopic \ndermatitis symptoms which has been sustained.  Eosinophilic \nEsophagitis (EoE) Initial Review:  Member must meet all of the following \ncriteria:  40 kg (88 pounds) or higher, Diagnosis of eosinophilic \nesophagitis (EOE) identified by endoscopic biopsy with evidence of peak \ncell count of greater than or equal to 15 eosinophils per high power field \nin 2 or more biopsied esophageal regions, two or more episodes of \ndysphagia per week, unable to achieve adequate control of symptoms \nwith guideline directed therapy (e.g., generic high dose proton pump \ninhibitors or topical corticosteroids).  Continuation of therapy: member \nmust meet all the following criteria: 40 kg (88 pounds) or higher, \nreduction of esophagitis symptoms identified by one of the following: \nendoscopic biopsy shows evidence of histological remission or reduction \nof symptoms (e.g., Decreased episodes of dysphagia).\nAge Restriction\nAtopic dermatitis: The member must be 6 months of age or older. \nChronic rhinosinusitis with nasal polyposis, Prurigo Nodularis: The \nmember must be 18 years of age or older. Eosinophilic Esophagitis: 12 \nyears of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 99 of 497\n", "doc_id": "8ffb72cc-e0f5-473c-9e12-4742cea7dfa1", "embedding": null, "doc_hash": "8a21196f496f2f35531d36e3327239e7f55c00b7bd12e894adf00fa568fa71ca", "extra_info": {"page_label": "99", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2093, "_node_type": "1"}, "relationships": {"1": "32094063-fa64-4695-8860-22c4e06ddbac"}}, "__type__": "1"}, "1d10d145-a211-4325-964c-6764b0e548b0": {"__data__": {"text": "DUPIXENT PEN\nOther Criteria\nModerate-to-severe asthma with an eosinophilic phenotypic or with oral \ncorticosteroid dependent asthma. Initial Review: The member has a \ndiagnosis of moderate-to-severe asthma AND The member has an \neosinophilic phenotype, defined by an elevated peripheral blood \neosinophil level of: greater than or equal to 150 cells/uL at therapy \ninitiation, OR greater than or equal to 300 cells/uL in the previous 12 \nmonths, OR The member has oral corticosteroid-dependent asthma AND \nThe member has been unable to achieve adequate control of asthma \nwhile on maximum tolerated inhaled corticosteroid therapy in \ncombination with a long acting beta agonist (eg formoterol).  \nReauthorization. Member is currently stable on therapy AND Member will \ncontinue on asthma controller inhalers: inhaled corticosteroid with a long-\nacting beta2-agonist (e.g. Flovent HFA/Diskus, Arnuity Ellipta, Serevent \nDiskus, Striverdi Respimat, Advair Diskus, Breo Ellipta, Symbicort HFA).  \nChronic Rhinosinusitis with Nasal Polyposis. Initial Review: The member \nmust have a diagnosis of Chronic Rhinosinusitis with Nasal Polyposis \nAND Dupixent (dupilumab) will be used in conjunction with a daily \nintranasal corticosteroid spray AND The member has been unable to \nachieve adequate control of symptoms with maximum tolerated \nintranasal corticosteroid therapy. Reauthorization: The member has had \nan improvement in symptoms (e.g. decrease in nasal congestion, \ndecrease in polyp size, improvement in ability to smell) which has been \nsustained AND Member will continue intranasal corticosteroid spray \ntherapy.  Prurigo Nodularis, initial review:  member must meet all of the \nfollowing criteria:  diagnosis of Prurigo Nodularis AND prescribed by or in \nconsultation with a dermatologist, allergist, or immunologist AND unable \nto achieve adequate control of symptoms after 2 or more weeks of \ncontinuous treatment with moderate to super potent topical \ncorticosteroids OR prescriber determines that treatment with a topical \ncorticosteroid would be inappropriate.  Reauthorization:  member has an \nimprovement in symptoms defined by a decrease in number of Prurigo \nNodularis lesions and/or reduction in pruritis symptoms.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 100 of 497\n", "doc_id": "1d10d145-a211-4325-964c-6764b0e548b0", "embedding": null, "doc_hash": "2505950c41a1d9b1dbb38436e2773c49a51ca2b00b92b834aefe729b14d5ba57", "extra_info": {"page_label": "100", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2305, "_node_type": "1"}, "relationships": {"1": "ea2617c4-4154-4dc4-b3f1-4df529abeb33"}}, "__type__": "1"}, "b0a5720f-37b0-4434-8a5f-8f31b83648f1": {"__data__": {"text": "DUPIXENT SYRINGE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nFor asthma indication only: Not for the relief of acute bronchospasm or \nstatus asthmaticus.\nRequired\nMedical\nInformation\nAtopic Dermatitis. Initial Review: The member has a diagnosis of \nmoderate to severe Atopic Dermatitis (e.g. erythema that is pink-red to \ndeep or bright red, moderate to severe induration/population, frequent to \nincessant itching, frequent to nightly loss of sleep) AND The member has \nhad previous treatment, intolerance to, or contraindication to one high \npotency topical corticosteroid (e.g. augmented betamethasone \ndipropionate 0.05%, clobetasol cream/gel/ointment, triamcinolone \nacetonide 0.5%) OR one topical calcineurin inhibitor (e.g. tacrolimus)  \nReauthorization: The member has had an improvement in atopic \ndermatitis symptoms which has been sustained.  Eosinophilic \nEsophagitis (EoE) Initial Review:  Member must meet all of the following \ncriteria:  40 kg (88 pounds) or higher, Diagnosis of eosinophilic \nesophagitis (EOE) identified by endoscopic biopsy with evidence of peak \ncell count of greater than or equal to 15 eosinophils per high power field \nin 2 or more biopsied esophageal regions, two or more episodes of \ndysphagia per week, unable to achieve adequate control of symptoms \nwith guideline directed therapy (e.g., generic high dose proton pump \ninhibitors or topical corticosteroids).  Continuation of therapy: member \nmust meet all the following criteria: 40 kg (88 pounds) or higher, \nreduction of esophagitis symptoms identified by one of the following: \nendoscopic biopsy shows evidence of histological remission or reduction \nof symptoms (e.g., Decreased episodes of dysphagia).\nAge Restriction\nAtopic dermatitis: The member must be 6 months of age or older. \nChronic rhinosinusitis with nasal polyposis, Prurigo Nodularis: The \nmember must be 18 years of age or older. Eosinophilic Esophagitis: 12 \nyears of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 101 of 497\n", "doc_id": "b0a5720f-37b0-4434-8a5f-8f31b83648f1", "embedding": null, "doc_hash": "9beb15151c1171cbacd4a8589a8576f236c7d9f4fb74cefebf863422cf7ea3fe", "extra_info": {"page_label": "101", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2098, "_node_type": "1"}, "relationships": {"1": "35b8e87b-8a75-4dd9-ad6c-bee57bf85129"}}, "__type__": "1"}, "b915dfaf-bf10-454a-8093-9ae8c923093d": {"__data__": {"text": "DUPIXENT SYRINGE\nOther Criteria\nModerate-to-severe asthma with an eosinophilic phenotypic or with oral \ncorticosteroid dependent asthma. Initial Review: The member has a \ndiagnosis of moderate-to-severe asthma AND The member has an \neosinophilic phenotype, defined by an elevated peripheral blood \neosinophil level of: greater than or equal to 150 cells/uL at therapy \ninitiation, OR greater than or equal to 300 cells/uL in the previous 12 \nmonths, OR The member has oral corticosteroid-dependent asthma AND \nThe member has been unable to achieve adequate control of asthma \nwhile on maximum tolerated inhaled corticosteroid therapy in \ncombination with a long acting beta agonist (eg formoterol).  \nReauthorization. Member is currently stable on therapy AND Member will \ncontinue on asthma controller inhalers: inhaled corticosteroid with a long-\nacting beta2-agonist (e.g. Flovent HFA/Diskus, Arnuity Ellipta, Serevent \nDiskus, Striverdi Respimat, Advair Diskus, Breo Ellipta, Symbicort HFA).  \nChronic Rhinosinusitis with Nasal Polyposis. Initial Review: The member \nmust have a diagnosis of Chronic Rhinosinusitis with Nasal Polyposis \nAND Dupixent (dupilumab) will be used in conjunction with a daily \nintranasal corticosteroid spray AND The member has been unable to \nachieve adequate control of symptoms with maximum tolerated \nintranasal corticosteroid therapy. Reauthorization: The member has had \nan improvement in symptoms (e.g. decrease in nasal congestion, \ndecrease in polyp size, improvement in ability to smell) which has been \nsustained AND Member will continue intranasal corticosteroid spray \ntherapy.  Prurigo Nodularis, initial review:  member must meet all of the \nfollowing criteria:  diagnosis of Prurigo Nodularis AND prescribed by or in \nconsultation with a dermatologist, allergist, or immunologist AND unable \nto achieve adequate control of symptoms after 2 or more weeks of \ncontinuous treatment with moderate to super potent topical \ncorticosteroids OR prescriber determines that treatment with a topical \ncorticosteroid would be inappropriate.  Reauthorization:  member has an \nimprovement in symptoms defined by a decrease in number of Prurigo \nNodularis lesions and/or reduction in pruritis symptoms.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 102 of 497\n", "doc_id": "b915dfaf-bf10-454a-8093-9ae8c923093d", "embedding": null, "doc_hash": "7af97c018a75b26d0a11ebf0b0a6e2e695758b58b5d47788f0fc5d6916573fd7", "extra_info": {"page_label": "102", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2309, "_node_type": "1"}, "relationships": {"1": "bf9eb918-bf6e-4d9d-85c0-03c90ccd2576"}}, "__type__": "1"}, "67bd0b8f-e8d8-461d-b0fb-a6f016623f71": {"__data__": {"text": "econazole\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nMember must be using the requested antifungal topically for the \ntreatment of an active susceptible fungal infection AND has had previous \ntreatment within the past 12 months, contraindication, or intolerance to \ntwo of the following:  clotrimazole cream, ciclopirox 0.77% \ncream/gel/suspension, or ketoconazole cream.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 103 of 497\n", "doc_id": "67bd0b8f-e8d8-461d-b0fb-a6f016623f71", "embedding": null, "doc_hash": "436fca9a9796d7f28c30199a4a1d3ce6f38880d043aeeec8e51f25558086cf01", "extra_info": {"page_label": "103", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 608, "_node_type": "1"}, "relationships": {"1": "1bd00564-4a13-47ac-a9d6-0d8f5a1ab342"}}, "__type__": "1"}, "af329d5e-0812-45de-804c-a0d6e908cc56": {"__data__": {"text": "EGRIFTA SV\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nEgrifta (tesamorelin) therapy is not considered medically necessary for \nmembers with the following concomitant conditions: The member must \nnot have an active malignancy. Pregnancy.\nRequired\nMedical\nInformation\nHIV-Associated Lipodystrophy. The member must have a diagnosis of \nHIV-associated lipodystrophy. The member must utilize Egrifta \n(tesamorelin) to reduce excess fat for the abdominal area. The member \nmust be/have been on a protease inhibitor (PI) and/or nucleoside reverse \ntranscriptase inhibitor (NRTI).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 104 of 497\n", "doc_id": "af329d5e-0812-45de-804c-a0d6e908cc56", "embedding": null, "doc_hash": "c315cac4b8fcae74d601bc56f8f0f93f7a94dd6a27b663b20696c8e9d230a373", "extra_info": {"page_label": "104", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 780, "_node_type": "1"}, "relationships": {"1": "9b43ab2a-a287-4469-92dd-715869a0d10e"}}, "__type__": "1"}, "e89acdd9-e4ad-41da-aabd-3a9d9cb749bf": {"__data__": {"text": "ELELYSO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nGaucher Disease. The member has a confirmed diagnosis of Type 1 \nGaucher disease.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner.\nCoverage\nDuration\nPlan Year Duration.\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 105 of 497\n", "doc_id": "e89acdd9-e4ad-41da-aabd-3a9d9cb749bf", "embedding": null, "doc_hash": "95f96ec86084137bf991d85e36d9aef425ebbc3c88be8c3a85d735d6ec2ed351", "extra_info": {"page_label": "105", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 380, "_node_type": "1"}, "relationships": {"1": "076873b3-32ef-42f5-81e4-e07bc1ac8b2e"}}, "__type__": "1"}, "c7c00819-2d91-44db-8eaa-12a40c7c256e": {"__data__": {"text": "ELIGARD\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agents.Should not be used in \npregnancy.\nRequired\nMedical\nInformation\nThe patient must have a diagnosis of advanced prostate cancer or has a \nhigh risk of disease recurrence.  Invasive Breast Cancer. The patient has \na diagnosis of hormone responsive (ER and/or PR +) invasive breast \ncancer. The patient must be pre or perimenopausal. Diagnosis of \nrecurrent ovarian cancer (epithelial cell or ovarian stromal tumor).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 106 of 497\n", "doc_id": "c7c00819-2d91-44db-8eaa-12a40c7c256e", "embedding": null, "doc_hash": "d9f417580d09a4eb092220916249343ac36dd6b7995ea38fadf9c65f2965ac8f", "extra_info": {"page_label": "106", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 718, "_node_type": "1"}, "relationships": {"1": "0871ba97-0496-4be7-9a3e-6dac3e94601a"}}, "__type__": "1"}, "5a85a3cd-9735-4482-abc5-b3f2006e73ef": {"__data__": {"text": "ELIGARD (3 MONTH)\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agents.Should not be used in \npregnancy.\nRequired\nMedical\nInformation\nThe patient must have a diagnosis of advanced prostate cancer or has a \nhigh risk of disease recurrence.  Invasive Breast Cancer. The patient has \na diagnosis of hormone responsive (ER and/or PR +) invasive breast \ncancer. The patient must be pre or perimenopausal. Diagnosis of \nrecurrent ovarian cancer (epithelial cell or ovarian stromal tumor).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 107 of 497\n", "doc_id": "5a85a3cd-9735-4482-abc5-b3f2006e73ef", "embedding": null, "doc_hash": "8cc184c0c6080da21ef6567d97912bbfa2bf00587a9c17e193217cac315cc737", "extra_info": {"page_label": "107", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 728, "_node_type": "1"}, "relationships": {"1": "3eb32836-1f31-462b-8949-43c92a79cbe3"}}, "__type__": "1"}, "355a5f10-cf03-4583-afaf-29b5cfafc1f5": {"__data__": {"text": "ELIGARD (4 MONTH)\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agents.Should not be used in \npregnancy.\nRequired\nMedical\nInformation\nThe patient must have a diagnosis of advanced prostate cancer or has a \nhigh risk of disease recurrence.  Invasive Breast Cancer. The patient has \na diagnosis of hormone responsive (ER and/or PR +) invasive breast \ncancer. The patient must be pre or perimenopausal. Diagnosis of \nrecurrent ovarian cancer (epithelial cell or ovarian stromal tumor).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 108 of 497\n", "doc_id": "355a5f10-cf03-4583-afaf-29b5cfafc1f5", "embedding": null, "doc_hash": "b46b70296bf1f9ea9be6ff67000129e6f2e778c27e7bd3e529a76bd06f9b0f65", "extra_info": {"page_label": "108", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 728, "_node_type": "1"}, "relationships": {"1": "2e7c1c93-eb61-4a1c-9e34-b85e5f682b3d"}}, "__type__": "1"}, "42b85f6a-a640-4a39-adc0-84f622c7bd5a": {"__data__": {"text": "ELIGARD (6 MONTH)\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agents.Should not be used in \npregnancy.\nRequired\nMedical\nInformation\nThe patient must have a diagnosis of advanced prostate cancer or has a \nhigh risk of disease recurrence.  Invasive Breast Cancer. The patient has \na diagnosis of hormone responsive (ER and/or PR +) invasive breast \ncancer. The patient must be pre or perimenopausal. Diagnosis of \nrecurrent ovarian cancer (epithelial cell or ovarian stromal tumor).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 109 of 497\n", "doc_id": "42b85f6a-a640-4a39-adc0-84f622c7bd5a", "embedding": null, "doc_hash": "6d35dd631ef0c937f8beaeb66b11b8b115e9561ecb659393a410b19226a6e171", "extra_info": {"page_label": "109", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 728, "_node_type": "1"}, "relationships": {"1": "13ff403e-e7c4-409e-92c5-fbe4b9a327bd"}}, "__type__": "1"}, "76dc2b01-9372-4245-a0de-7122a91e3d0b": {"__data__": {"text": "ELZONRIS\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nBlastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN): The member \nhas a diagnosis of blastic plasmacytoid dendritic cell neoplasm (BPDCN) \naccording to World Health Organization (WHO) classification AND the \nmember is able to be an inpatient for at least the first complete course of \ntherapy plus an additional 24 hours for observation.\nAge Restriction\nThe member must be 2 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 110 of 497\n", "doc_id": "76dc2b01-9372-4245-a0de-7122a91e3d0b", "embedding": null, "doc_hash": "733cae39985e5435af5246cbed86e4da4ad6049ec63ba5cd526c0933450a8950", "extra_info": {"page_label": "110", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 669, "_node_type": "1"}, "relationships": {"1": "6941a77e-c749-45fc-a48a-1e6c7603c248"}}, "__type__": "1"}, "aad90a0f-1566-403c-b132-b3ef43ab58ef": {"__data__": {"text": "EMGALITY PEN\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nEpisodic or Chronic Migraine.  Initial therapy: The member has \ndocumented history of greater than or equal to 4 migraine days per \nmonth AND the member has been unable to achieve at least a 2 day \nreduction in migraine headache days per month after previous treatment \n(of at least 2 months) with one of the following oral preventative \nmedications:  Divalproex, Topiramate, Metoprolol, Propranolol, or \nTimolol.  Reauthorization: The member has experienced a positive \nclinical response (e.g. sustained decrease in migraine days per month).\nAge Restriction\nThe member is 18 years of age or older\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial auth: 3 months.  Reauth: Plan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 111 of 497\n", "doc_id": "aad90a0f-1566-403c-b132-b3ef43ab58ef", "embedding": null, "doc_hash": "7a7adde68134ff87440ecb528a5a62807dcf0332389f79c8a28eb725db18e2eb", "extra_info": {"page_label": "111", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 916, "_node_type": "1"}, "relationships": {"1": "da9a64d1-3a3a-4ec5-bfb4-5735e9306135"}}, "__type__": "1"}, "8ca083b1-8da3-40d9-ae5a-cb34c38c8e74": {"__data__": {"text": "EMGALITY SYRINGE\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nEpisodic Cluster Headache:  The member has been diagnosed with \nepisodic cluster headaches as defined as having at least two cluster \nperiods lasting from 7 days to 1 year, separated by pain free remission \nperiods lasting at least 1 month AND the member has been unable to \nachieve a reduction in weekly cluster headache attack frequency with a \ntrial of verapamil.\nAge Restriction\nThe member is 18 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 112 of 497\n", "doc_id": "8ca083b1-8da3-40d9-ae5a-cb34c38c8e74", "embedding": null, "doc_hash": "e388dffb58f630ea4bbdc1ea422145d28a3cff23f66390a239a33507123371d9", "extra_info": {"page_label": "112", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 712, "_node_type": "1"}, "relationships": {"1": "cde128cc-37fb-42d9-85a5-6858c55e25a7"}}, "__type__": "1"}, "f18d6853-6c5c-4b8a-afde-55071a58e330": {"__data__": {"text": "EMPLICITI\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers with disease progression while on Empliciti (elotuzumab)\nRequired\nMedical\nInformation\nMultiple Myeloma:The member has a diagnosis of multiple myeloma \nAND One of the following scenarios apply: The member has disease \nprogression after receiving one to three prior lines of therapy AND \nEmpliciti (elotuzumab) will be given in combination with lenalidomide \n(Revlimid) and dexamethasone OR in combination with bortezomib \n(Velcade) and dexamethasone OR The member has disease \nprogression after receiving at least two prior therapies, including \nlenalidomide and a proteasome inhibitor AND Empliciti (elotuzumab) will \nbe given in combination with pomalidomide (Pomalyst) and \ndexamethasone (Omission of corticosteroid from regimen is allowed if \nintolerance/contraindication).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 113 of 497\n", "doc_id": "f18d6853-6c5c-4b8a-afde-55071a58e330", "embedding": null, "doc_hash": "0c425b4d4a6588ae74dfe11d64e61018170484b6e55c24f7582b7578a745087d", "extra_info": {"page_label": "113", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1053, "_node_type": "1"}, "relationships": {"1": "ceccd252-2c95-4e7b-8ccc-c0c37aaf5f42"}}, "__type__": "1"}, "de86728a-6452-4376-beff-146d1e5ba894": {"__data__": {"text": "EMSAM\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nPheochromocytoma.\nRequired\nMedical\nInformation\nMajor Depressive Disorder: The member is an adult with a clinical \ndiagnosis of major depressive disorder (MDD) as defined by DSM-5 \ncriteria and/or appropriate depression rating scale (e.g. PHQ-9, Clinically \nUseful Depression Outcome Scale, Quick Inventory of Depressive \nSymptomatology-Self Report 16 Item, MADRS, HAM-D). The member \nhas had prior therapy, intolerance, or contraindication with a generic \nSSRI (e.g. citalopram, fluoxetine, paroxetine, or sertraline), generic SNRI \n(e.g. venlafaxine or duloxetine), a generic bupropion product \n(75mg/100mg IR, 100mg/150mg/200mg SR, or 150mg/300mg XL) OR \nmirtazapine.\nAge Restriction\nThe member is at least 12 years of age.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 114 of 497\n", "doc_id": "de86728a-6452-4376-beff-146d1e5ba894", "embedding": null, "doc_hash": "e66e7052e8728527adee312153a513fde89def4ede7b734c4f2f271f0951dc70", "extra_info": {"page_label": "114", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 966, "_node_type": "1"}, "relationships": {"1": "d0edce96-0ce0-4724-a409-d3ebb40ea251"}}, "__type__": "1"}, "ac22adbf-d1c6-4ef0-b892-8eb512eedaca": {"__data__": {"text": "ENBREL\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnkylosing Spondylitis: The member has a diagnosis of ankylosing \nspondylitis. The member has prior therapy, contraindication, or \nintolerance with a non-steroidal anti-inflammatory drug (NSAIDs) (e.g. \nibuprofen, meloxicam, naproxen). Plaque Psoriasis: Diagnosis of chronic \nmoderate to severe plaque psoriasis. The member has had prior therapy \nwith or intolerance to conventional therapy including one or more oral \nsystemic treatments (e.g., methotrexate, cyclosporine) or \ncontraindication to all conventional oral systemic treatments. Psoriatic \nArthritis: Diagnosis of active psoriatic arthritis. Member has had prior \ntherapy with or intolerance to a single DMARD (e.g. methotrexate, \nsulfasalazine, hydroxychloroquine, leflunomide) or contraindication with \nall DMARDs. Rheumatoid Arthritis: Diagnosis of moderately to severely \nactive rheumatoid arthritis. Member has had prior therapy with or \nintolerance to a single DMARD (e.g. methotrexate, sulfasalazine, \nhydroxychloroquine, leflunomide) or contraindication with all DMARDs. \nPolyarticular Juvenile Idiopathic Arthritis: Diagnosis of moderately to \nseverely active polyarticular juvenile idiopathic arthritis. Member has had \nprior therapy with or intolerance to a single DMARD (e.g. methotrexate, \nsulfasalazine, leflunomide) or contraindication with all DMARDs.\nAge Restriction\nMust be 18 years of age for Ankylosing Spondylitis, Psoriatic arthritis, or \nRA. Must be 4 years of age for Plaque Psoriasis. Must be 2 years of age \nfor Polyarticular Juvenile Idiopathic Arthritis.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 115 of 497\n", "doc_id": "ac22adbf-d1c6-4ef0-b892-8eb512eedaca", "embedding": null, "doc_hash": "b74e1acf797088cf876f45035a48ec4acdb05e9d155e72636d3eb73de1969acb", "extra_info": {"page_label": "115", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1815, "_node_type": "1"}, "relationships": {"1": "9ea13dc3-7521-4584-8ce4-91f17b7710ba"}}, "__type__": "1"}, "2ab5c10d-481d-4aa6-91ef-aaf4d1cfd026": {"__data__": {"text": "ENBREL MINI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnkylosing Spondylitis: The member has a diagnosis of ankylosing \nspondylitis. The member has prior therapy, contraindication, or \nintolerance with a non-steroidal anti-inflammatory drug (NSAIDs) (e.g. \nibuprofen, meloxicam, naproxen). Plaque Psoriasis: Diagnosis of chronic \nmoderate to severe plaque psoriasis. The member has had prior therapy \nwith or intolerance to conventional therapy including one or more oral \nsystemic treatments (e.g., methotrexate, cyclosporine) or \ncontraindication to all conventional oral systemic treatments. Psoriatic \nArthritis: Diagnosis of active psoriatic arthritis. Member has had prior \ntherapy with or intolerance to a single DMARD (e.g. methotrexate, \nsulfasalazine, hydroxychloroquine, leflunomide) or contraindication with \nall DMARDs. Rheumatoid Arthritis: Diagnosis of moderately to severely \nactive rheumatoid arthritis. Member has had prior therapy with or \nintolerance to a single DMARD (e.g. methotrexate, sulfasalazine, \nhydroxychloroquine, leflunomide) or contraindication with all DMARDs. \nPolyarticular Juvenile Idiopathic Arthritis: Diagnosis of moderately to \nseverely active polyarticular juvenile idiopathic arthritis. Member has had \nprior therapy with or intolerance to a single DMARD (e.g. methotrexate, \nsulfasalazine, leflunomide) or contraindication with all DMARDs.\nAge Restriction\nMust be 18 years of age for Ankylosing Spondylitis, Psoriatic arthritis, or \nRA. Must be 4 years of age for Plaque Psoriasis. Must be 2 years of age \nfor Polyarticular Juvenile Idiopathic Arthritis.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 116 of 497\n", "doc_id": "2ab5c10d-481d-4aa6-91ef-aaf4d1cfd026", "embedding": null, "doc_hash": "7b40c904bd6f21123df6419f4dd45617832911eecf8ae20e325490884c122dd6", "extra_info": {"page_label": "116", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1820, "_node_type": "1"}, "relationships": {"1": "03bbc9de-ab91-43cf-a178-14655580c71b"}}, "__type__": "1"}, "9499f986-aa6a-4b21-a6ba-8972afbf4399": {"__data__": {"text": "ENBREL SURECLICK\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnkylosing Spondylitis: The member has a diagnosis of ankylosing \nspondylitis. The member has prior therapy, contraindication, or \nintolerance with a non-steroidal anti-inflammatory drug (NSAIDs) (e.g. \nibuprofen, meloxicam, naproxen). Plaque Psoriasis: Diagnosis of chronic \nmoderate to severe plaque psoriasis. The member has had prior therapy \nwith or intolerance to conventional therapy including one or more oral \nsystemic treatments (e.g., methotrexate, cyclosporine) or \ncontraindication to all conventional oral systemic treatments. Psoriatic \nArthritis: Diagnosis of active psoriatic arthritis. Member has had prior \ntherapy with or intolerance to a single DMARD (e.g. methotrexate, \nsulfasalazine, hydroxychloroquine, leflunomide) or contraindication with \nall DMARDs. Rheumatoid Arthritis: Diagnosis of moderately to severely \nactive rheumatoid arthritis. Member has had prior therapy with or \nintolerance to a single DMARD (e.g. methotrexate, sulfasalazine, \nhydroxychloroquine, leflunomide) or contraindication with all DMARDs. \nPolyarticular Juvenile Idiopathic Arthritis: Diagnosis of moderately to \nseverely active polyarticular juvenile idiopathic arthritis. Member has had \nprior therapy with or intolerance to a single DMARD (e.g. methotrexate, \nsulfasalazine, leflunomide) or contraindication with all DMARDs.\nAge Restriction\nMust be 18 years of age for Ankylosing Spondylitis, Psoriatic arthritis, or \nRA. Must be 4 years of age for Plaque Psoriasis. Must be 2 years of age \nfor Polyarticular Juvenile Idiopathic Arthritis.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 117 of 497\n", "doc_id": "9499f986-aa6a-4b21-a6ba-8972afbf4399", "embedding": null, "doc_hash": "536f769b63b8cfd091406169ae42d2d14fdbf67a6301ab25e692c54cc36ad158", "extra_info": {"page_label": "117", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1825, "_node_type": "1"}, "relationships": {"1": "6b534828-5cac-4f90-a41e-7c1b4c24a204"}}, "__type__": "1"}, "43e555ef-a8c3-44ab-8d5c-dba3f2e83198": {"__data__": {"text": "ENHERTU\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experiences disease progression on Enhertu (fam-trastuzumab \nderuxtecan-nxki)\nRequired\nMedical\nInformation\nBreast cancer: The member has a diagnosis of unresectable or \nmetastatic breast cancer AND The disease is human epidermal growth \nfactor receptor 2 (HER2) positive AND The member has received prior \nanti-HER2 based regimens [e.g., Perjeta (pertuzumab)- based regimens, \nKadcyla (ado-trastuzumab emtansine)] in the metastatic setting OR in \nthe neoadjuvant or adjuvant setting and has developed disease \nreoccurrence and one of the following applies:  during or within six \nmonths of completing therapy OR during or within twelve months of \ncompleting Perjeta-containing regimens.  The member does not have \nsymptomatic interstitial lung disease (ILD).  Enhertu (fam-trastuzumab \nderuxtecan-nxki) will be given as monotherapy. Gastric or \nGastroesophageal Junction Adenocarcinoma:  The member has a \ndiagnosis of locally advanced or metastatic gastric or gastroesophageal \njunction adenocarcinoma AND the disease is human epidermal growth \nfactor receptor 2 (HER2) positive AND The member has received prior \ntreatment with prior trastuzumab-based regimen AND The member does \nnot have symptomatic interstitial lung disease (ILD) AND Enhertu (fam-\ntrastuzumab deruxtecan-nxki) will be given as monotherapy.  HER2-Low \nBreast cancer: the member has a diagnosis of unresectable or \nmetastatic breast cancer AND the disease is human epidermal growth \nfactor receptor 2 (HER2) low (defined as IHC 1+ or IHC 2+/ISH-negative) \nAND the member has: received prior chemotherapy regimen(s) in the \nmetastatic setting (e.g. capecitabine, Eribulin, gemcitabine, paclitaxel) \nOR developed disease recurrence during or within six months of \ncompleting adjuvant chemotherapy AND the member has received at \nleast one line of endocrine therapy if the breast cancer subtype is \nhormone receptor positive (HR+), unless the member is contraindicated \nto endocrine therapy AND the member does not have symptomatic \ninterstitial lung disease (ILD) AND Enhertu (fam-trastuzumab \nderuxtecan-nxki) will be given as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 118 of 497\n", "doc_id": "43e555ef-a8c3-44ab-8d5c-dba3f2e83198", "embedding": null, "doc_hash": "2e93313ea768aa09c8d443f63cde2e91762c850132c20d00c62101ec2e17bc1a", "extra_info": {"page_label": "118", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2337, "_node_type": "1"}, "relationships": {"1": "4d7b994c-6b85-4629-b3a5-2f0114c69a69"}}, "__type__": "1"}, "498f781f-9405-4ee9-8471-2d43e1e45555": {"__data__": {"text": "ENHERTU\nOther Criteria\nHER2-Mutant Non-Small Cell Lung Cancer:  the member has a \ndiagnosis of unresectable or metastatic non-small cell lung cancer \n(NSCLC) AND NSCLC is documented (HER2 (ERBB2)) mutant AND the \nmember has received a prior systemic therapy (e.g. platinum-based \ntherapy, immunotherapy) AND the member does not have symptomatic \ninterstitial lung disease (ILD) AND Enhertu (fam-trastuzumab \nderuxtecan-nxki) will be given as monotherapy.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 119 of 497\n", "doc_id": "498f781f-9405-4ee9-8471-2d43e1e45555", "embedding": null, "doc_hash": "59669d50ec250de6b30927c4f808ff6a76d28cc39155bb89a15b5daa59ddb219", "extra_info": {"page_label": "119", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 529, "_node_type": "1"}, "relationships": {"1": "25770570-e267-42bf-b3ea-ee3edfea91b1"}}, "__type__": "1"}, "1279f856-82ec-46f6-a447-ad7a599a6085": {"__data__": {"text": "ENVARSUS XR\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nMember must have had a kidney transplant AND Must be using \nEnvarsus XR for prophylaxis of organ rejection AND Must be using in \ncombination with other immunosuppressants.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 120 of 497\n", "doc_id": "1279f856-82ec-46f6-a447-ad7a599a6085", "embedding": null, "doc_hash": "63b36739d3feeb9714012eb7b41472e2a6264d2ce2fb305c8fcb7d783149dfda", "extra_info": {"page_label": "120", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 475, "_node_type": "1"}, "relationships": {"1": "d2100424-b14e-47d4-8d4e-67e51a9c4a4b"}}, "__type__": "1"}, "4dad07c8-5c29-4af4-9a63-925c5af7d24c": {"__data__": {"text": "EPCLUSA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nChronic Hepatitis C Virus Genotypes: The member must have a \ndiagnosis of chronic hepatitis C (HCV). Baseline HCV RNA must be \ndocumented. Member must be tested for the presence of HBV by \nscreening for the surface antigen of HBV (HBsAg) and anti-hepatitis B \ncore total antibodies (anti-HBc) prior to initiation of therapy. For all \ngenotypes, criteria will be applied consistent with current AASLD-IDSA \nguidance.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n12 weeks depending on disease state and genotype based on AASLD \ntreatment guidelines for HCV.\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 121 of 497\n", "doc_id": "4dad07c8-5c29-4af4-9a63-925c5af7d24c", "embedding": null, "doc_hash": "a78e69c1b6440f77c2435dc02b38442febfe2c0301ff50ddc3e393fce8070526", "extra_info": {"page_label": "121", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 779, "_node_type": "1"}, "relationships": {"1": "e6e86a33-ba56-4249-88ec-c5945511b860"}}, "__type__": "1"}, "549b43eb-2f8f-4455-b247-de913cd3e17d": {"__data__": {"text": "EPIDIOLEX\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nDravet Syndrome: The member has a diagnosis of seizures associated \nwith Dravet Syndrome AND Epidiolex is prescribed by or in consultation \nwith a specialist (i.e. neurologist, epileptologist) AND The member has \nhad prior therapy with, contraindication, or intolerance to at least one \nother drug used for the treatment of Dravet Syndrome (e.g. clobazam, \nvalproic acid, topiramate).  Lennox-Gastaut: The member has a \ndiagnosis of seizures associated with Lennox-Gastaut syndrome AND \nEpidiolex is prescribed by or in consultation with a specialist (i.e. \nneurologist, epileptologist) AND The member has had prior therapy with, \ncontraindication, or intolerance to at least one other drug used for the \nreatment of Lennox-Gastaut syndrome (e.g. topiramate, lamotrigine). \nTuberous Sclerosis Complex: The member has a diagnosis of seizures \nassociated with Tuberous Sclerosis Complex. Reauthorization (all \nindications): The member has experienced an improvement in seizure \nfrequency from documented pre-treatment baseline.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 122 of 497\n", "doc_id": "549b43eb-2f8f-4455-b247-de913cd3e17d", "embedding": null, "doc_hash": "ec94dfcb285c5e4a1dd09cc803654e15b14cb25fd8dc9b5cfa3affa73073b8ee", "extra_info": {"page_label": "122", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1315, "_node_type": "1"}, "relationships": {"1": "636abaa5-e064-4d9d-9e2c-271cfead0645"}}, "__type__": "1"}, "114f6e63-f2b7-4302-b6cd-2f099778efbe": {"__data__": {"text": "EPKINLY\nPA Criteria\nCriteria Details\nOff-Label Uses\nPending CMS Review\nExclusion\nCriteria\nPending CMS Review\nRequired\nMedical\nInformation\nPending CMS Review\nAge Restriction\nPending CMS Review\nPrescriber\nRestriction\nPending CMS Review\nCoverage\nDuration\nPending CMS Review\nOther Criteria\nPending CMS Review\nPart B \nPrerequisite\nPending CMS Review\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 123 of 497\n", "doc_id": "114f6e63-f2b7-4302-b6cd-2f099778efbe", "embedding": null, "doc_hash": "da5cfd50d25e4412fee577d3b837f803b19f0578dc01e3cd8d830b2aa0fcacec", "extra_info": {"page_label": "123", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 396, "_node_type": "1"}, "relationships": {"1": "63db8505-21a4-4789-a851-56803e0da499"}}, "__type__": "1"}, "ecbc2516-8222-4b57-aff0-242125d1cec4": {"__data__": {"text": "epoprostenol (glycine)\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nHeart failure caused by reduced left ventricular ejection fraction.\nRequired\nMedical\nInformation\nPulmonary Arterial Hypertension (PAH). Higher Risk: Member has a \ndiagnosis of pulmonary arterial hypertension (WHO Group I) confirmed \nby right heart catheterization AND Member has WHO/NYHA Functional \nClass IV symptoms or is classified as high risk.  Determinants of high risk \ninclude: Clinical evidence of RV failure, Rapid progression of symptoms, \nShorter 6MW distance (less than300m), Peak VO2 less than 10.4 \nmL/kg/min for CPET, Pericardial effusion, significant RV \nenlargement/dysfunction, or right atrial enlargement on \nechocardiography, RAP greater than 20mmHg, CI less than 2.0 \nL/min/m2 and/or Significantly elevated BNP. Lower Risk: Member \ndiagnosis of pulmonary arterial hypertension (WHO Group I) confirmed \nby right heart catheterization with WHO/NYHA Functional Class II or III \nsymptoms.  AND  member must have had prior therapy, intolerance or \ncontraindication to an ERA (e.g., ambrisentan, bosentan, Opsumit \n[macitentan]), AND either a PDE5 inhibitor (e.g., sildenafil, tadalafil) OR \nAdempas (riociguat).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 124 of 497\n", "doc_id": "ecbc2516-8222-4b57-aff0-242125d1cec4", "embedding": null, "doc_hash": "f10801479b8556dc503e0dcc4a1ef942d4b06730563247181027817bb3b4a38b", "extra_info": {"page_label": "124", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1402, "_node_type": "1"}, "relationships": {"1": "60790017-88a6-4d03-a352-fb605a70f76a"}}, "__type__": "1"}, "301418c3-a7af-4f39-a698-c85bee52e037": {"__data__": {"text": "EPRONTIA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nMigraine Prophylaxis: Member is using for prophylaxis of migraine \nheadache AND has had previous treatment with or intolerance to \nimmediate release topiramate tablet or capsule AND has had previous \ntreatment, intolerance, or contraindication with propranolol or timolol. \nEpilepsy Adjunctive Therapy:  Member has a diagnosis of partial-onset \nseizures, primary generalized tonic-clonic seizures, or seizures \nassociated with Lennox-Gastaut syndrome (LGS) AND Concomitant use \nof at least one antiepileptic medication (e.g. lamotrigine, carbamazepine, \nlevetiracetam) AND Has had previous treatment with or intolerance to \nimmediate release topiramate tablet or capsule AND Has unsuccessful \ncontrol of seizures as determined by treating physician.  Epilepsy \nMonotherapy:  Member must have diagnosis of partial-onset seizures or \nprimary generalized tonic-clonic seizures AND Member has had previous \ntreatment with or intolerance to immediate release topiramate tablet or \ncapsule AND Has unsuccessful control of seizures as determined by \ntreating physician.\nAge Restriction\nMigraine Prophylaxis: Member must be 12 years of age or older. \nEpilepsy indications: Member must be 2 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 125 of 497\n", "doc_id": "301418c3-a7af-4f39-a698-c85bee52e037", "embedding": null, "doc_hash": "5f2d8e165efbd4f211ca51173010f8acac359251048fd64afecc69a09a057d33", "extra_info": {"page_label": "125", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1477, "_node_type": "1"}, "relationships": {"1": "1469e8e2-7d22-4d4e-9e63-4fa4fde57421"}}, "__type__": "1"}, "c7c06382-63b5-4e85-b65a-55b840a5b1b9": {"__data__": {"text": "ERBITUX\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMetastatic colorectal cancer patients with RAS mutations should not \nreceive cetuximab due to known lack of response and possible worse \noutcomes in this population. Member has disease progression on \nVectibix or Erbutux.Erbitux may not be used in conjunction with Vectibix, \nTarceva or Iressa (all are EGFR inhibitors). Erbitux may not be used in \nconjunction with Avastin.\nRequired\nMedical\nInformation\nMetastatic Colorectal Cancer (mCRC). Diagnosis of Metastatic (stage IV) \nColorectal Cancer.The member has mCRC that expresses verified wild-\ntype (normal) KRAS/NRAS.  Applies to new starts only.Erbitux \n(cetuximab) may be used as one of the following: monotherapy in mCRC \nmembers intolerant to irinotecan or who have experienced disease \nprogression following therapy with both irinotecan and oxaliplatin based \ntherapy OR combination with irinotecan-based therapy or with \nfluorouracil based  therapy (e.g. FOLFOX, FOLFIRI) OR member \nexperiences progressive disease on prior therapy and Erbitux is in \ncombination with Braftovi for documented BRAFV600E mCRC.  Head \nand Neck Cancer. Diagnosis of locally or regionally squamous cell \nadvanced Head and Neck Cancer with concomitant XRT OR The \nmember has recurrent or metastatic squamous cell Head and Neck \nCancer and is receiving Erbitux (cetuximab) monotherapy after \nexperiencing disease progression following platinum based therapy (may \nalso be used in conjunction with a platinum agent).OR The member has \nadvanced or recurrent squamous cell Head and Neck Cancer that is \nunresectable or the member is unfit for surgery OR The member has a \ndiagnosis of recurrent locoregional disease or metastatic squamous cell \ncarcinoma of the head and neck AND The member is receiving Erbitux \n(cetuximab) in combination with platinum-based therapy with 5-\nFluorouracil.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 126 of 497\n", "doc_id": "c7c06382-63b5-4e85-b65a-55b840a5b1b9", "embedding": null, "doc_hash": "ea2f81a5096345574c5c6528d8f1b93857a19f6765633507b10c86a613b56970", "extra_info": {"page_label": "126", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2087, "_node_type": "1"}, "relationships": {"1": "693c30aa-af1e-48a6-8973-b7eac99f46ee"}}, "__type__": "1"}, "00eecb98-85ba-4fb8-8cf5-6756e405b9a5": {"__data__": {"text": "ERIVEDGE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nErivedge (vismodegib) therapy is not considered medically necessary for \nmembers with the following concomitant conditions:Members that have \nexperienced disease progression while on Erivedge (vismodegib). \nMembers that are using Erivedge (vismodegib) as neoadjuvant therapy.\nRequired\nMedical\nInformation\nAdvanced Basal Cell Carcinoma.The member has a diagnosis of \nmetastatic basal cell carcinoma OR The member has a diagnosis of \nlocally advanced basal cell carcinoma AND one of the following applies: \nThe member has disease that has recurred following surgery OR the \nmember is not a candidate for surgery AND radiation.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 127 of 497\n", "doc_id": "00eecb98-85ba-4fb8-8cf5-6756e405b9a5", "embedding": null, "doc_hash": "4d253069141bde580e887331262d987e98b0ef704afcc79c85031046a3e07487", "extra_info": {"page_label": "127", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 888, "_node_type": "1"}, "relationships": {"1": "824ff52c-4e38-4750-a20f-bea9b33ef43b"}}, "__type__": "1"}, "912b3fc7-a3a3-4136-9bb0-f78d47a6ac12": {"__data__": {"text": "ERLEADA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers that have experienced disease progression while on Erleada \n(apalutamide). Concoitant use with an androgen receptor inhibitor or \nandrogen synthesis inhibitor (e.g., enzulutamide, abiraterone, nilutamide, \nflutamide, bicalutamide) due to lack of evidence supporting efficacy and \nsafety.\nRequired\nMedical\nInformation\nProstate Cancer (non-metastatic castration resistant): The member has a \ndiagnosis of non-metastatic castration resistant prostate cancer AND the \nmember will use Erleada (apalutamide) in combination with androgen \ndeprivation therapy (e.g. previous bilateral orchioectomy or GnRH \nanalog).  Prostate Cancer (metastatic castration-sensitive):  The member \nhas a diagnosis of metastatic castration-sensitive prostate cancer AND \nthe member will use Erleada (apalutamide) in combination with androgen \ndeprivation therapy (e.g. previous bilateral orchioectomy or GnRH \nanalog).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 128 of 497\n", "doc_id": "912b3fc7-a3a3-4136-9bb0-f78d47a6ac12", "embedding": null, "doc_hash": "bebc651f99362bb2693a6015db72da5086bf0ba4a29a8425ddd942216ab866cc", "extra_info": {"page_label": "128", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1167, "_node_type": "1"}, "relationships": {"1": "f57a5fbd-f3ca-4057-b090-ba2a8f8bb314"}}, "__type__": "1"}, "f45b9ea0-2ff6-4081-986e-00c2d40fba4b": {"__data__": {"text": "erlotinib\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors.\nRequired\nMedical\nInformation\nPancreatic Cancer: The member has a diagnosis of unresectable, locally \nadvanced or metastatic pancreatic cancer. AND erlotinib is being used in \ncombination with Gemzar (gemcitabine).Non-small cell lung cancer. The \nmember has a diagnosis of metastatic NSCLC AND all of the following \napply: The member has known documented activated EGFR mutation \n(such as E19del in exon 19 or L858R in exon 21). Renal Cell Carcinoma: \nDiagnosis of relapsed or unresectable stage IV renal cell carcinoma with \nnon clear histology and erlotinib will be used as monotherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 129 of 497\n", "doc_id": "f45b9ea0-2ff6-4081-986e-00c2d40fba4b", "embedding": null, "doc_hash": "e4a5dd089b48ed449e285ee276185a79055bc174e1f6594c4bcb19329a47bf80", "extra_info": {"page_label": "129", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 907, "_node_type": "1"}, "relationships": {"1": "e35e838b-48f0-4d5a-9d60-e526ade9a27f"}}, "__type__": "1"}, "7ed72470-ec09-495e-84a9-a1d7eeb90ba9": {"__data__": {"text": "ERWINAZE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nErwinaze (asparaginase Erwinia chrysanthemi) therapy is not considered \nmedically necessary for members with the following concomitant \nconditions:Members with a history of serious pancreatitis with prior \nasparaginase based therapy,Members with a history of serious \nthrombosis with prior asparaginase based therapy,Members with a \nhistory of serious hemorrhagic events with prior asparaginase based \ntherapy,Members that have experienced disease progression while on \nasparaginase based therapy.\nRequired\nMedical\nInformation\nErwinaze (asparaginase Erwinia chrysanthemi) will require prior \nauthorization. This agent may be considered medically necessary when \nthe following criteria are met: Acute Lymphoblastic Leukemia (ALL).The \nmember has a diagnosis of ALL. The member has documented, Grade 2 \n\u2013 4 \nhypersensitivity (based on Common Terminology Toxicity Criteria) as \na result of prior treatment with Oncaspar (pegaspargase).The member is \nusing Erwinaze (asparaginase Erwinia chrysanthemi) as a component of \na multi-agent chemotherapeutic regimen.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 130 of 497\n", "doc_id": "7ed72470-ec09-495e-84a9-a1d7eeb90ba9", "embedding": null, "doc_hash": "14d4d0d8ad1743519f6528f9bceedd8ab893c13f0f0e96b99e8b2dd4ad35577d", "extra_info": {"page_label": "130", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1322, "_node_type": "1"}, "relationships": {"1": "99c39dc7-a000-4839-8ddc-8fa6dfb26214"}}, "__type__": "1"}, "36189eaa-0809-4f77-a9a6-8c0310ee3d48": {"__data__": {"text": "EULEXIN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nThe member has a diagnosis of prostate cancer AND will be using \nEulexin (flutamide) alone or in combination therapy with a luteinizing \nhormone-releasing hormone (LHRH) analog.\nAge Restriction\nPrescriber\nRestriction\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 131 of 497\n", "doc_id": "36189eaa-0809-4f77-a9a6-8c0310ee3d48", "embedding": null, "doc_hash": "2c2992fba8a37944a70bb709f7fbc43f850b7bd075b89949b41b7bfc989e941f", "extra_info": {"page_label": "131", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 443, "_node_type": "1"}, "relationships": {"1": "9bd4cdcc-bdfc-4335-8088-5082f7addb1e"}}, "__type__": "1"}, "7f9a3cf2-b823-41b8-8e93-709afc490b0e": {"__data__": {"text": "everolimus (antineoplastic)\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on \neverolimus.\nRequired\nMedical\nInformation\nAdvanced Renal Cell Carcinoma (RCC). The member has a diagnosis of \nadvanced /metastatic renal cell carcinoma (stage IV) AND the member \nexperienced intolerance on Cabometyx (cabozantinib) as second line \ntherapy [e.g., severe hypertension/hypertensive crisis, cardiac failure, \nvenous thromboembolic event within the last 6 months, arterial \nthromboembolic event within the last 12 months, severe hemorrhage, \nreversible posterior leukoencephalopathy, unmanageable fistula/GI \nperforation, nephrotic syndrome) AND Afinitor (everolimus) is given as \nmonotherapy or being given in combination with Lenvima (lenvatinib).  \nThe member has a diagnosis of Subependymal Giant Cell Astrocytoma \n(SEGA) associated with tuberous sclerosis AND The member requires \ntherapeutic intervention but is not a candidate for curative surgical \nresection. Neuroendocrine Tumors: The member has disease that is \nunresectable, locally advanced or metastatic and one of the following \napplies: The member has a diagnosis of progressive neuroendocrine \ntumors of pancreatic origin (PNET) OR The member has a diagnosis of \nprogressive, well differentiated, non-functional neuroendocrine tumors of \ngastrointestestinal or lung. Waldenstroms \nmacroglobulinemia/Lymphoplasmacytic Lymphoma. The member has a \ndiagnosis of recurrent or not responsive to primary treatment or relapsed \nWaldenstroms Macroglobulinemia/Lymphoplasmacytic Lymphoma AND \nAfinitor (everolimus) will be used as monotherapy.\nAge Restriction\nTSC associated partial onset seizures: Member is 2 years of age or \nolder.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 132 of 497\n", "doc_id": "7f9a3cf2-b823-41b8-8e93-709afc490b0e", "embedding": null, "doc_hash": "5df838398f9c97ed88767017a8bd4e58a5186227ea3d33e691240f153515f94d", "extra_info": {"page_label": "132", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1885, "_node_type": "1"}, "relationships": {"1": "4efcc1d4-cabd-4dac-8bc7-a030573f2dc0"}}, "__type__": "1"}, "e8f3d5eb-9804-41e3-a09b-866af40bb43b": {"__data__": {"text": "everolimus (antineoplastic)\nOther Criteria\nAngiomyolipoma and Tuberous Sclerosis Complex (TSC).The member \nhas a diagnosis of renal angiomyolipoma and tuberous sclerosis \ncomplex AND Immediate surgery is not required. Metastatic Breast \nCancer. The member has a diagnosis of hormone receptor-positive and \nhuman epidermal growth factor receptor 2-negative metastatic disease \nAND the member has been treated with endocrine therapy (e.g. \nletrozole, anastrozole) within one year AND The member will use Afinitor \n(everolimus) in combination with exemestane or fulvestrant (Faslodex). \nTuberous sclerosis complex (TSC)- associated partial onset seizures \n[Adults and Pediatrics]: The member has diagnosis of TSC- associated \npartial onset seizures AND Afinitor Disperz (everolimus tablets for oral \nsolution) is being used as adjunctive therapy.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 133 of 497\n", "doc_id": "e8f3d5eb-9804-41e3-a09b-866af40bb43b", "embedding": null, "doc_hash": "8d3250b3017ee5f9d4d6b8251008992e174fca28a593667b0cc9a3a64a61950a", "extra_info": {"page_label": "133", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 918, "_node_type": "1"}, "relationships": {"1": "4dff1f51-2f7d-44e9-b59d-0f6d4e410fac"}}, "__type__": "1"}, "a0e9e368-78a1-4d62-9d17-6c8ebd462943": {"__data__": {"text": "EVOMELA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nMultiple Myeloma:The member has a diagnosis of mutliple myeloma. \nThe member is utilizing Evomela as:High-dose conditioning treatment \nprior to stem cell transplantation OR Palliative treatment in members for \nwhom oral therapy is not appropriate. Systemic Light Chain Amyloidosis: \nThe member has a diagnosis of systemic light chain amyloidosis.The \nmember will receive Evomela as:Primary treatment AND High-dose \nsingle-agent therapy with stem cell transplant.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nsix month durations\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 134 of 497\n", "doc_id": "a0e9e368-78a1-4d62-9d17-6c8ebd462943", "embedding": null, "doc_hash": "e832c5513a888f5175adbdaf3e1ea25cb4878444d5c5eb81296ae85eb418809c", "extra_info": {"page_label": "134", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 760, "_node_type": "1"}, "relationships": {"1": "ec87f510-8800-4cfd-9307-b8ed35a58b1a"}}, "__type__": "1"}, "bc3286cd-2a1e-4cc4-8f33-23d351e9ee5d": {"__data__": {"text": "EXKIVITY\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experiences disease progression on Exkivity (mobocertinib).\nRequired\nMedical\nInformation\nMetastatic Non-Small Cell Lung Cancer (NSCLC):  The member has \nlocally advanced or metastatic NSCLC AND The NSCLC has \ndocumented EGFR exon 20 insertion mutation AND The member has \nexperienced disease progression on platinum based therapy AND \nExkivity (mobocertinib) is administered as single agent as subsequent \ntherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 135 of 497\n", "doc_id": "bc3286cd-2a1e-4cc4-8f33-23d351e9ee5d", "embedding": null, "doc_hash": "7e542c9a1315718ae8903c36a2d9849175ced694f08489720f2718a9b9f2555c", "extra_info": {"page_label": "135", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 680, "_node_type": "1"}, "relationships": {"1": "945b7eb3-a377-4bb5-a85a-196e4c8974f5"}}, "__type__": "1"}, "15b3d481-01a3-4315-a917-73eab8018c92": {"__data__": {"text": "FANAPT\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDementia-related psychosis (in the absence of an approvable diagnosis), \nfor member 65 years of age or older.\nRequired\nMedical\nInformation\nSchizophrenia. The member must be utilizing it for treatment of \nschizophrenia.The member must have prior therapy or intolerance or \ncontraindication to at least 2 of the following: risperidone or olanzapine \nor quetiapine or ziprasidone or aripiprazole.\nAge Restriction\nThe member must be 18 years or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 136 of 497\n", "doc_id": "15b3d481-01a3-4315-a917-73eab8018c92", "embedding": null, "doc_hash": "fa337494b2f64ee1f0079f1ae00028ce66f410ff5612c0809d9c60691da4f6cd", "extra_info": {"page_label": "136", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 689, "_node_type": "1"}, "relationships": {"1": "434675b7-8f34-42ed-a031-e7721f8a63e3"}}, "__type__": "1"}, "cf489f58-1df0-41b4-a125-3f5d36223964": {"__data__": {"text": "FASENRA PEN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nSevere Asthma with an Eosinophilic Phenotype: The member has a \ndiagnosis of severe asthma AND the member has an eosinophilic \nphenotype, defined by an elevated peripheral blood eosinophil level of  \ngreater than or equal to 150 cells/microliter at therapy initiation OR \ngreater than or equal to 300 cells/microliter in the previous 12 months. \nThe member has been unable to achieve adequate control of asthma \nwhile on maximum tolerated inhaled corticosteroid therapy (e.g. \nmometasone greater than 400mcg daily, fluticasone greater than 440 \nmcg daily) in combination with a long acting beta agonist (e.g. \nformoterol).  Continuation of therapy:  Member is currently stable on \ntherapy. Member will continue on asthma controller inhalers: inhaled \ncorticosteroids (ICS) with or without a long-acting beta2-agonist (LABA). \nEosinophilic Granulomatosis with Polyangiitis (EGPA): The member has \na diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA) AND \nthe member has a baseline elevated peripheral blood eosinophil level of \ngreater than 10% of total leukocyte count AND two or more systemic \nmanifestations of EGPA.  The member has been unable to achieve \nadequate control of EGPA while on oral corticosteroid therapy (e.g. \nprednisone, methylprednisolone).  Hypereosinophilic Syndrome (HES) - \nNucala only:  The member has a diagnosis of hypereosinophilic \nsyndrome (HES) for at least 6 months AND The member has a baseline \nblood eosinophil level of greater than or equal to 1000 cells/microliter.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nChronic Rhinosinusitis with Nasal Polyposis - Nucala Only:  Initial \nReview- The member must meet ALL of the following criteria:  Diagnosis \nof Chronic Rhinosinusitis with Nasal Polyposis AND Nucala \n(mepolizumab) will be used in conjunction with a daily intranasal \ncorticosteroid spray AND member is unable to achieve adequate control \nof symptoms with maximum tolerated intranasal corticosteroid therapy.  \nContinuation of Therapy - The member must meet ALL of the following \ncriteria:  Improvement in symptoms (e.g., decrease in nasal congestion, \ndecrease in polyp size, improvement in ability to smell) which has been \nsustained AND continuing intranasal corticosteroid spray therapy.\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 137 of 497\n", "doc_id": "cf489f58-1df0-41b4-a125-3f5d36223964", "embedding": null, "doc_hash": "3b72a8131b8ebedead84a07fc3544540b8be23fd5db5b44f15a8b6350c9922c7", "extra_info": {"page_label": "137", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2477, "_node_type": "1"}, "relationships": {"1": "5a367987-1ac2-4066-b913-4be442ff7277"}}, "__type__": "1"}, "0e72d7ce-69ae-42d6-9664-aeaea91cfe47": {"__data__": {"text": "FASENRA PEN\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 138 of 497\n", "doc_id": "0e72d7ce-69ae-42d6-9664-aeaea91cfe47", "embedding": null, "doc_hash": "47d6254cb87248c5963ed5a8bd19db323e3b9ea9decfd87255b5b9cec3ad6d31", "extra_info": {"page_label": "138", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 86, "_node_type": "1"}, "relationships": {"1": "c99fa275-3e9e-4027-9c9a-8fc93ba1ba08"}}, "__type__": "1"}, "e8569ca7-3931-4eb6-89b9-8a42301f5777": {"__data__": {"text": "fentanyl citrate\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nTreatment of acute or post-operative pain.\nRequired\nMedical\nInformation\nThe member is currently diagnosed with cancer. Fentanyl citrate is \nrequired to manage breakthrough cancer pain. The member is currently \ntaking opioid therapy and is opioid tolerant. Tolerance is defined as any \nof the following: greater than or equal 60 mg oral morphine/day, 25 mcg \ntransdermal fentanyl/hour, 30 mg oral oxycodone/day, 8 mg oral \nhydromorphone/day, 25 mg oral oxymorphone/day, 60 mg oral \nhydrocodone/day for greater than or equal 1 week, An equianalgesic \ndose of another opioid for greater than or equal 1 week.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 139 of 497\n", "doc_id": "e8569ca7-3931-4eb6-89b9-8a42301f5777", "embedding": null, "doc_hash": "a7e5a7407797a503f32e8cc32eab38c14ed542d3619b66c85f634792428dcc44", "extra_info": {"page_label": "139", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 872, "_node_type": "1"}, "relationships": {"1": "a726362b-9703-43e5-b715-3daa2496daae"}}, "__type__": "1"}, "18c7d6b2-32a4-46bd-882c-e4aedc7ba081": {"__data__": {"text": "FETZIMA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nMajor depressive disorder: The member must be utilizing Fetzima for \ntreatment of major depressive disorder. For new starts only: The member \nmust have a documentation of prior therapy, intolerance, or \ncontraindication to a serotonin and norepinephrine reuptake inhibitor \n(SNRI) AND a generic bupropion product (75mg/100mg IR, \n100mg/150mg/200mg SR, or 150mg/300mg XL) or mirtazapine.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 140 of 497\n", "doc_id": "18c7d6b2-32a4-46bd-882c-e4aedc7ba081", "embedding": null, "doc_hash": "ab7b4e799d36959ce62f82d1f1f83f2b808b6bdd6b5ab547a0dad00bf5293bc9", "extra_info": {"page_label": "140", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 686, "_node_type": "1"}, "relationships": {"1": "78fa39f7-fb98-4698-9bdb-8c9aeec7f76b"}}, "__type__": "1"}, "b0daf8e6-d5f0-423a-80a1-fb99df57c45d": {"__data__": {"text": "fingolimod\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nThe member has a diagnosis of a relapsing form of multiple sclerosis, to \ninclude relapsing-remitting or active secondary progressive disease OR \nthe member has a diagnosis of a clinically isolated syndrome (CIS).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 141 of 497\n", "doc_id": "b0daf8e6-d5f0-423a-80a1-fb99df57c45d", "embedding": null, "doc_hash": "29ce901208117f04a851ac494ce8dc215ef1de5d3ddb3124495aa7a922666c97", "extra_info": {"page_label": "141", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 516, "_node_type": "1"}, "relationships": {"1": "24bf670b-55f4-49d0-b465-1d2dcf564b18"}}, "__type__": "1"}, "2abe43eb-d385-42f0-9e6d-308bef91b460": {"__data__": {"text": "FINTEPLA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nDravet Syndrome:  The member has a diagnosis of Dravet syndrome \nAND the member is experiencing seizures associated with Dravet \nsyndrome on current therapy at baseline AND The member has had \nprevious treatment with one antiepileptic supported for the treatment of \nseizures associated with Dravet Syndrome (e.g. valproic acid, clobazam, \ntopiramate).  Lennox-Gastaut Syndrome:  The member has a diagnosis \nof Lennox-Gastaut Syndrome AND the member has had prior therapy \nwith, contraindication, or intolerance to at least two antiepileptics \nsupported for the treatment of Lennox-Gastaut syndrome (e.g. \ntopiramate, lamotrigine) AND Fintepla (fenfluramine) is prescribed by or \nin consultation with a specialist (i.e. neurologist, epileptologist).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 142 of 497\n", "doc_id": "2abe43eb-d385-42f0-9e6d-308bef91b460", "embedding": null, "doc_hash": "067d78d93141d03e9e31e4feea9cd7678f18186f42d2a5c1a2e46b90a8100791", "extra_info": {"page_label": "142", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1038, "_node_type": "1"}, "relationships": {"1": "03a751cd-12ff-42da-aca7-4c995e8e7273"}}, "__type__": "1"}, "c421ae8e-4e55-4c52-b7c8-44f746aad846": {"__data__": {"text": "FIRDAPSE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nHistory of seizures (not to be inferred from pharmacy claims)\nRequired\nMedical\nInformation\nLambert-Eaton Myasthenic Syndrome (LEMS). The member has a \nconfirmed diagnosis of Lambert-Eaton Myasthenic Syndrome (LEMS) by \na specialist (e.g. neurologist) AND The diagnosis is supported by results \nfrom a clinical evaluation (e.g. electromyography or the presence of \nautoantibodies directed against VGCC {voltagegated calcium channels}).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 143 of 497\n", "doc_id": "c421ae8e-4e55-4c52-b7c8-44f746aad846", "embedding": null, "doc_hash": "9f1144c808e64eb74d7eb2619ad21a279460a27ceeb434a8831b076461dc5f73", "extra_info": {"page_label": "143", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 694, "_node_type": "1"}, "relationships": {"1": "a2134412-3d8e-4f29-bcf7-26e226ca9503"}}, "__type__": "1"}, "5e61c914-e60d-41ca-b980-3b330eacb402": {"__data__": {"text": "FIRMAGON\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agents.\nRequired\nMedical\nInformation\nThe patient has a diagnosis of advanced prostate cancer or has a high \nrisk of disease recurence.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 144 of 497\n", "doc_id": "5e61c914-e60d-41ca-b980-3b330eacb402", "embedding": null, "doc_hash": "d815f9d46348ed5bc5f77dc5a7cb59f6ac8a56a111c66b00c9808ba294b5af7f", "extra_info": {"page_label": "144", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 435, "_node_type": "1"}, "relationships": {"1": "2b696b53-b50b-4f4d-97d8-6ee5c0d2a4eb"}}, "__type__": "1"}, "a80e5fb1-c2c1-469a-91a3-ffa14b038b22": {"__data__": {"text": "FIRMAGON KIT W DILUENT SYRINGE\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agents.\nRequired\nMedical\nInformation\nThe patient has a diagnosis of advanced prostate cancer or has a high \nrisk of disease recurence.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 145 of 497\n", "doc_id": "a80e5fb1-c2c1-469a-91a3-ffa14b038b22", "embedding": null, "doc_hash": "a40b17578edb72244bd0bb65c185affaa1f04e545bd21a8b8d411eb60d6cfd09", "extra_info": {"page_label": "145", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 457, "_node_type": "1"}, "relationships": {"1": "f53b7745-7f92-47d5-a611-ecfe0d6de377"}}, "__type__": "1"}, "d39c2688-4f24-4049-bb96-3115fc30d07b": {"__data__": {"text": "FOLOTYN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on \npralatrexate.\nRequired\nMedical\nInformation\nPeripheral T-cell Lymphoma(PTCL):relapsed or refractory. Pralatrexate \nis being used to treat relapsed or refractory peripheral T-cell lymphoma \n(PTCL) (eg peripheral T-cell lymphoma, not otherwise specified: \nangioimmunoblastic T-cell lymphoma, anaplastic large cell lymphoma or \nenteropathy-associated T-cell lymphoma.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 146 of 497\n", "doc_id": "d39c2688-4f24-4049-bb96-3115fc30d07b", "embedding": null, "doc_hash": "826d3f8725c949fc4241133cdf4e9aa7a7d375c1649973c675c27e92ef3f53e8", "extra_info": {"page_label": "146", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 678, "_node_type": "1"}, "relationships": {"1": "3b744cf3-158e-4ddd-90c2-c2f6f3b8864d"}}, "__type__": "1"}, "63998638-a523-41c9-9e09-d9ff08c5a2e9": {"__data__": {"text": "formoterol fumarate\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nAsthma, in the absence of concurrent medication containing inhaled \ncorticosteroid and comorbid COPD diagnosis.\nRequired\nMedical\nInformation\nChronic Obstructive Pulmonary Disease (COPD).Diagnosis of Chronic \nObstructive Pulmonary Disease (COPD), including chronic bronchitis \nand emphysema, requiring maintenance treatment of \nbronchoconstriction.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 147 of 497\n", "doc_id": "63998638-a523-41c9-9e09-d9ff08c5a2e9", "embedding": null, "doc_hash": "44478db1a023c76dcea6b84fee97f8543e7a01fa55e48599396a38340f9ca985", "extra_info": {"page_label": "147", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 618, "_node_type": "1"}, "relationships": {"1": "83325c20-279a-45b0-87c7-1e9fa8b8f004"}}, "__type__": "1"}, "a1b6a349-57ec-45a2-985a-8a6c61c2181e": {"__data__": {"text": "FORTEO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nThe member is postmenopausal with a diagnosis of osteoporosis. The \nmember is at high risk for osteoporotic fracture as evident by one of the \nfollowing: The member has a history of osteoporotic fracture OR The \nmember has new fractures or significant loss of bone mineral density \ndespite previous treatment contraindication or intolerance with an oral \nOR intravenous bisphosphonate (e.g. alendronate, ibandronate, \npamidronate).  The member is taking sustained systemic glucocorticoid \ntherapy (daily dosage equivalent to 5 mg or greater of prednisone). The \nmember is at high risk for osteoporotic fracture as evident by one of the \nfollowing: The member has a history of osteoporotic fracture OR The \nmember has new fractures or significant loss of bone mineral density \ndespite previous treatment, contraindication or intolerance with an oral \nOR intravenous bisphosphonate (e.g. alendronate, ibrandronate, \npamidronate). The member has a diagnosis of primary or hypogonadal \nosteoporosis, who is at high risk for fracture, defined as history of \nosteoporotic fracture, or who have multiple risk factors for fracture.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 148 of 497\n", "doc_id": "a1b6a349-57ec-45a2-985a-8a6c61c2181e", "embedding": null, "doc_hash": "e76b223947f1d2e7f2258b870bbb261f6d23051afa4ba6d433b5ba8e620a19fb", "extra_info": {"page_label": "148", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1410, "_node_type": "1"}, "relationships": {"1": "da1c62ec-2636-4424-9800-b7f0cb1c92ad"}}, "__type__": "1"}, "e66cb4aa-e780-4769-b248-bd5821fc0fcd": {"__data__": {"text": "FOTIVDA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMember experiences disease progression on Fotivda (tivozanib).\nRequired\nMedical\nInformation\nRelapsed or refractory advanced renal cell carcinoma:  The member has \na diagnosis of relapsed or refractory advanced renal cell carcinoma AND \nThe member has received two prior systemic therapies (e.g., immuno-\noncology checkpoint inhibitors, cabozantinib, axitinib) AND Fotivda \n(tivozanib) is given as a single agent for subsequent therapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 149 of 497\n", "doc_id": "e66cb4aa-e780-4769-b248-bd5821fc0fcd", "embedding": null, "doc_hash": "faa309d0fe92f3e8e902befac4eb2544a76ad9384370f345de4836e2d794ab20", "extra_info": {"page_label": "149", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 702, "_node_type": "1"}, "relationships": {"1": "23ceedd7-57e1-42be-8905-7d96b813f318"}}, "__type__": "1"}, "cc1de9fc-57b3-4593-9c1a-a2a656c25258": {"__data__": {"text": "FULPHILA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant use with filgrastim, biosimilar filgrastim (e.g. filgastrim-sndz \nor filgastrim-aafi), tbo-filgratim, sargramostim (unless part of stem cell \nmobilization protocol), pegfilgrastim (within seven days of pegfilgrastim \ndose), or biosimiliar pegfilgrastim (e.g. pegfilgrastim-jmbd or \npegfilgastrim-cbqv, within seven days of pegfilgrastim dose). Same day \nadministration with myelosuppressive chemotherapy or therapeutic \n(Administration of pegfilgrastim occurs no less than 24 hours following \nmyelosuppressive chemotherapy).  Cannot be given more than once per \nchemotherapy cycle.\nRequired\nMedical\nInformation\nFebrile Neutropenia Prophylaxis. The member must have a diagnosis of \nnon-myeloid malignancy (e.g. solid tumors) AND The member has \nreceived or will receive pegfilgrastim product 24-72 hours after the \nadministration of myelosuppressive chemotherapy AND The member \nmust also meet ONE OR MORE of the following criteria: A risk of febrile \nneutropenia (FN) of greater than 20% based on current chemotherapy \nregimen (as listed in current ASCO and NCCN guidelines for myeloid \ngrowth factors) OR A risk of febrile neutropenia of 10-20% based on \nchemotherapy regimen, and one or more of the following risk factors \napply: Prior chemotherapy or radiation therapy OR Persistent \nneutropenia (defined as neutrophil count less than 500 neutrophils/mcL \nor less than 1,000 neutrophils/mcL and a predicted decline to less than \nor equal to 500 neutrophils/mcL over next 48 hours) OR Bone marrow \ninvolvement by tumor OR Recent surgery and/or open wounds OR Liver \ndysfunction (bilirubin greater than 2.0 mg/dL) OR Renal dysfunction \n(creatinine clearance less than 50 mL/min) OR Age greater than 65 \nreceiving full chemotherapy dose intensity OR Previous neutropenic \nfever complication or dose-limiting neutropenic event from a prior cycle \nof similar chemotherapy OR The member is receiving a dose-dense \nchemotherapy regimen OR As secondary prophylaxis in the curative \nsetting to maintain dosing schedule and/or intensity.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n4 months duration\nOther Criteria\nHematopoietic Subsyndrome of Acute Radiation Syndrome. The \nmember has been acutely exposed to myelosuppressive doses of \nnontherapeutic radiation.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 150 of 497\n", "doc_id": "cc1de9fc-57b3-4593-9c1a-a2a656c25258", "embedding": null, "doc_hash": "36c6ae69164b0895872ba9e49081cc4410e657d57383878edd34f0bc3db0a262", "extra_info": {"page_label": "150", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2449, "_node_type": "1"}, "relationships": {"1": "7f48cc91-9c3e-46f5-85c8-567291df5f20"}}, "__type__": "1"}, "c5e41230-db5d-4cfc-8bdf-239f58f55839": {"__data__": {"text": "fulvestrant\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experiences disease progression on Faslodex.\nRequired\nMedical\nInformation\nBreast Cancer. The member is post-menopausal or premenopausal but \nreceiving ovarian ablation/suppression AND The member has a \ndiagnosis of hormone receptor (HR)- positive metastatic breast cancer \nAND  The member experienced disease progression, intolerance, or has \na contraindication to endocrine therapy AND Faslodex (fulvestrant) is \ngiven as monotherapy OR The member has HR-positive and human \nepidermal growth factor receptor 2 negative breast cancer AND one of \nthe following applies: The post-menopausal member has not previously \nbeen treated with endocrine therapy for advanced disease and Faslodex \n(fulvestrant) will be used as monotherapy OR Faslodex (fulvestrant) is \ngiven in combination with Kisqali (ribociclib) as initial endocrine based \ntherapy OR Faslodex (fulvestrant) is given in combination with Ibrance \n(palbociclib) or Verzenio (abemaciclib) or Kisqali (ribociclib) as \nsubsequent therapy after disease progression on or following endocrine \nbased therapy (e.g., anastrazole) for their recurrent disease OR \nFaslodex (fulvestrant) is given in combination with Ibrance (palbociclib) \nor Verzenio (abemaciclib) or Kisqali (ribociclib) as subsequent therapy \nafter disease progression on or following endocrine based therapy (e.g., \nanastrazole) for their metastatic disease OR Faslodex (fulvestrant) is \ngiven in combination with Afinitor (everolimus) for disease that has been \ntreated with endocrine therapy (e.g. letrozole, anastrazole) OR Faslodex \n(fulvestrant) is given in combination with Piqray (alpelisib) for disease \nprogression on or after endocrine based therapy (e.g. anstrazole, \npalbociclib) within one year of PIK3CA mutated disease.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 151 of 497\n", "doc_id": "c5e41230-db5d-4cfc-8bdf-239f58f55839", "embedding": null, "doc_hash": "75e0875a37fa4c0d3d3be8eee61ebd0ea70f88e03e7b69ba40534e183854b6ed", "extra_info": {"page_label": "151", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2027, "_node_type": "1"}, "relationships": {"1": "e871de30-8532-491e-a792-180d7ee77014"}}, "__type__": "1"}, "9d0c893b-33d8-472a-927f-63490f0a3b02": {"__data__": {"text": "FYARRO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember has a history of severe hypersensitivity to sirolimus, other \nrapamycin derivatives, or albumin. Member experiences disease \nprogression on Fyarro (sirolimus protein-bound particles for injectable \nsuspension).\nRequired\nMedical\nInformation\nPerivascular epithelioid cell tumor. The member had diagnosis of locally \nadvanced unresectable or metastatic perivascular epithelioid cell tumor \nAND Fyarro (sirolimus protein-bound particles for injectable suspension) \nwill be administered as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 152 of 497\n", "doc_id": "9d0c893b-33d8-472a-927f-63490f0a3b02", "embedding": null, "doc_hash": "3be337ea1ed16f86e492ba4e4a815ce36eccc8d32a23493eb744b5532f32e49b", "extra_info": {"page_label": "152", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 762, "_node_type": "1"}, "relationships": {"1": "23d2c467-48f7-4a22-84a0-fe72036924a2"}}, "__type__": "1"}, "b59aa77e-9613-44f0-b431-f70f52d718d3": {"__data__": {"text": "FYCOMPA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nPartial-onset (Focal) Seizures: The member has inadequately controlled \npartial-onset (i.e. focal) seizures AND Member has been unable to \nachieve seizure control with at least TWO other antiepileptic medications \nsupported for partial-onset seizures (e.g. lamotrigine, topiramate, \ncarbamazepine, gabapentin, divalproex).  Adjunctive treatment for \nmembers with generalized tonic-clonic seizures: The member has \ninadequately controlled generalized tonic-clonic seizures AND \nConcomitant use of at least one antiepileptic medication AND Member \nhas been unable to achieve seizure control with at least TWO other \nantiepileptic medications supported for generalized tonic-clonic seizures \n(e.g. lamotrigine, topiramate, carbamazepine, gabapentin, divalproex).\nAge Restriction\nAdjunctive treatment for generalized tonic-clonic seizures: Age 12 years \nand older. Partial-onset seizures: age 4 years and older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 153 of 497\n", "doc_id": "b59aa77e-9613-44f0-b431-f70f52d718d3", "embedding": null, "doc_hash": "1d1f47f418d92523e89731869ed8a1dad95634b3ba503b837a67a383438fe39c", "extra_info": {"page_label": "153", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1179, "_node_type": "1"}, "relationships": {"1": "138865f7-77b0-4e77-a646-e9945b79649b"}}, "__type__": "1"}, "698946bf-c232-405f-a056-231e6a7941b9": {"__data__": {"text": "GAMUNEX-C\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nFor Medicare Part D requests, Humana's preferred product is Gamunex-\nC. Diagnosis of a primary humoral immunodeficiency disorder such as: \nprimary immunoglobulin deficiency syndrome, X-linked \nimmunodeficiency with hyperimmunoglobulin, etc)OR Documented \nhypogammaglobulinemia (IgG less than 600mg/dl) Idiopathic/Immune \nThrombocytopenia Purpura. Diagnosis of Acute ITP with any of the \nfollowing: Management of acute bleeding due to severe \nthrombocytopenia (platelets less than 30,000/L),To increase platelet \ncounts prior major surgical procedures, Severe thrombocytopenia \n(platelets less than 20,000/mcL), at risk for intracerebral hemorrhage. \nDiagnosis of Chronic ITP and ALL of the following are met:Prior \ntreatment has included corticosteroids, No concurrent illness explaining \nthrombocytopenia, Platelets persistently at or below 20,000/mcL.Chronic \nLymphocytic Leukemia (CLL, B-cell).With either of the following present: \nHypogammaglobulinemia ( IgG less than 600mg/dL),Recurrent bacterial \ninfections associated with B-cell CLL. Kawasaki Disease. Diagnosed with \nKawasaki Syndrome within ten days of onset of disease manifestations \nor is diagnosed after ten days of disease onset and continues to exhibit \nmanifestations of inflammation or evolving coronary artery disease.IVIG \nis used in combination with high dose aspirin for the prevention of \ncoronary artery aneurysms.Bone Marrow Transplant (BMT). Member is \nhypogammaglobinemic (IgG less than 400mg/dL). Hematopoietic Stem \nCell Transplantation (HSCT). Is within first 100 days of allogenic \nhematopoeietic stem cell transplantation. Is experiencing \nhypogammaglobulinemia (serum IgG level less than 400 mg/dL). \nAIDS/HIV. Has any of the following conditions: CD4+ T-cell counts \ngreater than or equal 200/mm3, to prevent maternal transmission of HIV \ninfection, IVIG is used in conjunction with zidovudine to prevent serious \nbacterial infections in HIV-infected members who have \nhypogammaglobulinemia (serum IgG less than 400 mg/dL).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 154 of 497\n", "doc_id": "698946bf-c232-405f-a056-231e6a7941b9", "embedding": null, "doc_hash": "38d9aa8b391fd444c84e0480df1473bf2b9a3f4a4a6edab296111828581f0e2a", "extra_info": {"page_label": "154", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2261, "_node_type": "1"}, "relationships": {"1": "a0c02117-9c30-4611-9a04-2789d85a6782"}}, "__type__": "1"}, "ff2264ee-dc44-42f5-b3f0-352e0bde6cec": {"__data__": {"text": "GAMUNEX-C\nOther Criteria\nInfections in Low-Birthweight Neonates.Prophylaxis and treatment of \ninfections in high-risk, preterm, low-birth weight members.Diagnosed \nwith staphylococcal / streptococcal toxic shock syndrome. Infection is \nrefractory to several hours of aggressive therapy, an undrainable focus is \npresent, or has persistent oliguria with pulmonary edema. Diagnosed \nwith autoimmune neutropenia and G-CSF therapy is not appropriate. \nAutoimmune Hemolytic Anemia. Is refractory to corticosteroid therapy \nand splenectomy. Myasthenia Gravis. Is experiencing acute myasthenic \ncrisis with decompensation.Other treatments have been unsuccessful \n(e.g., corticosteroids, azathioprine, cyclosporine, and \ncyclophosphamide). Guillain-Barre Syndrome. Is severely affected by the \ndisease and requires an aid to walk. Diagnosed with biopsy-proven \npolymyositis OR dermatomyositis and has failed treatment with \ncorticosteroids and azathioprine or methotrexate.  Diagnosed with \nmultifocal motor neuropathy confirmed by electrophysiologic studies. \nDiagnosed with relapsing-remitting multiple sclerosis and has failed \nconventional therapy (Betaseron, Avonex, etc.).Parvovirus B19 Infection, \nchronic. Chronic Parvovirus B19 infection with severe anemia associated \nwith bone marrow suppression. Chronic Inflammatory Demyelinating \nPolyneuropathies. Not responded to corticosteroid treatment. One of the \nfollowing criteria are met: Electrodiagnostic evidence of demyelinating \nneuropathy in at least two limbs, OR There is muscle weakness and \ndiagnostic testing was conducted in accordance with AAN diagnostic \ncriteria. Diagnosis of Lambart-Eaton myasthenic syndrome confirmed by \nelectrophysiologic studies. Has not responded to diaminopyridine, \nazathioprine, corticosteroids, or anticholinesterases. Neonate is \ndiagnosed with isoimmune hemolytic disease. Allosensitized Solid Organ \nTransplantation. Allosensitized members who are awaiting solid organ \ntransplant. Multiple Myeloma. Has life-threatening infections OR the \nmember is experiencing hypogammaglobulinemia  (IgG less than or \nequal to 400mg/dL). Autoimmune Blistering Diseases. Biopsy-proven \ndiagnosis of an autoimmune blistering disease such as epidermolysis \nbullosa acquisista,etc. Has tried and failed conventional therapy or has \nrapidly progressive disease in which a clinical response could not be \naffected quickly enough using conventional agents.Stiff-Person \nSyndrome. Other interventions (diazepam) have been unsuccessful. \nSystemic Lupus Erythematosus. Active/chronic SLE that is refractory to \ncorticosteroid therapy or in members with hemolytic anemia/ \nthrombocytopenia. Prevention of Bacterial / Viral Infections in Non-\nprimary Immunodeficiency Members. Experiencing iatrogenically \ninduced or disease associated immunosuppression. Or diagnosed with \nhematologic malignancy.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 155 of 497\n", "doc_id": "ff2264ee-dc44-42f5-b3f0-352e0bde6cec", "embedding": null, "doc_hash": "df7877725509f70329e15d66609f0b109717b4824a357138cacc37f63f5f490d", "extra_info": {"page_label": "155", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2941, "_node_type": "1"}, "relationships": {"1": "2ac6849b-d9a1-42e7-8fff-2859fa9c34d1"}}, "__type__": "1"}, "8c4266d6-8538-488a-a396-305464f8b1ac": {"__data__": {"text": "GATTEX 30-VIAL\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nShort Bowel Syndrome initial review: Member has a diagnosis of Short \nBowel Syndrome. Member is dependent on parenteral support (ie. \nparenteral nutrition and/or intravenous fluids). Member does not have \nactive gastrointestinal malignancy. Member does not have biliary and/or \npancreatic disease. Reauthorization: Member does not have active \ngastrointestinal malignancy. Member does not have biliary and/or \npancreatic disease. Need for parenteral support (ie. parenteral nutrition \nand/or intravenous fluids) has decreased in volume (mL) from baseline \nweekly requirement at start of Gattex treatment and as documented by \nactual change in volume. (Note: discontinuation of parental support \nwould be considered a decrease in volume from baseline).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n3 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 156 of 497\n", "doc_id": "8c4266d6-8538-488a-a396-305464f8b1ac", "embedding": null, "doc_hash": "93aae3caec4a52ba6ebe7e95e62de982bae5420a35dbef2bd65f3ed7d2adc94a", "extra_info": {"page_label": "156", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1045, "_node_type": "1"}, "relationships": {"1": "275a1c0d-d39d-4fc0-989f-8fc8fd430d9b"}}, "__type__": "1"}, "ef1064c8-00a1-43e0-a4dc-f08f656ec9ac": {"__data__": {"text": "GATTEX ONE-VIAL\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nShort Bowel Syndrome initial review: Member has a diagnosis of Short \nBowel Syndrome. Member is dependent on parenteral support (ie. \nparenteral nutrition and/or intravenous fluids). Member does not have \nactive gastrointestinal malignancy. Member does not have biliary and/or \npancreatic disease. Reauthorization: Member does not have active \ngastrointestinal malignancy. Member does not have biliary and/or \npancreatic disease. Need for parenteral support (ie. parenteral nutrition \nand/or intravenous fluids) has decreased in volume (mL) from baseline \nweekly requirement at start of Gattex treatment and as documented by \nactual change in volume. (Note: discontinuation of parental support \nwould be considered a decrease in volume from baseline).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n3 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 157 of 497\n", "doc_id": "ef1064c8-00a1-43e0-a4dc-f08f656ec9ac", "embedding": null, "doc_hash": "bcabc2182bc49c61e37eba4e88cbb1d7acf8d83890c463cb6350f35dc35c4ca0", "extra_info": {"page_label": "157", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1046, "_node_type": "1"}, "relationships": {"1": "a47ec575-ab3c-418b-b63f-5d2a8f738cac"}}, "__type__": "1"}, "dd33c794-f724-4f91-b027-a0a3d30846ba": {"__data__": {"text": "GAVRETO\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMember experiences disease progression on RET inhibitors (e.g., \npralsetinib, selpercatinib).\nRequired\nMedical\nInformation\nNon-small cell lung cancer:  The member has a diagnosis of metastatic \nnon-small lung cancer AND the disease is documented as RET fusion \npositive AND Gavreto (pralsetinib) is being used as monotherapy. \nMedullary Thyroid cancer:  The member has a diagnosis of metastatic or \nadvanced medullary thyroid cancer AND The disease is documented \nRET mutant AND Gavreto (pralsetinib) is being used as monotherapy for \nsystemic therapy.  Thyroid cancer:  The member has a diagnosis of \nmetastatic or advanced thyroid cancer AND The disease is documented \nRET fusion positive AND The disease is radioactive iodine refractory \nAND Gavreto (pralsetinib) is being used as monotherapy for systemic \ntherapy.\nAge Restriction\nThyroid Cancer and Medullary Thyroid Cancer:  The member is 12 years \nof age and older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 158 of 497\n", "doc_id": "dd33c794-f724-4f91-b027-a0a3d30846ba", "embedding": null, "doc_hash": "ba3d39849afc427d091e6e18103386a4439031ca15b5dd43c7cd380aeebb112f", "extra_info": {"page_label": "158", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1170, "_node_type": "1"}, "relationships": {"1": "78fab72b-a332-4216-9842-4dbf17e3c871"}}, "__type__": "1"}, "ac950014-551a-4a18-ad18-8517ece31e9b": {"__data__": {"text": "GAZYVA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers that have experienced disease progression while on Gazyva \n(obinutuzumab). The member will be using obinutuzumab as \nmaintenance therapy for diffuse large B cell lymphoma (DLBCL).  The \nlength of maintenance therapy exceeds 2 years for low-grade non-\nHodgkins lymphoma (e.g. follicular lymphoma, marginal zone \nlymphoma).\nRequired\nMedical\nInformation\nChronic Lymphocytic Leukemia: The member must have a diagnosis of \nchronic lymphocytic leukemia AND The member is using Gazyva \n(obinutuzumab) in combination with Chlorambucil OR the member is \nusing Gazyva (obinutuzumab) in combination with bendamustine OR the \nmember is using Gazyva (obinutuzumab) in combination with Venclexta \n(venetoclax) OR the member is using Gazyva (obinutuzumab) as \nmonotherapy.  Follicular Lymphoma: The member has a diagnosis of \nfollicular lymphoma AND One of the following sets of criteria apply: The \nmember will be using Gazyva (obinutuzumab) for first line therapy OR \nThe member has relapsed after, or is refractory to, a rituximab-containing \nregimen (defined as progression on or within 6 months of prior rituximab \nproduct therapy) AND The member will initially be using Gazyva \n(obinutuzumab) in combination with chemotherapy (e.g. CHOP, CVP, \nbendamustine) (after 6-8 cycles Gazyva (obinutuzumab) may be \ncontinued as monotherapy per reauthorization criteria below).  Follicular \nLymphoma--Reauthorization Criteria: The member has achieved stable \ndisease, complete response, or partial response after therapy with \nGazyva (obinutuzumab) in combination with chemotherapy (e.g, CHOP, \nCVP, bendamustine).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nCLL: 6 months. Follicular Lymphoma: Initial auth: 6 months, Reauth: \nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 159 of 497\n", "doc_id": "ac950014-551a-4a18-ad18-8517ece31e9b", "embedding": null, "doc_hash": "4e8487c7367c3c3329dee795a8abd0a3e235460a169d31b6b74e2d2d5dd64164", "extra_info": {"page_label": "159", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1939, "_node_type": "1"}, "relationships": {"1": "8fdb09d9-4a84-4d9f-ad21-56bb090c6f0f"}}, "__type__": "1"}, "28fc359d-c4b7-4381-9d73-ec1739438393": {"__data__": {"text": "gefitinib\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors\nRequired\nMedical\nInformation\nNon-small cell lung cancer (NSCLC): The member has a diagnosis of \nmetastatic or recurrent non-small cell lung cancer (NSCLC) AND the \nfollowing applies: The member has a documented epidermal growth \nfactor receptor (EGFR) exon 19 deletion or exon 21 (L858R) substitution \nmutation AND The member is using Iressa (gefitinib) as monotherapy \n(without concomitant chemotherapy).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 160 of 497\n", "doc_id": "28fc359d-c4b7-4381-9d73-ec1739438393", "embedding": null, "doc_hash": "03f903ae91fa2e38e6a937a67f4a150290a7a0a31824e80f57ee214de5f886ba", "extra_info": {"page_label": "160", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 725, "_node_type": "1"}, "relationships": {"1": "de6326c3-8f5d-402a-84f0-1d3b8cd968c8"}}, "__type__": "1"}, "0e3274c6-18a8-4e9f-970f-d8f249d17e74": {"__data__": {"text": "GILENYA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nThe member has a diagnosis of a relapsing form of multiple sclerosis, to \ninclude relapsing-remitting or active secondary progressive disease OR \nthe member has a diagnosis of a clinically isolated syndrome (CIS).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 161 of 497\n", "doc_id": "0e3274c6-18a8-4e9f-970f-d8f249d17e74", "embedding": null, "doc_hash": "d7bd156ef9b89d5ffbaa475442804a1dfaf0309c210fc0da62c8f0365cc48b38", "extra_info": {"page_label": "161", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 513, "_node_type": "1"}, "relationships": {"1": "32d2ff3c-083b-4707-b558-9d7e94cda8c9"}}, "__type__": "1"}, "5daafa88-9c03-4038-86a9-1fe80786afcc": {"__data__": {"text": "GILOTRIF\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nNon-small cell lung cancer (NSCLC): The member has a diagnosis of \nmetastatic non-small cell lung cancer (NSCLC) AND the following apply: \nThe member has a documented non-resistant epidermal growth factor \nreceptor (EGFR) mutation (sensitizing EGFR mutation e.g., exon 19 \ndeletion, L861Q, S768I, G719X, L858R) AND The member is using \nGilotrif (afatinib) as monotherapy (without concomitant chemotherapy) \nOR squamous cell histology after disease progression on platinum \ncontaining chemotherapy and is using Gilotrif (afatinib) as monotherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 162 of 497\n", "doc_id": "5daafa88-9c03-4038-86a9-1fe80786afcc", "embedding": null, "doc_hash": "9e83d051baf3267b21d43c5c45347e9e846390072238c5b1854fbe487a779914", "extra_info": {"page_label": "162", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 846, "_node_type": "1"}, "relationships": {"1": "1393c641-8e24-47ac-a333-28fb99f2fce2"}}, "__type__": "1"}, "5e6a013b-07f3-4535-acfe-58b2d788f510": {"__data__": {"text": "glatiramer\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nThe member has a diagnosis of a relapsing form of multiple sclerosis, to \ninclude relapsing-remitting or active secondary progressive disease OR \nthe member has a diagnosis of a clinically isolated syndrome (CIS).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 163 of 497\n", "doc_id": "5e6a013b-07f3-4535-acfe-58b2d788f510", "embedding": null, "doc_hash": "d69086ad99b07bafbe1440ed2fdb72cd6d3264315985bdb1c6f04cc19c7ea8c8", "extra_info": {"page_label": "163", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 516, "_node_type": "1"}, "relationships": {"1": "80080954-fc66-4edb-bdfc-35982c5c93cd"}}, "__type__": "1"}, "9f1b0313-2218-45ad-b5e9-18781765919c": {"__data__": {"text": "glatopa\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nThe member has a diagnosis of a relapsing form of multiple sclerosis, to \ninclude relapsing-remitting or active secondary progressive disease OR \nthe member has a diagnosis of a clinically isolated syndrome (CIS).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 164 of 497\n", "doc_id": "9f1b0313-2218-45ad-b5e9-18781765919c", "embedding": null, "doc_hash": "d7d25a2944336762d297677c3a2ce615b1a64abfc7ca60fca5b8dfefcbaf6419", "extra_info": {"page_label": "164", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 513, "_node_type": "1"}, "relationships": {"1": "2b3bdc96-a2de-4efa-9967-a01a58900e50"}}, "__type__": "1"}, "6e73d11b-b0ca-4575-9d22-5cd1b3743326": {"__data__": {"text": "GLEOSTINE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on Gleostine \n(lomustine).\nRequired\nMedical\nInformation\nBrain Tumors. The member has a diagnosis of primary or metastastic \nbrain tumor AND one of the following applies: the member will use \nGleostine (lomustine) after appropriate surgical and/or radiotherapeutic \nprocedures OR the member has recurrent or progressive disease. \nHodgkin Lymphoma. The member has a diagnosis of Hodgkin \nLymphoma AND the member has disease progression following initial \nchemotherapy AND the member will use Gleostine (lomustine) as a \ncomponent of combination chemotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 165 of 497\n", "doc_id": "6e73d11b-b0ca-4575-9d22-5cd1b3743326", "embedding": null, "doc_hash": "11b88d313cb4fe57c5f5ef0c5a11a6a5359c828b1f7170aebf9aabbddf66f3d3", "extra_info": {"page_label": "165", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 869, "_node_type": "1"}, "relationships": {"1": "25925ec5-0707-4f25-874d-11816a34f621"}}, "__type__": "1"}, "1936b253-6bb0-476d-9767-6fdf5c2c8096": {"__data__": {"text": "HAEGARDA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nUse for acute treatment of HAE attack. Evidence of autoantibodies \nagainst the C1INH protein. Evidence of underlying lymphoproliferative, \nmalignant, or autoimmune disorder that causes angioedema attacks. \nUse in combination with other agents approved for prophylactic \ntreatment of HAE attack (e.g. Cinryze).\nRequired\nMedical\nInformation\nHereditary Angioedema (HAE) Prophylaxis: The member must have a \ndiagnosis of hereditary angioedema (HAE) type 1 or type 2. The member \nmust have documentation of: Low evidence of C4 level (i.e. C4 level \nbelow lower limit of normal laboratory reference range) AND Low C1 \ninhibitor (C1INH) antigenic level (i.e. C1INH level below lower limit of \nnormal laboratory reference range) OR Low C1INH functional level (i.e. \nfunctional C1INH less than 50% or below lower limit of normal laboratory \nreference range) OR Known HAE-causing C1INH mutation. The member \nis being treated by a specialist in hereditary angioedema (i.e. allergist \nand/or immunologist). Must provide lab report or medical record \ndocumentation which include lab values as required by policy. Lab \nvalues must include C1q level. The member must be using Haegarda for \nprophylaxis to prevent attacks of HAE.\nAge Restriction\nThe member must be 6 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 166 of 497\n", "doc_id": "1936b253-6bb0-476d-9767-6fdf5c2c8096", "embedding": null, "doc_hash": "663f93477c68dd2f9b7791496116e7a588618dd211494b69582967fb06de3b34", "extra_info": {"page_label": "166", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1517, "_node_type": "1"}, "relationships": {"1": "d4547b89-f042-4a34-9e7e-9526ea72964f"}}, "__type__": "1"}, "0909c775-3215-476c-a519-2095af621a55": {"__data__": {"text": "HALAVEN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nBreast Cancer. The member has a diagnosis of metastatic breast cancer \nAND The member has progressive disease following at least two \nchemotherapeutic regimens for the treatment of metastatic disease AND \nThe member has had prior therapy, contraindication or intolerance with \nan anthracycline and a taxane in either the adjuvant or metastatic \nsetting.Liposarcoma: The member has a diagnosis of unresectable or \nmetastatic liposarcoma and has received a prior anthracycline containing \nregimen.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nsix months\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 167 of 497\n", "doc_id": "0909c775-3215-476c-a519-2095af621a55", "embedding": null, "doc_hash": "588fcdb60947348fe7e9bb8e45e99a365f38df0e775a16b0a4072fd84e37cf52", "extra_info": {"page_label": "167", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 784, "_node_type": "1"}, "relationships": {"1": "d488199d-a5a5-4915-8320-ee2e8072addb"}}, "__type__": "1"}, "5c1e9478-004d-45eb-b533-019abd4fffd3": {"__data__": {"text": "HARVONI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant use with other Direct Acting Antivirals (e.g. HCV protease \ninhibitors, polymerase inhibitors, NS5A inhibitors).\nRequired\nMedical\nInformation\nChronic Hepatitis C: Member must have a diagnosis of chronic hepatitis \nC infection. Member must have documented Genotypes 1,4,5 and 6 \ninfection. HCV RNA level must be documented prior to therapy. Member \nmust be tested for the presence of HBV by screening for the surface \nantigen of HBV (HBsAg) and anti-hepatitis B core total antibodies (anti-\nHBc) prior to initiation of therapy. Chronic Hepatitis C - GT1 treatment \nnaive without cirrhosis and HCV RNA under 6 million will be approved for \n8 weeks. Pediatrics:  Member must have a diagnosis of chronic hepatitis \nC infection. Member must have documented Genotype 1, 4, 5 or 6 \ninfection. HCV RNA level must be documented prior to therapy. Member \nmust be tested for the presence of HBV by screening for the surface \nantigen of HBV (HBsAg) and anti-hepatitis B core total antibodies (anti-\nHBc) prior to initiation of therapy. Chronic Hepatitis C Post Liver \nTransplant - Member must have received a liver transplant, Must must \nhave experienced recurrent HCV infection post-transplant in the allograft \nliver, Member must have document genotype 1, 4, 5 or 6 infection, \nMember must be tested for the presence of HBV by screening for the \nsurface antigen of HBV (HBsAg) and anti-hepatitis B core total \nantibodies (anti-HBc) prior to initiation of therapy. Chronic Hepatitis C \nWith Decompensated Cirrhosis - Member must have diagnosis of chronic \nhepatitis C with decompensated cirrhosis, Member must have genotype \n1,  4, 5 or 6 infection,  Member must be tested for the presence of HBV \nby screening for surface antigen of HBV (HBsAg) and anti-hepatitis B \ncore total antibodies (anti-HBc) prior to initiation of therapy. For all \ngenotypes, criteria will be applied consistent with current AASLD-IDSA \nguidance.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n8 to 24 weeks depending on disease state and genotype based on \nAASLD treatment guidelines for HCV.\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 168 of 497\n", "doc_id": "5c1e9478-004d-45eb-b533-019abd4fffd3", "embedding": null, "doc_hash": "1e6cb2b0300877df8aa5ded7090366f9bedcf3c3bb9886e5e19cf91f4e78121a", "extra_info": {"page_label": "168", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2264, "_node_type": "1"}, "relationships": {"1": "5f1cb4c2-ecbf-4d79-8994-902ffcce0731"}}, "__type__": "1"}, "8edded74-e740-4262-a311-93789f1ab6c4": {"__data__": {"text": "HETLIOZ\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nNon-24-Hour Sleep-Wake Disorder. The member must utilize Hetlioz \n(tasimelteon) for the treatment of Non-24-Hour Sleep-Wake Disorder. \nSmith-Magenis Syndrome (SMS): The member has a documented \ndiagnosis of SMS and documented evidence of nighttime sleep \ndisturbances associated with SMS.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 169 of 497\n", "doc_id": "8edded74-e740-4262-a311-93789f1ab6c4", "embedding": null, "doc_hash": "5aa10e7b0fbead8cae03c641076b7fa30f3611626193ed4c3ce5fd7a111c5089", "extra_info": {"page_label": "169", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 576, "_node_type": "1"}, "relationships": {"1": "68d71651-8483-47de-b2df-196156f4ba87"}}, "__type__": "1"}, "fe0ef0b1-77bd-49c3-8750-f309bbf82e92": {"__data__": {"text": "HETLIOZ LQ\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nNon-24-Hour Sleep-Wake Disorder. The member must utilize Hetlioz \n(tasimelteon) for the treatment of Non-24-Hour Sleep-Wake Disorder. \nSmith-Magenis Syndrome (SMS): The member has a documented \ndiagnosis of SMS and documented evidence of nighttime sleep \ndisturbances associated with SMS.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 170 of 497\n", "doc_id": "fe0ef0b1-77bd-49c3-8750-f309bbf82e92", "embedding": null, "doc_hash": "eaf56dc52b431b7080eb7cff71b1a92047f34f8e531b7c686814d05e3076aca1", "extra_info": {"page_label": "170", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 579, "_node_type": "1"}, "relationships": {"1": "a2c6720d-624d-437d-b303-a798899684b9"}}, "__type__": "1"}, "dc8f0491-16f2-4149-8d92-4e4324ddbb4f": {"__data__": {"text": "HUMIRA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnkylosing Spondylitis. Diagnosis of active ankylosing spondylitis. \nMember has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drug (NSAIDs) (e.g. ibuprofen, \nmeloxicam, naproxen). Psoriatic Arthritis. Diagnosis of active psoriatic \narthritis. Member has had prior therapy with or intolerance to a single \nDMARD (e.g. methotrexate, sulfasalazine, hydroxychloroquine, \nleflunomide) or contraindication with all DMARDs. Rheumatoid Arthritis. \nDiagnosis of moderately to severely active rheumatoid arthritis. Member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine, hydroxychloroquine, leflunomide) or \ncontraindication with all DMARDs. Polyarticular Juvenile Idiopathic \nArthritis. Diagnosis of moderately to severely active polyarticular juvenile \nidiopathic arthritis. Member has had prior therapy with or intolerance to a \nsingle DMARD (e.g. methotrexate, sulfasalazine, leflunomide) or \ncontraindication with all DMARDs. Moderate to severe Chronic Plaque \nPsoriasis. Diagnosis of moderate to severe chronic plaque psoriasis. The \nmember has had prior therapy with or intolerance to conventional \ntherapy including one or more oral systemic treatments (e.g., \nmethotrexate, cyclosporine) or contraindication to all conventional oral \nsystemic treatments.\nAge Restriction\nThe member must be at least 18 years of age for the following \nindications: Rheumatoid Arthritis, Moderate to severe Chronic Plaque \nPsoriasis, Psoriatic Arthritis, Ankylosing Spondylitis. The member must \nbe two years of age or older and have a diagnosis of moderately to \nseverely active polyarticular juvenile idiopathic arthritis or Uveitis. Must \nbe six years or older for Crohns Disease. Must be 12 years or older for \nHidradenitis Suppurativa. Must be 5 years or older for Ulcerative Colitis.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 171 of 497\n", "doc_id": "dc8f0491-16f2-4149-8d92-4e4324ddbb4f", "embedding": null, "doc_hash": "b635bb81fe0a606a541ee57e011ccdf659ca6478428a0b15cb6f8b9c269f1659", "extra_info": {"page_label": "171", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2096, "_node_type": "1"}, "relationships": {"1": "a63ff3c3-fa23-4c8a-9b12-0c9b76ff128a"}}, "__type__": "1"}, "f3e8d359-4f61-4c4d-bc12-3487e43f8b4e": {"__data__": {"text": "HUMIRA\nOther Criteria\nUlcerative Colitis: The member has a diagnosis of moderate to severely \nactive ulcerative colitis. The member has had prior therapy, \ncontraindication, or intolerance to one or more of the following \nconventional therapies: 5-aminosalicylic acids (e.g. mesalamine, \nbalsalazide) OR Corticosteroids (e.g. prednisone, methylprednisolone) \nOR Immunomodulators (e.g. azathioprine or 6-mercaptopurine).  Crohn's \nDisease: The member must have moderately to severely active Crohn's \ndisease. The member has had prior therapy, contraindication, or \nintolerance to a corticosteroid (e.g. prednisone, methylprednisolone) or \nan immunomodulator (e.g.azathioprine, 6-mercaptopurine, \nmethotrexate). Hidradenitis Suppurativa: The member must have a \ndiagnosis of moderate to severe Hidradenitis Suppurativa. Uveitis: The \nmember must have a diagnosis of non-infectious, intermediate, posterior, \nor pan-uveitis. The member has had prior therapy, contraindication, or \nintolerance with one of the following:  an intravitreal steroid (e.g. \ntriamcinolone, dexamethasone) OR a systemic corticosteroid (e.g. \nprednisone, methylprednisolone) OR an anti-metabolite (e.g. \nmethotrexate, azathioprine, mycophenolate) OR a calcineurin inhibitor \n(e.g. cyclosporine, tacrolimus).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 172 of 497\n", "doc_id": "f3e8d359-4f61-4c4d-bc12-3487e43f8b4e", "embedding": null, "doc_hash": "dd71627ef29544446ad19570269460b1a7eec6c91d6935a5632e91e42e9552ab", "extra_info": {"page_label": "172", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1354, "_node_type": "1"}, "relationships": {"1": "b7018b8d-a764-4dcb-b8e2-17c5ee384e9d"}}, "__type__": "1"}, "c928124f-cda7-46ab-9435-0ceac7997798": {"__data__": {"text": "HUMIRA PEN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnkylosing Spondylitis. Diagnosis of active ankylosing spondylitis. \nMember has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drug (NSAIDs) (e.g. ibuprofen, \nmeloxicam, naproxen). Psoriatic Arthritis. Diagnosis of active psoriatic \narthritis. Member has had prior therapy with or intolerance to a single \nDMARD (e.g. methotrexate, sulfasalazine, hydroxychloroquine, \nleflunomide) or contraindication with all DMARDs. Rheumatoid Arthritis. \nDiagnosis of moderately to severely active rheumatoid arthritis. Member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine, hydroxychloroquine, leflunomide) or \ncontraindication with all DMARDs. Polyarticular Juvenile Idiopathic \nArthritis. Diagnosis of moderately to severely active polyarticular juvenile \nidiopathic arthritis. Member has had prior therapy with or intolerance to a \nsingle DMARD (e.g. methotrexate, sulfasalazine, leflunomide) or \ncontraindication with all DMARDs. Moderate to severe Chronic Plaque \nPsoriasis. Diagnosis of moderate to severe chronic plaque psoriasis. The \nmember has had prior therapy with or intolerance to conventional \ntherapy including one or more oral systemic treatments (e.g., \nmethotrexate, cyclosporine) or contraindication to all conventional oral \nsystemic treatments.\nAge Restriction\nThe member must be at least 18 years of age for the following \nindications: Rheumatoid Arthritis, Moderate to severe Chronic Plaque \nPsoriasis, Psoriatic Arthritis, Ankylosing Spondylitis. The member must \nbe two years of age or older and have a diagnosis of moderately to \nseverely active polyarticular juvenile idiopathic arthritis or Uveitis. Must \nbe six years or older for Crohns Disease. Must be 12 years or older for \nHidradenitis Suppurativa. Must be 5 years or older for Ulcerative Colitis.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 173 of 497\n", "doc_id": "c928124f-cda7-46ab-9435-0ceac7997798", "embedding": null, "doc_hash": "ba1bc93b37c0779d747451d96cb8c692e5c83ebb2de6dab1eee1277f4df351b0", "extra_info": {"page_label": "173", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2100, "_node_type": "1"}, "relationships": {"1": "a059e43d-b131-4725-81af-1599493cf769"}}, "__type__": "1"}, "d4bc3108-9569-45d0-89e7-9fcd314a5a5c": {"__data__": {"text": "HUMIRA PEN\nOther Criteria\nUlcerative Colitis: The member has a diagnosis of moderate to severely \nactive ulcerative colitis. The member has had prior therapy, \ncontraindication, or intolerance to one or more of the following \nconventional therapies: 5-aminosalicylic acids (e.g. mesalamine, \nbalsalazide) OR Corticosteroids (e.g. prednisone, methylprednisolone) \nOR Immunomodulators (e.g. azathioprine or 6-mercaptopurine).  Crohn's \nDisease: The member must have moderately to severely active Crohn's \ndisease. The member has had prior therapy, contraindication, or \nintolerance to a corticosteroid (e.g. prednisone, methylprednisolone) or \nan immunomodulator (e.g.azathioprine, 6-mercaptopurine, \nmethotrexate). Hidradenitis Suppurativa: The member must have a \ndiagnosis of moderate to severe Hidradenitis Suppurativa. Uveitis: The \nmember must have a diagnosis of non-infectious, intermediate, posterior, \nor pan-uveitis. The member has had prior therapy, contraindication, or \nintolerance with one of the following:  an intravitreal steroid (e.g. \ntriamcinolone, dexamethasone) OR a systemic corticosteroid (e.g. \nprednisone, methylprednisolone) OR an anti-metabolite (e.g. \nmethotrexate, azathioprine, mycophenolate) OR a calcineurin inhibitor \n(e.g. cyclosporine, tacrolimus).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 174 of 497\n", "doc_id": "d4bc3108-9569-45d0-89e7-9fcd314a5a5c", "embedding": null, "doc_hash": "ecf9dad0a22b67c68d00613aaf2392c47fde43ee32f65ca64fbb1c67b81e67c7", "extra_info": {"page_label": "174", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1358, "_node_type": "1"}, "relationships": {"1": "8707fba8-509d-41de-9f7d-f8c1006e27de"}}, "__type__": "1"}, "e0104e43-de56-472c-9450-b731fa80e4c4": {"__data__": {"text": "HUMIRA PEN CROHNS-UC-HS START\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnkylosing Spondylitis. Diagnosis of active ankylosing spondylitis. \nMember has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drug (NSAIDs) (e.g. ibuprofen, \nmeloxicam, naproxen). Psoriatic Arthritis. Diagnosis of active psoriatic \narthritis. Member has had prior therapy with or intolerance to a single \nDMARD (e.g. methotrexate, sulfasalazine, hydroxychloroquine, \nleflunomide) or contraindication with all DMARDs. Rheumatoid Arthritis. \nDiagnosis of moderately to severely active rheumatoid arthritis. Member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine, hydroxychloroquine, leflunomide) or \ncontraindication with all DMARDs. Polyarticular Juvenile Idiopathic \nArthritis. Diagnosis of moderately to severely active polyarticular juvenile \nidiopathic arthritis. Member has had prior therapy with or intolerance to a \nsingle DMARD (e.g. methotrexate, sulfasalazine, leflunomide) or \ncontraindication with all DMARDs. Moderate to severe Chronic Plaque \nPsoriasis. Diagnosis of moderate to severe chronic plaque psoriasis. The \nmember has had prior therapy with or intolerance to conventional \ntherapy including one or more oral systemic treatments (e.g., \nmethotrexate, cyclosporine) or contraindication to all conventional oral \nsystemic treatments.\nAge Restriction\nThe member must be at least 18 years of age for the following \nindications: Rheumatoid Arthritis, Moderate to severe Chronic Plaque \nPsoriasis, Psoriatic Arthritis, Ankylosing Spondylitis. The member must \nbe two years of age or older and have a diagnosis of moderately to \nseverely active polyarticular juvenile idiopathic arthritis or Uveitis. Must \nbe six years or older for Crohns Disease. Must be 12 years or older for \nHidradenitis Suppurativa. Must be 5 years or older for Ulcerative Colitis.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 175 of 497\n", "doc_id": "e0104e43-de56-472c-9450-b731fa80e4c4", "embedding": null, "doc_hash": "2fcfe85eee704f2e471f96bc9aa9c3de429d5af5210d36eebdcb28f9f035e0b4", "extra_info": {"page_label": "175", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2119, "_node_type": "1"}, "relationships": {"1": "cd22d62b-0d90-40fa-8ab0-26511e5675e8"}}, "__type__": "1"}, "2aa89f8a-55cf-4430-974d-fe8556c11031": {"__data__": {"text": "HUMIRA PEN CROHNS-UC-HS START\nOther Criteria\nUlcerative Colitis: The member has a diagnosis of moderate to severely \nactive ulcerative colitis. The member has had prior therapy, \ncontraindication, or intolerance to one or more of the following \nconventional therapies: 5-aminosalicylic acids (e.g. mesalamine, \nbalsalazide) OR Corticosteroids (e.g. prednisone, methylprednisolone) \nOR Immunomodulators (e.g. azathioprine or 6-mercaptopurine).  Crohn's \nDisease: The member must have moderately to severely active Crohn's \ndisease. The member has had prior therapy, contraindication, or \nintolerance to a corticosteroid (e.g. prednisone, methylprednisolone) or \nan immunomodulator (e.g.azathioprine, 6-mercaptopurine, \nmethotrexate). Hidradenitis Suppurativa: The member must have a \ndiagnosis of moderate to severe Hidradenitis Suppurativa. Uveitis: The \nmember must have a diagnosis of non-infectious, intermediate, posterior, \nor pan-uveitis. The member has had prior therapy, contraindication, or \nintolerance with one of the following:  an intravitreal steroid (e.g. \ntriamcinolone, dexamethasone) OR a systemic corticosteroid (e.g. \nprednisone, methylprednisolone) OR an anti-metabolite (e.g. \nmethotrexate, azathioprine, mycophenolate) OR a calcineurin inhibitor \n(e.g. cyclosporine, tacrolimus).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 176 of 497\n", "doc_id": "2aa89f8a-55cf-4430-974d-fe8556c11031", "embedding": null, "doc_hash": "52ab9036e0a0e51b5b6516e23ee003c7815a9bbc6dec7a57494bb760bc52bed7", "extra_info": {"page_label": "176", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1377, "_node_type": "1"}, "relationships": {"1": "b896a6e8-3eb5-4336-ae98-cb78e86b357f"}}, "__type__": "1"}, "a3a76478-420e-4e7b-b530-e47c9538a1d2": {"__data__": {"text": "HUMIRA PEN PSOR-UVEITS-ADOL HS\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnkylosing Spondylitis. Diagnosis of active ankylosing spondylitis. \nMember has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drug (NSAIDs) (e.g. ibuprofen, \nmeloxicam, naproxen). Psoriatic Arthritis. Diagnosis of active psoriatic \narthritis. Member has had prior therapy with or intolerance to a single \nDMARD (e.g. methotrexate, sulfasalazine, hydroxychloroquine, \nleflunomide) or contraindication with all DMARDs. Rheumatoid Arthritis. \nDiagnosis of moderately to severely active rheumatoid arthritis. Member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine, hydroxychloroquine, leflunomide) or \ncontraindication with all DMARDs. Polyarticular Juvenile Idiopathic \nArthritis. Diagnosis of moderately to severely active polyarticular juvenile \nidiopathic arthritis. Member has had prior therapy with or intolerance to a \nsingle DMARD (e.g. methotrexate, sulfasalazine, leflunomide) or \ncontraindication with all DMARDs. Moderate to severe Chronic Plaque \nPsoriasis. Diagnosis of moderate to severe chronic plaque psoriasis. The \nmember has had prior therapy with or intolerance to conventional \ntherapy including one or more oral systemic treatments (e.g., \nmethotrexate, cyclosporine) or contraindication to all conventional oral \nsystemic treatments.\nAge Restriction\nThe member must be at least 18 years of age for the following \nindications: Rheumatoid Arthritis, Moderate to severe Chronic Plaque \nPsoriasis, Psoriatic Arthritis, Ankylosing Spondylitis. The member must \nbe two years of age or older and have a diagnosis of moderately to \nseverely active polyarticular juvenile idiopathic arthritis or Uveitis. Must \nbe six years or older for Crohns Disease. Must be 12 years or older for \nHidradenitis Suppurativa. Must be 5 years or older for Ulcerative Colitis.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 177 of 497\n", "doc_id": "a3a76478-420e-4e7b-b530-e47c9538a1d2", "embedding": null, "doc_hash": "08ce8d9ed558a2eaead177cca82e8bb05140115144fca3ebedfc3f4e4f6bd5fe", "extra_info": {"page_label": "177", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2120, "_node_type": "1"}, "relationships": {"1": "7f5d26a1-0c64-45b0-94d3-0c2e9aed4898"}}, "__type__": "1"}, "5a1402c5-7458-4e64-8c4e-2540e2a6a8d1": {"__data__": {"text": "HUMIRA PEN PSOR-UVEITS-ADOL HS\nOther Criteria\nUlcerative Colitis: The member has a diagnosis of moderate to severely \nactive ulcerative colitis. The member has had prior therapy, \ncontraindication, or intolerance to one or more of the following \nconventional therapies: 5-aminosalicylic acids (e.g. mesalamine, \nbalsalazide) OR Corticosteroids (e.g. prednisone, methylprednisolone) \nOR Immunomodulators (e.g. azathioprine or 6-mercaptopurine).  Crohn's \nDisease: The member must have moderately to severely active Crohn's \ndisease. The member has had prior therapy, contraindication, or \nintolerance to a corticosteroid (e.g. prednisone, methylprednisolone) or \nan immunomodulator (e.g.azathioprine, 6-mercaptopurine, \nmethotrexate). Hidradenitis Suppurativa: The member must have a \ndiagnosis of moderate to severe Hidradenitis Suppurativa. Uveitis: The \nmember must have a diagnosis of non-infectious, intermediate, posterior, \nor pan-uveitis. The member has had prior therapy, contraindication, or \nintolerance with one of the following:  an intravitreal steroid (e.g. \ntriamcinolone, dexamethasone) OR a systemic corticosteroid (e.g. \nprednisone, methylprednisolone) OR an anti-metabolite (e.g. \nmethotrexate, azathioprine, mycophenolate) OR a calcineurin inhibitor \n(e.g. cyclosporine, tacrolimus).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 178 of 497\n", "doc_id": "5a1402c5-7458-4e64-8c4e-2540e2a6a8d1", "embedding": null, "doc_hash": "047cf01696def947f98d905771db75af927aec138695687916948a07daf23649", "extra_info": {"page_label": "178", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1378, "_node_type": "1"}, "relationships": {"1": "c8fca6bd-03d3-4bf3-a23a-5a93ef07c027"}}, "__type__": "1"}, "9551cf04-fec4-4910-a89a-aed5427eb987": {"__data__": {"text": "HUMIRA(CF)\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnkylosing Spondylitis. Diagnosis of active ankylosing spondylitis. \nMember has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drug (NSAIDs) (e.g. ibuprofen, \nmeloxicam, naproxen). Psoriatic Arthritis. Diagnosis of active psoriatic \narthritis. Member has had prior therapy with or intolerance to a single \nDMARD (e.g. methotrexate, sulfasalazine, hydroxychloroquine, \nleflunomide) or contraindication with all DMARDs. Rheumatoid Arthritis. \nDiagnosis of moderately to severely active rheumatoid arthritis. Member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine, hydroxychloroquine, leflunomide) or \ncontraindication with all DMARDs. Polyarticular Juvenile Idiopathic \nArthritis. Diagnosis of moderately to severely active polyarticular juvenile \nidiopathic arthritis. Member has had prior therapy with or intolerance to a \nsingle DMARD (e.g. methotrexate, sulfasalazine, leflunomide) or \ncontraindication with all DMARDs. Moderate to severe Chronic Plaque \nPsoriasis. Diagnosis of moderate to severe chronic plaque psoriasis. The \nmember has had prior therapy with or intolerance to conventional \ntherapy including one or more oral systemic treatments (e.g., \nmethotrexate, cyclosporine) or contraindication to all conventional oral \nsystemic treatments.\nAge Restriction\nThe member must be at least 18 years of age for the following \nindications: Rheumatoid Arthritis, Moderate to severe Chronic Plaque \nPsoriasis, Psoriatic Arthritis, Ankylosing Spondylitis. The member must \nbe two years of age or older and have a diagnosis of moderately to \nseverely active polyarticular juvenile idiopathic arthritis or Uveitis. Must \nbe six years or older for Crohns Disease. Must be 12 years or older for \nHidradenitis Suppurativa. Must be 5 years or older for Ulcerative Colitis.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 179 of 497\n", "doc_id": "9551cf04-fec4-4910-a89a-aed5427eb987", "embedding": null, "doc_hash": "204a343085b9f07eefb4b2ae34c983a2bdf80574979548fb41f06c2a557518a0", "extra_info": {"page_label": "179", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2100, "_node_type": "1"}, "relationships": {"1": "46097bfd-96ab-421d-b6a3-de00c4b9694b"}}, "__type__": "1"}, "0369a904-39f2-457c-a4dd-074cc1eab899": {"__data__": {"text": "HUMIRA(CF)\nOther Criteria\nUlcerative Colitis: The member has a diagnosis of moderate to severely \nactive ulcerative colitis. The member has had prior therapy, \ncontraindication, or intolerance to one or more of the following \nconventional therapies: 5-aminosalicylic acids (e.g. mesalamine, \nbalsalazide) OR Corticosteroids (e.g. prednisone, methylprednisolone) \nOR Immunomodulators (e.g. azathioprine or 6-mercaptopurine).  Crohn's \nDisease: The member must have moderately to severely active Crohn's \ndisease. The member has had prior therapy, contraindication, or \nintolerance to a corticosteroid (e.g. prednisone, methylprednisolone) or \nan immunomodulator (e.g.azathioprine, 6-mercaptopurine, \nmethotrexate). Hidradenitis Suppurativa: The member must have a \ndiagnosis of moderate to severe Hidradenitis Suppurativa. Uveitis: The \nmember must have a diagnosis of non-infectious, intermediate, posterior, \nor pan-uveitis. The member has had prior therapy, contraindication, or \nintolerance with one of the following:  an intravitreal steroid (e.g. \ntriamcinolone, dexamethasone) OR a systemic corticosteroid (e.g. \nprednisone, methylprednisolone) OR an anti-metabolite (e.g. \nmethotrexate, azathioprine, mycophenolate) OR a calcineurin inhibitor \n(e.g. cyclosporine, tacrolimus).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 180 of 497\n", "doc_id": "0369a904-39f2-457c-a4dd-074cc1eab899", "embedding": null, "doc_hash": "5fea9c6dc2cfacc108ae293d980b632eb7e31da9e7bfd377eaa98c0b0c9c7cf7", "extra_info": {"page_label": "180", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1358, "_node_type": "1"}, "relationships": {"1": "6e4100ab-734f-4c5a-8386-b61029b126c9"}}, "__type__": "1"}, "1f791435-7faf-46c3-8bc4-9978134fbde9": {"__data__": {"text": "HUMIRA(CF) PEDI CROHNS STARTER\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnkylosing Spondylitis. Diagnosis of active ankylosing spondylitis. \nMember has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drug (NSAIDs) (e.g. ibuprofen, \nmeloxicam, naproxen). Psoriatic Arthritis. Diagnosis of active psoriatic \narthritis. Member has had prior therapy with or intolerance to a single \nDMARD (e.g. methotrexate, sulfasalazine, hydroxychloroquine, \nleflunomide) or contraindication with all DMARDs. Rheumatoid Arthritis. \nDiagnosis of moderately to severely active rheumatoid arthritis. Member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine, hydroxychloroquine, leflunomide) or \ncontraindication with all DMARDs. Polyarticular Juvenile Idiopathic \nArthritis. Diagnosis of moderately to severely active polyarticular juvenile \nidiopathic arthritis. Member has had prior therapy with or intolerance to a \nsingle DMARD (e.g. methotrexate, sulfasalazine, leflunomide) or \ncontraindication with all DMARDs. Moderate to severe Chronic Plaque \nPsoriasis. Diagnosis of moderate to severe chronic plaque psoriasis. The \nmember has had prior therapy with or intolerance to conventional \ntherapy including one or more oral systemic treatments (e.g., \nmethotrexate, cyclosporine) or contraindication to all conventional oral \nsystemic treatments.\nAge Restriction\nThe member must be at least 18 years of age for the following \nindications: Rheumatoid Arthritis, Moderate to severe Chronic Plaque \nPsoriasis, Psoriatic Arthritis, Ankylosing Spondylitis. The member must \nbe two years of age or older and have a diagnosis of moderately to \nseverely active polyarticular juvenile idiopathic arthritis or Uveitis. Must \nbe six years or older for Crohns Disease. Must be 12 years or older for \nHidradenitis Suppurativa. Must be 5 years or older for Ulcerative Colitis.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 181 of 497\n", "doc_id": "1f791435-7faf-46c3-8bc4-9978134fbde9", "embedding": null, "doc_hash": "815d69831aa9310dd69a681f92a749ec09b1e9a3d82224690d3cd4a3d8a1afa9", "extra_info": {"page_label": "181", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2120, "_node_type": "1"}, "relationships": {"1": "8bebe3e5-0529-413b-b243-b3d499a873c5"}}, "__type__": "1"}, "8f2edc7e-4440-48b6-af9c-9bcd938548a4": {"__data__": {"text": "HUMIRA(CF) PEDI CROHNS STARTER\nOther Criteria\nUlcerative Colitis: The member has a diagnosis of moderate to severely \nactive ulcerative colitis. The member has had prior therapy, \ncontraindication, or intolerance to one or more of the following \nconventional therapies: 5-aminosalicylic acids (e.g. mesalamine, \nbalsalazide) OR Corticosteroids (e.g. prednisone, methylprednisolone) \nOR Immunomodulators (e.g. azathioprine or 6-mercaptopurine).  Crohn's \nDisease: The member must have moderately to severely active Crohn's \ndisease. The member has had prior therapy, contraindication, or \nintolerance to a corticosteroid (e.g. prednisone, methylprednisolone) or \nan immunomodulator (e.g.azathioprine, 6-mercaptopurine, \nmethotrexate). Hidradenitis Suppurativa: The member must have a \ndiagnosis of moderate to severe Hidradenitis Suppurativa. Uveitis: The \nmember must have a diagnosis of non-infectious, intermediate, posterior, \nor pan-uveitis. The member has had prior therapy, contraindication, or \nintolerance with one of the following:  an intravitreal steroid (e.g. \ntriamcinolone, dexamethasone) OR a systemic corticosteroid (e.g. \nprednisone, methylprednisolone) OR an anti-metabolite (e.g. \nmethotrexate, azathioprine, mycophenolate) OR a calcineurin inhibitor \n(e.g. cyclosporine, tacrolimus).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 182 of 497\n", "doc_id": "8f2edc7e-4440-48b6-af9c-9bcd938548a4", "embedding": null, "doc_hash": "d43d23c6ce1622181273ba4ccc758f5d8eab91f748e9fa9b6b546e8ea39f8582", "extra_info": {"page_label": "182", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1378, "_node_type": "1"}, "relationships": {"1": "6a4cfe11-fc27-4b83-bcad-342a38c3f039"}}, "__type__": "1"}, "5208a8ba-07f2-47d1-9abc-85e1b1c6167b": {"__data__": {"text": "HUMIRA(CF) PEN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnkylosing Spondylitis. Diagnosis of active ankylosing spondylitis. \nMember has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drug (NSAIDs) (e.g. ibuprofen, \nmeloxicam, naproxen). Psoriatic Arthritis. Diagnosis of active psoriatic \narthritis. Member has had prior therapy with or intolerance to a single \nDMARD (e.g. methotrexate, sulfasalazine, hydroxychloroquine, \nleflunomide) or contraindication with all DMARDs. Rheumatoid Arthritis. \nDiagnosis of moderately to severely active rheumatoid arthritis. Member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine, hydroxychloroquine, leflunomide) or \ncontraindication with all DMARDs. Polyarticular Juvenile Idiopathic \nArthritis. Diagnosis of moderately to severely active polyarticular juvenile \nidiopathic arthritis. Member has had prior therapy with or intolerance to a \nsingle DMARD (e.g. methotrexate, sulfasalazine, leflunomide) or \ncontraindication with all DMARDs. Moderate to severe Chronic Plaque \nPsoriasis. Diagnosis of moderate to severe chronic plaque psoriasis. The \nmember has had prior therapy with or intolerance to conventional \ntherapy including one or more oral systemic treatments (e.g., \nmethotrexate, cyclosporine) or contraindication to all conventional oral \nsystemic treatments.\nAge Restriction\nThe member must be at least 18 years of age for the following \nindications: Rheumatoid Arthritis, Moderate to severe Chronic Plaque \nPsoriasis, Psoriatic Arthritis, Ankylosing Spondylitis. The member must \nbe two years of age or older and have a diagnosis of moderately to \nseverely active polyarticular juvenile idiopathic arthritis or Uveitis. Must \nbe six years or older for Crohns Disease. Must be 12 years or older for \nHidradenitis Suppurativa. Must be 5 years or older for Ulcerative Colitis.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 183 of 497\n", "doc_id": "5208a8ba-07f2-47d1-9abc-85e1b1c6167b", "embedding": null, "doc_hash": "659eed4ddb3a41133cfb8365f1c01412e6532f751a3b0e698d757501d620c644", "extra_info": {"page_label": "183", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2104, "_node_type": "1"}, "relationships": {"1": "62ea4c80-a0ca-4665-a4d5-c4b0cc2cb7f0"}}, "__type__": "1"}, "97ce3b47-1d3b-422d-af18-6b2d09342048": {"__data__": {"text": "HUMIRA(CF) PEN\nOther Criteria\nUlcerative Colitis: The member has a diagnosis of moderate to severely \nactive ulcerative colitis. The member has had prior therapy, \ncontraindication, or intolerance to one or more of the following \nconventional therapies: 5-aminosalicylic acids (e.g. mesalamine, \nbalsalazide) OR Corticosteroids (e.g. prednisone, methylprednisolone) \nOR Immunomodulators (e.g. azathioprine or 6-mercaptopurine).  Crohn's \nDisease: The member must have moderately to severely active Crohn's \ndisease. The member has had prior therapy, contraindication, or \nintolerance to a corticosteroid (e.g. prednisone, methylprednisolone) or \nan immunomodulator (e.g.azathioprine, 6-mercaptopurine, \nmethotrexate). Hidradenitis Suppurativa: The member must have a \ndiagnosis of moderate to severe Hidradenitis Suppurativa. Uveitis: The \nmember must have a diagnosis of non-infectious, intermediate, posterior, \nor pan-uveitis. The member has had prior therapy, contraindication, or \nintolerance with one of the following:  an intravitreal steroid (e.g. \ntriamcinolone, dexamethasone) OR a systemic corticosteroid (e.g. \nprednisone, methylprednisolone) OR an anti-metabolite (e.g. \nmethotrexate, azathioprine, mycophenolate) OR a calcineurin inhibitor \n(e.g. cyclosporine, tacrolimus).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 184 of 497\n", "doc_id": "97ce3b47-1d3b-422d-af18-6b2d09342048", "embedding": null, "doc_hash": "02a7d48d1e314d2d24cc061287e2e9a4fd3bf3bbcd8eafdd1f06f8236c49a308", "extra_info": {"page_label": "184", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1362, "_node_type": "1"}, "relationships": {"1": "6080e8ff-e7be-4981-aed6-01c683f169ac"}}, "__type__": "1"}, "2382fb7c-33d2-4539-ae03-e13f1de8a54a": {"__data__": {"text": "HUMIRA(CF) PEN CROHNS-UC-HS\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnkylosing Spondylitis. Diagnosis of active ankylosing spondylitis. \nMember has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drug (NSAIDs) (e.g. ibuprofen, \nmeloxicam, naproxen). Psoriatic Arthritis. Diagnosis of active psoriatic \narthritis. Member has had prior therapy with or intolerance to a single \nDMARD (e.g. methotrexate, sulfasalazine, hydroxychloroquine, \nleflunomide) or contraindication with all DMARDs. Rheumatoid Arthritis. \nDiagnosis of moderately to severely active rheumatoid arthritis. Member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine, hydroxychloroquine, leflunomide) or \ncontraindication with all DMARDs. Polyarticular Juvenile Idiopathic \nArthritis. Diagnosis of moderately to severely active polyarticular juvenile \nidiopathic arthritis. Member has had prior therapy with or intolerance to a \nsingle DMARD (e.g. methotrexate, sulfasalazine, leflunomide) or \ncontraindication with all DMARDs. Moderate to severe Chronic Plaque \nPsoriasis. Diagnosis of moderate to severe chronic plaque psoriasis. The \nmember has had prior therapy with or intolerance to conventional \ntherapy including one or more oral systemic treatments (e.g., \nmethotrexate, cyclosporine) or contraindication to all conventional oral \nsystemic treatments.\nAge Restriction\nThe member must be at least 18 years of age for the following \nindications: Rheumatoid Arthritis, Moderate to severe Chronic Plaque \nPsoriasis, Psoriatic Arthritis, Ankylosing Spondylitis. The member must \nbe two years of age or older and have a diagnosis of moderately to \nseverely active polyarticular juvenile idiopathic arthritis or Uveitis. Must \nbe six years or older for Crohns Disease. Must be 12 years or older for \nHidradenitis Suppurativa. Must be 5 years or older for Ulcerative Colitis.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 185 of 497\n", "doc_id": "2382fb7c-33d2-4539-ae03-e13f1de8a54a", "embedding": null, "doc_hash": "3589384c0e0abfc1338540f6150710bc35c4e0dededc339fef3f912da60e03cc", "extra_info": {"page_label": "185", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2117, "_node_type": "1"}, "relationships": {"1": "87d7aa3c-80fb-4c2c-8e92-eb6c67428315"}}, "__type__": "1"}, "29dcfd9a-f700-4f8b-b1ba-261e3b15a12d": {"__data__": {"text": "HUMIRA(CF) PEN CROHNS-UC-HS\nOther Criteria\nUlcerative Colitis: The member has a diagnosis of moderate to severely \nactive ulcerative colitis. The member has had prior therapy, \ncontraindication, or intolerance to one or more of the following \nconventional therapies: 5-aminosalicylic acids (e.g. mesalamine, \nbalsalazide) OR Corticosteroids (e.g. prednisone, methylprednisolone) \nOR Immunomodulators (e.g. azathioprine or 6-mercaptopurine).  Crohn's \nDisease: The member must have moderately to severely active Crohn's \ndisease. The member has had prior therapy, contraindication, or \nintolerance to a corticosteroid (e.g. prednisone, methylprednisolone) or \nan immunomodulator (e.g.azathioprine, 6-mercaptopurine, \nmethotrexate). Hidradenitis Suppurativa: The member must have a \ndiagnosis of moderate to severe Hidradenitis Suppurativa. Uveitis: The \nmember must have a diagnosis of non-infectious, intermediate, posterior, \nor pan-uveitis. The member has had prior therapy, contraindication, or \nintolerance with one of the following:  an intravitreal steroid (e.g. \ntriamcinolone, dexamethasone) OR a systemic corticosteroid (e.g. \nprednisone, methylprednisolone) OR an anti-metabolite (e.g. \nmethotrexate, azathioprine, mycophenolate) OR a calcineurin inhibitor \n(e.g. cyclosporine, tacrolimus).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 186 of 497\n", "doc_id": "29dcfd9a-f700-4f8b-b1ba-261e3b15a12d", "embedding": null, "doc_hash": "25f15807b97bd532758384550bc03421abf254181ab5317c4b9259339becb401", "extra_info": {"page_label": "186", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1375, "_node_type": "1"}, "relationships": {"1": "3c310313-3c33-45ee-ad42-17dff9eae989"}}, "__type__": "1"}, "9ab19c9b-62df-4c36-8180-8d5092d6a246": {"__data__": {"text": "HUMIRA(CF) PEN PEDIATRIC UC\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnkylosing Spondylitis. Diagnosis of active ankylosing spondylitis. \nMember has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drug (NSAIDs) (e.g. ibuprofen, \nmeloxicam, naproxen). Psoriatic Arthritis. Diagnosis of active psoriatic \narthritis. Member has had prior therapy with or intolerance to a single \nDMARD (e.g. methotrexate, sulfasalazine, hydroxychloroquine, \nleflunomide) or contraindication with all DMARDs. Rheumatoid Arthritis. \nDiagnosis of moderately to severely active rheumatoid arthritis. Member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine, hydroxychloroquine, leflunomide) or \ncontraindication with all DMARDs. Polyarticular Juvenile Idiopathic \nArthritis. Diagnosis of moderately to severely active polyarticular juvenile \nidiopathic arthritis. Member has had prior therapy with or intolerance to a \nsingle DMARD (e.g. methotrexate, sulfasalazine, leflunomide) or \ncontraindication with all DMARDs. Moderate to severe Chronic Plaque \nPsoriasis. Diagnosis of moderate to severe chronic plaque psoriasis. The \nmember has had prior therapy with or intolerance to conventional \ntherapy including one or more oral systemic treatments (e.g., \nmethotrexate, cyclosporine) or contraindication to all conventional oral \nsystemic treatments.\nAge Restriction\nThe member must be at least 18 years of age for the following \nindications: Rheumatoid Arthritis, Moderate to severe Chronic Plaque \nPsoriasis, Psoriatic Arthritis, Ankylosing Spondylitis. The member must \nbe two years of age or older and have a diagnosis of moderately to \nseverely active polyarticular juvenile idiopathic arthritis or Uveitis. Must \nbe six years or older for Crohns Disease. Must be 12 years or older for \nHidradenitis Suppurativa. Must be 5 years or older for Ulcerative Colitis.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 187 of 497\n", "doc_id": "9ab19c9b-62df-4c36-8180-8d5092d6a246", "embedding": null, "doc_hash": "a802a37fed1ee307e90be8396b1826434c1105135b5b0a39c4fbcb9e04ae4332", "extra_info": {"page_label": "187", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2117, "_node_type": "1"}, "relationships": {"1": "21e86423-e88a-4b97-b736-b0b0d7ab8efe"}}, "__type__": "1"}, "b946b8c4-9ff3-470b-a231-cde95a3dfcb5": {"__data__": {"text": "HUMIRA(CF) PEN PEDIATRIC UC\nOther Criteria\nUlcerative Colitis: The member has a diagnosis of moderate to severely \nactive ulcerative colitis. The member has had prior therapy, \ncontraindication, or intolerance to one or more of the following \nconventional therapies: 5-aminosalicylic acids (e.g. mesalamine, \nbalsalazide) OR Corticosteroids (e.g. prednisone, methylprednisolone) \nOR Immunomodulators (e.g. azathioprine or 6-mercaptopurine).  Crohn's \nDisease: The member must have moderately to severely active Crohn's \ndisease. The member has had prior therapy, contraindication, or \nintolerance to a corticosteroid (e.g. prednisone, methylprednisolone) or \nan immunomodulator (e.g.azathioprine, 6-mercaptopurine, \nmethotrexate). Hidradenitis Suppurativa: The member must have a \ndiagnosis of moderate to severe Hidradenitis Suppurativa. Uveitis: The \nmember must have a diagnosis of non-infectious, intermediate, posterior, \nor pan-uveitis. The member has had prior therapy, contraindication, or \nintolerance with one of the following:  an intravitreal steroid (e.g. \ntriamcinolone, dexamethasone) OR a systemic corticosteroid (e.g. \nprednisone, methylprednisolone) OR an anti-metabolite (e.g. \nmethotrexate, azathioprine, mycophenolate) OR a calcineurin inhibitor \n(e.g. cyclosporine, tacrolimus).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 188 of 497\n", "doc_id": "b946b8c4-9ff3-470b-a231-cde95a3dfcb5", "embedding": null, "doc_hash": "6ada347a29cc792a49af8a334ca4433e55d4c48c51766ccc36825e17fc7071e5", "extra_info": {"page_label": "188", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1375, "_node_type": "1"}, "relationships": {"1": "bdd4f762-f7b8-4fbb-add2-ffa79a22ca37"}}, "__type__": "1"}, "8b148c6d-a5cb-4b0c-95b9-f4ad38276193": {"__data__": {"text": "HUMIRA(CF) PEN PSOR-UV-ADOL HS\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnkylosing Spondylitis. Diagnosis of active ankylosing spondylitis. \nMember has had prior therapy, contraindication, or intolerance with a \nnon-steroidal anti-inflammatory drug (NSAIDs) (e.g. ibuprofen, \nmeloxicam, naproxen). Psoriatic Arthritis. Diagnosis of active psoriatic \narthritis. Member has had prior therapy with or intolerance to a single \nDMARD (e.g. methotrexate, sulfasalazine, hydroxychloroquine, \nleflunomide) or contraindication with all DMARDs. Rheumatoid Arthritis. \nDiagnosis of moderately to severely active rheumatoid arthritis. Member \nhas had prior therapy with or intolerance to a single DMARD (e.g. \nmethotrexate, sulfasalazine, hydroxychloroquine, leflunomide) or \ncontraindication with all DMARDs. Polyarticular Juvenile Idiopathic \nArthritis. Diagnosis of moderately to severely active polyarticular juvenile \nidiopathic arthritis. Member has had prior therapy with or intolerance to a \nsingle DMARD (e.g. methotrexate, sulfasalazine, leflunomide) or \ncontraindication with all DMARDs. Moderate to severe Chronic Plaque \nPsoriasis. Diagnosis of moderate to severe chronic plaque psoriasis. The \nmember has had prior therapy with or intolerance to conventional \ntherapy including one or more oral systemic treatments (e.g., \nmethotrexate, cyclosporine) or contraindication to all conventional oral \nsystemic treatments.\nAge Restriction\nThe member must be at least 18 years of age for the following \nindications: Rheumatoid Arthritis, Moderate to severe Chronic Plaque \nPsoriasis, Psoriatic Arthritis, Ankylosing Spondylitis. The member must \nbe two years of age or older and have a diagnosis of moderately to \nseverely active polyarticular juvenile idiopathic arthritis or Uveitis. Must \nbe six years or older for Crohns Disease. Must be 12 years or older for \nHidradenitis Suppurativa. Must be 5 years or older for Ulcerative Colitis.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 189 of 497\n", "doc_id": "8b148c6d-a5cb-4b0c-95b9-f4ad38276193", "embedding": null, "doc_hash": "b1fb0b82584ddbab4903f9fb59ff2e69a531c86898bdbe7aa1b73dcc2d477398", "extra_info": {"page_label": "189", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2120, "_node_type": "1"}, "relationships": {"1": "dfa3cfcf-269f-43a7-a294-dbf998169be5"}}, "__type__": "1"}, "6eaf47b1-8994-4b8d-8327-94c5f6fcc5a2": {"__data__": {"text": "HUMIRA(CF) PEN PSOR-UV-ADOL HS\nOther Criteria\nUlcerative Colitis: The member has a diagnosis of moderate to severely \nactive ulcerative colitis. The member has had prior therapy, \ncontraindication, or intolerance to one or more of the following \nconventional therapies: 5-aminosalicylic acids (e.g. mesalamine, \nbalsalazide) OR Corticosteroids (e.g. prednisone, methylprednisolone) \nOR Immunomodulators (e.g. azathioprine or 6-mercaptopurine).  Crohn's \nDisease: The member must have moderately to severely active Crohn's \ndisease. The member has had prior therapy, contraindication, or \nintolerance to a corticosteroid (e.g. prednisone, methylprednisolone) or \nan immunomodulator (e.g.azathioprine, 6-mercaptopurine, \nmethotrexate). Hidradenitis Suppurativa: The member must have a \ndiagnosis of moderate to severe Hidradenitis Suppurativa. Uveitis: The \nmember must have a diagnosis of non-infectious, intermediate, posterior, \nor pan-uveitis. The member has had prior therapy, contraindication, or \nintolerance with one of the following:  an intravitreal steroid (e.g. \ntriamcinolone, dexamethasone) OR a systemic corticosteroid (e.g. \nprednisone, methylprednisolone) OR an anti-metabolite (e.g. \nmethotrexate, azathioprine, mycophenolate) OR a calcineurin inhibitor \n(e.g. cyclosporine, tacrolimus).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 190 of 497\n", "doc_id": "6eaf47b1-8994-4b8d-8327-94c5f6fcc5a2", "embedding": null, "doc_hash": "69defdce2a5c0e9847c1f099f1af81e0534dbaa94892d97c4c5661a561773031", "extra_info": {"page_label": "190", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1378, "_node_type": "1"}, "relationships": {"1": "508dc100-0972-4dc6-ae44-d57084fced3a"}}, "__type__": "1"}, "bf8eda26-dd22-4642-be2b-708f66631e52": {"__data__": {"text": "HYFTOR\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nFacial Angiofibroma:  the member must meet all of the following criteria: \ndiagnosis of tuberous sclerosis complex (TSC), experiencing greater \nthan or equal to three facial angiofibromas, and is not receiving systemic \nmTOR inhibitor therapy (e.g. everolimus).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 191 of 497\n", "doc_id": "bf8eda26-dd22-4642-be2b-708f66631e52", "embedding": null, "doc_hash": "1da287fd24ddfec814c827606d39b4f7c8e201b2e17f136e108f3666e6998f66", "extra_info": {"page_label": "191", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 548, "_node_type": "1"}, "relationships": {"1": "507849b8-ed25-4346-99f5-7d108fc54753"}}, "__type__": "1"}, "08643010-bf07-45f6-94ba-f27742e767ea": {"__data__": {"text": "ibandronate\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nIn patients with severe renal impairment (patients with serum creatinine \ngreater than 200uMol/L [2.3 mg/dL] or creatinine clearance less than \n30mL/min.\nRequired\nMedical\nInformation\nPostmenopausal Osteoporosis: The member is a postmenopausal with a \ndiagnosis of osteoporosis or at high risk for osteoporosis. The member \nhas new fractures or significant loss of bone mineral density despite \nprevious treatment contraindication or intolerance with an oral OR \nintravenous bisphosphonate (e.g. alendronate, ibandronate, \npamidronate).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 192 of 497\n", "doc_id": "08643010-bf07-45f6-94ba-f27742e767ea", "embedding": null, "doc_hash": "fe2486e98d50259561a8939afd8f6045bdcebc3809cf38c5ec37b6420d0a0a26", "extra_info": {"page_label": "192", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 795, "_node_type": "1"}, "relationships": {"1": "004efd65-2443-48ea-9d2c-c73983289e0d"}}, "__type__": "1"}, "382991f7-fb0d-44f1-9c18-2870fefec121": {"__data__": {"text": "IBRANCE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember has experienced disease progression on CDK 4/6 inhibitor (e.g., \nribociclib, abemaciclib).\nRequired\nMedical\nInformation\nBreast Cancer:The member has a diagnosis of estrogen receptor-\npositive and human epidermal growth factor receptor 2-negative breast \ncancer AND one of the following applies: The member will be using \nIbrance in combination with an aromatase inhibitor (e.g., letrozole) as \ninitial endocrine-based therapy for their recurrent disease OR The \nmember will be taking Ibrance (palbociclib) in combination with an \naromatase inhibitor (e.g., letrozole) as initial endocrine based therapy for \ntheir metastatic disease or the member will be using Ibrance in \ncombination with Faslodex as subsequent therapy after disease \nprogression on or following endocrine based therapy ( e.g. anastrazole) \nfor their recurrent disease or the member will be using Ibrance in \ncombination with Faslodex as subsequent therapy after disease \nprogression on or following endocrine based therapy (e.g. anastrazole) \nfor their metastatic disease.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 193 of 497\n", "doc_id": "382991f7-fb0d-44f1-9c18-2870fefec121", "embedding": null, "doc_hash": "a095c48dbd922ae690c1b8d7ab0cb2cae9417b5e8f80e3f4d19e6d7de8733e16", "extra_info": {"page_label": "193", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1306, "_node_type": "1"}, "relationships": {"1": "f2c25fbb-ed9b-4816-b720-5ee7cf8c2221"}}, "__type__": "1"}, "e81b8a8b-418c-4703-ac45-f2d7f40766c8": {"__data__": {"text": "icatibant\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nUse for prophylaxis of HAE attack. Evidence of autoantibodies against \nthe C1INH protein. Evidence of underlying lymphoproliferative, \nmalignant, or autoimmune disorder that causes angioedema attacks. \nUse in combination with other agents approved for acute treatment of \nHAE attack (e.g. Berinert, Kalbitor, Ruconest).\nRequired\nMedical\nInformation\nHereditary Angioedema (HAE): The member must have a diagnosis of \nhereditary angioedema (HAE) type 1 or type 2. The member must have \ndocumentation of: Low evidence of C4 level (i.e. C4 level below lower \nlimit of normal laboratory reference range) AND Low C1 inhibitor (i.e. \nC1INH level below lower limit of normal laboratory reference range) \nantigenic level (C1INH less than 19 mg/dL) OR Low C1INH functional \nlevel (i.e. functional C1INH less than 50% or below lower limit of normal \nlaboratory reference range) OR Known HAE-causing C1INH mutation. \nThe member is being treated by a specialist in hereditary angioedema \n(i.e. allergist and/or immunologist). Must provide lab report or medical \nrecord documentation which include lab values as required by policy. \nLab values must include C1q level. The member is using icatibant for \ntreatment of acute attacks of HAE.\nAge Restriction\nThe member must be 18 years or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 194 of 497\n", "doc_id": "e81b8a8b-418c-4703-ac45-f2d7f40766c8", "embedding": null, "doc_hash": "a79e7f083a1f3379fd53dc2f9d15a89ce40e62a6866092b23b1af0d6e79ca404", "extra_info": {"page_label": "194", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1521, "_node_type": "1"}, "relationships": {"1": "086565fa-f127-4e47-8260-022216a8a6c1"}}, "__type__": "1"}, "1ab588e2-d47b-4882-9da1-d5ac28693eda": {"__data__": {"text": "ICLUSIG\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on Iclusig \n(ponatinib). Members on concomitant tyrosine kinase inhibitors.\nRequired\nMedical\nInformation\nChronic Myeloid Leukemia (chronic phase):The member has a diagnosis \nof chronic phase chronic myeloid leukemia (CML) AND one of the \nfollowing apply: The member has an intolerance, resistance, or \ncontraindication to at least two available tyrosine kinase inhibitors \nindicated for the treatment of CML OR The member has a documented \nT315I mutation.  Chronic Myeloid Leukemia (accelerated or blast phase): \nThe member has a diagnosis of accelerated or blast phase chronic \nmyeloid leukemia (CML) AND one of the following apply: There are no \nother kinase inhibitors indicated OR the member has a documented \nT315I mutation.  Acute Lymphoblastic Leukemia: The member has a \ndiagnosis of Philadelphia chromosome positive acute lymphoblastic \nleukemia (Ph+ ALL) AND one of the following apply: There are no other \nkinase inhibitors indicated OR The member has a documented T315I \nmutation.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 195 of 497\n", "doc_id": "1ab588e2-d47b-4882-9da1-d5ac28693eda", "embedding": null, "doc_hash": "cc2b704088cd619993d51463f1c7d01e2a6fa7fd53d7b5f7d966125627f30f34", "extra_info": {"page_label": "195", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1303, "_node_type": "1"}, "relationships": {"1": "114b8ce6-75da-4212-9013-bef3907dd520"}}, "__type__": "1"}, "34dee817-57e0-46b4-8a11-584a8bef5444": {"__data__": {"text": "IDHIFA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember has experienced disease progression while on or following \nIdhifa(enasidenib).\nRequired\nMedical\nInformation\nAcute Myeloid Leukemia, Relapsed/Refractory: The member has a \ndiagnosis of acute myeloid leukemia (AML) AND The member has \nrelapsed or refractory disease AND The member has a documented \nIDH2 mutation AND One of the following applies: The member will be \nusing Idhifa (enasidenib) as monotherapy OR the member will be using \nIdhifa (enasidenib) as a component of repeating the initial successful \ninduction regimen, if late relapse (relapse occurring later than 12 \nmonths).  Acute Myeloid Leukemia, Newly diagnosed:  The member has \na diagnosis of acute myeloid leukemia (AML) AND the member has \nnewly diagnosed disease AND the member is not a candidate for \nintensive induction therapy due to comorbidities AND the member has a \ndocumented IDH2 mutation AND the member will be using Idhifa \n(enasidenib) as monotherapy.\nAge Restriction\nThe member is 60 years of age or older for newly diagnosed AML.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 196 of 497\n", "doc_id": "34dee817-57e0-46b4-8a11-584a8bef5444", "embedding": null, "doc_hash": "06080d4a5a4288e2c1933b57dd7ea22f6262f21324c50180bd99e6da676f869e", "extra_info": {"page_label": "196", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1262, "_node_type": "1"}, "relationships": {"1": "8c8fcb7f-2b9a-48b0-a7ff-8e843b2f74f5"}}, "__type__": "1"}, "e6f7f79a-de3f-4fe0-a123-bb76e0ab69db": {"__data__": {"text": "imatinib\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nPatients on concomitant tyrosine kinase inhibitors. Patients that have \nexperienced disease progression while on imatinib.\nRequired\nMedical\nInformation\nThe member has a diagnosis of Ph+ CML that is newly diagnosed in the \nchronic phase OR The member has a diagnosis of Ph+ CML that is in \naccelerated phase or blast crisis. Acute lymphoid leukemia (ALL).The \nmember has a diagnosis of Ph+ ALL that is relapsed, refractory, or newly \ndiagnosed and imatinib is being added to consolidation or induction \ntherapy OR the member has a diagnosis of PH+ALL and receiving \nmaintenance therapy. The member has a diagnosis of Kit (CD117)-\npositive GIST. The member has a diagnosis of Dermatofibrosacrome \nprotuberans (DFSP) that is adjuvant (positive surgical margins following \nexcision) unresectable, recurrent, and/or metastatic. The member has a \ndiagnosis of chronic eosinophilic leukemia or hypereosinophilic \nsyndrome. The member has a diagnosis of MDS or chronic MPD that is \nassociated with platelet-derived growth factor receptor (PDGFR) gene \nrearrangement.(ex. Chronic myelomonocyte leukemia, atypical chronic \nmyeloid leukemia, juvenile myelomonocyte leukemia).The member has a \ndiagnosis of aggressive systemic mastocytosis. The member must not \nharbor the D816v mutation of C-kit. Melanoma. The member has a \ndiagnosis of unresectable melanoma with activating mutation of C-kit. \nImatinib will be used as single agent in subsequent therapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPediatric indications: The patient has a diagnosis of Philadelphia \nchromosome positive (Ph+) CML that is newly diagnosed in chronic \nphase OR The patient has a diagnosis of Ph+ CML that is in chronic \nphase with disease recurrence after stem cell transplant OR The patient \nhas a diagnosis of Ph+ CML that is in chronic phase after failure of \ninterferon-alpha therapy.Acute Lymphoid Luekemia (ALL). The member \nis newly diagnosed with Ph+ ALL AND the member will be using imatinib \nin combination with chemotherapy.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 197 of 497\n", "doc_id": "e6f7f79a-de3f-4fe0-a123-bb76e0ab69db", "embedding": null, "doc_hash": "56ab3f641216409cb104637f513ff96a2c03bf0a02e934c394d04f0405604fea", "extra_info": {"page_label": "197", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2229, "_node_type": "1"}, "relationships": {"1": "633af932-0c41-4c87-8252-32bb7894481d"}}, "__type__": "1"}, "322a4344-3a7b-4cdf-8ffb-dc679e967ef2": {"__data__": {"text": "IMBRUVICA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on or following \nImbruvica (ibrutinib).\nRequired\nMedical\nInformation\nMantle Cell Lymphoma: The member has a diagnosis of Mantle Cell \nLymphoma (MCL) AND The member has received at least one prior \ntherapy for the treatment of MCL AND The member is using Imbruvica as \nmonotherapy. Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic \nLymphoma (SLL): The member has a diagnosis of Chronic Lymphocytic \nLeukemia (CLL)/Small Lymphocytic Lymphoma (SLL). Waldenstrom's \nMacroglobulinemia:The member has a diagnosis of Waldenstrom\n\u2019\ns \nmacroglobulinemia AND The member is using Imbruvica (ibrutinib) as \nmonotherapy or in combination with a rituximab product. Marginal Zone \nLymphoma: The member has a diagnosis of marginal zone lymphoma \nAND The member is using Imbruvica (ibrutinib) as second line or \nsubsequent for refractory or progressive disease AND The member is \nusing Imbruvica (ibrutinib) as monotherapy. Chronic Graft Versus Host \nDisease (adult): The member has a diagnosis of chronic graft versus \nhost disease (cGVHD) AND The member has been unable to achieve \ntreatment goals with at least one prior line of systemic therapy (e.g. \ncorticosteroids).  Chronic Graft Versus Host Disease (pediatric): The \nmember has a diagnosis of chronic graft versus host disease (cGVHD) \nAND The member has been unable to achieve treatment goals with at \nleast one prior line of systemic therapy (e.g. corticosteroids).\nAge Restriction\npediatric cGVHD: Member age is 1 year or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 198 of 497\n", "doc_id": "322a4344-3a7b-4cdf-8ffb-dc679e967ef2", "embedding": null, "doc_hash": "fcb041679fb90d5931b03d11009bbf07b5a20292a48f96234508bc9c959d5535", "extra_info": {"page_label": "198", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1776, "_node_type": "1"}, "relationships": {"1": "dcca2fee-d258-4bcf-abbf-276e9244e1b4"}}, "__type__": "1"}, "9d15791c-7d16-4f1d-b961-a7f05d0ac272": {"__data__": {"text": "IMFINZI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDisease progression while on anti-PD-1/PD-L1 therapy [e.g., Opdivo \n(nivolumab), Keytruda (pembrolizumab), Tecentriq (atezolizumab), \nImfinzi (durvalumab)]. For unresectable stage III NSCLC, member has \nnot exceeded a maximum of twelve (12) months of therapy.\nRequired\nMedical\nInformation\nNon-Small Cell Lung Cancer (NSCLC): Member has diagnosis of \nunresectable stage III non-small cell lung cancer (NSCLC) AND Imfinzi \n(durvalumab) will be used as consolidation therapy after completion of \nconcurrent platinum containing chemotherapy and radiation AND \nMember has not experienced progression of disease after at least two \ncycles of chemotherapy and radiation AND Imfinzi (durvalumab) will be \nused as monotherapy OR Member has a diagnosis of metastatic non-\nsmall cell lung cancer (NSCLC) AND Member has no documented EGFR \nor ALK genomic tumor aberrations AND Member will be using Imfinzi in \ncombination with Imjudo and platinum-based chemotherapy as first-line \ntherapy only. Small Cell Lung Cancer: The member has a diagnosis of \nextensive-stage small cell lung cancer AND Imfinzi will be given in \ncombination with etoposide and carboplatin as first line therapy followed \nby maintenance therapy with Imfinzi as a single agent.  Biliary Tract \nCancer:  the member has a diagnosis of locally advanced or metastatic \nbiliary tract cancer AND the member will be using Imfinzi (durvalumab) in \ncombination with gemcitabine and cisplatin. Hepatocellular Carcinoma: \nThe member has a diagnosis of locally advanced unresectable and/or \nmetastatic hepatocellular carcinoma AND The member will be using \nImfinzi in combination with Imjudo as first-line therapy only.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner.\nCoverage\nDuration\n6 months Duration.\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 199 of 497\n", "doc_id": "9d15791c-7d16-4f1d-b961-a7f05d0ac272", "embedding": null, "doc_hash": "22fd1db4f4070f6c9338bf10bb13b7e8dab3317caa78456b2db6912863f3db20", "extra_info": {"page_label": "199", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1926, "_node_type": "1"}, "relationships": {"1": "6631ce49-9c9c-45ed-b570-66b6950ec48a"}}, "__type__": "1"}, "c3945cc4-1d98-4b71-b97f-205d4b56a744": {"__data__": {"text": "IMJUDO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDisease progression on Imjudo (tremelimumab-actl)\nRequired\nMedical\nInformation\nHepatocellular carcinoma (HCC): The member has diagnosis of \nunresectable hepatocellular carcinoma AND The member will be given \nImjudo (tremelimumab-actl) in combination with Imfinzi (durvalumab). \nNon-small cell lung cancer (NSCLC): The member has a diagnosis of \nmetastatic, advanced, recurrent non-small cell lung cancer AND NSCLC \ndoes not express sensitizing genomic tumor aberrations (e.g., EGFR, \nALK) AND The member will be given Imjudo (tremelimumab-actl) in \ncombination with Imfinzi (durvalumab) and platinum based \nchemotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 200 of 497\n", "doc_id": "c3945cc4-1d98-4b71-b97f-205d4b56a744", "embedding": null, "doc_hash": "c22fd420604f25904319ab4efe0e01774897718058a27ed3d617143e4d425fa7", "extra_info": {"page_label": "200", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 878, "_node_type": "1"}, "relationships": {"1": "9ac6e846-2e0d-49bd-a299-f608b265b393"}}, "__type__": "1"}, "9f2bf40c-90c9-45fb-a375-63017cc36302": {"__data__": {"text": "IMLYGIC\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers who are immunocompromised. Members who are pregnant. \nMembers that have experienced disease progression while on Imlygic \n(talimogene laherparepvec). Concomitant therapy with anti-PD-1/PD-L1 \nagents (e.g. Opdivo [nivolumab], Keytruda [pembrolizumab], Tecentriq \n[atezolizumab], Bavencio [avelumab]).\nRequired\nMedical\nInformation\nUnresectable Melanoma: The member must have one of the following \nmelanoma diagnoses:unresectable Stage III with in-transit metastases, \nunresectable local/satellite recurrence (may also have in-transit \nmetastases), unresectable or distant metastatic disease. The member \nwill receive Imlygic as an intralesional therapy into cutaneous, \nsubcutaneous, or nodal lesions that are visible on the skin, palpable, or \ndetectable by ultrasound guidance.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 201 of 497\n", "doc_id": "9f2bf40c-90c9-45fb-a375-63017cc36302", "embedding": null, "doc_hash": "ce43f0450a9711588f033aaaadebc45ac6b8c9f637b730f9d0f83c117c4381b4", "extra_info": {"page_label": "201", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1052, "_node_type": "1"}, "relationships": {"1": "ad7e60da-c33f-4f92-80e4-0d25dde15446"}}, "__type__": "1"}, "c39e743b-b20e-4949-b697-5984952ac433": {"__data__": {"text": "INCRELEX\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe bone epiphyses are closed.\nRequired\nMedical\nInformation\nMember has a diagnosis of GH gene deletion with development of \nneutralizing antibodies to GH OR The patient has a diagnosis of severe \nprimary IGF-1 deficiency defined by:height standard deviation score \nbelow or equal -3.0 and basal IGF-1 standard deviation score below or \nequal -3.0 and normal or elevated growth hormone.\nAge Restriction\nThe patient is 2 years or older\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 202 of 497\n", "doc_id": "c39e743b-b20e-4949-b697-5984952ac433", "embedding": null, "doc_hash": "f21fc0540e903293a6e77a8e751bc00629449b65e064b3bd964fb2d9f20b7785", "extra_info": {"page_label": "202", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 683, "_node_type": "1"}, "relationships": {"1": "e1e146aa-baac-4e5e-b32f-eaccc391aad3"}}, "__type__": "1"}, "fca1d3f2-4034-441b-ad32-bae654b0d2ac": {"__data__": {"text": "INGREZZA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nTardive Dyskinesia Initial therapy. The member is utilizing Ingrezza \n(valbenazine) for the treatment of moderate to severe tardive dyskinesia \nas seen by the following:  the member has abnormal involuntary \nmovements related to treatment with one or more dopamine receptor \nblocking agents AND Symptoms persist despite one of the following: \nDiscontinuation or reduction in dose of dopamine blocking agent(s) or \nDiscontinuation or reduction in dose of dopamine blocking agent(s) is not \npossible. OR the member will be using Ingrezza for the treatment of \nmoderate to severe tardive dyskinesia that is not associated with other \nmedication therapies (e.g. dopamine blocking agents).  AND The \nprovider attests that the risk versus benefit of depression and suicidality \nhas been considered, and the benefits of treatment outweigh the risks \nAND the member has had previous treatment, contraindication, or \nintolerance to Austedo (deutetrabenazine).  Tardive Dyskinesia -\nReauthorization: The member has a documented improvement or \nmaintenance of symptoms while on Ingrezza (valbenazine) (e.g. \nreduction in Abnormal Involuntary Movement Scale [AIMS] score or \nDyskinesia Identification System: Condensed User Scale [DISCUS] from \nbaseline) AND The provider attests that the risk versus benefit of \ndepression and suicidality has been considered, and the benefits of \ntreatment outweigh the risks\nAge Restriction\nThe member is 18 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial authorization: 3 months. Reauthorization: Plan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 203 of 497\n", "doc_id": "fca1d3f2-4034-441b-ad32-bae654b0d2ac", "embedding": null, "doc_hash": "eff0c14240f7ca8543c5d064b21e7a1ff4a13b53c23ca0648f484d442c46fbce", "extra_info": {"page_label": "203", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1777, "_node_type": "1"}, "relationships": {"1": "1499f467-6304-481b-a63a-cfa688140176"}}, "__type__": "1"}, "75c23303-1371-416a-a3e0-935de045b55f": {"__data__": {"text": "INGREZZA INITIATION PACK\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nTardive Dyskinesia Initial therapy. The member is utilizing Ingrezza \n(valbenazine) for the treatment of moderate to severe tardive dyskinesia \nas seen by the following:  the member has abnormal involuntary \nmovements related to treatment with one or more dopamine receptor \nblocking agents AND Symptoms persist despite one of the following: \nDiscontinuation or reduction in dose of dopamine blocking agent(s) or \nDiscontinuation or reduction in dose of dopamine blocking agent(s) is not \npossible. OR the member will be using Ingrezza for the treatment of \nmoderate to severe tardive dyskinesia that is not associated with other \nmedication therapies (e.g. dopamine blocking agents).  AND The \nprovider attests that the risk versus benefit of depression and suicidality \nhas been considered, and the benefits of treatment outweigh the risks \nAND the member has had previous treatment, contraindication, or \nintolerance to Austedo (deutetrabenazine).  Tardive Dyskinesia -\nReauthorization: The member has a documented improvement or \nmaintenance of symptoms while on Ingrezza (valbenazine) (e.g. \nreduction in Abnormal Involuntary Movement Scale [AIMS] score or \nDyskinesia Identification System: Condensed User Scale [DISCUS] from \nbaseline) AND The provider attests that the risk versus benefit of \ndepression and suicidality has been considered, and the benefits of \ntreatment outweigh the risks\nAge Restriction\nThe member is 18 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial authorization: 3 months. Reauthorization: Plan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 204 of 497\n", "doc_id": "75c23303-1371-416a-a3e0-935de045b55f", "embedding": null, "doc_hash": "f5122213749d6e0c2cc96a1b66c1bcd713e67927961a1a33ff7780e31aedb3a0", "extra_info": {"page_label": "204", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1793, "_node_type": "1"}, "relationships": {"1": "ce7887fa-11d6-47ed-8b51-9eac3f4d80df"}}, "__type__": "1"}, "f4e12164-6f7a-4055-8a7c-e4a9c9f46052": {"__data__": {"text": "INLYTA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors. Members that have \nexperienced disease progression while on Inlyta (axitinib).\nRequired\nMedical\nInformation\nRenal Cell Carcinoma: The member has a diagnosis of advanced renal \ncell carcinoma AND Inlyta will be given as one of the following: \nmonotherapy AND the member has a medical reason as to why \nCabometyx (cabozantinib) can not be initiated or continued  OR in \ncombination with Keytruda or Bavencio as first-line therapy. Advanced \nThyroid Carcinoma: The member has a diagnosis of \nadvanced/metastatic follicular carcinoma, Hurthle cell carcinoma, or \npapillary carcinoma and clinical trials are not available or appropriate \nAND The member has disease that is not responsive to radio-iodine \ntreatment.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 205 of 497\n", "doc_id": "f4e12164-6f7a-4055-8a7c-e4a9c9f46052", "embedding": null, "doc_hash": "90b3de80cc4a75ac654b33c0bcd5e12daf8af9a2db499843477e8d2020983d50", "extra_info": {"page_label": "205", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1017, "_node_type": "1"}, "relationships": {"1": "758dbe39-d01c-43ff-9823-6cf8e62879f9"}}, "__type__": "1"}, "15ce4fc7-8c50-47d9-8105-7a9526fddaa5": {"__data__": {"text": "INQOVI\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member has experienced disease progression on hypomethylators \n(e.g. azacitidine, decitabine).\nRequired\nMedical\nInformation\nMyelodysplastic Syndromes - Chronic Myelomonocytic Leukemia:  The \nmember has a diagnosis of myelodysplastic syndromes (MDS), including \npreviously treated and untreated, de novo or secondary MDS OR chronic \nmyelomonocytic leukemia (CMML) AND the member will be using Inqovi \n(decitabine and cedazuridine) as a single agent.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 206 of 497\n", "doc_id": "15ce4fc7-8c50-47d9-8105-7a9526fddaa5", "embedding": null, "doc_hash": "e3de7779484c8845d4855ae9a85399e94c46ed4c2c4d6ed4c2d9a4b4a1f0afc4", "extra_info": {"page_label": "206", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 718, "_node_type": "1"}, "relationships": {"1": "d50d8d90-7c9a-4f96-9cb6-2302cd20fcf3"}}, "__type__": "1"}, "56e7ccb7-6298-49bf-aea3-77442de968cd": {"__data__": {"text": "INREBIC\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers that have experienced disease progression while on Inrebic \n(fedratinib).\nRequired\nMedical\nInformation\nMyelofibrosis: The member has a diagnosis of primary myelofibrosis or \nsecondary myelofibrosis (i.e. post-polycythemia vera or post-essential \nthrombocythemia) AND The member has one of the following risk \ncategories, as defined by accepted risk stratification tools for \nmyelofibrosis (e.g. International Prognostic Scoring System (IPSS), \nDynamic International Prognostic Scoring System (DIPSS), or DIPSS-\nPLUS): Intermediate-2 risk disease OR High-risk disease AND the \nmember will be using Inrebic (fedratinib) as monotherapy AND The \nmember has a medical reason as to why Jakafi (ruxolitinib) cannot be \nused. Reauthorization criteria: Physician attestation that the member has \ncontinued to receive a clinical benefit (e.g. spleen volume reduction from \nbaseline, symptom improvement) AND physician attestation that the \nmember has not experienced unacceptable toxicities.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial auth: 6 months duration. Reauthorization: 6 months Duration.\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 207 of 497\n", "doc_id": "56e7ccb7-6298-49bf-aea3-77442de968cd", "embedding": null, "doc_hash": "759c1f4bda7037f51e59160d4032c7ce6a46b11eabaa1a7ef62b5f1aa0d1573b", "extra_info": {"page_label": "207", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1307, "_node_type": "1"}, "relationships": {"1": "0247e755-31c2-449b-85b3-33650727f053"}}, "__type__": "1"}, "d8ce423b-15f1-4b3a-9fc0-8132db0130b3": {"__data__": {"text": "INTRON A\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nChronic Hepatitis C. Diagnosis of chronic hepatitis C with compensated \nliver disease (without jaundice, ascites, active gastrointestinal bleeding, \nencephalopathy). Documentation of quantitative HCV RNA (viral load). \nFor members 18 years of age older: For treatment naive members with \nHepatitis C, the member must first consider pegylated products (Pegasys \nor Peg-Intron plus ribavirin) or have a contraindication or other clinical \ncircumstance preventing them from using before the member will be \neligible to receive Intron A. For members 3 - 17 years of age: Intron A \nmust be used in combination with ribavirin. Chronic Hepatitis B: \nDiagnosis of chronic HBeAG-positive hepatitis B with compensated liver. \nMust have ALT greater than 2x the upper limit of normal and have HBV \nDNA greater than 20,000 IU/ml. Hairy Cell Leukemia. Diagnosis of hairy \ncell leukemia.  Malignant Melanoma. Diagnosis of malignant melanoma \nand utilizing Intron A as an adjuvant therapy to surgical treatment. \nFollicular Non-Hodgkin's Lymphoma. Diagnosis of follicular non-\nHodgkin's lymphoma.Must be utilizing Intron A in conjunction with \nanthracycline-containing combination chemotherapy. Condylomata \nAcuminata. Diagnosis of condylomata acuminata involving external \nsurfaces of the genital and perianal areas. AIDS-Related Kaposi's \nSarcoma. Diagnosis of AIDS-related Kaposi's sarcoma.\nAge Restriction\nChronic Hep C must 3 years or older. Must be 18 years or older for Hairy \nCell Leukemia, Malignant Melanoma, Follicular Non-Hodkins \nLymphoma, Condylomata Acuminata, AIDS-related Kaposis Sacroma. 1 \nyear or older for Chronic Hep B.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nHepC:24months, Melanoma,lymphoma:PlanYear,leukemia,HepB:6 \nmonths,Condylomata:3weeks,Kaposis:4months\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 208 of 497\n", "doc_id": "d8ce423b-15f1-4b3a-9fc0-8132db0130b3", "embedding": null, "doc_hash": "1fb9881486a6724d0f3b9eef11102ded42fe42eaf7e9152272eeeb4ad87e3402", "extra_info": {"page_label": "208", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1980, "_node_type": "1"}, "relationships": {"1": "0fbbf768-8dce-44f6-9522-ee8750bac54d"}}, "__type__": "1"}, "1358ae23-f358-4669-ba8d-e5392cfd733c": {"__data__": {"text": "IRESSA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors\nRequired\nMedical\nInformation\nNon-small cell lung cancer (NSCLC): The member has a diagnosis of \nmetastatic or recurrent non-small cell lung cancer (NSCLC) AND the \nfollowing applies: The member has a documented epidermal growth \nfactor receptor (EGFR) exon 19 deletion or exon 21 (L858R) substitution \nmutation AND The member is using Iressa (gefitinib) as monotherapy \n(without concomitant chemotherapy).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 209 of 497\n", "doc_id": "1358ae23-f358-4669-ba8d-e5392cfd733c", "embedding": null, "doc_hash": "48ec33070d1b691b20059dc18967569f7ff68f83e33be117166c5cdc48e16a85", "extra_info": {"page_label": "209", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 722, "_node_type": "1"}, "relationships": {"1": "80da111d-306d-43b4-9811-3bd1f9a93c24"}}, "__type__": "1"}, "6a8b72ae-8c38-498a-9d1f-706ee147745d": {"__data__": {"text": "ISTODAX\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on \nromidepsin.Members on concomitant hypomethylator (e.g. vorinostat) \ntherapy.\nRequired\nMedical\nInformation\nCutaneous T-cell Lymphoma (CTCL). Istodax (romidepsin) is being used \nto treat cutaneous T-cell lymphoma AND one of the following applies:  \nthe member will be using Istodax (romidepsin) as primary biologic \nsystemic therapy OR the member has received at least one prior \ntherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 210 of 497\n", "doc_id": "6a8b72ae-8c38-498a-9d1f-706ee147745d", "embedding": null, "doc_hash": "0d68b3691d9cfe29b4829f4b337aca609c12990089e276618213f8e5f5a8cbde", "extra_info": {"page_label": "210", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 703, "_node_type": "1"}, "relationships": {"1": "d6eb2dd0-1c37-4e68-8932-6eaaf36fd94c"}}, "__type__": "1"}, "a151bbba-d08f-4d98-b064-ffe798529f73": {"__data__": {"text": "IXEMPRA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced severve (CTC grade \n3/4)hypersensitivity reactions to medications formulated with Cremophor \nEL/ polyoxyethylated castor oil. Ixempra (ixabepilone) should be \ndiscontinued after disease progression constituting treatment failure.\nRequired\nMedical\nInformation\nBreast Cancer.The member has a diagnosis of locally advanced or \nmetastatic breast cancer and one of the following: When used as \nmonotherapy: the member has disease that is refractory or resistant to \nan anthracycline (e.g. Doxorubicin),a taxane(e.g.paclitaxel) and Xeloda \n(capecitabine)OR When used in conjunction with Xeloda (capecitabine) \n(or 5-FU/fluorouracil): the member has disease that is refractory to both \nan anthracycline (e.g. Doxorubicin),and a taxane (e.g.paclitaxel)(or \nfurther anthracycline therapy is contraindicated and disease is refractory \nto a taxane).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nsix months\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 211 of 497\n", "doc_id": "a151bbba-d08f-4d98-b064-ffe798529f73", "embedding": null, "doc_hash": "3d737599f04cf1f4f357a55ccb8d823ce089f0cedaf62b07c1f6332fdda441a7", "extra_info": {"page_label": "211", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1125, "_node_type": "1"}, "relationships": {"1": "78ade4ee-520d-4f5c-81e8-0c6f9bd532bd"}}, "__type__": "1"}, "2e83f2cd-2261-44f3-81db-a879c9df1b8c": {"__data__": {"text": "JAKAFI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nJakafi (ruxolitinib) therapy is not considered medically necessary for \nmembers with the following concomitant conditions:Members that have \nexperienced disease progression while on Jakafi (ruxolitinib).Members \non concomitant tyrosine kinase inhibitors or immunomodulatory \nmedications (example: Revlimid/lenalidomide)\nRequired\nMedical\nInformation\nMyelofibrosis.The member has a documented diagnosis of primary \nmyelofibrosis, post-polycythemia vera myelofibrosis or post-essential \nthrombocythemia myelofibrosis AND The member has one of the \nfollowing risk categories, as defined by International Prognostic Scoring \nSystem (IPSS):  Symptomatic low risk disease OR Symptomatic \nintermediate-1 risk disease OR Intermediate-2 risk disease OR High risk \ndisease. The member will be using Jakafi (ruxolitinib) as monotherapy \n(excludes medically necessary supportive agents). Polycythemia Vera: \nThe member has a diagnosis of polycythemia vera AND The member \nhas not achieved treatment goals, has an intolerance, or contraindication \nto hydroxyurea. Acute Graft Versus Host Disease: The member has a \ndiagnosis of steroid-refractory acute graft versus host disease.  \nReauthorization criteria. Physician attestation that the member has \ncontinued to receive a clinical benefit (e.g. spleen volume reduction from \nbaseline, symptom improvement, hematocrit control) AND Physician \nattestation that the member has not experienced unacceptable toxicities.  \nChronic Graft Versus Host Disease (cGVHD):  The member has a \ndiagnosis of chronic graft-versus-host disease (cGVHD) AND the \nmember has been unable to achieve treatment goals with at least one \nprior line of systemic therapy (e.g., corticosteroids).  Reauthorization \ncriteria. Physician attestation that the member has continued to receive a \nclinical benefit (e.g. spleen volume reduction from baseline, symptom \nimprovement, hematocrit control) AND Physician attestation that the \nmember has not experienced unacceptable toxicities.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial Authorization: Plan Year Duration. Reauthorization: Plan Year \nDuration.\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 212 of 497\n", "doc_id": "2e83f2cd-2261-44f3-81db-a879c9df1b8c", "embedding": null, "doc_hash": "4fe69da0f1200232529f6920997243e39587c4eca5fe5cc403cf482af96399ac", "extra_info": {"page_label": "212", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2310, "_node_type": "1"}, "relationships": {"1": "15f1f5c2-f546-416a-ab51-b72076e93bdf"}}, "__type__": "1"}, "7e8e88a7-1cfc-4cde-92f7-5ff9d027cdef": {"__data__": {"text": "javygtor\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nInitial: The member has a diagnosis of PKU.  Reauth - The member has \ntetrahydobiopterin -(BH4) responsive PKU defined by: The member has \nachieved a greater than or equal to a 20% reduction in blood \nphenylalanine concentration from pre-treatment baseline OR the \nmember has had a clinical response (e.g., cognitive and/or behavioral \nimprovements) as determined by the prescriber.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nFirst approval: three months. if response is positive extended for plan \nyear duration.\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 213 of 497\n", "doc_id": "7e8e88a7-1cfc-4cde-92f7-5ff9d027cdef", "embedding": null, "doc_hash": "4847a0dfa3923fd2db5bd44b52a3d3fe389d79d93436aefb76755f4e8a84e09d", "extra_info": {"page_label": "213", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 752, "_node_type": "1"}, "relationships": {"1": "ef49c2e6-b8a7-4354-a499-2cba224dd3c6"}}, "__type__": "1"}, "ffbbac72-413c-4de9-9d88-ddee9d1c4be3": {"__data__": {"text": "JAYPIRCA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nMantle cell lymphoma: The member has a diagnosis of mantle cell \nlymphoma AND the member has relasped or refractory disease AND the \nmember has received at least two prior lines of systemic therapy, \nincluding a BTK inhibitor AND the member will be using Jaypirca \n(pirtobrutinib) as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 214 of 497\n", "doc_id": "ffbbac72-413c-4de9-9d88-ddee9d1c4be3", "embedding": null, "doc_hash": "75d60fa6d97098acf6296f304c0cc55150f4c7d5e5a258eaa13d5e9287bc9fd8", "extra_info": {"page_label": "214", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 585, "_node_type": "1"}, "relationships": {"1": "121f9361-40a1-4d85-9f3e-21dd1e81f272"}}, "__type__": "1"}, "6bcd7c42-c58a-4c15-b063-b271a24faa3c": {"__data__": {"text": "JEMPERLI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDisease progression while on or following prior anti-PD-1/PD-L1 therapy \n(e.g.,nivolumab, pembrolizumab).\nRequired\nMedical\nInformation\nEndometrial cancer:  The member has diagnosis of recurrent or \nadvanced endometrial cancer AND The member has documented dMMR \nendometrial cancer AND The member has progressed on prior platinum \ncontaining regimen AND There is a medical reason why Keytruda \n(pembrolizumab) cannot be initiated as subsequent therapy AND \nJemperli (dostarlimab-gxly) is administered as monotherapy as \nsubsequent therapy.  Solid tumors (dMMR):  The member has a \ndiagnosis of unresectable or metastatic documented mismatch repair \ndeficient (d-MMR) solid tumors AND the member has disease that has \nprogressed on prior therapy with no alternative treatments AND The \nmember has a medical reason why Keytruda (pembrolizumab) cannot be \ninitiated as subsequent therapy AND Jemperli (dostarlimab-gxly) is \nadministered as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 215 of 497\n", "doc_id": "6bcd7c42-c58a-4c15-b063-b271a24faa3c", "embedding": null, "doc_hash": "cfaf06a3b20fd5356a82a042ae75b76f9331664fb40ee5414b87f87daa390a58", "extra_info": {"page_label": "215", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1207, "_node_type": "1"}, "relationships": {"1": "07d0943b-9d24-460f-a58b-f2d5ff609048"}}, "__type__": "1"}, "927e27d1-dcff-4052-9766-055fe1e97283": {"__data__": {"text": "JEVTANA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nJevtana should not be administered to patients with neutrophils less than \nor equal to 1,500/mm3. Jevtana should not be given to patients with \nhepatic impairment (total bilirubin greater than 3 x ULN. Concomitant use \nwith abiraterone acetatate, Yonsa, or Xtandi.\nRequired\nMedical\nInformation\nHormone-Refractory Metastatic Prostate Cancer. The member must \nhave a diagnosis of hormone-refractory metastatic prostate cancer. The \nmember must have previously been treated with a docetaxol-containing \ntreatment regimen. The member must be taking Jevtana in combination \nwith concurrent corticosteroid (e.g., dexamethasone, prednisone).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 216 of 497\n", "doc_id": "927e27d1-dcff-4052-9766-055fe1e97283", "embedding": null, "doc_hash": "8cd316ce2de078d9148582c825ea1e8648355ce7d5c29bd37023490a5781add9", "extra_info": {"page_label": "216", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 902, "_node_type": "1"}, "relationships": {"1": "df1c1dc0-89aa-421a-93a7-f05576c40e0d"}}, "__type__": "1"}, "ad8525aa-308f-49c1-9b33-a6d7def983ef": {"__data__": {"text": "KADCYLA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member has experienced disease progression while on Kadcyla \n(ado-trastuzumab emtansine. Use in the adjuvant setting. Members on \nconcomitant trastuzumab product, Tykerb (lapatinib), or Perjeta \n(pertuzumab).\nRequired\nMedical\nInformation\nMetastatic Breast Cancer. The member has a diagnosis of metastatic \nbreast cancer and HER2 (human epidermal growth factor receptor2) \npositive disease AND the member is using Kadcyla (ado-trastuzumab \nemtansine) as monotherapy AND the member has received prior therapy \nwith a trastuzumab product and a taxane (eg. paclitaxel, docetaxel), \nseparately or in combination and one of the following applies: Received \nprior treatment for metastatic disease. Recurrence occurred during or \nwithin six months of completing adjuvant therapy. Early Breast cancer: \nThe member has a diagnosis of early HER 2 positive breast AND the \nmember has received neoadjuvant taxane (e.g. paclitaxel) and \ntrastuzumab containing regimen AND the member is receiving Kadcyla \n(ado-trastuzumab emtansine) as adjuvant treatment.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 217 of 497\n", "doc_id": "ad8525aa-308f-49c1-9b33-a6d7def983ef", "embedding": null, "doc_hash": "cd13007712490784015ec52134380926d688cac3130e1592bd6914bf080fd291", "extra_info": {"page_label": "217", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1312, "_node_type": "1"}, "relationships": {"1": "de9b9807-c0ef-41b4-a497-862040ccc0a7"}}, "__type__": "1"}, "c819d81d-d153-4f02-ad38-a22196b46829": {"__data__": {"text": "KALYDECO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nCystic Fibrosis: The member must meet ALL of the following criteria: \nDiagnosis of Cystic Fibrosis AND submission of lab testing with \ndocumentation of a mutation in the CFTR gene that is responsive to \ntherapy based on clinical literature and/or in vitro assay data.\nAge Restriction\nPrescriber\nRestriction\nThe member is being treated by or in consultation with a specialist (e.g. \npulmonologist).\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 218 of 497\n", "doc_id": "c819d81d-d153-4f02-ad38-a22196b46829", "embedding": null, "doc_hash": "c9143fcf7ba22bb390e78020f56c7cad136ad2e5f9fb69785306cbceeaf3ff08", "extra_info": {"page_label": "218", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 625, "_node_type": "1"}, "relationships": {"1": "0276bb85-a36a-40c3-9d81-ae61429ccef6"}}, "__type__": "1"}, "90fbb569-1fb7-4cd3-b2bb-d172e9bcd9b4": {"__data__": {"text": "KANJINTI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nFor Herceptin (trastuzumab), Ogivri, Herzuma or Ontruzant requests: \nmember must have an intolerance or contraindication Trazimera \n(trastuzumab-qyyp) OR Kanjinti (trastuzumab-anns) and meets below \ncriteria: Breast Cancer: The member has a diagnosis of breast cancer \nand HER2 (human epidermal growth factor receptor2) positive disease. \nGastric Cancer: The member has a diagnosis of advanced, gastric \ncancer or gastroesophageal adenocarcinoma and HER2 positive \ndisease AND trastuzumab is being used in combination with cisplatin \nand fluorouracil or capecitabine.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 219 of 497\n", "doc_id": "90fbb569-1fb7-4cd3-b2bb-d172e9bcd9b4", "embedding": null, "doc_hash": "522cff4a43fac222ee0fd066b010782291f66b503d8962c9611a9c58f785e080", "extra_info": {"page_label": "219", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 855, "_node_type": "1"}, "relationships": {"1": "a4635b4b-7196-4b9c-a071-2bb83fc59786"}}, "__type__": "1"}, "2953ac72-eb20-4d77-b539-e45ffa4dd9ea": {"__data__": {"text": "KERENDIA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nChronic kidney disease associated with type 2 diabetes:  The member \nhas a diagnosis of chronic kidney disease (CKD) associated with type 2 \ndiabetes (T2D) AND The member has serum potassium less than or \nequal to 5.0 mEq/L upon initiation of therapy AND The member is \ncurrently receiving, unless contraindicated or intolerant, the maximally \ntolerated dose of:  Either an angiotensin-converting enzyme inhibitor \n(e.g. Lisinopril) OR an  angiotensin receptor blocker (e.g. losartan).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 220 of 497\n", "doc_id": "2953ac72-eb20-4d77-b539-e45ffa4dd9ea", "embedding": null, "doc_hash": "091e9d2a14f963ba70904d6fbd5eeb0e94daadd2e64d0e5b1771b59055a98a31", "extra_info": {"page_label": "220", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 774, "_node_type": "1"}, "relationships": {"1": "dadde287-8b1e-4bb8-b813-b0a4f176316b"}}, "__type__": "1"}, "d6379e70-3ee9-4c0c-b530-8edbe76cfe3f": {"__data__": {"text": "KESIMPTA PEN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nRelapsing Forms of Multiple Sclerosis:  The member has a diagnosis of \none of the following:  A relapsing form of multiple sclerosis, to include \nrelapsing-remitting or active secondary progressive disease, OR \nClinically isolated syndrome (CIS).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 221 of 497\n", "doc_id": "d6379e70-3ee9-4c0c-b530-8edbe76cfe3f", "embedding": null, "doc_hash": "a2ff1bca71d1c2fefba75551831383757cd06c03fc7e316aa598d9c4f47a48d7", "extra_info": {"page_label": "221", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 539, "_node_type": "1"}, "relationships": {"1": "46840c2c-9db3-48e3-8526-ed50c89481e1"}}, "__type__": "1"}, "dfd217cc-57d5-4110-8a4c-dfe7c580ad9f": {"__data__": {"text": "ketoconazole\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nSystemic Fungal Infection: member has a diagnosis of a systemic fungal \ninfection (i.e., blastomycosis, coccidioidomycosis, histoplasmosis, \nparacoccidioidomycosis, chromomycosis). Prophylaxis - Transplanted \nOrgan Rejection: member has a transplanted organ AND member will \nconcurrently receive immunuosuppresant therapy with cyclosporine.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 222 of 497\n", "doc_id": "dfd217cc-57d5-4110-8a4c-dfe7c580ad9f", "embedding": null, "doc_hash": "40c6c7b2e250cbce0884b30313d25182735d422f2c5dbf1ae69c3763ab339eee", "extra_info": {"page_label": "222", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 645, "_node_type": "1"}, "relationships": {"1": "1add03c0-848a-4cb8-8bad-3265c8d61752"}}, "__type__": "1"}, "b6a15f9f-0bbf-4a2c-b50e-4e12228ed010": {"__data__": {"text": "KEVZARA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nModerate to Severe Rheumatoid Arthritis: The member must have a \ndiagnosis of moderately to severely active rheumatoid arthritis AND the \nmember has had prior therapy with or intolerance to a single DMARD \n(e.g. methotrexate, sulfasalazine, cyclosporine, leflunomide) or \ncontraindication to all DMARDs. Polymyalgia Rheumatica: The member \nmust have a diagnosis of polymyalgia rheumatica AND The member has \nhad prior therapy with or intolerance to a single corticosteroid (e.g. \nprednisone, methylprednisolone) or contraindication to all \ncorticosteroids.\nAge Restriction\nThe member must be at least 18 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 223 of 497\n", "doc_id": "b6a15f9f-0bbf-4a2c-b50e-4e12228ed010", "embedding": null, "doc_hash": "abf65f546e7f96f06dc59e8751a50ea09c884fc8e1c9d26f07ba0cc290173364", "extra_info": {"page_label": "223", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 898, "_node_type": "1"}, "relationships": {"1": "e21d9c6d-8438-49bd-a5ab-90f5560a2ce7"}}, "__type__": "1"}, "07a84d7c-7fc1-4a18-a1cc-147c02f5f819": {"__data__": {"text": "KEYTRUDA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDisease progression while on or following prior anti-PD-1/PD-L1 therapy \n(e.g., nivolumab, atezolizumab). Member requiring urgent cytoreductive \ntherapy (applicable to PMBCL only).  Member not to exceed one year of \ntotal adjuvant treatment (applicable to melanoma, NSCLC, and renal cell \ncarcinoma only).\nRequired\nMedical\nInformation\nMelanoma: unresectable or metastatic melanoma OR melanoma OR \nstage IIB, IIC, or III melanoma AND as monotherapy for adjuvant \ntreatment after complete resection with involvement of lymph node(s). \nNSCLC-1st Line: metastatic NSCLC AND 1 of the following applies: \ndisease with PD-L1 expression [TPS greater than or equal to 1%] with no \nEGFR or ALK genomic tumor aberrations and as 1st line AND tumor \nexpresses PD-L1 as determined by an FDA-approved test AND used as \nmonotherapy OR nonsquamous histology with no EGFR or ALK genomic \ntumor aberrations and in combo with pemetrexed and carboplatin or \ncisplatin as 1st line therapy followed by Keytruda maintenance in combo \nwith pemetrexed OR squamous histology and used in combo with \ncarboplatin and paclitaxel or Abraxane as 1st line followed by Keytruda \nmaintenance OR stage III NSCLC and not candidate for surgical \nresection or definitive chemoradiation AND PD-L1 expression with no \nEGFR or ALK genomic tumor aberrations and as 1st line AND Tumor \nexpresses PD-L1 as determined by an FDA-approved test AND as \nmonotherapy. NSCLC-Subsequent: metastatic NSCLC AND progression \non or following chemo and EGFR inhibitor, if EGFR mutation positive or \nALK inhibitor, if ALK positive AND Tumor expresses PD-L1 as \ndetermined by an FDA-approved test AND as monotherapy. Head-Neck \nCancer: recurrent or metastatic non-nasopharyngeal head and neck \nsquamous cell carcinoma AND 1 of following: disease progression on \nplatinum-containing chemo and as monotherapy OR in combo with \nplatinum and 5-FU for 1st line treatment OR monotherapy in 1st line and \ndisease expresses CPS score greater than or equal to 1 as detected by \nan FDA-approved test. Hodgkin's Lymphoma-Adult: as monotherapy for \nrefractory or relapsed disease. Hodgkin's Lymphoma-Peds: \nmonotherapy and 1 of following: Refractory disease OR Relapsed after 2 \nor more lines of prior therapy.  CSCC: recurrent or metastatic CSCC \nAND disease is not amenable to curative surgery or radiation AND used \nas a monotherapy.\nAge Restriction\nStage IIB, IIC, or III melanoma - member is 12 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 224 of 497\n", "doc_id": "07a84d7c-7fc1-4a18-a1cc-147c02f5f819", "embedding": null, "doc_hash": "7d103cbe20a57d3adbb526da4f9a9efe4d29c4001a67fb4a7b03dde5de61fd4a", "extra_info": {"page_label": "224", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2619, "_node_type": "1"}, "relationships": {"1": "8ea60a77-e6c6-42bc-b230-596bd0eb64ed"}}, "__type__": "1"}, "7a51fad4-2cb5-4ce1-80a6-a387fa11e76b": {"__data__": {"text": "KEYTRUDA\nCoverage\nDuration\n6 months duration\nOther Criteria\nMSI-High/d-MMR Solid tumors: unresectable or metastatic documented \nmicrosatellite instability-high or mismatch repair deficient solid tumors \n(excluding pediatric patients with MSI-H central nervous system cancers) \nAND 1 of the following: disease that progressed on prior therapy with no \nalternative treatments and as monotherapy OR colorectal cancer AND 1 \nof the following: Keytruda as monotherapy and as subsequent therapy \nafter progression on fluoropyrimidine, oxaliplatin, and irinotecan or 1st \nline as monotherapy in unresectable or metastatic colorectal cancer. \nUrothelial Cancer: locally advanced or metastatic urothelial cancer AND \nas monotherapy AND 1 of the following: initial therapy in members who \nare ineligible for cisplatin containing chemotherapy and disease \nexpressing CPS score greater than or equal to 10 OR initial therapy in \nmembers ineligible to receive platinum containing chemo regardless of \nPD-L1 status OR as subsequent therapy after disease progression within \n12 months of neoadjuvant or adjuvant chemo. Cervical Cancer: recurrent \nor metastatic cervical cancer AND disease progression on or after \nchemo AND disease expresses CPS score greater than or equal to 1 as \ndetermined by an FDA approved test AND as monotherapy OR \npersistent, recurrent, or metastatic cervical cancer AND cancer express \nCPS score of greater than or equal to 1 as determined by an FDA \napproved test and will be used with chemo, with or without bevacizumab, \nas 1st line therapy. Primary Mediastinal Large B-Cell Lymphoma [Adults \nand pediatrics]: relapsed or refractory disease after 2 or more prior lines \nof treatment AND as monotherapy. Merkel cell carcinoma-Adult and \npediatric: recurrent locally advanced or metastatic merkel cell carcinoma \nAND as monotherapy. HCC: has prior therapy with a 1st line therapy \n(e.g., sorafenib) AND as monotherapy. RCC: advanced or metastatic \nRCC AND in combo with Inlyta or Lenvima as 1st line therapy. \nEsophageal Cancer: recurrent locally advanced or metastatic squamous \ncell carcinoma of the esophagus AND disease expresses PD-L1 as \ndetermined by an FDA approved test AND given as subsequent therapy \nas a single agent. Endometrial cancer: metastatic or recurrent \nendometrial cancer AND not MSI-H or pMMR as determined by an FDA \napproved test AND not candidate for surgery or radiation AND has \nexperienced disease progression on prior systemic therapy AND given in \ncombo with Lenvima as subsequent therapy. NMIBC with carcinoma in \nsitu AND ineligible for or has elected not to undergo cystectomy AND has \nBCG-unresponsive disease, defined as persistent or recurrent high-\ngrade bladder cancer within 6 months of intravesical BCG therapy AND \nas monotherapy. TMB-H Solid tumors:  unresectable or metastatic solid \ntumors with documented TMB-H [greater than or equal to 10 \nmutations/megabase] (excluding pediatric patients with TMB-H central \nnervous system cancers) AND disease progressed on prior therapy with \nno alternative treatments AND given as monotherapy.\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 225 of 497\n", "doc_id": "7a51fad4-2cb5-4ce1-80a6-a387fa11e76b", "embedding": null, "doc_hash": "77a005e5e899bc43000fc312baf91acee47e5f02122fdf49bbb9fc5129e6c8dd", "extra_info": {"page_label": "225", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 3145, "_node_type": "1"}, "relationships": {"1": "558ad263-ffde-42c6-b7b5-913533920fa2"}}, "__type__": "1"}, "1edceb96-1176-4f7e-bc71-60294ae22cd4": {"__data__": {"text": "KEYTRUDA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 226 of 497\n", "doc_id": "1edceb96-1176-4f7e-bc71-60294ae22cd4", "embedding": null, "doc_hash": "f770e057fa2014dea042765aa9939b4f6a727e28427fc9f09a12244b637a9f9b", "extra_info": {"page_label": "226", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 83, "_node_type": "1"}, "relationships": {"1": "3557d504-42cb-468f-9d55-834cf519c63a"}}, "__type__": "1"}, "a3f77112-987d-4ea8-a45d-29c10de4833f": {"__data__": {"text": "KIMMTRAK\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on Kimmtrak \n(tebentafusp-tebn).\nRequired\nMedical\nInformation\nMetastatic Uveal Melanoma:  the member has a diagnosis of \nunresectable or metastatic uveal melanoma AND the member has \ndocumentation of HLA-A 02:01 positive disease by assay results AND \nKimmtrak (tebentafusp-tebn) will be used as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 227 of 497\n", "doc_id": "a3f77112-987d-4ea8-a45d-29c10de4833f", "embedding": null, "doc_hash": "c78c462db5d642d53c4c5c9ef61740c40ea39ec4eb45dc694ff6f5c59aed59ba", "extra_info": {"page_label": "227", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 623, "_node_type": "1"}, "relationships": {"1": "cd67c46f-a9d4-488d-9e00-99038ddd1b57"}}, "__type__": "1"}, "aa7b5a31-6b96-4bd9-9a72-a33f6c414a96": {"__data__": {"text": "KISQALI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember has experienced disease progression on CDK 4/6 inhibitor (e.g., \npalbociclib, abemaciclib).\nRequired\nMedical\nInformation\nBreast Cancer-Combination with Aromatase Inhibitors. The member has \na diagnosis of advanced or metastatic hormone receptor (HR)-positive \nand human epidermal growth factor receptor 2 (Her2neu)-negative \nbreast cancer and one of the following applies:  the member is post-\nmenopausal or men AND the member will be using Kisqali (ribociclib) in \ncombination with an aromatase inhibitor (e.g., letrozole) as first line \nendocrine therapy AND the member has a medical reason as to why \nIbrance (palbociclib) and Verzenio (abemaciclib) cannot be started or \ncontinued as initial endocrine based therapy OR The member will be \nusing Kisqali (ribociclib) in combination with aromatase inhibitor \n(e.g.,letrozole) as initial endocrine-based therapy for their metastatic \ndisease AND The member is pre/peri menopausal or men and taking \nLHRH agonist (eg, leuprolide) concomitantly or treated with ovarian \nablation. Breast Cancer- Combination with Faslodex (fulvestrant). The \nmember has a diagnosis of hormone receptor-positive and human \nepidermal growth factor receptor 2-negative breast cancer and one of the \nfollowing applies: The member will be using Kisqali (ribociclib) in \ncombination with Faslodex (fulvestrant) as initial endocrine based \ntherapy AND The member is post-menopausal or men OR the member \nwill be using Kisqali (ribociclib) in combination with Faslodex (fulvestrant) \nas subsequent therapy AND The member has a medical reason as to \nwhy Ibrance (palbociclib) AND Verzenio (abemaciclib) cannot be started \nor continued as subsequent therapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 228 of 497\n", "doc_id": "aa7b5a31-6b96-4bd9-9a72-a33f6c414a96", "embedding": null, "doc_hash": "6697c1882b325dca0c065f2ed79cabf78e86cf02fe7e75c3ba566f68e443cc67", "extra_info": {"page_label": "228", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1944, "_node_type": "1"}, "relationships": {"1": "c8327f63-39fc-4b79-b811-8ca9067e337e"}}, "__type__": "1"}, "ffa3cb6c-2251-4b0b-a72d-60043472bcba": {"__data__": {"text": "KISQALI FEMARA CO-PACK\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember has experienced disease progression on CDK 4/6 inhibitor (e.g., \npalbociclib, abemaciclib).\nRequired\nMedical\nInformation\nBreast Cancer-Combination with Aromatase Inhibitors. The member has \na diagnosis of advanced or metastatic hormone receptor (HR)-positive \nand human epidermal growth factor receptor 2 (Her2neu)-negative \nbreast cancer and one of the following applies:  the member is post-\nmenopausal or men AND the member will be using Kisqali (ribociclib) in \ncombination with an aromatase inhibitor (e.g., letrozole) as first line \nendocrine therapy AND the member has a medical reason as to why \nIbrance (palbociclib) and Verzenio (abemaciclib) cannot be started or \ncontinued as initial endocrine based therapy OR The member will be \nusing Kisqali (ribociclib) in combination with aromatase inhibitor \n(e.g.,letrozole) as initial endocrine-based therapy for their metastatic \ndisease AND The member is pre/peri menopausal or men and taking \nLHRH agonist (eg, leuprolide) concomitantly or treated with ovarian \nablation. Breast Cancer- Combination with Faslodex (fulvestrant). The \nmember has a diagnosis of hormone receptor-positive and human \nepidermal growth factor receptor 2-negative breast cancer and one of the \nfollowing applies: The member will be using Kisqali (ribociclib) in \ncombination with Faslodex (fulvestrant) as initial endocrine based \ntherapy AND The member is post-menopausal or men OR the member \nwill be using Kisqali (ribociclib) in combination with Faslodex (fulvestrant) \nas subsequent therapy AND The member has a medical reason as to \nwhy Ibrance (palbociclib) AND Verzenio (abemaciclib) cannot be started \nor continued as subsequent therapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 229 of 497\n", "doc_id": "ffa3cb6c-2251-4b0b-a72d-60043472bcba", "embedding": null, "doc_hash": "3d6f9b8d291c9a741f0a5bdfa47e55c776d6587d5c0b2e24391edb4753518c62", "extra_info": {"page_label": "229", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1959, "_node_type": "1"}, "relationships": {"1": "bc8292de-1df3-4da7-becb-8b614abad96a"}}, "__type__": "1"}, "bcaa6cfd-7c75-4880-890b-f10a2b6b07b0": {"__data__": {"text": "KORLYM\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nPregnancy. Members with a history of unexplained vaginal bleeding. \nMembers with endometrial hyperplasia with atypia or endometrial \ncarcinoma. Concurrent long-term corticosteroid use.\nRequired\nMedical\nInformation\nHyperglycemia secondary to hypercortisolism. Diagnosis of endogenous \nCushing's syndrome. AND Type 2 diabetes mellitus or glucose \nintolerance. AND Failed surgery or are not candidates for surgery.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 230 of 497\n", "doc_id": "bcaa6cfd-7c75-4880-890b-f10a2b6b07b0", "embedding": null, "doc_hash": "d7c7a5994a063a1bb50b8c00d67bcf1ddf75ac59fb5ad08a5f07e359ad24077c", "extra_info": {"page_label": "230", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 669, "_node_type": "1"}, "relationships": {"1": "c72bef93-2767-43ae-a693-ae4e47eff9ac"}}, "__type__": "1"}, "29158ac0-f1ff-49c6-9c60-e41a54a15b3e": {"__data__": {"text": "KOSELUGO\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMember experienced disease progression on Koselugo  (selumetinib)\nRequired\nMedical\nInformation\nNeurofibromatosis type 1: The member has a diagnosis of \nneurofibromatosis type 1 which is symptomatic, inoperable plexiform \nneurofibromas and Koselugo  (selumetinib) is given as a monotherapy\nAge Restriction\nThe member is 2 years of age up to 18 years of age (labeled for use in \npediatric patients only).\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 231 of 497\n", "doc_id": "29158ac0-f1ff-49c6-9c60-e41a54a15b3e", "embedding": null, "doc_hash": "81c75c3aff6da8299c096d87c966e7c41d9e58d5a6df557bef98ecbbc11441d4", "extra_info": {"page_label": "231", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 652, "_node_type": "1"}, "relationships": {"1": "78f3dcf2-29bb-4b88-a975-a6429119e755"}}, "__type__": "1"}, "f2137c9e-41d9-4791-be45-cc75b4a0d843": {"__data__": {"text": "KRAZATI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experienced disease progression on KRAS G12C inhibitor (e.g., \nsotorasib, adagrasib).\nRequired\nMedical\nInformation\nThe member has a diagnosis of locally advanced or metastatic NSCLC \nAND the NSCLC has documented KRAS G12C mutation AND the \nmember has experienced disease progression on one prior therapy AND \nKrazati (adagrasib) will be given as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 232 of 497\n", "doc_id": "f2137c9e-41d9-4791-be45-cc75b4a0d843", "embedding": null, "doc_hash": "5019d6b0b761d8e4e578c728e50658a1f0d0682201454b49f40d71dffd8e776a", "extra_info": {"page_label": "232", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 623, "_node_type": "1"}, "relationships": {"1": "0d78ed61-4e05-4750-9e20-c7caad359760"}}, "__type__": "1"}, "8a51eee4-4faa-4984-8ba5-bd269564d700": {"__data__": {"text": "KYNMOBI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nParkinson's off episodes: The member has a diagnosis of Parkinson's \ndisease AND is currently taking carbidopa/levodopa and will continue \ntaking carbidopa/levodopa with Kynmobi AND is experiencing \nbreakthrough off periods related to their Parkinson's disease AND has \nhad previous treatment, contraindication, or intolerance to at least one of \nthe following: A dopamine agonist (e.g. ropinirole, pramipexole) OR a \nCOMT inhibitor (e.g. entacapone) OR a MAO-B inhibitor (e.g. selegiline).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 233 of 497\n", "doc_id": "8a51eee4-4faa-4984-8ba5-bd269564d700", "embedding": null, "doc_hash": "a855c87ffe5f16bfb2ce86a04deb8628258917511de433f6c570bc54774e2cff", "extra_info": {"page_label": "233", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 778, "_node_type": "1"}, "relationships": {"1": "e08a4edd-af60-4719-b1d2-e3c070c07a82"}}, "__type__": "1"}, "354e0415-cf38-41c7-8fc3-ba2ebc3eb896": {"__data__": {"text": "KYPROLIS\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers receiving concomitant therapy with a proteasome inhibitor.The \nmember has experienced disease progression while on Kyprolis\n(carfilzomib).\nRequired\nMedical\nInformation\nMultiple Myeloma: The member has a diagnosis of Multiple Myeloma \nAND The member is using Kyprolis (carfilzomib) as a single agent or in \ncombination with dexamethasone for disease relapse or progressive \ndisease OR the member will be using Kyprolis (carfilzomi) in combination \nwith Farydak (panobinostat) and the member has received at least two \nprior regimens, including both bortezomib and an immunomodulatory \ndrug (e.g. thalidomide, lenalidomide, pomalidomide) OR the member will \nbe using Kyprolis (carfilzomib) in combination with Pomalyst \n(pomalidomide) and dexamethasone and the member has received at \nleast two prior therapies, including an immunomodulatory agent (e.g. \nthalidomide, lenalidomide, pomalidomide) and a proteasome inhibitor \n(e.g. bortezomib) (Omission of corticosteroid from regimen is allowed if \nintolerance/contraindication) AND the member has demonstrated \ndisease progression on or within 60 days of completion of the last \ntherapy OR The member will be using Kyprolis (carfilzomib) in \ncombination with Revlimid (lenalidomide) and dexamethasone or in \ncombination with cyclophosphamide and dexamethasone (Omission of \ncorticosteroid from regimen is allowed if intolerance/contraindication) \nand one of the following  applies: Is using as primary therapy OR Using \nfor treatment of disease relapse (disease relapse must be after 6 months \nfollowing primary chemotherapy with the same regimen) or progressive \ndisease OR the member will be using Kyprolis (carfilzomib) in \ncombination with Darzalex (daratumumab) and dexamethasone and the \nmember has received at least one prior line of therapy (Omission of \ncorticosteroid from regimen is allowed if intolerance/contraindication).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nWaldenstrom's Macroglobulinemia: The member has a diagnosis of \nWaldenstrom\u00e2??s macroglobulinemia AND Kyprolis (carfilzomib) will be \nused as a component of CaRD regimen (carfilzomib, rituximab, and \ndexamethasone) as primary therapy (Omission of corticosteroid from \nregimen is allowed if intolerance/contraindication) OR for relapsed \ndisease (if CaRD previously used as primary therapy relapse must occur \nafter 24 months).\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 234 of 497\n", "doc_id": "354e0415-cf38-41c7-8fc3-ba2ebc3eb896", "embedding": null, "doc_hash": "2724a3610435f7e486dee0f339937b386f3752be844b7b54cd63d46a243323c6", "extra_info": {"page_label": "234", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2554, "_node_type": "1"}, "relationships": {"1": "247d984a-3c79-4e3e-be60-6b7050b69a65"}}, "__type__": "1"}, "f0e09827-31fb-40cc-ab3d-dc20bd175f01": {"__data__": {"text": "KYPROLIS\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 235 of 497\n", "doc_id": "f0e09827-31fb-40cc-ab3d-dc20bd175f01", "embedding": null, "doc_hash": "fbee2ccc541889a0cafb9e49d8d8aeb3d655a77e09bd4b6b67768607c1b4d3e8", "extra_info": {"page_label": "235", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 83, "_node_type": "1"}, "relationships": {"1": "ffeb173c-1a18-4e34-9cf7-ed5081d5c7d5"}}, "__type__": "1"}, "7ae7478f-1f22-442b-b640-a8a527039da4": {"__data__": {"text": "lanreotide\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nFor generic lanreotide requests: member has had prior therapy with or \nintolerance to brand Somatuline Depot AND meets clinical criteria.  \nDiagnosis of acromegaly. The patient has a diagnosis of acromegaly. \nThe patient has had an inadequate response to or cannot be treated with \nsurgical resection OR The patient has had an inadequate response to or \ncannot be treated with radiation therapy.  Gastroenteropancreatic \nNeuroendocrine Tumors (GEP-NETs): The member has a diagnosis of \nunresectable, well- or moderately-differentiated, locally advanced, or \nmetastatic gastroenteropancreatic neuroendocrine tumors.  Carcinoid \nSyndrome: The member has a diagnosis of carcinoid syndrome with \nsymptoms of flushing and/or diarrhea.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 236 of 497\n", "doc_id": "7ae7478f-1f22-442b-b640-a8a527039da4", "embedding": null, "doc_hash": "5ab6784992831b45307bd0bd7e281c155d8228f0a83ba4f15bf8e39064d24846", "extra_info": {"page_label": "236", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1020, "_node_type": "1"}, "relationships": {"1": "87d61007-2221-4876-a1ac-60dd7acf8240"}}, "__type__": "1"}, "94895fba-960d-45ea-8b45-2e8e7def4a0a": {"__data__": {"text": "lapatinib\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors. Members that have \nexperienced disease progression while on Tykerb (lapatinib).\nRequired\nMedical\nInformation\nBreast Cancer. The member has a diagnosis of HER2(human epidermal \ngrowth factor receptor2) positive advanced or metastatic breast cancer \nAND The member  had prior therapy, contraindication, or intolerance \nwith an anthracycline (e.g. doxorubicin) and a taxane (e.g. paclitaxel) OR \nThe member has a diagnosis of HER2 positive metastatic breast cancer \nAND Used as first line treatment in combination with an aromatase \ninhibitor (Femara (letrozole), Arimidex (anastrozole) or Aromasin \n(exemestane)) for hormone receptor positive disease.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 237 of 497\n", "doc_id": "94895fba-960d-45ea-8b45-2e8e7def4a0a", "embedding": null, "doc_hash": "73c6e20a37c3a86cfb785893fa3d30883dc5e7793f9b91afef846252fe57292f", "extra_info": {"page_label": "237", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 959, "_node_type": "1"}, "relationships": {"1": "4e73fb27-a794-451b-8b84-ab0ff5410d36"}}, "__type__": "1"}, "a9195cca-1f1f-4cd0-acee-c8c14bd2d101": {"__data__": {"text": "LATUDA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nDementia-related psychosis (in the absence of an approvable diagnosis), \nfor member 65 years of age or older.\nRequired\nMedical\nInformation\nDiagnosis of Schizophrenia or Schizoaffective Disorder: The member \nmust have prior therapy, intolerance or contraindication to at least 2 of \nthe following: risperidone or olanzapine or quetiapine or ziprasidone or \naripiprazole. Diagnosis of Bipolar I Disorder (Bipolar Depression): The \nmember must have documentation of prior therapy, intolerance, or \ncontraindication to quetiapine.\nAge Restriction\nFor diagnosis of Schizophrenia or schizoaffective disorder, the member \nmust be 13 years of age or older.  For diagnosis of Bipolar I Disorder \n(Bipolar Depression), the member must be 10 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 238 of 497\n", "doc_id": "a9195cca-1f1f-4cd0-acee-c8c14bd2d101", "embedding": null, "doc_hash": "e5cd126a3090044b8e1c54050407fca4628ab4102350ad4f7df960d1c4e2a63d", "extra_info": {"page_label": "238", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1001, "_node_type": "1"}, "relationships": {"1": "77faf3d9-1103-4f77-9a61-498e5aafa985"}}, "__type__": "1"}, "bd078d28-ffd8-4672-ae70-958598be15d1": {"__data__": {"text": "ledipasvir-sofosbuvir\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant use with other Direct Acting Antivirals (e.g. HCV protease \ninhibitors, polymerase inhibitors, NS5A inhibitors).\nRequired\nMedical\nInformation\nChronic Hepatitis C: Member must have a diagnosis of chronic hepatitis \nC infection. Member must have documented Genotypes 1,4,5 and 6 \ninfection. HCV RNA level must be documented prior to therapy. Member \nmust be tested for the presence of HBV by screening for the surface \nantigen of HBV (HBsAg) and anti-hepatitis B core total antibodies (anti-\nHBc) prior to initiation of therapy. Chronic Hepatitis C - GT1 treatment \nnaive without cirrhosis and HCV RNA under 6 million will be approved for \n8 weeks. Pediatrics:  Member must have a diagnosis of chronic hepatitis \nC infection. Member must have documented Genotype 1, 4, 5 or 6 \ninfection. HCV RNA level must be documented prior to therapy. Member \nmust be tested for the presence of HBV by screening for the surface \nantigen of HBV (HBsAg) and anti-hepatitis B core total antibodies (anti-\nHBc) prior to initiation of therapy. Chronic Hepatitis C Post Liver \nTransplant - Member must have received a liver transplant, Must must \nhave experienced recurrent HCV infection post-transplant in the allograft \nliver, Member must have document genotype 1, 4, 5 or 6 infection, \nMember must be tested for the presence of HBV by screening for the \nsurface antigen of HBV (HBsAg) and anti-hepatitis B core total \nantibodies (anti-HBc) prior to initiation of therapy. Chronic Hepatitis C \nWith Decompensated Cirrhosis - Member must have diagnosis of chronic \nhepatitis C with decompensated cirrhosis, Member must have genotype \n1,  4, 5 or 6 infection,  Member must be tested for the presence of HBV \nby screening for surface antigen of HBV (HBsAg) and anti-hepatitis B \ncore total antibodies (anti-HBc) prior to initiation of therapy. For all \ngenotypes, criteria will be applied consistent with current AASLD-IDSA \nguidance.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n8 to 24 weeks depending on disease state and genotype based on \nAASLD treatment guidelines for HCV.\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 239 of 497\n", "doc_id": "bd078d28-ffd8-4672-ae70-958598be15d1", "embedding": null, "doc_hash": "e1fe03af5443ed606a776e8ae9cdc4e09a0cf145198b34d91274c65c4a72f281", "extra_info": {"page_label": "239", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2278, "_node_type": "1"}, "relationships": {"1": "7951d1a5-4df4-4973-b4ea-935c3c12c081"}}, "__type__": "1"}, "fa3b70d8-8c5b-4185-9f7b-711c67b7ca10": {"__data__": {"text": "lenalidomide\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers on concomitant Thalomid (thalidomide) or Pomalyst \n(pomalidomide).Members that have experienced disease progression \nwhile on Revlimid (lenalidomide).\nRequired\nMedical\nInformation\nMyelodysplastic Syndromes (MDS) with 5Q deletion. The member has a \ndiagnosis of low- or intermediate-1 risk myelodysplastic syndrome (MDS) \nAND the member has a documented deletion 5q chromosomal \nabnormality AND the member has one of the following:  Symptomatic \nAnemia (e.g. chronic fatigue, malaise) OR Transfusion-dependent \nanemia OR Anemia that is not controlled with erythroid stimulating agent. \n Myelodysplastic Syndromes (MDS) without 5Q deletion (non-5Q \ndeletion). The member has a diagnosis of low- or intermediate-1 risk \nmyelodysplastic syndrome (MDS) AND the member has no documented \n5q deletion abnormality AND the member has one of the following:  \nSymptomatic Anemia (e.g. chronic fatigue, malaise) OR Transfusion-\ndependent anemia OR Anemia that is not controlled with erythroid \nstimulating agent.  Multiple Myeloma. Diagnosis of active Multiple \nMyeloma or Systemic Light Chain Amyloidosis. Primary induction OR for \nrelapsed/refractory disease, Revlimid (lenalidomide) therapy should be \nutilized in conjunction with dexamethasone if no contraindication. As \nmaintenance therapy in patients with multiple myeloma following \nautologous hematopoietic stem cell transplantation. For \nReauthorizations: The approval duration may be continued for six \nadditional months if benefit is shown via no evidence of disease \nprogression/treatment failure. Chronic Lymphoid Leukemia. Diagnosis of \nrelapsed or refractory Chronic Lymphocytic Leukemia (CLL). For \nReauthorizations: The approval duration may be continued for six \nadditional months if benefit is shown via no evidence of disease \nprogression.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 240 of 497\n", "doc_id": "fa3b70d8-8c5b-4185-9f7b-711c67b7ca10", "embedding": null, "doc_hash": "898baae75c00a99235a30dcbdc9822cf665acb36d1c894ffc2308b772dbc1248", "extra_info": {"page_label": "240", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2032, "_node_type": "1"}, "relationships": {"1": "51d7c345-f023-4f57-9f51-b04fc2432cc2"}}, "__type__": "1"}, "8203a1a4-3767-4635-aaa1-d4a57d5a0f92": {"__data__": {"text": "lenalidomide\nOther Criteria\nHodgkin Lymphoma: The member has a diagnosis of classical Hodgkin \nlymphoma AND The member has relapsed or refractory disease AND \nThe member will be using for third line or subsequent systemic therapy. \nNon-Hodgkin Lymphoma: The member has one of the following \ndiagnoses: AIDS-related B-cell lymphoma, diffuse large B-cell \nlymphoma, mucosa-associated lymphoid tissue (MALT) lymphoma \n[either gastric or nongastric], marginal zone lymphoma, or mantle cell \nlymphoma AND The member has relapsed or refractory disease OR The \nmember has a diagnosis of follicular lymphoma AND The member will \nuse as first line therapy or for relapsed or refractory disease.\nPart B \nPrerequisite\n0\n Y0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 241 of 497\n", "doc_id": "8203a1a4-3767-4635-aaa1-d4a57d5a0f92", "embedding": null, "doc_hash": "74979817b6e4e4b1ab62a249b2e7f440f31c310cf97609aad4927f37e99e747b", "extra_info": {"page_label": "241", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 761, "_node_type": "1"}, "relationships": {"1": "94bb0a44-3fef-4c51-99f4-550737ce40d2"}}, "__type__": "1"}, "61ee8ba5-d018-431e-9872-ddbf292d7fee": {"__data__": {"text": "LENVIMA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors.Members that have \nexperienced disease progression while on Lenvima (lenvatinib).\nRequired\nMedical\nInformation\nThyroid Cancer:The member has a diagnosis of locally recurrent or \nmetastatic, progressive differentiated thyroid cancer (i.e. papillary \ncarcinoma, follicular carcinoma or Hurthle cell carcinoma) AND The \ntumors are not responsive to radio-iodine treatment AND Lenvima \n(lenvatinib) will be used as monotherapy.  Renal Cell Carcinoma. The \nmember has a diagnosis of advanced renal cell carcinoma AND the \nmember is using in combination with Afinitor (everolimus) AND the \nmember has experienced intolerance on Cabometyx (cabozantinib) as \nsecond line therapy [e.g., severe hypertension/hypertensive crisis, \ncardiac failure, venous thromboembolic event within the last 6 months, \narterial thromboembolic event within the last 12 months, severe \nhemorrhage, reversible posterior leukoencephalopathy, unmanageable \nfistula/GI perforation, nephrotic syndrome).  Hepatocelluar Carcinoma: \nThe member has a diagnosis of unresectable carcinoma AND Lenvima \n(lenvatinib) will be given as a single agent as first line therapy. \nEndometrial cancer: The member has a diagnosis of metastatic or \nrecurrent endometrial cancer AND The disease is not MSI-H or pMMR \nas determined by an FDA approved test AND The member is not a \ncandidate for curative surgery or radiation AND The member has \nexperienced disease progression on prior systemic therapy AND \nLenvima (levantinib) will be given in combination with Keytruda \n(pembrolizumab) as subsequent therapy.  Renal cell carcinoma- first line \ntherapy:  The member has a diagnosis of advanced renal cell carcinoma \nAND Lenvima (levatinib) will be given in combination with Keytruda \n(pembrolizumab) as first line therapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 242 of 497\n", "doc_id": "61ee8ba5-d018-431e-9872-ddbf292d7fee", "embedding": null, "doc_hash": "ac092515d4f70edab0dd1ef9c55bcb87d575e49a7fb023ce22f979dbcf4595cf", "extra_info": {"page_label": "242", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2078, "_node_type": "1"}, "relationships": {"1": "a9682377-c0ee-49ef-a23d-4d7e182419ef"}}, "__type__": "1"}, "787d20d6-7df4-49b1-ad16-fc483d7e54a8": {"__data__": {"text": "leuprolide (3 month)\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agents.\nRequired\nMedical\nInformation\nDiagnosis of advanced prostate cancer or at risk for disease recurrence. \nEndometriosis: Diagnosis of endometriosis. Fibroids (Uterine \nleiomyomata). The patient must have a diagnosis of anemia due to \nuterine leiomymoma. Central Precocious Puberty: Pediatric member with \na diagnosis of central precocious puberty (idiopathic or neurogenic). \nInvasive Breast Cancer.The patient has a diagnosis of hormone \nresponsive (ER and/or PR +) invasive breast cancer.The patient must be \npre or perimenopausal. Recurrent Ovarian Cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor. Patient has recurrent ovarian cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration for all except for Endometriosis: 6 months and \nUterine Leiomyoma: 3 months\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 243 of 497\n", "doc_id": "787d20d6-7df4-49b1-ad16-fc483d7e54a8", "embedding": null, "doc_hash": "84efc887676bb35164cd0e19a6f31b6715479b19ae21ed29dc25ee70e78f052c", "extra_info": {"page_label": "243", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1196, "_node_type": "1"}, "relationships": {"1": "6abc409f-37cf-4a53-8400-7ff57472ee2f"}}, "__type__": "1"}, "44e87891-92f3-48ff-8053-3031cd806cef": {"__data__": {"text": "levoleucovorin calcium\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nFusilev (levoleucovorin) is considered not medically necessary for \nmembers with the following concomitant conditions:Members with \npernicious anemia or megaloblastic anemia secondary to the lack of \nvitamin B12\nRequired\nMedical\nInformation\nFusilev/levoleucovorin will require prior authorization and may be \nconsidered medically necessary when the following criteria are met: \nLevoleucovorin rescue is indicated after high-dose methotrexate therapy \nin osteosarcoma. The patient is being treated with methotrexate for \nosteosarcoma. The patient has been treated with leucovorin calcium and \nhas experienced documented side effects either due to lack of leucovorin \ncalcium efficacy or due to leucovorin calcium formulation necessitating a \nchange in therapy. Levoleucovorin is also indicated to diminish the \ntoxicity and counteract the effects of impaired methotrexate elimination \nand of inadvertent overdosage of folic acid antagonists.The patient has \nbeen treated with methotrexate or other folic acid antagonist and is \ncurrently exhibiting signs of toxicity likely due to aforementioned \ntherapy.The patient has been treated with leucovorin calcium and has \nexperienced documented side effects either due to lack of leucovorin \ncalcium efficacy or due to leucovorin calcium formulation necessitating a \nchange in therapy.Advanced Metastatic Colorectal Cancer.The member \nhas advanced metastatic colorectal cancer.The member is receiving \npalliative treatment with combination chemotherapy with 5-\nfluorouracil.The member has been treated with leucovorin calcium and \nhas experienced documented side effects either due to lack of leucovorin \ncalcium efficacy or due to leucovorin calcium formulation necessitating a \nchange in therapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nsix months\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 244 of 497\n", "doc_id": "44e87891-92f3-48ff-8053-3031cd806cef", "embedding": null, "doc_hash": "01c0250d20891821ac858803825b4c0b9856fcfe68d5a9c4fdcb06a8c31176c2", "extra_info": {"page_label": "244", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2014, "_node_type": "1"}, "relationships": {"1": "94ac2ab4-47c6-4d10-8110-0d238cb078cf"}}, "__type__": "1"}, "f6d91ea9-4812-4c4b-b44b-d8939a797599": {"__data__": {"text": "LIBTAYO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember has experienced disease progression on or after prior PD-1/PD-\nL1 inhibitor (e.g., Keytruda).\nRequired\nMedical\nInformation\nCutaneous squamous cell carcinoma. The member has a diagnosis of \nlocally advanced or metastatic cutaneous squamous cell carcinoma \n(CSCC) AND the disease is not amenable to curative surgery or \nradiation AND Libtayo (cemiplimab-rwlc) is being used as a \nmonotherapy.  Basal cell carcinoma (BCC):  The member has locally \nadvanced BCC or metastatic BCC AND the disease has been treated \nwith prior hedgehog pathway inhibitor OR treatment with a hedgehog \npathway inhibitor is inappropriate AND Libtayo (cemiplimab-rwlc) is given \nmonotherapy.  Non-small cell lung cancer (NSCLC):  The member has a \ndiagnosis of NSCLC without tumor aberrations (e.g., EGFR, ALK, ROS-\n1) AND The disease is locally advanced (not amenable to surgery or \ndefinitive chemoradiation) or metastatic AND The tumor expresses \ndocumented high PD-L1 expression [Tumor Proportion Score (TPS) \ngreater than or equal to 50%] AND Libtayo (cemiplimab-rwlc) is given as \nmonotherapy OR Libtayo (cemiplimab-rwlc) is given in combination with \nplatinum based chemotherapy as first line therapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 245 of 497\n", "doc_id": "f6d91ea9-4812-4c4b-b44b-d8939a797599", "embedding": null, "doc_hash": "cf09c049ca9dda0bdeaf840902a0cfde7f79aaf498e07f51ebba4ee3783c813b", "extra_info": {"page_label": "245", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1448, "_node_type": "1"}, "relationships": {"1": "95a005ad-f0b5-4a3a-a0f1-16c992eb5d74"}}, "__type__": "1"}, "eea281bb-fa93-40df-aa47-2e5e25749def": {"__data__": {"text": "lidocaine\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nPost-Herpetic Neuralgia: The member must have a diagnosis of post-\nherpetic neuralgia. Diabetic Neuropathy: The member must have a \ndiagnosis of diabetic neuropathy. Neuropathic cancer pain. The member \nmust have a diagnosis of neuropathic cancer pain. Chronic Back Pain: \nThe member must have a diagnosis of chronic back pain. Pain \nassociated with hip or knee osteoarthritis: the member must have a \ndiagnosis of pain associated with hip or knee osteoarthritis.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 246 of 497\n", "doc_id": "eea281bb-fa93-40df-aa47-2e5e25749def", "embedding": null, "doc_hash": "ef77519d1fe8f5c16f3fdc9a3a1610cdcac5f8abd0ae497486d30b8b6d59a3da", "extra_info": {"page_label": "246", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 753, "_node_type": "1"}, "relationships": {"1": "a02bcb24-35ff-4e4c-aafd-0c6b9b5957de"}}, "__type__": "1"}, "d307392c-3912-46bd-b72f-0da258fccee8": {"__data__": {"text": "LONSURF\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on Lonsurf.\nRequired\nMedical\nInformation\nMetastatic Colorectal Cancer:The member has a diagnosis of metastatic \ncolorectal cancer AND The member is using Lonsurf as monotherapy \nAND The member has experienced disease progression, intolerance, or \ncontraindication with ALL of the following therapies: fluoropyrimidine-\nbased chemotherapy (e.g., 5-fluorouracil, capecitabine),oxaliplatin-based \nchemotherapy, irinotecan-based chemotherapy, and anti-VEGF therapy \n(e.g. bevacizumab, ziv-aflibercept) AND If the member is RAS wild-type: \nthe member has experienced disease progression,intolerance, or \ncontraindication with anti-EGFR therapy (e.g. cetuximab or \npanitumumab). Gastric cancer. The member has recurrent locally \nadvanced or metastatic gastric or gastroesophageal junction \nadenocarcinoma AND The member has experienced disease \nprogression on or after two lines of therapy including fluoropyrimidine, \nplatinum (e.g., cisplatin), either taxane (e.g., paclitaxel) or irinotecan and \nif appropriate, HER2/neu-targeted therapy (e.g., trastuzumab) AND \nLonsurf will be given subsequent therapy as a single agent.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 247 of 497\n", "doc_id": "d307392c-3912-46bd-b72f-0da258fccee8", "embedding": null, "doc_hash": "f1d78af87a0e18975392e9ff5e92c65484530480f67760ab928e5d68a43a0032", "extra_info": {"page_label": "247", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1438, "_node_type": "1"}, "relationships": {"1": "ab72c98b-4577-4160-9502-097e7e780f15"}}, "__type__": "1"}, "0401efeb-ca89-42de-959d-8a0ef7fe0424": {"__data__": {"text": "LORBRENA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers on concomitant ALK inhibitors (e.g., Zykadia [certinib], \nAlecensa [alectinib]). Members experience disease progression on \nLorbrena (lorlatinib).\nRequired\nMedical\nInformation\nNon-small cell lung cancer. The member has a diagnosis of metastatic \nNSCLC with documented anaplastic lymphoma kinase (ALK) positivity \nAND Lorbrena (lorlatinib) will be given as monotherapy AND one of the \nfollowing applies in the metastatic setting: as first line therapy AND the \nmember has a medical reason as to why Alecensa (alectinib) or Alunbrig \n(brigatinib) cannot be initiated or continued as first line therapy OR \nSubsequent therapy after disease progression on prior ALK inhibitor \n(e.g., alectinib, brigatinib).  Non- small cell lung cancer [ROS-1 \nrearrangement]:  The member has a diagnosis of recurrent, advanced, or \nmetastatic non-small cell lung cancer AND The disease is positive for \ndocumented ROS-1 rearrangement and following disease progression \non Xalkori (crizotinib), Rozlytrek (entrectinib), or Zykadia (ceritinib) AND \nLorbrena (lorlatinib) will be given as a single agent as subsequent \ntherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 248 of 497\n", "doc_id": "0401efeb-ca89-42de-959d-8a0ef7fe0424", "embedding": null, "doc_hash": "b9072a06cc43f0eb752a9fe8e9b39f2d3dfb7f4c2abf03a2ac634bf6fa83dfd0", "extra_info": {"page_label": "248", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1381, "_node_type": "1"}, "relationships": {"1": "f7f7af08-1552-482d-b735-e1a3ce67bf28"}}, "__type__": "1"}, "9513b161-e964-4cb4-82f5-2a0580d998ce": {"__data__": {"text": "LUMAKRAS\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experienced disease progression on Lumakras.\nRequired\nMedical\nInformation\nNon-small cell lung cancer (NSCLC):  The member has a diagnosis of \nlocally advanced or metastatic NSCLC AND The NSCLC has \ndocumented KRAS G12C mutation AND The member has experienced \ndisease progression on one prior therapy AND Lumakras (sotorasib) will \nbe given as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 249 of 497\n", "doc_id": "9513b161-e964-4cb4-82f5-2a0580d998ce", "embedding": null, "doc_hash": "dfc629e66f477b7c794f00e582d417cfd6bb8e369dbc7e9ecdbb66e8222cf41c", "extra_info": {"page_label": "249", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 622, "_node_type": "1"}, "relationships": {"1": "69a32055-d30f-4946-a47f-14a264f19eee"}}, "__type__": "1"}, "e9cf8cba-9068-4103-a120-29dae73227d5": {"__data__": {"text": "LUMOXITI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on or following \nLumoxiti (moxetumomab pasudotox-tdfk).\nRequired\nMedical\nInformation\nHairy cell leukemia. The member has a diagnosis of relapsed or \nrefractory hairy cell leukemia AND The member has received at least two \nprior therapies, including treatment with a purine nucleoside analog (e.g. \ncladribine, pentostatin) AND The member will be using Lumoxiti \n(moxetumomab pasudotox-tdfk) as monotherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 250 of 497\n", "doc_id": "e9cf8cba-9068-4103-a120-29dae73227d5", "embedding": null, "doc_hash": "42759cc2876e960ecafd7e4c5475c258b111caefd38038fb4c13c7796dc47930", "extra_info": {"page_label": "250", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 725, "_node_type": "1"}, "relationships": {"1": "acf7146f-75e4-47fa-acf2-3fe31fd6fe4d"}}, "__type__": "1"}, "8c6b3641-ecc3-4e6b-bd1c-39d0a9cf6812": {"__data__": {"text": "LUNSUMIO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on or following \nLunsumio (mosunetuzumab-axgb).\nRequired\nMedical\nInformation\nFollicular Lymphoma. The member has a diagnosis of follicular \nlymphoma AND the member has relapsed or refractory disease AND the \nmember has received at least two prior lines of systemic therapy AND \nthe member will be using Lunsumio (mosunetuzumab-axgb) as \nmonotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 251 of 497\n", "doc_id": "8c6b3641-ecc3-4e6b-bd1c-39d0a9cf6812", "embedding": null, "doc_hash": "bb1abf5fba81a6bf4a3a2b1e4cdcce185c49e5ad59d0349fe51f638f6f39caa2", "extra_info": {"page_label": "251", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 661, "_node_type": "1"}, "relationships": {"1": "5cdb6e55-b772-44b5-9f33-ba9307e9583d"}}, "__type__": "1"}, "850f9238-d920-4d5c-babb-b9fdf722674d": {"__data__": {"text": "LUPRON DEPOT\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agents.\nRequired\nMedical\nInformation\nDiagnosis of advanced prostate cancer or at risk for disease recurrence. \nEndometriosis: Diagnosis of endometriosis. Fibroids (Uterine \nleiomyomata). The patient must have a diagnosis of anemia due to \nuterine leiomymoma. Central Precocious Puberty: Pediatric member with \na diagnosis of central precocious puberty (idiopathic or neurogenic). \nInvasive Breast Cancer.The patient has a diagnosis of hormone \nresponsive (ER and/or PR +) invasive breast cancer.The patient must be \npre or perimenopausal. Recurrent Ovarian Cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor. Patient has recurrent ovarian cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration for all except for Endometriosis: 6 months and \nUterine Leiomyoma: 3 months\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 252 of 497\n", "doc_id": "850f9238-d920-4d5c-babb-b9fdf722674d", "embedding": null, "doc_hash": "9b7c0c2b664fbb13e978faa8a8f422b7314a16295158af9a7954a0cdaf1ff0fe", "extra_info": {"page_label": "252", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1188, "_node_type": "1"}, "relationships": {"1": "4725e493-7f03-4188-9bcb-5e3ca2762b24"}}, "__type__": "1"}, "780cf419-b5ce-4175-b2e6-3aa435bc5d3c": {"__data__": {"text": "LUPRON DEPOT (3 MONTH)\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agents.\nRequired\nMedical\nInformation\nDiagnosis of advanced prostate cancer or at risk for disease recurrence. \nEndometriosis: Diagnosis of endometriosis. Fibroids (Uterine \nleiomyomata). The patient must have a diagnosis of anemia due to \nuterine leiomymoma. Central Precocious Puberty: Pediatric member with \na diagnosis of central precocious puberty (idiopathic or neurogenic). \nInvasive Breast Cancer.The patient has a diagnosis of hormone \nresponsive (ER and/or PR +) invasive breast cancer.The patient must be \npre or perimenopausal. Recurrent Ovarian Cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor. Patient has recurrent ovarian cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration for all except for Endometriosis: 6 months and \nUterine Leiomyoma: 3 months\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 253 of 497\n", "doc_id": "780cf419-b5ce-4175-b2e6-3aa435bc5d3c", "embedding": null, "doc_hash": "d793db3bdbf8d8e715b2e33055489226e77b457dee3cdca629f0f1c8b46c4c30", "extra_info": {"page_label": "253", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1198, "_node_type": "1"}, "relationships": {"1": "ab2c3c79-d20e-4657-b26d-e36edc75c654"}}, "__type__": "1"}, "6bfaac1d-955a-4e06-aec4-f69b457ee3aa": {"__data__": {"text": "LUPRON DEPOT (4 MONTH)\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agents.\nRequired\nMedical\nInformation\nDiagnosis of advanced prostate cancer or at risk for disease recurrence. \nEndometriosis: Diagnosis of endometriosis. Fibroids (Uterine \nleiomyomata). The patient must have a diagnosis of anemia due to \nuterine leiomymoma. Central Precocious Puberty: Pediatric member with \na diagnosis of central precocious puberty (idiopathic or neurogenic). \nInvasive Breast Cancer.The patient has a diagnosis of hormone \nresponsive (ER and/or PR +) invasive breast cancer.The patient must be \npre or perimenopausal. Recurrent Ovarian Cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor. Patient has recurrent ovarian cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration for all except for Endometriosis: 6 months and \nUterine Leiomyoma: 3 months\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 254 of 497\n", "doc_id": "6bfaac1d-955a-4e06-aec4-f69b457ee3aa", "embedding": null, "doc_hash": "f0d12c25732ed5698235ac1a97706c0416dce143804960459ce40a3ce4d55e5e", "extra_info": {"page_label": "254", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1198, "_node_type": "1"}, "relationships": {"1": "e7043aa8-4ada-463f-aea8-364ad491fcac"}}, "__type__": "1"}, "4ae3188c-374f-4252-9fcb-fd3280a1749e": {"__data__": {"text": "LUPRON DEPOT (6 MONTH)\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agents.\nRequired\nMedical\nInformation\nDiagnosis of advanced prostate cancer or at risk for disease recurrence. \nEndometriosis: Diagnosis of endometriosis. Fibroids (Uterine \nleiomyomata). The patient must have a diagnosis of anemia due to \nuterine leiomymoma. Central Precocious Puberty: Pediatric member with \na diagnosis of central precocious puberty (idiopathic or neurogenic). \nInvasive Breast Cancer.The patient has a diagnosis of hormone \nresponsive (ER and/or PR +) invasive breast cancer.The patient must be \npre or perimenopausal. Recurrent Ovarian Cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor. Patient has recurrent ovarian cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration for all except for Endometriosis: 6 months and \nUterine Leiomyoma: 3 months\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 255 of 497\n", "doc_id": "4ae3188c-374f-4252-9fcb-fd3280a1749e", "embedding": null, "doc_hash": "24893caec51284b9334139afd060cd494afe01762ed6fa16e90c8d89be74e180", "extra_info": {"page_label": "255", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1198, "_node_type": "1"}, "relationships": {"1": "ba4d27fb-10a6-49ef-8b51-6b27c61b80fe"}}, "__type__": "1"}, "7d7c0d3d-4a72-4566-8d7a-77908c94092e": {"__data__": {"text": "LUPRON DEPOT-PED\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agents.\nRequired\nMedical\nInformation\nDiagnosis of advanced prostate cancer or at risk for disease recurrence. \nEndometriosis: Diagnosis of endometriosis. Fibroids (Uterine \nleiomyomata). The patient must have a diagnosis of anemia due to \nuterine leiomymoma. Central Precocious Puberty: Pediatric member with \na diagnosis of central precocious puberty (idiopathic or neurogenic). \nInvasive Breast Cancer.The patient has a diagnosis of hormone \nresponsive (ER and/or PR +) invasive breast cancer.The patient must be \npre or perimenopausal. Recurrent Ovarian Cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor. Patient has recurrent ovarian cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration for all except for Endometriosis: 6 months and \nUterine Leiomyoma: 3 months\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 256 of 497\n", "doc_id": "7d7c0d3d-4a72-4566-8d7a-77908c94092e", "embedding": null, "doc_hash": "f8e55b6c88dfeaf980a10b60dbf676055f0346a0ef9afa8ba6afb22218d618fb", "extra_info": {"page_label": "256", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1192, "_node_type": "1"}, "relationships": {"1": "e55f865f-8e11-4f7e-b4db-59f0aa92da85"}}, "__type__": "1"}, "3d49904c-dd3c-4ecb-abc0-28fa7920627a": {"__data__": {"text": "LUPRON DEPOT-PED (3 MONTH)\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agents.\nRequired\nMedical\nInformation\nDiagnosis of advanced prostate cancer or at risk for disease recurrence. \nEndometriosis: Diagnosis of endometriosis. Fibroids (Uterine \nleiomyomata). The patient must have a diagnosis of anemia due to \nuterine leiomymoma. Central Precocious Puberty: Pediatric member with \na diagnosis of central precocious puberty (idiopathic or neurogenic). \nInvasive Breast Cancer.The patient has a diagnosis of hormone \nresponsive (ER and/or PR +) invasive breast cancer.The patient must be \npre or perimenopausal. Recurrent Ovarian Cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor. Patient has recurrent ovarian cancer  (epithelial cell \ncancer, fallopian tube cancer, primary peritoneal cancer or ovarian \nstromal tumor).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration for all except for Endometriosis: 6 months and \nUterine Leiomyoma: 3 months\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 257 of 497\n", "doc_id": "3d49904c-dd3c-4ecb-abc0-28fa7920627a", "embedding": null, "doc_hash": "68b72d0b7b94670355f29b004f31645e0aac3a70e40f00a937c96f4285e7bf68", "extra_info": {"page_label": "257", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1202, "_node_type": "1"}, "relationships": {"1": "5ede3ff9-e7f4-4745-ad15-3ee087bfbdc1"}}, "__type__": "1"}, "9e95ffa3-48b7-4d7d-bbad-a587064b7a8f": {"__data__": {"text": "lurasidone\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nDementia-related psychosis (in the absence of an approvable diagnosis), \nfor member 65 years of age or older.\nRequired\nMedical\nInformation\nDiagnosis of Schizophrenia or Schizoaffective Disorder: The member \nmust have prior therapy, intolerance or contraindication to at least 2 of \nthe following: risperidone or olanzapine or quetiapine or ziprasidone or \naripiprazole. Diagnosis of Bipolar I Disorder (Bipolar Depression): The \nmember must have documentation of prior therapy, intolerance, or \ncontraindication to quetiapine.\nAge Restriction\nFor diagnosis of Schizophrenia or schizoaffective disorder, the member \nmust be 13 years of age or older.  For diagnosis of Bipolar I Disorder \n(Bipolar Depression), the member must be 10 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 258 of 497\n", "doc_id": "9e95ffa3-48b7-4d7d-bbad-a587064b7a8f", "embedding": null, "doc_hash": "4f4de71634a68ac1ce61f6f095b946f38016e966fbf3c21d3d5ec3c3b556243b", "extra_info": {"page_label": "258", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1005, "_node_type": "1"}, "relationships": {"1": "5a22b1aa-b859-485d-bdb5-6bc47d2804fa"}}, "__type__": "1"}, "17bb1153-5581-45f5-9c0d-a3bcf3987a8e": {"__data__": {"text": "LYBALVI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nUse of opioids.  Episode of acute opioid withdrawal.\nRequired\nMedical\nInformation\nSchizophrenia or Bipolar I Disorder (Bipolar Depression):  The member \nmust have a diagnosis of schizophrenia or bipolar I disorder (bipolar \ndepression) AND the member must have documentation of clinically \nsignificant weight gain from baseline body weight at maximally tolerated \nefficacious dosage after initiation of therapy with generic olanzapine or \nmember has documented intolerance to generic olanzapine that is \nunrelated to weight gain AND The member must have documentation of \nprior therapy, intolerance, or contraindication to at least one of the \nfollowing generic atypical antipsychotics: risperidone, quetiapine, \nziprasidone, or aripiprazole.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 259 of 497\n", "doc_id": "17bb1153-5581-45f5-9c0d-a3bcf3987a8e", "embedding": null, "doc_hash": "77c3f5614edea36f547606a5d12d5103d18e81863212678bfe42fadc36929e50", "extra_info": {"page_label": "259", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1001, "_node_type": "1"}, "relationships": {"1": "24dab8f4-7064-41ee-80c1-6bd7cc23c3fd"}}, "__type__": "1"}, "ed4c92b1-2ed6-4356-be3d-7770969f728c": {"__data__": {"text": "LYNPARZA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on or \nfollowing PARP inhibitor therapy [e.g. Rubraca (rucaparib), Lynparza \n(olaparib), Zejula (niraparib)].  Adjuvant setting for High-Risk Early \nBreast Cancer: member is taking Lynparza (olaparib) total treatment for \nmore than one year.\nRequired\nMedical\nInformation\nBreast Cancer: Member has a diagnosis of recurrent or metastatic breast \ncancer AND Member has deleterious germline or suspected germline \nBRCA-mutated disease as detected by an FDA-approved test AND \nMember has HER-2 negative disease, hormone receptor positive or \nnegative, treated with prior chemotherapy and/or endocrine therapy AND \nLynparza will be used as subsequent therapy as a single agent. Ovarian \nCancer, Fallopian Tube, or Peritoneal Cancer First Line Maintenance \nTherapy: The member has a diagnosis of advanced epithelial ovarian \ncancer, fallopian tube cancer, or primary peritoneal cancer AND \nmember's disease is associated with homologous recombination \ndeficiency (HRD) positive status defined by either:  a deleterious or \nsuspected deleterious BRCA mutation or genomic instability.  Member is \nin complete response or partial response to first line treatment with \nplatinum based chemotherapy.  Ovarian Cancer, Fallopian Tube, or \nPeritoneal Cancer Second Line Maintenance Therapy: The member has \na diagnosis of recurrent epithelial ovarian cancer, fallopian tube cancer, \nor primary peritoneal cancer AND The member has been treated with at \nleast two prior lines of platinum based chemotherapy AND The member \nis in complete or partial response to their last platinum regimen AND The \nmember will utilize Lynparza (olaparib) tablets as monotherapy. \n*Discontinue Bevacizumab Product before initiating maintenance therapy \nwith Lynparza.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 month duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 260 of 497\n", "doc_id": "ed4c92b1-2ed6-4356-be3d-7770969f728c", "embedding": null, "doc_hash": "b96f0f1e0b8a0c0a48001c60e736c8e344d6aed59d53ee338b43a1f1c5dde461", "extra_info": {"page_label": "260", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2009, "_node_type": "1"}, "relationships": {"1": "0c73d0f3-876a-4b87-a42e-9c8d1b560bee"}}, "__type__": "1"}, "068874b1-4336-4741-a970-f55f0c5be626": {"__data__": {"text": "LYNPARZA\nOther Criteria\nPancreatic Adenocarcinoma - First line maintenance therapy: Member \nhas a diagnosis of metastatic pancreatic adenocarcinoma AND member \nhas deleterious germline or suspected germline BRCA-mutated disease \nAND member's disease has not progressed on at least 16 weeks of a \nfirst-line platinum-based chemotherapy regimen.  Metastatic Castration-\nResistant Prostate Cancer (mCRPC):  Member has a diagnosis \nmetastatic castration-resistant prostate cancer (mCRPC) AND Member \nhas documented deleterious or suspected deleterious germline, or \nsomatic homologous recombination repair (HRR) gene-mutated disease \nAND Member has experienced progressive disease following prior \ntreatment with Xtandi (enzalutamide) or abiraterone AND Member will \nuse Lynparza (olaparib) in combination with androgen \ndeprivationtherapy (e.g. previous bilateral orchiectomy or concurrent \nGnRH analog).  Breast Cancer (Adjuvant):  Member has a diagnosis of \nhigh-risk early breast cancer AND Member has deleterious germline or \nsuspected germline BRCA-mutated disease as detected by an FDA-\napproved test AND Member has HER-2 negative disease, hormone \nreceptor positive or negative, treated with prior chemotherapy AND \nLynparza will be used as subsequent therapy as a single agent.  High \nRisk early breast cancer defined as patients who:  1. Received prior \nneoadjuvant chemotherapy: patients with either triple negative breast \ncancer (TNBC) or hormone receptor positive breast cancer must have \nhad residual invasive cancer in the breast and/or the resected lymph \nnodes (nonpathologic complete response) at the time of surgery. \nAdditionally, patients with hormone receptor positive breast cancer must \nhave had a score of greater than or equal to 3 based on pretreatment \nclinical and post-treatment pathologic stage (CPS), estrogen receptor \n(ER) status, and histologic grade. 2. TNBC with greater than or equal to \npT2 or greater than or equal to pN1 prior to adjuvant chemotherapy 3. \nHR+/HER2-negative with greater than or equal to 4 positive lymph nodes \nprior to adjuvant chemotherapy.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 261 of 497\n", "doc_id": "068874b1-4336-4741-a970-f55f0c5be626", "embedding": null, "doc_hash": "e0ec4cc3a74e8f4bd7a9d020df1ab9d117d06e085eb4bdf000a0128645e66ab5", "extra_info": {"page_label": "261", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2172, "_node_type": "1"}, "relationships": {"1": "3583205d-5450-4b31-8a49-4c0b5cb65b14"}}, "__type__": "1"}, "4cd2d5c1-8abe-4989-b475-362d9f7fa550": {"__data__": {"text": "LYTGOBI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDisease progression on Lytgobi (futibatinib)\nRequired\nMedical\nInformation\nCholangiocarcinoma: The member has unresectable locally advanced or \nmetastatic intrahepatic cholangiocarcinoma (iCCA) AND The member \nhas iCCA with documented FGFR2 gene fusions or other \nrearrangements AND The member has received prior treatment AND \nLytgobi (futibatinib) is given as a single agent for subsequent therapy\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 262 of 497\n", "doc_id": "4cd2d5c1-8abe-4989-b475-362d9f7fa550", "embedding": null, "doc_hash": "dd2a63809c1a1ad7a222ef24aaacab3ecce30e52ad48aba9e9aa6199ef63e212", "extra_info": {"page_label": "262", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 657, "_node_type": "1"}, "relationships": {"1": "39b31029-8c1c-4ada-a102-2d7631aa8471"}}, "__type__": "1"}, "8e905a21-69fe-49da-8dd3-d81a3724dc1c": {"__data__": {"text": "MARGENZA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMember experiences disease progression on Margenza (margetuximab-\ncmkb).\nRequired\nMedical\nInformation\nBreast cancer:  The member has a diagnosis of metastatic breast cancer \nAND The disease is documented HER2 neu positive AND The member \nhas received two prior anti-HER2 neu based therapies (including \ntrastuzumab products) where one therapy was given in the metastatic \nsetting AND Margenza (margetuximab-cmkb) is given in combination \nwith chemotherapy (gemcitabine, eribulin, vinorelbine, capecitabine) as \nsubsequent therapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 263 of 497\n", "doc_id": "8e905a21-69fe-49da-8dd3-d81a3724dc1c", "embedding": null, "doc_hash": "aeec1b4f9da2a8a266ed4377823f0aa664b3dcf6ebd05b41ecbcb0a52a26057b", "extra_info": {"page_label": "263", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 798, "_node_type": "1"}, "relationships": {"1": "5cb561e4-ec01-4b82-a21b-9dcec146fa1d"}}, "__type__": "1"}, "d6f9a5cb-6c10-4ba0-b48b-8ba49f7f9b94": {"__data__": {"text": "MEKINIST\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers on concomitant Yervoy (ipilimumab), Zelboraf (vemurafenib), \nOpdivo (nivolumab), Keytruda (pembrolizumab), Cotellic (cobimetinib), \nBraftovi (encorafenib), or Mektovi (binimetinib). Members that have \nexperienced disease progression while on Mekinist (trametinib). \nMembers that have experienced disease progression while on prior anti-\nBRAF/MEK combination therapy [e.g. Cotellic (cobimetinib) with Zelboraf \n(vemurafenib) or Tafinlar (dabrafenib) with Mekinist (trametinib).] \nAdjuvant melanoma only: member is taking Mekinist (trametinib) total \ntreatment for more than one year.\nRequired\nMedical\nInformation\nMelanoma-Unresectable or Metastatic: The member has a diagnosis of \nunresectable or stage IV metastatic melanoma AND The member has a \ndocumented BRAF V600 activating mutation AND The member will be \nusing Mekinist as a single-agent (member has not received prior BRAF-\ninhibitor therapy) OR in combination with Tafinlar (dabrafenib). Non-\nsmall cell lung cancer: The member has a diagnosis of recurrent or \nmetastatic non-small cell lung cancer(NSCLC) AND The member has a \ndocumented BRAF V600E mutation AND The member will be using \nMekinist (trametinib) in combination with Tafinlar (dabrafenib). \nMelanoma - Adjuvant. The member has a diagnosis of stage III \nmelanoma AND The member has undergone lymph node resection of \ninvolved lymph nodes AND The member has a documented BRAF V600 \nactivating mutation AND The member will be using Mekinist (trametinib) \nin combination with Tafinlar (dabrafenib) for adjuvant treatment. \nAnaplastic Thyroid Cancer. The member has a diagnosis of locally \nadvanced or metastatic anaplastic thyroid cancer AND The member has \na documented V600E mutation AND The member has no satisfactory \nlocoregional treatment options AND The member will be using Tafinlar \n(dabrafenib) in combination with Mekinist (trametinib).  Metastatic Solid \nTumors: the member has a diagnosis of unresectable or metastatic solid \ntumors with documented BRAF V600E mutation AND the member has \ndisease that has progressed on prior therapy and has no satisfactory \nalternative treatments AND Mekinist is given in combination with Tafinlar.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 264 of 497\n", "doc_id": "d6f9a5cb-6c10-4ba0-b48b-8ba49f7f9b94", "embedding": null, "doc_hash": "ebc8b38bb28ee7a8f9c48fd4538429bbe565c4aa78b5c67e88127b12682da0dc", "extra_info": {"page_label": "264", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2409, "_node_type": "1"}, "relationships": {"1": "07286f3f-8e8b-4733-ae7d-b70ea7f4d0e4"}}, "__type__": "1"}, "ea0b4c78-3082-480c-af75-9d8e49bb26b0": {"__data__": {"text": "MEKINIST\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 265 of 497\n", "doc_id": "ea0b4c78-3082-480c-af75-9d8e49bb26b0", "embedding": null, "doc_hash": "5c983d4150a73b7cf143d1c07aaa625f123e0727a04caa6feb45586def0d0398", "extra_info": {"page_label": "265", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 83, "_node_type": "1"}, "relationships": {"1": "94a1ea6c-87e6-49d5-ae67-3e19b07ce9fa"}}, "__type__": "1"}, "78acd7bd-575c-49a9-9f74-73428925ec4a": {"__data__": {"text": "MEKTOVI\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers on concomitant Yervoy (ipilimumab), Opdivo (nivolumab), \nKeytruda (pembrolizumab), Zelboraf (vemurafenib), Cotellic\n(cobimetinib), Tafinlar (dabrafenib), or Mekinist (trametinib) OR Members \nthat have experienced disease progression while on prior anti-\nBRAF/MEK combination therapy [e.g. Cotellic (cobimetinib) with Zelboraf \n(vemurafenib) or Tafinlar (dabrafenib) with Mekinist (trametinib)].\nRequired\nMedical\nInformation\nMelanoma - Unresectable or metastatic. The member has a diagnosis of \nunresectable or stage IV metastatic melanoma AND The member has a \ndocumented BRAF V600 activating mutation AND The member will be \nusing Braftovi (encorafenib) in combination with Mektovi (binimetinib). \nColorectal Cancer - [Braftovi (encorafenib) requests only]:  The member \nhas documented BRAFV600E metastatic metastatic colorectal cancer \nand progressive disease on prior therapy AND Braftovi (encorafenib) is \ngiven in combination with Erbitux (cetuximab).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month durations or as determined through clinical review\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 266 of 497\n", "doc_id": "78acd7bd-575c-49a9-9f74-73428925ec4a", "embedding": null, "doc_hash": "f3e8a57340f4051d254d5680f4b8b9015f8f506bb35ed653635c0deaed677e66", "extra_info": {"page_label": "266", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1274, "_node_type": "1"}, "relationships": {"1": "2609894b-b9b0-4655-8497-aa10c4708dd8"}}, "__type__": "1"}, "201e6356-0f8b-4d36-b64d-26d18f295f45": {"__data__": {"text": "memantine\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDiagnosis of Autism or Atypical Autism (PDD)\nRequired\nMedical\nInformation\nAge Restriction\nAn automatic approval if member is greater than 26 years of age.Prior \nAuth required for age 26 or younger.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 267 of 497\n", "doc_id": "201e6356-0f8b-4d36-b64d-26d18f295f45", "embedding": null, "doc_hash": "fb479cb1d362be018c31c730212687c9ec38737e7fbce9b0ac31b41b95cdce85", "extra_info": {"page_label": "267", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 442, "_node_type": "1"}, "relationships": {"1": "3b0b1a52-c981-4627-9a14-15d7cadbbcd2"}}, "__type__": "1"}, "f49d2f07-6985-4185-a032-4d31f7cb6801": {"__data__": {"text": "modafinil\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nExcessive Daytime Sleepiness.For the treatment of excessive daytime \nsleepiness or hypersomnolence associated with Narcolepsy,obstructive \nsleep apnea,or due to sleep problems resulting from circadian rhythm \ndisruption (i.e., shift-work sleep disorder). Steinert myotonic dystrophy \nsyndrome.Member must have hypersomnia due to Steinert myotonic \ndystrophy syndrome.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 268 of 497\n", "doc_id": "f49d2f07-6985-4185-a032-4d31f7cb6801", "embedding": null, "doc_hash": "b06744f639c2df9219e0673890da560d2f1528326ce90b71ef1957a510993ea2", "extra_info": {"page_label": "268", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 666, "_node_type": "1"}, "relationships": {"1": "60eb08b1-d2ac-4cb7-a94c-d177c8c958c5"}}, "__type__": "1"}, "abe04782-6de9-457d-8211-0a0a2209e5d6": {"__data__": {"text": "molindone\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDementia-related psychosis (in the absence of an approvable diagnosis), \nfor member 65 years of age or older. Drug or alcohol induced severe \ncentral nervous system depression.\nRequired\nMedical\nInformation\nSchizophrenia: The member must utilize molindone hydrochloride for the \nmanagement of clinically diagnosed schizophrenia. The member must \nhave documentation of prior therapy, intolerance, or contraindication to \ntwo (2) of the following: risperidone or olanzapine or quetiapine or \nziprasidone or aripiprazole.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 269 of 497\n", "doc_id": "abe04782-6de9-457d-8211-0a0a2209e5d6", "embedding": null, "doc_hash": "f8150989de0d5a70a3f7bd0a22f6201bb877a8c36fdfca9ab381e13b028f2e20", "extra_info": {"page_label": "269", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 778, "_node_type": "1"}, "relationships": {"1": "df3c0f07-6a28-4edc-8094-cd7814cbb23c"}}, "__type__": "1"}, "0b60e6b8-801e-4b79-970b-38d804d7c7ae": {"__data__": {"text": "MONJUVI\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member has experienced disease progression on anti-CD-19-\ndirected therapy.\nRequired\nMedical\nInformation\nDiffuse large B-cell lymphoma:  The member has a diagnosis of diffuse \nlarge B-cell lymphoma (DLBCL) not otherwise specified, including \nDLBCL arising from low grade lymphoma (e.g. follicular lymphoma) AND \nThe member has relapsed or refractory disease AND The member is not \neligible for autologous stem cell transplant AND The member will be \nusing Monjuvi (tafasitamab-cxix) in combination with lenalidomide for a \nmaximum of 12 cycles, then Monjuvi (tafasitamab-cxix) can be used as a \nsingle agent.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 270 of 497\n", "doc_id": "0b60e6b8-801e-4b79-970b-38d804d7c7ae", "embedding": null, "doc_hash": "d27844384061e827c012de5c58b86022b891e9b8a923f59840942665bb0ff62a", "extra_info": {"page_label": "270", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 880, "_node_type": "1"}, "relationships": {"1": "26f4e3b4-6fa4-4365-9e8b-a0ea729102a3"}}, "__type__": "1"}, "d034c4fe-4a0e-4a02-a954-e9490577c00c": {"__data__": {"text": "MOZOBIL\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nTreatment or prophylaxis of neutropenia or febrile neutropenia. \nConcomitant use with sargramostim or within seven days of pegfilgrastim \ndose.Same day administration with myelosuppressive chemotherapy or \nradiation.Use beyond four consecutive days or use after completion of \nstem cell harvest/apheresis.Mozobil is not intended for stem cell \nmobilization and harvest in patients with leukemia.\nRequired\nMedical\nInformation\nAutologous transplantation in patients with non-Hodgkin\n\u2019\ns Lymphoma \n(NHL) or Multiple Myeloma (MM):  The member must have a diagnosis of \nnon-Hodgkin\n\u2019\ns Lymphoma (NHL) or multiple myeloma (MM) AND \nMozobil (plerixafor) must be used in combination with filgrastim, \nbiosimilar filgrastim, or tbo-filgrastim AND Mozobil (plerixafor) must be a \ncomponent of an autologous stem cell transplant mobilization protocol.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n30 days. Mozobil will be approved for a 30-day interval once per \ntransplant.\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 271 of 497\n", "doc_id": "d034c4fe-4a0e-4a02-a954-e9490577c00c", "embedding": null, "doc_hash": "60571da3db9ceb7953dc1523926c037a4e97ac5d2184c565889571f19026b8eb", "extra_info": {"page_label": "271", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1167, "_node_type": "1"}, "relationships": {"1": "df2a3492-1771-460d-9f63-fa6cf8014eec"}}, "__type__": "1"}, "9855127c-d5a1-4d20-8905-7293d3ab727b": {"__data__": {"text": "MVASI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nUsed in lung cancer members that have small cell or squamous cell \ndisease, recent hemoptysis, history of bleeding, continuing \nanticoagulation, or as a single agent (unless maintenance as described \nin Coverage Determinations). Should not be initiated in members with \nrecent hemoptysis. Should not be used in members who experience a \nsevere arterial thromboembolic event. Should not be used in members \nwith gastrointestinal perforation. Bevacizumab should not be used in \nmembers with fistula formation involving internal organs. Bevacizumab \nshould not be used in members experiencing a hypertensive crisis or \nhypertensive encephalopathy. Bevacizumab should not be used for at \nleast 28 days following major surgery or until surgical incision is fully \nhealed. Bevacizumab may not be used in conjunction with Vectibix. \nBevacizumab may not be used in conjunction with Erbitux. Bevacizumab \nmay not be used in the adjuvant or neoadjuvant setting (except in \nepithelial ovarian, fallopian tube, or primary peritoneal cancer adjuvant \nsetting). Bevacizumab should not be continued or restarted after disease \nprogression with the exception of metastatic colorectal cancer.\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 272 of 497\n", "doc_id": "9855127c-d5a1-4d20-8905-7293d3ab727b", "embedding": null, "doc_hash": "7a16cf3cc2c3cf61f6fa8029d74dd93d180e2b0f4692bb8ee8a88f154fbbe3ed", "extra_info": {"page_label": "272", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1296, "_node_type": "1"}, "relationships": {"1": "0b452979-6d92-483c-9c4a-e658f7f7c57e"}}, "__type__": "1"}, "a6dacf3f-50a3-449d-b9db-eb3b69390aea": {"__data__": {"text": "MVASI\nRequired\nMedical\nInformation\nAvastin (bevacizumab), Alymsys (bevacizumab-\nmaly) and Vegzelma (bevacizumab-adcd) oncology requests: must have \nan intolerance or contraindication with Mvasi or Zirabev. Metastatic \ncolorectal cancer: metastatic colorectal cancer AND 1 of the following \napply: using bevacizumab in combo with fluoropyrimidine (e.g., 5-\nfluorouracil or capecitabine) based chemo for 1st or 2nd-line therapy OR \nin combo with fluoropyrimidine-irinotecan or fluoropyrimidine-oxaliplatin-\nbased chemo for 2nd-line therapy in patients who have progressed on \n1st-line bevacizumab-containing regimens. Non-small cell lung cancer \n(non-squamous cell histology). NSCLC with non-squamous cell histology \nAND using bevacizumab in combo with cisplatin or carboplatin based \nregimens for unresectable, locally advanced, recurrent, or metastatic \nNSCLC AND 1 of the following apply: for 1st line therapy OR as \nsubsequent therapy immediately after 1 of the following situations:  \nEGFR mutation-positive tumors after prior therapy [if cytotoxic therapy \nnot previously given] OR ALK-positive tumors after prior therapy [if \ncytotoxic therapy not previously given] OR ROS-1 positive disease after \nprior therapy [if cytotoxic therapy not previously given] OR \nPembrolizumab (with PD-L1 expression of greater than or equal to 1%) \nadministered as 1st line therapy and EGFR, ALK, BRAF V600E, and \nROS1 negative tumors (if cytotoxic therapy not previously given) OR has \nBRAF V600E positive disease (if cytotoxic therapy not previously given) \nOR using bevacizumab as single-agent continuation maintenance \ntherapy if bevacizumab was used as 1st line treatment for recurrence or \nmetastasis OR has disease with no EGFR or ALK genomic tumor \naberrations AND bevacizumab will be given in combo with carboplatin \nand paclitaxel and Tecentriq as 1st line therapy followed by maintenance \ntherapy with combo Tecentriq and bevacizumab. Hepatocellular \ncarcinoma:  unresectable or metastatic HCC AND used will be used as \n1st line therapy in combo with Tecentriq.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration. Ocular indications: Plan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 273 of 497\n", "doc_id": "a6dacf3f-50a3-449d-b9db-eb3b69390aea", "embedding": null, "doc_hash": "ee81a4018a4780266cc90facdb023e94c862d8fd92eff3c4aea8dd0531c377e1", "extra_info": {"page_label": "273", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2248, "_node_type": "1"}, "relationships": {"1": "81308c8a-2f9d-435a-8e09-775896c8e395"}}, "__type__": "1"}, "3cac6de3-595c-4cc6-8b18-56a969b78536": {"__data__": {"text": "MVASI\nOther Criteria\nMetastatic breast cancer (Effectiveness based on improvement in \nprogression-free survival. No data available demonstrating improvement \nin disease-related symptoms or survival with bevacizumab). Member has \nmetastatic HER-2 negative breast cancer AND is using bevacizumab in \ncombo with paclitaxel. Recurrent Ovarian Cancer. Bevacizumab is being \nused to treat recurrent or persistent ovarian cancer for 1 of the following \nsituations: in combo with liposomal doxorubicin or weekly paclitaxel or \ntopotecan for platinum resistant disease or as monotherapy or in combo \nwith carboplatin and gemcitabine for platinum sensitive disease. Stage \nIV/Metastatic (Unresectable) RCC. Member has RCC and is using \nbevacizumab to treat stage IV unresectable kidney cancer in combo with \ninterferon alpha OR is using bevacizumab as systemic therapy for non-\nclear cell histology. Recurrent Primary CNS Tumor (including \nGlioblastoma multiforme). Diagnosis of progressive or recurrent \nglioblastoma or anaplastic glioma AND Bevacizumab is being used as a \nsingle agent or in combo with irinotecan, carmustine, lomustine or \ntemozolomide. Member does not have a CNS hemorrhage. Soft Tissue \nSarcoma. Diagnosis of angiosarcoma and bevacizumab is being used as \na single agent OR member has a diagnosis of solitary fibrous tumor and \nhemangiopericytoma and bevacizumab is being used in combo with \ntemozolomide. Macular Retinal Edema. Avastin is being used to treat \ncentral or branch retinal vein occlusion with macular retinal edema. \nCervical Cancer: member has recurrent, or metastatic cervical cancer \nAND Bevacizumab will be used in combo with paclitaxel and cisplatin or \ncarboplatin and paclitaxel or paclitaxel and topotecan as first line \ntherapy. Endometrial Cancer: progressive endometrial cancer AND \nBevacizumab will be used as a single-agent.  Malignant Pleural \nMesothelioma. Diagnosis of unresectable malignant pleural \nmesothelioma and bevacizumab will be used in combo with cisplatin and \npemetrexed followed by bevacizumab monotherapy for maintenance \ntherapy (for responders). Epithelial ovarian, fallopian tube, or primary \nperitoneal cancer:  Diagnosis of epithelial ovarian, fallopian tube or \nprimary peritoneal cancer AND has Stage III or IV disease AND \nbevacizumab is initially being given in combo with carboplatin and \npaclitaxel after initial surgical resection followed by bevacizumab \nmonotherapy OR advanced epithelial ovarian, fallopian tube or primary \nperitoneal cancer AND disease is associated with homologous \nrecombination deficiency (HRD) positive status defined by either: a \ndeleterious or suspected deleterious BRCA mutation OR genomic \ninstability as defined by FDA approved test AND Member is in complete \nresponse or partial response to 1st line treatment with platinum-based \nchemo AND Bevacizumab is given in combo with Lynparza. Age Related \nMacular Degeneration (Avastin requests only). Diabetic Macular Edema \n(Avastin requests only).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 274 of 497\n", "doc_id": "3cac6de3-595c-4cc6-8b18-56a969b78536", "embedding": null, "doc_hash": "51b13133ea9f64520df2d8ce83ad33e1084e93f39b1e42a8bf7a727cc3e8970a", "extra_info": {"page_label": "274", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 3068, "_node_type": "1"}, "relationships": {"1": "1a5972b4-cd29-429f-a8ec-6b2ab6beb073"}}, "__type__": "1"}, "97193ef7-ac5d-4541-bd90-b235fc1dc844": {"__data__": {"text": "MYALEPT\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nPartial lipodystrophy OR Liver disease including non-alcoholic \nsteatohepatitis (NASH) OR HIV related lipodystophy OR Diabetes \nmellitus and hypertriglyceridemia without concurrent evidence of \ncongenital or acquired generalized lipodystrophy OR Generalized \nobesity not associated with congenital leptin deficiency.\nRequired\nMedical\nInformation\nCongenital of Acquired Lipodystrophy: The member has a diagnosis of \ncongenital OR acquired generalized lipodystrophy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 275 of 497\n", "doc_id": "97193ef7-ac5d-4541-bd90-b235fc1dc844", "embedding": null, "doc_hash": "c10794d9e97cc4f0696ce8778f63501ea5fbeca65e4fa96a11a9087294a458bc", "extra_info": {"page_label": "275", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 729, "_node_type": "1"}, "relationships": {"1": "66e468b7-4c21-40d2-a900-0ee735401d7b"}}, "__type__": "1"}, "c90eb876-9688-4547-84ae-72b5ceedfa78": {"__data__": {"text": "MYLOTARG\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMember has experienced disease progression on Mylotarg \n(gemtuzumab ozogamicin)\nRequired\nMedical\nInformation\nAcute Myelogenous Leukemia: The member has a diagnosis of acute \nmyeloid leukemia (AML) AND the member has documented CD\n33\n-\npositive disease AND One of the following applies: the member has \nnewly-diagnosed disease and is an adult or pediatric patient one month \nor older OR the member has relapsed/refractory disease and is an adult \nor pediatric patient \n2\n years and older.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nNewly dx AML:6 months(max 1 cycle induction-8 cycles consolidation) \nRel/Ref AML:3months(max 1 cycle)\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 276 of 497\n", "doc_id": "c90eb876-9688-4547-84ae-72b5ceedfa78", "embedding": null, "doc_hash": "32cf77a8997a8fd3b425a9e96173aacc08f1d47567edf2e842e03ef45813faa9", "extra_info": {"page_label": "276", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 839, "_node_type": "1"}, "relationships": {"1": "0e0cb180-f887-4458-bed6-35464a266f7d"}}, "__type__": "1"}, "f39c49e5-a9e2-42a4-a561-1846d3d5a97b": {"__data__": {"text": "NATPARA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nPatients with hypoparathyroidism caused by calcium-sensing receptor \nmutations.Patients with acute post-surgical hypoparathyroidism due to \nsurgery within the past 4 months.\nRequired\nMedical\nInformation\nHypocalcemia in patients with hypoparathyroidism: Member must have a \ndiagnosis of hypocalcemia secondary to hypoparathyroidism\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 277 of 497\n", "doc_id": "f39c49e5-a9e2-42a4-a561-1846d3d5a97b", "embedding": null, "doc_hash": "84a0dc01c27bf5fc495f0f45ac34880e22edbcf7e5c0e99b6e4d9bd50a69dc9e", "extra_info": {"page_label": "277", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 595, "_node_type": "1"}, "relationships": {"1": "6cef2fb0-b427-4e6f-a6e6-14933765b29c"}}, "__type__": "1"}, "4b9759b5-0d72-46aa-ae7e-60aa904a0a0e": {"__data__": {"text": "NERLYNX\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMember has disease progression on Nerlynx (neratinib). Member is \ntaking Nerlynx (neratinib) total treatment for more than one year \n[applicable only to early stage breast cancer].\nRequired\nMedical\nInformation\nEarly stage Breast Cancer: Initial Therapy. The member has early stage \n(i.e. Stage I, II, III) documented HER2 + positive disease AND The \nmember has completed adjuvant therapy with a trastuzumab containing \ntreatment AND Nerlynx (neratinib) is being used for the treatment in \nextended adjuvant setting AND The member is taking antidiarrheal \nprophylaxis (loperamide) concomitantly during the first two cycles. \nContinuation of therapy. The member is not experiencing any of the \nfollowing situations: Grade 4 any adverse event [e.g., diarrhea, ALT \n(greater than 20 times ULN), bilirubin (greater than 10 times ULN)], \nGreater than or equal to grade 2 diarrhea with Nerlynx (neratinib dosing \nof 120mg per day AND If any of the above severe adverse reactions \nhave been experienced, then provider has given a rationale for benefit of \ncontinued use that outweighs risk. Metastatic Breast Cancer.  The \nmember has metastatic or advanced breast cancer and all of the \nfollowing apply:  The member has documented HER2 positive disease \nand The member has received two or more prior anti-HER2 based \nregimens in the metastatic setting and Nerlynx (neratinib) is given in \ncombination with capecitabine.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nEarly stage: Initial - 3 months, Continuation therapy- 9 months. \nMetastatic or advanced: 6 months\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 278 of 497\n", "doc_id": "4b9759b5-0d72-46aa-ae7e-60aa904a0a0e", "embedding": null, "doc_hash": "5103f73893757a1774fec31b960c4c2af2974e979c273a42da6ec19568a5ead8", "extra_info": {"page_label": "278", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1759, "_node_type": "1"}, "relationships": {"1": "01cb1b4c-cc47-4f16-bf45-7b5a6447f76f"}}, "__type__": "1"}, "c73a8c23-3ed7-4084-945b-940d3b56ebfc": {"__data__": {"text": "NEULASTA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant use with filgrastim, biosimilar filgrastim (e.g. filgastrim-sndz \nor filgastrim-aafi), tbo-filgratim, sargramostim (unless part of stem cell \nmobilization protocol), pegfilgrastim (within seven days of pegfilgrastim \ndose), or biosimiliar pegfilgrastim (e.g. pegfilgrastim-jmbd or \npegfilgastrim-cbqv, within seven days of pegfilgrastim dose). Same day \nadministration with myelosuppressive chemotherapy or therapeutic \n(Administration of pegfilgrastim occurs no less than 24 hours following \nmyelosuppressive chemotherapy).  Cannot be given more than once per \nchemotherapy cycle.\nRequired\nMedical\nInformation\nFebrile Neutropenia Prophylaxis. The member must have a diagnosis of \nnon-myeloid malignancy (e.g. solid tumors) AND The member has \nreceived or will receive pegfilgrastim product 24-72 hours after the \nadministration of myelosuppressive chemotherapy AND The member \nmust also meet ONE OR MORE of the following criteria: A risk of febrile \nneutropenia (FN) of greater than 20% based on current chemotherapy \nregimen (as listed in current ASCO and NCCN guidelines for myeloid \ngrowth factors) OR A risk of febrile neutropenia of 10-20% based on \nchemotherapy regimen, and one or more of the following risk factors \napply: Prior chemotherapy or radiation therapy OR Persistent \nneutropenia (defined as neutrophil count less than 500 neutrophils/mcL \nor less than 1,000 neutrophils/mcL and a predicted decline to less than \nor equal to 500 neutrophils/mcL over next 48 hours) OR Bone marrow \ninvolvement by tumor OR Recent surgery and/or open wounds OR Liver \ndysfunction (bilirubin greater than 2.0 mg/dL) OR Renal dysfunction \n(creatinine clearance less than 50 mL/min) OR Age greater than 65 \nreceiving full chemotherapy dose intensity OR Previous neutropenic \nfever complication or dose-limiting neutropenic event from a prior cycle \nof similar chemotherapy OR The member is receiving a dose-dense \nchemotherapy regimen OR As secondary prophylaxis in the curative \nsetting to maintain dosing schedule and/or intensity.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n4 months duration\nOther Criteria\nHematopoietic Subsyndrome of Acute Radiation Syndrome. The \nmember has been acutely exposed to myelosuppressive doses of \nnontherapeutic radiation.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 279 of 497\n", "doc_id": "c73a8c23-3ed7-4084-945b-940d3b56ebfc", "embedding": null, "doc_hash": "586926c7f0998b016d8d858c3ce54235056cf1dc81097bb6b5167ff07356bf72", "extra_info": {"page_label": "279", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2449, "_node_type": "1"}, "relationships": {"1": "3c430dd1-ed89-4dc1-8514-f8865fbbecb4"}}, "__type__": "1"}, "955fecd9-cc4d-4682-8aa5-6513c8bfcc84": {"__data__": {"text": "NEULASTA ONPRO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant use with filgrastim, biosimilar filgrastim (e.g. filgastrim-sndz \nor filgastrim-aafi), tbo-filgratim, sargramostim (unless part of stem cell \nmobilization protocol), pegfilgrastim (within seven days of pegfilgrastim \ndose), or biosimiliar pegfilgrastim (e.g. pegfilgrastim-jmbd or \npegfilgastrim-cbqv, within seven days of pegfilgrastim dose). Same day \nadministration with myelosuppressive chemotherapy or therapeutic \n(Administration of pegfilgrastim occurs no less than 24 hours following \nmyelosuppressive chemotherapy).  Cannot be given more than once per \nchemotherapy cycle.\nRequired\nMedical\nInformation\nFebrile Neutropenia Prophylaxis. The member must have a diagnosis of \nnon-myeloid malignancy (e.g. solid tumors) AND The member has \nreceived or will receive pegfilgrastim product 24-72 hours after the \nadministration of myelosuppressive chemotherapy AND The member \nmust also meet ONE OR MORE of the following criteria: A risk of febrile \nneutropenia (FN) of greater than 20% based on current chemotherapy \nregimen (as listed in current ASCO and NCCN guidelines for myeloid \ngrowth factors) OR A risk of febrile neutropenia of 10-20% based on \nchemotherapy regimen, and one or more of the following risk factors \napply: Prior chemotherapy or radiation therapy OR Persistent \nneutropenia (defined as neutrophil count less than 500 neutrophils/mcL \nor less than 1,000 neutrophils/mcL and a predicted decline to less than \nor equal to 500 neutrophils/mcL over next 48 hours) OR Bone marrow \ninvolvement by tumor OR Recent surgery and/or open wounds OR Liver \ndysfunction (bilirubin greater than 2.0 mg/dL) OR Renal dysfunction \n(creatinine clearance less than 50 mL/min) OR Age greater than 65 \nreceiving full chemotherapy dose intensity OR Previous neutropenic \nfever complication or dose-limiting neutropenic event from a prior cycle \nof similar chemotherapy OR The member is receiving a dose-dense \nchemotherapy regimen OR As secondary prophylaxis in the curative \nsetting to maintain dosing schedule and/or intensity.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n4 months duration\nOther Criteria\nHematopoietic Subsyndrome of Acute Radiation Syndrome. The \nmember has been acutely exposed to myelosuppressive doses of \nnontherapeutic radiation.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 280 of 497\n", "doc_id": "955fecd9-cc4d-4682-8aa5-6513c8bfcc84", "embedding": null, "doc_hash": "e58228ea1fac30da91d145d2a952351be42527972d4e9f32bd2407d50b516360", "extra_info": {"page_label": "280", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2455, "_node_type": "1"}, "relationships": {"1": "cff80025-df10-49be-9301-6b2836922236"}}, "__type__": "1"}, "0038f1f2-7755-454e-be67-97aa6fc46bd0": {"__data__": {"text": "NEXLETOL\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nMember must meet all of the following criteria:  Diagnosis of \nheterozygous familial hypercholesterolemia (HeFH) OR established \natherosclerotic cardiovascular disease (ASCVD).  One of the following: \nUsed as adjunctive therapy after failure to achieve goal LDL-C reduction \non maximally-tolerated statin (e.g., atorvastatin, rosuvastatin, \nsimvastatin, pravastatin, lovastatin) OR Statin Intolerant (e.g., has \nsymptoms of rhabdomyolysis, statin-associated muscle symptoms).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 281 of 497\n", "doc_id": "0038f1f2-7755-454e-be67-97aa6fc46bd0", "embedding": null, "doc_hash": "e5bf9bb3c8e4f4fcc6f6933ffae53d2c7187261c1eabb26b8f12749a6048f8a3", "extra_info": {"page_label": "281", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 764, "_node_type": "1"}, "relationships": {"1": "749cd542-5c14-4707-b708-2d5f5ae288ab"}}, "__type__": "1"}, "e730bf65-1ec8-490e-b04a-ab55149a2c0c": {"__data__": {"text": "NEXLIZET\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nMember meets all of the following criteria:  Diagnosis of heterozygous \nfamilial hypercholesterolemia (HeFH) OR established atherosclerotic \ncardiovascular disease (ASCVD).  One of the following: Used as \nadjunctive therapy after failure to achieve goal LDL-C reduction on \nmaximally-tolerated statin (e.g., atorvastatin, rosuvastatin, simvastatin, \npravastatin, lovastatin) OR Statin Intolerant (e.g., has symptoms of \nrhabdomyolysis, statin-associated muscle symptoms).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 282 of 497\n", "doc_id": "e730bf65-1ec8-490e-b04a-ab55149a2c0c", "embedding": null, "doc_hash": "6cc3ea426a05c04151f3871b2a52b40364cab9c4ee5ba789791ffd67083d4d55", "extra_info": {"page_label": "282", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 772, "_node_type": "1"}, "relationships": {"1": "bdde8bcf-c9c4-42a0-936a-d8cc8ec932e8"}}, "__type__": "1"}, "6515052e-4dc8-49e7-a11d-15dfae7deb7a": {"__data__": {"text": "NINLARO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant use with proteasome inhibitors. Members with disease \nprogression on Ninlaro (ixazomib).\nRequired\nMedical\nInformation\nMultiple Myeloma: second line. The member has a diagnosis of relapsed \nor refractory multiple myeloma AND Ninlaro (ixazomib) will be used after \ndisease progression on at least one prior therapy AND Ninlaro \n(ixazomib) will be used in combination with either dexamethasone OR \nlenalidomide and dexamethasone or cyclophosphamide and \ndexamethasone (Omission of corticosteroid from regimen is allowed if \nintolerance/contraindication).  Multiple Myeloma: third line or \nsubsequent. The member has a diagnosis of relapsed or refractory \nmultiple myeloma AND Ninlaro (ixazomib) will be used after disease \nprogression on at least two prior therapies AND Ninlaro (ixazomib) will \nbe used in combination with pomalidomide and dexamethasone \n(Omission of corticosteroid from regimen is allowed if \nintolerance/contraindication) AND The members has demonstrated \ndisease progression on or within 60 days of completion of the last \ntherapy.  Multiple Myeloma (maintenance): The member has a diagnosis \nof multiple myeloma AND Ninlaro (ixazomib) will be used as \nmonotherapy AND Ninlaro (ixazomib) will be used as maintenance \ntherapy.  Multiple Myeloma: primary therapy.  The member has a \ndiagnosis of symptomatic multiple myeloma AND The request is for \nprimary therapy AND One of the following sets of criteria applies: In \ncombination with lenalidomide and dexamethasone AND member is not \na transplant candidate OR in combination with cyclophosphamide and \ndexamethasone AND member is a transplant candidate.  (Omission of \ncorticosteroid from regimen is allowed if intolerance/contraindication).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 283 of 497\n", "doc_id": "6515052e-4dc8-49e7-a11d-15dfae7deb7a", "embedding": null, "doc_hash": "5941607df7694b294118d43d3be44ae4c71eee1e67f4a3d8a401add97641cdb5", "extra_info": {"page_label": "283", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1980, "_node_type": "1"}, "relationships": {"1": "336abce8-ec2c-4360-a948-5e01dd0d7783"}}, "__type__": "1"}, "ec29bb5c-6b44-4086-a389-d20f6ac21da4": {"__data__": {"text": "NIVESTYM\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant use with filgrastim, biosimilar filgrastim (e.g. filgrastim-sndz \nor filgrastim-aafi), tbo-filgrastim, sargramostim (unless part of stem cell \nmobilization protocol), pegfilgrastim (within seven days of pegfilgrastim \ndose), or biosimiliar pegfilgrastim (e.g. pegfilgrastim-jmbd or \npegfilgastrim-cbqv, within seven days of pegfilgrastim dose).\nRequired\nMedical\nInformation\nNeutropenia in Myelodysplastic Syndromes. The member must have a \ndiagnosis of neutropenia associated with myelodysplastic syndrome.  \nTreatment of Febrile Neutropenia:  The member must have a diagnosis \nof febrile neutropenia AND filgrastim product must be used in adjunct \nwith appropriate antibiotics in high risk members. Febrile Neutropenia \nProphylaxis, In non-myeloid malignancies following myelosuppressive \nchemotherapy: The member must have a diagnosis of non-myeloid \nmalignancy (e.g. breast cancer, lung cancer) AND The member has \nreceived or will receive filgrastim product 24-72 hours after the \nadministration of  myelosuppressive chemotherapy AND The member \nmust also meet ONE OR MORE of the following criteria:  A risk of febrile \nneutropenia (FN) of greater than 20% based on current chemotherapy \nregimen (as listed in current ASCO and NCCN guidelines for myeloid \ngrowth factors) OR A risk of febrile neutropenia of 10-20% based on \nchemotherapy regimen and one or more of the following risk factors \napply:  Prior chemotherapy or radiation therapy, Persistent neutropenia \n(defined as neutrophil count less than 500 neutrophils/mcL or less than \n1,000 neutrophils/mcL and a predicted decline to less than or equal to \n500 neutrophils/mcL over next 48 hours), Bone marrow involvement by \ntumor, Recent surgery and/or open wounds, Liver dysfunction (bilirubin \ngreater than 2.0 mg/dL), Renal dysfunction (creatinine clearance less \nthan 50 mL/min), Age greater than 65 receiving full chemotherapy dose \nintensity OR Previous neutropenic fever complication or dose-limiting \nneutropenic event from a prior cycle of similar chemotherapy OR The \nmember is receiving a dose-dense chemotherapy regimen OR As \nsecondary prophylaxis in the curative setting to maintain dosing \nschedule and/or intensity\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n4 Months Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 284 of 497\n", "doc_id": "ec29bb5c-6b44-4086-a389-d20f6ac21da4", "embedding": null, "doc_hash": "dee8decf6f0d7b20bb20210651f643523d1b04ea5ab51fdfbead69aeb9bddd84", "extra_info": {"page_label": "284", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2423, "_node_type": "1"}, "relationships": {"1": "384768ff-e2aa-40ca-912f-5b6416124c3a"}}, "__type__": "1"}, "4fae2431-af9b-4060-8a32-32cddc5e4291": {"__data__": {"text": "NIVESTYM\nOther Criteria\nFebrile Neutropenia Prophylaxis, in members with acute myeloid \nleukemia receiving chemotherapy:  The member must have a diagnosis \nAcute Myeloid Leukemia (AML). The member must be receiving either \ninduction chemotherapy OR consolidation Chemotherapy AND The \nmember is not administering filgrastim product earlier than 24 hours after \ncytotoxic chemotherapy or within 24 hours before chemotherapy. Febrile \nNeutropenia Prophylaxis, In non-myeloid malignancies following \nHematopoietic Stem Cell Transplant (HCST):  The member must have \nhad a Hematopoietic Stem Cell Transplant (HCST) (e.g. bone marrow \ntransplant, peripheral-blood progenitor cell (PBPC) transplant) for a non-\nmyeloid malignancy AND The member is not administering filgrastim \nproduct earlier than 24 hours after cytotoxic chemotherapy or within 24 \nhours before chemotherapy Harvesting of peripheral blood stem \ncells.The member must be scheduled for autologous peripheral-blood \nstem cell (PBSC) transplantation, storing cells for a possible future \nautologous transplant, or donating stem cells for an allogeneic or \nsyngeneic PBSC transplant. Neutropenic disorder, chronic (Severe), \nSymptomatic:  The member must have a diagnosis of congenital, cyclic, \nor idiopathic neutropenia. Neutropenia in AIDS patients. The member \nmust have a diagnosis of AIDS with neutropenia. Treatment of Aplastic \nAnemia. The member must have a diagnosis of Aplastic Anemia. \nTreatment of Agranulocytosis.The member must have a diagnosis of \ncongenital or drug induced agranulocytosis. Hematopoietic Syndrome of \nAcute radiation syndrome. The member has been acutely exposed to \nmyelosuppressive doses of radiation.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 285 of 497\n", "doc_id": "4fae2431-af9b-4060-8a32-32cddc5e4291", "embedding": null, "doc_hash": "c532d623ad6afb76f5251804b368d58299560f1ce94655a95b5f1be1ad20eaa2", "extra_info": {"page_label": "285", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1770, "_node_type": "1"}, "relationships": {"1": "776d0b00-5b8a-4b45-b458-ef32f5193812"}}, "__type__": "1"}, "d1363008-a323-44bf-b2aa-1da950980fcc": {"__data__": {"text": "NOXAFIL\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nProphylaxis against Invasive Aspergillus and Candida Infections. The \nmember must be using it for prophylaxis against invasive Aspergillus or \nCandida infections, and The member must be severely \nimmunocompromised (such as hematopoietic stem cell transplant \nrecipient with graft-vs-host disease, or neutropenic patients with acute \nmyelogenous leukemia (AML) or myelodysplastic syndromes \n(MDS).Treatment of invasive Aspergillus or fungal infections caused by \nFusarium and/or Zygomycetes. The member must have documentation \nfor treatment of invasive Aspergillus or fungal infections caused by \nFusarium and/or Zygomycetes, and The member must have documented \nresistant strains of or clinically refractory to standard antifungal agents \n(e.g. voriconazole, itraconazole) or those who can not receive other \nantifungal agents due to potential toxicities, intolerance, or \ncontraindications.Treatment of Oropharyngeal or Esophageal \nCandidiasis.The member must have a diagnosis for orpharnygeal or \nesophageal candidiasis and The member has a documented inadequate \nresponse/refractory or intolerant to itraconazole and fluconazole.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 286 of 497\n", "doc_id": "d1363008-a323-44bf-b2aa-1da950980fcc", "embedding": null, "doc_hash": "b71c6f327b4ca6fe5644334ef25aa932f5d2a1a04b2b321d83b259f29de2fd64", "extra_info": {"page_label": "286", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1421, "_node_type": "1"}, "relationships": {"1": "b4c149af-53d6-4255-9210-7d4d7357e3c2"}}, "__type__": "1"}, "f727b4fb-6d3b-430b-a0c3-bcb7f59f7046": {"__data__": {"text": "NUBEQA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on Nubeqa \n(darolutamide). Concomitant use with an androgen receptor inhibitor or \nandrogen synthesis inhibitor (e.g. enzalutamide, abiraterone, nilutamide, \nflutamide, bicalutamide) due to lack of evidence supporting efficacy and \nsafety.\nRequired\nMedical\nInformation\nProstate Cancer (non-metastatic castration-resistant): The member has \na diagnosis of non-metastatic castration-resistant prostate cancer AND \nthe member will use Nubeqa (darolutamide) in combination with \nandrogen deprivation therapy (e.g. previous bilateral orchiectomy or \nGnRH analog).  Prostate Cancer (metastatic hormone-sensitive prostate \ncancer):  The member has a diagnosis of metastatic hormone-sensitive \nprostate cancer AND the member will use Nubeqa (darolutamide) in \ncombination with docetaxel AND the member will use Nubeqa \n(darolutamide) in combination with androgen deprivation therapy (e.g. \nprevious bilateral orchiectomy or GnRH analog).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 287 of 497\n", "doc_id": "f727b4fb-6d3b-430b-a0c3-bcb7f59f7046", "embedding": null, "doc_hash": "97f1e5f704be4eee24ae333b87bd74e36a69869f4673f73837dd1b438503b957", "extra_info": {"page_label": "287", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1242, "_node_type": "1"}, "relationships": {"1": "462d23ff-7436-4a2c-ade2-41f55927ca03"}}, "__type__": "1"}, "f6f2655c-1288-4b4f-9929-3ba335aefab2": {"__data__": {"text": "NUCALA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nSevere Asthma with an Eosinophilic Phenotype: The member has a \ndiagnosis of severe asthma AND the member has an eosinophilic \nphenotype, defined by an elevated peripheral blood eosinophil level of  \ngreater than or equal to 150 cells/microliter at therapy initiation OR \ngreater than or equal to 300 cells/microliter in the previous 12 months. \nThe member has been unable to achieve adequate control of asthma \nwhile on maximum tolerated inhaled corticosteroid therapy (e.g. \nmometasone greater than 400mcg daily, fluticasone greater than 440 \nmcg daily) in combination with a long acting beta agonist (e.g. \nformoterol).  Continuation of therapy:  Member is currently stable on \ntherapy. Member will continue on asthma controller inhalers: inhaled \ncorticosteroids (ICS) with or without a long-acting beta2-agonist (LABA). \nEosinophilic Granulomatosis with Polyangiitis (EGPA): The member has \na diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA) AND \nthe member has a baseline elevated peripheral blood eosinophil level of \ngreater than 10% of total leukocyte count AND two or more systemic \nmanifestations of EGPA.  The member has been unable to achieve \nadequate control of EGPA while on oral corticosteroid therapy (e.g. \nprednisone, methylprednisolone).  Hypereosinophilic Syndrome (HES) - \nNucala only:  The member has a diagnosis of hypereosinophilic \nsyndrome (HES) for at least 6 months AND The member has a baseline \nblood eosinophil level of greater than or equal to 1000 cells/microliter.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nChronic Rhinosinusitis with Nasal Polyposis - Nucala Only:  Initial \nReview- The member must meet ALL of the following criteria:  Diagnosis \nof Chronic Rhinosinusitis with Nasal Polyposis AND Nucala \n(mepolizumab) will be used in conjunction with a daily intranasal \ncorticosteroid spray AND member is unable to achieve adequate control \nof symptoms with maximum tolerated intranasal corticosteroid therapy.  \nContinuation of Therapy - The member must meet ALL of the following \ncriteria:  Improvement in symptoms (e.g., decrease in nasal congestion, \ndecrease in polyp size, improvement in ability to smell) which has been \nsustained AND continuing intranasal corticosteroid spray therapy.\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 288 of 497\n", "doc_id": "f6f2655c-1288-4b4f-9929-3ba335aefab2", "embedding": null, "doc_hash": "d26aba8762b31362a12c8f59e7682f3eb03daf502e0470eb00dea1a60c209c68", "extra_info": {"page_label": "288", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2472, "_node_type": "1"}, "relationships": {"1": "414ecf77-57d4-413a-94ae-750508e5ed94"}}, "__type__": "1"}, "a38bb385-df45-4fd4-b059-8b0dea2bbb6d": {"__data__": {"text": "NUCALA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 289 of 497\n", "doc_id": "a38bb385-df45-4fd4-b059-8b0dea2bbb6d", "embedding": null, "doc_hash": "3902ae7a7307a0f51aa204c6fe89dbf4c8f25878bc3fb297bcfd07c98f4bfff0", "extra_info": {"page_label": "289", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 81, "_node_type": "1"}, "relationships": {"1": "4171b3ff-2964-4db9-8628-002c92bce3b9"}}, "__type__": "1"}, "2f907a19-b6d3-4e7f-9fec-a8d6d7547a9f": {"__data__": {"text": "NUEDEXTA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nPseudobulbar Affect: The member must have a diagnosis of \nPseudobulbar Affect (PBA) secondary to brain injury or underlying \nneurologic disease (e.g., stroke, multiple sclerosis, ALS, Parkinson's \ndisease, traumatic brain injury) AND The member is experiencing \ncharacteristic behavior episodes (e.g inappropriate laughing or crying) \nconsistent with PBA at baseline AND the provider attests that the risk of \nQT prolongation with Nuedexta has been considered, and benefits of \ntreatment outweigh risks.  Reauthorization: Documented improvement in \nbehavior with Nuedexta (e.g. reduction in episodes of inappropriate \nlaughing or crying) AND the provider attests that the risk of QT \nprolongation with Nuedexta has been considered, and benefits of \ntreatment outweigh risks.\nAge Restriction\nMember must be 18 years of age or older\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial and Reauth:  Plan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 290 of 497\n", "doc_id": "2f907a19-b6d3-4e7f-9fec-a8d6d7547a9f", "embedding": null, "doc_hash": "f365d5f79f2c1e926fcae2f52efd3b99818b5a8e6f8c085d04766ea088175bd2", "extra_info": {"page_label": "290", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1133, "_node_type": "1"}, "relationships": {"1": "af5f1c45-7c22-4c70-99a6-98d8cb2721bd"}}, "__type__": "1"}, "9865f2ad-f6a1-467e-8ff7-85b77c5ee8c6": {"__data__": {"text": "NUPLAZID\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nDementia related psychosis(in the absence of an approvable \ndiagnosis)for members 65 years of age or older.\nRequired\nMedical\nInformation\nParkinson's Disease Psychosis: The member is using Nuplazid for the \ntreatment of hallucinations and delusions associated with Parkinson's \ndisease (PD) psychosis AND the symptoms of psychosis have appeared \nafter the diagnosis of PD AND psychosis is not related to other causes \nother than PD. Reauthorization: Documentation must be provided \ndemonstrating an improvement in symptoms of psychosis.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial authorization: 3 months. Reauthorization: 6 months.\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 291 of 497\n", "doc_id": "9865f2ad-f6a1-467e-8ff7-85b77c5ee8c6", "embedding": null, "doc_hash": "09c68b04858cd3c1f9c6caa730431addf7e46d39090d543e74fc3802f9c32d0b", "extra_info": {"page_label": "291", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 845, "_node_type": "1"}, "relationships": {"1": "2a48de98-0286-414d-a6db-3aee15c99be6"}}, "__type__": "1"}, "dcd7e421-86ff-4257-b1c6-a572af7a1084": {"__data__": {"text": "nyamyc\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nMember must be using topically for the treatment active cutaneous or \nmucocutaneous candidiasis.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 292 of 497\n", "doc_id": "dcd7e421-86ff-4257-b1c6-a572af7a1084", "embedding": null, "doc_hash": "5288d8602834d1ecf55e72bb312248df106ff1d2df950348fb5702ceebc8193b", "extra_info": {"page_label": "292", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 395, "_node_type": "1"}, "relationships": {"1": "3a8df7df-0ae3-4bfd-ac1d-42ba092c7d6b"}}, "__type__": "1"}, "43ada732-52bc-4fb6-9c15-b2638262c489": {"__data__": {"text": "nystatin\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nMember must be using topically for the treatment active cutaneous or \nmucocutaneous candidiasis.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 293 of 497\n", "doc_id": "43ada732-52bc-4fb6-9c15-b2638262c489", "embedding": null, "doc_hash": "53cb4a9ec7e8c1eecf8768103d7c01b7c311e353ac2fe519f9985fd470cff3bc", "extra_info": {"page_label": "293", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 397, "_node_type": "1"}, "relationships": {"1": "ec850558-5fe6-48b8-b194-602252973974"}}, "__type__": "1"}, "7c254f65-67de-43a8-bf9c-453305b0913c": {"__data__": {"text": "nystop\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nMember must be using topically for the treatment active cutaneous or \nmucocutaneous candidiasis.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 294 of 497\n", "doc_id": "7c254f65-67de-43a8-bf9c-453305b0913c", "embedding": null, "doc_hash": "e8fc83ac2ad82677b11cb4613efdbd2b8ceca4072edb37f97155ea520a2a519f", "extra_info": {"page_label": "294", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 395, "_node_type": "1"}, "relationships": {"1": "24a41545-a3fc-4622-a3bb-c00df3d5db67"}}, "__type__": "1"}, "0ed4d19c-a44b-46a4-a741-c9fa1b3ee5f4": {"__data__": {"text": "octreotide acetate\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nAcromegaly: The member must have a diagnosis of Acromegaly. Must \nhave had an inadequate response to surgery/radiation or for whom \nsurgical resection/radiation is not an option.  Treatment of metastatic \ncarcinoid tumors.  Must have a diagnosis of a carcinoid tumor. Patient \nmust have severe diarrhea and flushing resulting from carcinoid tumor. \nTreatment of vasoactive intestinal peptide tumors (VIPomas). Patient \nmust be diagnosed with a vasoactive intestinal peptide tumor. Patient \nmust have diagnosis of profuse watery diarrhea associated with VIP-\nsecreting tumor. Treatment of chemotherapy or radiation induced \ndiarrhea. Patient must have grade 3 or above diarrhea according to NCI \ncommon toxicity. Patient must have NCI grade 1 or 2 diarrhea and have \nfailed treatment with loperamide or diphenoxylate and atropine. \nTreatment of severe secretory diarrhea in acquired immune deficiency \nsyndrome (AIDS) patients.  Patient must have diagnosis of severe \ndiarrhea resulting from acquired immune deficiency syndrome (AIDS). \nPatient must have tried and failed antimicrobial agents (eg. ciprofloxacin \nor metronidazole) and/or anti-motility agents (eg. loperamide or \ndiphenoxylate and atropine). Reversal of life-threatening hypotension \ndue to carcinoid crisis during induction of anesthesia. Patient must have \nlife-threatening hypotension due to carcinoid crisis.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 295 of 497\n", "doc_id": "0ed4d19c-a44b-46a4-a741-c9fa1b3ee5f4", "embedding": null, "doc_hash": "52372f4d820d92df1d19a5080bb8c4840413760ab34c9724f81d2fe4230270e2", "extra_info": {"page_label": "295", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1688, "_node_type": "1"}, "relationships": {"1": "37d01a7f-8a52-4362-8b82-9c0def403bb2"}}, "__type__": "1"}, "03a16896-b01b-4385-9277-0490c71ea03f": {"__data__": {"text": "ODOMZO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on Odomzo.\nRequired\nMedical\nInformation\nBasal Cell Carcinoma:The member has a diagnosis of locally advanced \nor metastatic basal cell carcinoma AND The member has experienced \nrecurrence or disease progression following surgery or radiation OR has \na contraindication to surgery or radiation.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 296 of 497\n", "doc_id": "03a16896-b01b-4385-9277-0490c71ea03f", "embedding": null, "doc_hash": "17198ac5f239d40e4f9d3c038ae68705bd65315d3cc4ef41cee15db7e9830d34", "extra_info": {"page_label": "296", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 609, "_node_type": "1"}, "relationships": {"1": "9ecb09c7-a8ae-4ede-bd71-ba6c1bed02a2"}}, "__type__": "1"}, "4f89973b-478e-46f3-bc78-4cf742266554": {"__data__": {"text": "OFEV\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nThe member has a diagnosis of a Chronic Fibrosing Interstitial Lung \nDisease[ILD] (e.g., Idiopathic Pulmonary Fibrosis [IPF], Hypersensitivity \npneumonitis, Autoimmune ILD, Rheumatoid arthritis-associated ILD [RA-\nILD],  Systemic Sclerosis-associated ILD [SSc-ILD], Mixed Connective \nTissue Disease-associated ILD, Idiopathic non-specific interstitial \npneumonia, Unclassifiable Idiopathic Interstitial Pneumonia, Exposure-\nrelated ILDs, Sarcoidosis with Fibrosing ILD, in addition to other chronic \nfibrosing ILDs) confirmed by one of the following: Computer Tomography \n(CT) with evidence of fibrosis OR Lung Biopsy. Member has a \nprogressive phenotype confirmed by one of the following: Diagnosis is \nfor Idiopathic Pulmonary Fibrosis OR Has had a relative decline in FVC \nof at least 10% OR worsening respiratory symptoms OR increased \nextent of fibrotic change on CT scan.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 297 of 497\n", "doc_id": "4f89973b-478e-46f3-bc78-4cf742266554", "embedding": null, "doc_hash": "e710b25d5b5454a7cd2dc4a72c339fc1e1f703ea08437b4cede4d039b1168dc6", "extra_info": {"page_label": "297", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1162, "_node_type": "1"}, "relationships": {"1": "5dfdd7d6-b8aa-40f0-9540-53005d5051f8"}}, "__type__": "1"}, "8f8f06a8-f407-478d-b35a-43fd7aeed25f": {"__data__": {"text": "OMNITROPE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nPediatric growth hormone discontinuation. Increase in height velocity is \nless than 2 cm total growth in one year of therapy: OR Final adult height \nhas been achieved (member's calculated mid-parental height).The \nepiphyses have closed. Constitutional delay of growth and development. \nSkeletal dysplasias (e.g., achondroplasia, kyphomelic dysplasia). \nOsteogenesis imperfect. Somatopause in older adults. Infertility. Burn \ninjuries. Obesity/morbid obesity. Hypophosphatemia (hypophosphatemic \nrickets). Muscular dystrophy. Cystic fibrosis. Spina bifida. Juvenile \nrheumatoid arthritis. Osteoporosis. Post-traumatic stress disorder. \nDepression. Hypertension. Corticosteroid-induced pituitary ablation. \nPrecocious puberty. Chronic fatigue syndrome. Crohn's disease . Anti-\naging . Growth retardation due to amphetamines. Chronic catabolic \nstates, including respiratory failure, pharmacologic glucocorticoid \nadministration, and inflammatory bowel disease. Down syndrome and \nother syndromes associated with short stature and increased \nsusceptibility to neoplasms (Bloom syndrome, Fanconi syndrome).\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 298 of 497\n", "doc_id": "8f8f06a8-f407-478d-b35a-43fd7aeed25f", "embedding": null, "doc_hash": "9cc44d18ebe796b136889c2e598d2394ae94a23bb8cfada6792a434a0cebfaef", "extra_info": {"page_label": "298", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1227, "_node_type": "1"}, "relationships": {"1": "ca0cbef1-2f62-4bd2-b5cd-e1c8567310c1"}}, "__type__": "1"}, "e27fe8dd-f326-4ee9-bfd2-4b1ee0dee945": {"__data__": {"text": "OMNITROPE\nRequired\nMedical\nInformation\nGH Therapy in Adults (18 or older). Must have previous tx with \nOmnitrope. Adult-onset GHD either alone or with multiple hormone \ndeficiencies (hypopituitarism) as a result of pituitary, hypothalamic \ndisease, surgery, radiation, or trauma OR has a diagnosis of childhood-\nonset GHD. A subnormal response to two standard GH stimulation tests \n(1 must be insulin tolerance test [ITT]). If contraindication to ITT, a \nsubnormal response to a standardized stimulation test must be provided \nalong with Insulin like growth factor.  Acceptable tests are ITT,glucagon, \nand macimorelin test. Assay type must be documented. Subnormal \nresponse to ITT is defined as peak serum GH level less than or equal to \n5 ng/ml. Subnormal response to glucagon stimulation test is: Less than \nor equal to 3 mcg/L in patients with a BMI of less than 25 kg/m2 OR Less \nthan or equal to 3 mcg/L in patients with a BMI of 25 - 30 kg/m2 and high \npre-test probability, Less than or equal to 1 mcg/L in patients with a BMI \nof 25 - 30 kg/m2 and a low pre-test probability OR Less than or equal to \n1 mcg/L in patients with a BMI of greater than 30 kg/m2. Subnormal \nresponse to the macimorelin test is defined as peak serum GH level less \nthan or equal to 2.8 mcg/L. For ITT, blood glucose nadir of less than \n40mg/dL must be documented. Certain patient subtypes (e.g. those with \norganic hypothalamic-pituitary disease and biochemical evidence of \nmultiple pituitary hormone deficiencies (MPHD)) together with low-serum \nIGF-1 levels (less than -2.0 standard deviation score [SDS]) with genetic \ndefects affecting the hypothalamic-pituitary axes, and hypothalamic-\npituitary structural brain defects, can be diagnosed with adult GHD \nwithout performing GH-stimulation test. In patients with less than or \nequal to 2 pituitary hormone deficiencies, low-serum IGF-1 levels (less \nthan -2.0 SDS) alone are not enough for a diagnosis of adult GHD, one \nGH-stimulation test is required to confirm the diagnosis.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 299 of 497\n", "doc_id": "e27fe8dd-f326-4ee9-bfd2-4b1ee0dee945", "embedding": null, "doc_hash": "64ec383759adf12b7206cf43527f1caeaf3dc70ce800834fcc9d72cb76f4765f", "extra_info": {"page_label": "299", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2170, "_node_type": "1"}, "relationships": {"1": "ecede01a-446b-4293-b61c-d048af2c319f"}}, "__type__": "1"}, "2529215b-cf3b-41f9-98a7-e65d906a44ce": {"__data__": {"text": "OMNITROPE\nOther Criteria\nGHT in Children (less than 18). GH failure associated with GH \ndeficiency. Bone age is at least 1 year or 2 SDs delayed compared to \nchronological age AND epiphyses not closed. Growth rate is less than: \n4.5 cm/yr for age over 4, 7cm/yr for ages 2-4, 9 cm/yr for ages 1-2. Two \nGH stimulation test results with GH secretion less than 10 ng/ml. \nAcceptable tests include L-dopa, arginine, clonidine, glucagon, exercise, \ninsulin-induced hypoglycemia. Small for gestational age. Born small for \ngestational age, defined as birth weight or length 2 or more SDs below \nthe mean for gestational age: and fails to catch up growth by age 2 \nyears, defined as height 2 or more SDs below the mean for age and \nsex.Short Stature Homeobox-Containing Gene (SHOX) Deficiency. \nChildren with SHOX deficiency whose epiphyses are not closed. Chronic \nRenal insufficiency. Children with CRI and growth retardation who meet \nboth: metabolic abnormalities have been corrected, and steroid usage \nhas been reduced to a minimum AND At least 1 of the following criteria is \nmet: has severe growth retardation with height SDS more than 3 SDS \nbelow the mean for chronological age and sex: OR  has moderate \ngrowth retardation with height SDS between -2 and -3 SDS below the \nmean for chronological age and sex and decreased growth rate (GV \nmeasured over 1 year below 25th percentile for age and sex): OR Child \nexhibits severe deceleration in growth rate (GV measured over 1 year -2 \nSDS below the mean for age,sex).Prader-Willi Syndrome or Turner's \nSyndrome. Diagnosis of growth failure due to Prader-Willi syndrome OR \nDiagnosis of short stature associated with Turner's syndrome  AND At \nleast 1 of the following: severe growth retardation with height SDS more \nthan 3 SDS below the mean for chronological age and sex: OR Child has \nmoderate growth retardation with height SDS between -2 and -3 SDS \nbelow the mean for chronological age and sex and decreased growth \nrate (GV measured over 1year below 25th percentile for age and sex): \nOR Child exhibits severe deceleration in growth rate (GV measured over \n1 year -2 SDS below the mean for age and sex). For Prader Willi \nSyndrome only: Is not severely obese or has a severe respiratory \nimpairment . Noonan Syndrome.Height 2 SDS or more below the mean \nfor chronological age and sex: AND GV measured over 1 year prior to \ninitiation of therapy of 1 or more SDS below the mean for age and sex.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 300 of 497\n", "doc_id": "2529215b-cf3b-41f9-98a7-e65d906a44ce", "embedding": null, "doc_hash": "6ebb28facbb788e9ceb951419d013f930a221bc53280090e4b288af25012dc90", "extra_info": {"page_label": "300", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2527, "_node_type": "1"}, "relationships": {"1": "f3d745c2-a69c-4c86-b0fa-d7b548f01c3e"}}, "__type__": "1"}, "81dca8f8-2d17-4589-bd11-e97503a4cc52": {"__data__": {"text": "ONCASPAR\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on or \nfollowing Oncaspar. Members with a history of serious thrombosis with \nprior asparaginase therapy. Members with a history of pancreatitis with \nprior asparaginase therapy. Members with a history of serious \nhemorrhagic events with prior asparaginase therapy. Members with total \nbilirubin more than 10 times the upper limit of normal.\nRequired\nMedical\nInformation\nAcute Lymphoblastic Leukemia: The member has a diagnosis of acute \nlymphoblastic leukemia (ALL) AND the member will be using Oncaspar \n(pegaspargase) as a component of a multi-agent chemotherapy regimen.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 301 of 497\n", "doc_id": "81dca8f8-2d17-4589-bd11-e97503a4cc52", "embedding": null, "doc_hash": "b6f591966d7cbe3c8b00bb6e8e05cb1193e69477f83fadc823ee4493f6b8a82b", "extra_info": {"page_label": "301", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 895, "_node_type": "1"}, "relationships": {"1": "60bc563b-5de0-4d8f-9706-3cd073d7e0b2"}}, "__type__": "1"}, "387d8976-73a1-4622-ae5a-5f2b4ee107a1": {"__data__": {"text": "ONIVYDE\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMonotherapy with Onivyde (liposomal irinotecan). Members that have \nexperienced disease progression while on Onivyde (liposomal \nirinotecan).\nRequired\nMedical\nInformation\nPancreatic Cancer: The member has a diagnosis of metastatic \nadenocarcinoma of the pancreas.The member has previously received \ngemcitabine based therapy or fluoropyrimidine based therapy (not \nincluding irinotecan) and experienced disease progression. The member \nwill be using Onivyde (liposomal irinotecan) in combination with \nfluorouracil and leucovorin.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 302 of 497\n", "doc_id": "387d8976-73a1-4622-ae5a-5f2b4ee107a1", "embedding": null, "doc_hash": "872ff7ac39936528c40290eabeadbbead51d8f93392733b686d6eedac1e123b5", "extra_info": {"page_label": "302", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 797, "_node_type": "1"}, "relationships": {"1": "ce8a2086-3000-4a51-bb7b-29520c7f2ba4"}}, "__type__": "1"}, "55967287-7588-4a47-ba8d-d401fb7b476f": {"__data__": {"text": "ONUREG\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member has experienced disease progression on hypomethylators \n(e.g. azacitidine, decitabine).\nRequired\nMedical\nInformation\nAcute Myeloid Leukemia:  The member has a diagnosis of acute myeloid \nleukemia AND The member is using Onureg (azacitidine) for post-\nremission therapy AND The member has achieved first complete \nremission (CR) or complete remission with incomplete blood count \nrecovery (CRi) following intensive induction chemotherapy AND The \nmember is not able to complete or declines intensive curative therapy \n(e.g. allogeneic hematopoietic stem cell transplant) AND The member \nwill use Onureg (azacitidine) as a single agent.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 303 of 497\n", "doc_id": "55967287-7588-4a47-ba8d-d401fb7b476f", "embedding": null, "doc_hash": "831cef305f57543741bad238d22de900cde4a636ca585bc0bad6d4e7693da81a", "extra_info": {"page_label": "303", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 911, "_node_type": "1"}, "relationships": {"1": "40876388-91ee-4964-a5bf-131db01c4e0f"}}, "__type__": "1"}, "d4dde60a-ed31-4d33-82b9-9a30a7bb5214": {"__data__": {"text": "OPDIVO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDisease progression while on or following anti-PD-1/PD-L1 therapy (e.g. \nOpdivo [nivolumab], Keytruda [pembrolizumab], Tecentriq \n[atezolizumab], Bavencio [avelumab]).  Adjuvant melanoma only: \nmember is taking Opdivo (nivolumab) total treatment for more than one \nyear. Neoadjuvant NSCLC only: member is taking Opdivo (nivolumab) \ntotal treatment in combination with platinum-doublet chemotherapy for \nmore than 3 cycles.\nRequired\nMedical\nInformation\nMelanoma: must have a diagnosis of unresectable or metastatic \nmelanoma AND will be using Opdivo (nivolumab) in combination with \nYervoy (ipilimumab) OR the member will be using Opdivo as \nmonotherapy. Melanoma-Adjuvant: member has diagnosis of stage III or \nstage IV melanoma AND has undergone complete resection of disease \nAND will be using Opdivo as adjuvant treatment AND will be using \nOpdivo as monotherapy. Non-Small Cell Lung Cancer-subsequent \ntherapy: member must have a diagnosis of metastatic squamous or non-\nsquamous NSCLC AND member has experienced disease progression \non or after chemotherapy and EGFR inhibitor (e.g.,Tarceva [erlotinib], \nIressa [gefitinib], Gilotrif [afatinib]), if EGFR mutation positive or ALK \ninhibitor (e.g., Xalkori (crizotinib)), if ALK positive AND will be using \nOpdivo as monotherapy. Renal Cell Carcinoma (RCC): member has a \ndiagnosis of advanced RCC AND The member will be using Opdivo as \nmonotherapy AND one of the following applies: the member has \npredominant clear cell histology and will be using Opdivo as subsequent \ntherapy OR the member has non-clear cell histology OR The member \nwill be using Opdivo in combination with Yervoy AND has intermediate or \npoor risk disease, based on International Metastatic Renal Cell \nCarcinoma Database Consortium Criteria AND has predominant clear \ncell histology AND will be using for first line therapy OR member is using \nOpdivo in combo with Cabometyx AND will be using for first line therapy. \nClassical Hodgkin Lymphoma: The member has a diagnosis of classical \nHodgkin Lymphoma AND The member has relapsed or refractory \ndisease AND The member will be using Opdivo as monotherapy AND \nThe member will be using as third-line or subsequent therapy AND One \nof the following criteria applies: The member will be using Opdivo \nfollowing autologous stem cell transplant OR The member is transplant \nineligible (based on comorbidity or failure of second-line chemotherapy) \nOR The member will be using post-allogeneic transplant.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 304 of 497\n", "doc_id": "d4dde60a-ed31-4d33-82b9-9a30a7bb5214", "embedding": null, "doc_hash": "3ca47e7c03c7d67cb188e1ad943fe9dbccdb0a350bd45b9ae09e86b74133711b", "extra_info": {"page_label": "304", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2661, "_node_type": "1"}, "relationships": {"1": "fe42144d-77fe-4521-b31e-f0823544694b"}}, "__type__": "1"}, "c324b847-384d-467f-961e-c16ae97d54f2": {"__data__": {"text": "OPDIVO\nCoverage\nDuration\n6 months duration\nOther Criteria\nNon-nasopharyngeal recurrent or metastatic Squamous Cell Carcinoma \nof the Head and Neck (SCCHN) AND using as monotherapy AND \ndisease progression on or after platinum based therapy.  Locally \nadvanced or metastatic urothelial cancer AND will use Opdivo as \nmonotherapy AND 1 of the following apply: use as a 2nd or subsequent \nline-therapy OR Disease progression within 12 months of neoadjuvant or \nadjuvant chemo OR has high risk of recurrence after radical surgical \nresection of disease. Hepatocellular Carcinoma and has received prior \ntreatment with a Nexavar (sorafenib) AND will be using in combo with \nYervoy.  Unresectable or metastatic colorectal cancer with documented \nMicrosatellite Instability-High (MSI-H) or Mistmatch Repair Deficient \n(dMMR) AND will be using as monotherapy or in combo with ipilimumab \nAND 1 of the following applies: disease that has progressed following \ntreatment with oxaliplatin-, irinotecan-, or fluoropyrimidine-based therapy \nOR has unresectable metachronous metastases and previously received \nadjuvant FOLFOX (fluorouracil, leucovorin, and oxaliplatin) or CapeOX \n(capecitabine and oxaliplatin) within the past 12 months.  Non-small cell \nlung cancer (NSCLC) 1st Line Therapy: metastatic NSCLC AND 1 of the \nfollowing applies: Disease with PD-L1 expression greater than or equal \nto 1% with no EGFR or ALK genomic tumor aberrations and given as 1st \nline therapy AND Tumor expresses PD-L1 as determined by an FDA-\napproved test AND in combo with Yervoy OR Disease with no EGFR or \nALK genomic tumor aberrations and given as 1st line therapy AND in \ncombo with Yervoy AND used in combo with 2 cycles of platinum doublet \nchemotherapy. Esophageal cancer: unresectable advanced, recurrent, \nor metastatic squamous cell carcinoma of the esophagus and 1 of the \nfollowing apply: disease progressed after prior fluoropyrimidine- and \nplatinum-based chemo AND will be given as subsequent monotherapy \nOR in combo with fluoropyrimidine- and platinum containing \nchemotherapy for 1st line treatment OR as 1st line treatment in combo \nwith Yervoy.  Unresectable malignant pleural mesothelioma AND 1 of the \nfollowing scenarios applies: 1st-line treatment AND in combo with Yervoy \nOR as subsequent treatment, if not administered 1st-line AND as single \nagent OR in combo with Yervoy. Gastric Cancer, Gastroesophageal \nJunction Cancer, and Esophageal Adenocarcinoma (advanced or \nmetastatic):  given with a regimen containing fluoropyrimidine- and \nplatinum-based chemo. Esophageal or Gastroesophageal Junction \ncancer (residual disease post-surgery and preoperative chemoradiation): \nreceived neoadjuvant chemoradiation AND complete surgical resection \nof esophageal or gastroesophageal junction AND has residual pathologic \ndisease AND given as subsequent monotherapy.  NSCLC- Neoadjuvant \nTherapy: early stage NSCLC AND must have resectable disease (tumors \ngreater than 4 cm or node positive) AND will be using in the neoadjuvant \nsetting, in combo with platinum-doublet chemo.\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 305 of 497\n", "doc_id": "c324b847-384d-467f-961e-c16ae97d54f2", "embedding": null, "doc_hash": "4faddd1708707537999b52f41f823f593de2f6aca877e222bf2ba04cd0052db6", "extra_info": {"page_label": "305", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 3126, "_node_type": "1"}, "relationships": {"1": "4f2454e1-59fb-4793-8932-fb2a993618a6"}}, "__type__": "1"}, "88243c49-1427-4a22-bf7c-249b6432eadd": {"__data__": {"text": "OPDIVO\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 306 of 497\n", "doc_id": "88243c49-1427-4a22-bf7c-249b6432eadd", "embedding": null, "doc_hash": "ae4a7706e20151fbe14c3c37ce8e58497e0f41e83da0c3dbc2fac95d4d995cff", "extra_info": {"page_label": "306", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 81, "_node_type": "1"}, "relationships": {"1": "b0974ac5-8ae1-4b2f-8a9c-69f0b6eac6e6"}}, "__type__": "1"}, "44cbde19-d1c0-4f53-ab2a-5286ef34e289": {"__data__": {"text": "OPDUALAG\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDisease progression while on or following prior anti-PD-1/PD-L1 therapy \n(e.g., nivolumab, atezolizumab).  Members on concomitant Zelboraf \n(vemurafenib), Tafinlar (dabrafenib), Mekinist (trametinib) or Cotellic \n(cobimetinib) therapy. Safety and efficacy have not been established.\nRequired\nMedical\nInformation\nMelanoma: Unresectable or metastatic melanoma:  The member must \nhave a diagnosis of unresectable or metastatic melanoma AND \nOpdualag is administered as monotherapy AND there is a medical \nreason why Keytruda or Opdivo as monotherapy or Opdivo in \ncombination with Yervoy cannot be initiated or continued.\nAge Restriction\nThe member must be 12 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 307 of 497\n", "doc_id": "44cbde19-d1c0-4f53-ab2a-5286ef34e289", "embedding": null, "doc_hash": "f97023581a23d4570bee46d2c57dec570a09aa8df4bf45af45b351cb5e0051e6", "extra_info": {"page_label": "307", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 922, "_node_type": "1"}, "relationships": {"1": "226b529d-4b0b-49fa-a8b2-7064d3b5cbea"}}, "__type__": "1"}, "0175dfc5-757e-4ae4-9db0-740cf8dc1d90": {"__data__": {"text": "OPSUMIT\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nPulmonary Arterial Hypertension (PAH). The member has a diagnosis of \npulmonary arterial hypertension (WHO Group I) confirmed by right heart \ncatheterization.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 308 of 497\n", "doc_id": "0175dfc5-757e-4ae4-9db0-740cf8dc1d90", "embedding": null, "doc_hash": "9243e0544449bc6d5fdd41e528b065a058bd50a22f9d679ebe2b1bf3834741ad", "extra_info": {"page_label": "308", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 446, "_node_type": "1"}, "relationships": {"1": "e6e5ddac-d620-4627-93ec-5337445784c2"}}, "__type__": "1"}, "98d4c05e-08f3-4328-9da6-8f91d50122b0": {"__data__": {"text": "ORGOVYX\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant use with other LHRH agents.  Pediatric members less than \n18 years old.\nRequired\nMedical\nInformation\nProstate Cancer:  The member has a diagnosis of advanced prostate \ncancer or has a high risk of disease recurrence.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 309 of 497\n", "doc_id": "98d4c05e-08f3-4328-9da6-8f91d50122b0", "embedding": null, "doc_hash": "7bfcbbc3f5a3ff0ae52f6b499ef2dde4efb2fc34edad96569cb12920243f9922", "extra_info": {"page_label": "309", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 487, "_node_type": "1"}, "relationships": {"1": "232f29bc-c4a0-42ff-96a1-a90352605f5d"}}, "__type__": "1"}, "006990df-7627-4faf-a24b-62ff39751d36": {"__data__": {"text": "ORKAMBI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nCystic Fibrosis: The member must meet ALL of the following criteria: \nDiagnosis of Cystic Fibrosis AND submission of lab testing with \ndocumentation of a mutation in the CFTR gene that is responsive to \ntherapy based on clinical literature and/or in vitro assay data.\nAge Restriction\nPrescriber\nRestriction\nThe member is being treated by or in consultation with a specialist (e.g. \npulmonologist).\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 310 of 497\n", "doc_id": "006990df-7627-4faf-a24b-62ff39751d36", "embedding": null, "doc_hash": "5e0769f500009d63deb2be747b906a5739e958feb4a3cc3075c819aa429532d5", "extra_info": {"page_label": "310", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 624, "_node_type": "1"}, "relationships": {"1": "b51c56fc-0a71-49e6-a1b7-10a32cebd706"}}, "__type__": "1"}, "96a84b8f-7a50-4f93-8fdd-43cbffbb3d87": {"__data__": {"text": "ORSERDU\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nEstrogen Receptor (ER)- positive Breast Cancer: The member has ER- \npositive, HER2-negative advanced or metastatic breast cancer AND the \nbreast cancer has documented ESR1-mutation as determined by FDA \napproved test AND the member has progressive disease following at \nleast one prior line endocrine therapy (e.g., fulvestrant, CDK 4/6 \ninhibitor) AND Orserdu (elacestrant) is given as single agent as \nsubsequent therapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 311 of 497\n", "doc_id": "96a84b8f-7a50-4f93-8fdd-43cbffbb3d87", "embedding": null, "doc_hash": "2579680557a62cb562075ad9c14091ea02cad2d9b307912d1b669075ca8fdc42", "extra_info": {"page_label": "311", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 710, "_node_type": "1"}, "relationships": {"1": "98ff0b8f-129c-47e3-b55c-809f905860e4"}}, "__type__": "1"}, "b2e5479c-9bfe-4b19-9887-942dd000daf1": {"__data__": {"text": "OSPHENA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nUndiagnosed abnormal genital bleeding.  Known or suspected estrogen \ndependent neoplasia.\nRequired\nMedical\nInformation\nThe member must be a post-menopausal AND the member must have \nvulvar and/or vaginal atrophy AND the member must have moderate to \nsevere dyspareunia.  Treatment of moderate to severe vaginal dryness: \nThe member must have moderate to severe vaginal dryness.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 312 of 497\n", "doc_id": "b2e5479c-9bfe-4b19-9887-942dd000daf1", "embedding": null, "doc_hash": "c7109b8c8c656b83c7d3d6c006c59fe776ae89dd8f9d82c939e0463a117067e7", "extra_info": {"page_label": "312", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 636, "_node_type": "1"}, "relationships": {"1": "b5f65755-5547-45ee-b105-565be28f523f"}}, "__type__": "1"}, "af3be54d-6663-44ef-8f12-b87bd7945823": {"__data__": {"text": "OTEZLA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nPsoriatic Arthritis: The member has a diagnosis of active psoriatic \narthritis. The member has had prior therapy or intolerance to a single \nDMARD (e.g. methotrexate, sulfasalazine, leflunomide), or \ncontraindication with all DMARDS. Psoriasis: The member has a \ndiagnosis of moderate to severe plaque psoriasis AND the member has \nhad prior therapy or intolerance to one or more oral systemic treatments \n(e.g. methotrexate, cyclosporine) OR the member has a diagnosis of \nmild plaque psoriasis (e.g. involvement of less than 3% of body surface \narea) AND member has had prior therapy, contraindication, or \nintolerance with a high potency topical corticosteroid (e.g. triamcinolone \n0.5%, betamethasone dipropionate/dipropionate augmented, or \nclobetasol) AND has had prior therapy, contraindication, or intolerance \nwith a topical vitamin D product (e.g. calcipotriene cream or solution).  \nOral Ulcers Associated with Behcets Disease: The member has a \ndiagnosis of Behcets disease AND Otezla (apremilast) will be used for \nthe treatment of oral ulcers AND has had previous treatment with, \ncontraindication, or intolerance to topical corticosteroid therapy (e.g. \ntriamcinolone oral paste).\nAge Restriction\nMember is 18 years of age or older for treatment of oral ulcers \nassociated with Behcet's Disease.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 313 of 497\n", "doc_id": "af3be54d-6663-44ef-8f12-b87bd7945823", "embedding": null, "doc_hash": "3d16620256ca28cec4e4e57c9108ed43a3123502da73589c7d641ddd5823bb9f", "extra_info": {"page_label": "313", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1581, "_node_type": "1"}, "relationships": {"1": "42ea1e25-cf2f-43a3-9337-11dc472a014e"}}, "__type__": "1"}, "38cda45c-009a-4bdc-a434-ba23aa7503b1": {"__data__": {"text": "OTEZLA STARTER\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nPsoriatic Arthritis: The member has a diagnosis of active psoriatic \narthritis. The member has had prior therapy or intolerance to a single \nDMARD (e.g. methotrexate, sulfasalazine, leflunomide), or \ncontraindication with all DMARDS. Psoriasis: The member has a \ndiagnosis of moderate to severe plaque psoriasis AND the member has \nhad prior therapy or intolerance to one or more oral systemic treatments \n(e.g. methotrexate, cyclosporine) OR the member has a diagnosis of \nmild plaque psoriasis (e.g. involvement of less than 3% of body surface \narea) AND member has had prior therapy, contraindication, or \nintolerance with a high potency topical corticosteroid (e.g. triamcinolone \n0.5%, betamethasone dipropionate/dipropionate augmented, or \nclobetasol) AND has had prior therapy, contraindication, or intolerance \nwith a topical vitamin D product (e.g. calcipotriene cream or solution).  \nOral Ulcers Associated with Behcets Disease: The member has a \ndiagnosis of Behcets disease AND Otezla (apremilast) will be used for \nthe treatment of oral ulcers AND has had previous treatment with, \ncontraindication, or intolerance to topical corticosteroid therapy (e.g. \ntriamcinolone oral paste).\nAge Restriction\nMember is 18 years of age or older for treatment of oral ulcers \nassociated with Behcet's Disease.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 314 of 497\n", "doc_id": "38cda45c-009a-4bdc-a434-ba23aa7503b1", "embedding": null, "doc_hash": "a47cc75861908b7e421874700d0513e30fec6839eca3054d481f70029fd9315a", "extra_info": {"page_label": "314", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1589, "_node_type": "1"}, "relationships": {"1": "18d36f4d-ca74-4901-9067-94bbd0efe45d"}}, "__type__": "1"}, "4710042e-9a78-447f-b4fa-8f4078a8a1df": {"__data__": {"text": "oxandrolone\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nEnhancement of athletic performance.\nRequired\nMedical\nInformation\nCachexia associated with AIDS wasting syndrome: weight loss from \ncancer chemotherapy, severe burns, spinal cord injury, Corticosteroid-\ninduced protein catabolism, Symptomatic treatment of bone pain \naccompanying osteoporosis, Alcoholic hepatitis, Turner Syndrome, \nConstitutional delay in growth and puberty, Duchenne muscular \ndystrophy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 315 of 497\n", "doc_id": "4710042e-9a78-447f-b4fa-8f4078a8a1df", "embedding": null, "doc_hash": "7125ae6f7b6764ae917df0a3bb2963371ae9459dc8658dcae8ea0d5d9789dc34", "extra_info": {"page_label": "315", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 669, "_node_type": "1"}, "relationships": {"1": "d6e934d2-8c37-42a4-8778-736efd10fde4"}}, "__type__": "1"}, "4ceb835b-878a-4611-b0a6-4a6d4c7ab15a": {"__data__": {"text": "paclitaxel protein-bound\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nBreast Cancer. The member has a diagnosis of metastatic (Stage IV) or \nrecurrent breast cancer. The member received prior therapy that \nincluded an anthracycline (unless contraindicated). The member has \ndocumented hypersensitivity reaction to conventional Taxol or Taxotere \nor the member has a documented contraindication to standard \nhypersensitivity premedications. Non-small Cell Lung Cancer (NSCLC). \nThe member has a diagnosis of locally advanced, recurrent or metastatic \nNSCLC. Member has documented hypersensitivity reaction to \nconventional Taxol or Taxotere or the member has a documented \ncontraindication to standard hypersensitivity premedications AND \nmember has squamous histology where Abraxane will be given in combo \nwith Keytruda and carboplatin as first line therapy OR member will be \nusing Abraxane as monotherapy or in combo with carboplatin AND One \nof the following apply: will be using for first line therapy OR member will \nbe using as subsequent therapy for EGFR mutation-positive tumors after \nprior therapy OR The member will be using as subsequent therapy for \nALK-positive tumors after prior therapy  OR  member will be using as \nsubsequent therapy for ROS-1 positive disease after prior therapy OR \nmember will be using as subsequent therapy for BRAF V600E positive \ndisease  OR The member will be using as subsequent therapy after \npembrolizumab and EGFR, ALK, BRAF V600E, and ROS-1 negative \ndisease OR member has metastatic NSCLC, non- squamous histology \nwith no EGFR or ALK genomic tumor aberrations AND Abraxane will be \ngiven combo with Tecentriq and carboplatin as first line therapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 316 of 497\n", "doc_id": "4ceb835b-878a-4611-b0a6-4a6d4c7ab15a", "embedding": null, "doc_hash": "c2ac0e2626fb83f0f2e6e3e015592b09815eaddf8ae4b07b4650e62c17343953", "extra_info": {"page_label": "316", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1893, "_node_type": "1"}, "relationships": {"1": "96dff55e-3917-43d3-b8ab-99863b131ce6"}}, "__type__": "1"}, "ea866d2d-4a9a-4190-aa49-06b057298ef3": {"__data__": {"text": "paclitaxel protein-bound\nOther Criteria\nOvarian Cancer. The member has a diagnosis of epithelial ovarian \ncancer, fallopian tube cancer or primary peritoneal cancer. The member \nmeets one of the following criteria: Progressive, stable or persistent \ndisease on primary chemotherapy OR Recurrent disease. The member \nhas documented hypersensitivity reaction to conventional Taxol \n(paclitaxel) or Taxotere (docetaxol) or the member has a documented \ncontraindication to standard hypersensitivity premedications. Pancreatic \nCancer: The member has a diagnosis of pancreatic cancer and \nAbraxane is being used in combination with gemcitabine as neoadjuvant \ntherapy or The member has a diagnosis of metastatic pancreatic cancer \nAND The member will be using Abraxane in combination with \ngemcitabine. Melanoma: The member has a diagnosis of unresectable \nor metastatic melanoma AND The member will be using Abraxane (nab-\npaclitaxel) as monotherapy AND The member will be using Abraxane \n(nab-paclitaxel) as second-line or subsequent therapy after progression \non BRAF targeted therapy AND The member has documented \nhypersensitivity reaction to conventional Taxol (paclitaxel) or Taxotere \n(docetaxol) or the member has a documented contraindication to \nstandard hypersensitivity premedications.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 317 of 497\n", "doc_id": "ea866d2d-4a9a-4190-aa49-06b057298ef3", "embedding": null, "doc_hash": "8f8b1115864e7bf4d931f054d9a8d33bbb0136a4ddc680a52829a0f9b6c44415", "extra_info": {"page_label": "317", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1368, "_node_type": "1"}, "relationships": {"1": "257468ea-ae7d-4161-ae66-83ce63718261"}}, "__type__": "1"}, "e998a342-b8f8-4c30-aa32-3b5859069d7d": {"__data__": {"text": "PADCEV\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nBladder Cancer. The member has locally advanced or metastatic \nbladder cancer AND The member has received prior treatment with a \nplatinum-containing chemotherapy AND The member has received \nprevious treatment with a programmed death receptor-1 (PD-1) or \nprogrammed death-ligand 1 (PD-L1) inhibitor OR The member has \npreviously received one or more prior lines of therapy AND The member \nis ineligible for cisplatin-containing chemotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 318 of 497\n", "doc_id": "e998a342-b8f8-4c30-aa32-3b5859069d7d", "embedding": null, "doc_hash": "899cb8ad8910cdbab3ed79a90b3685b26f8c379ae2850cadab851696d49c7513", "extra_info": {"page_label": "318", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 730, "_node_type": "1"}, "relationships": {"1": "44fe6449-503d-400a-8f3d-3f275a100420"}}, "__type__": "1"}, "5bb4148a-6227-4ae9-a44b-5ca5fca286c6": {"__data__": {"text": "PANRETIN\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nThe member has a diagnosis of AIDS-related Kaposi's sarcoma AND \nsystemic therapy is not required.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 319 of 497\n", "doc_id": "5bb4148a-6227-4ae9-a44b-5ca5fca286c6", "embedding": null, "doc_hash": "0eb23c61c195267a7ec40dc5fdba90797e24287895f7b395a4aaf2070ba931c9", "extra_info": {"page_label": "319", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 399, "_node_type": "1"}, "relationships": {"1": "e2333efd-72b0-4095-8c0e-3b3fbe4692f7"}}, "__type__": "1"}, "451e9d7f-0538-42cb-97a8-dacd4e1710cc": {"__data__": {"text": "PEGASYS\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nChronic Hepatitis B - Adults:  The member must have a diagnosis of \nchronic hepatitis B AND The member must have compensated liver \ndisease AND The member must have evidence of viral replication AND \nThe member must have evidence of liver inflammation AND The member \nmust have had prior therapy, contraindication, or intolerance with \ntenofovir disoproxil fumarate AND entecavir.  Chronic Hepatitis B - \nPediatrics:  The member must have a diagnosis of chronic hepatitis B \nAND The member must be non-cirrhotic AND The member must be \nHBeAg-positive AND The member must have evidence of viral \nreplication AND The member must have elevation in serum alanine \naminotransferase (ALT) AND the member must have had prior therapy, \ncontraindication, or intolerance with tenofovir disoproxil fumarate AND \nentecavir.  Chronic Hepatitis C - Adults:  The member must have a \ndiagnosis of chronic hepatitis C AND HCV ribonucleic acid (RNA) level \nmust be documented prior to therapy AND The member has \ncompensated liver disease AND Pegasys (peginterferon alpha-2a) will \nbe taken in combination with at least 1 other medication indicated for the \ntreatment of chronic Hepatitis C AND In members with genotypes 2 or 3, \nthe member has had previous treatment, contraindication, or intolerance \nto Epclusa OR In members with genotyes 1,4,5 or 6, The member has \nhad previous treatment, contraindication, or intolerance to Epclusa AND \nHarvoni.  Chronic Hepatitis C - Pediatrics:  The member must have a \ndiagnosis of chronic hepatitis C AND HCV ribonucleic acid (RNA) level \nmust be documented prior to therapy AND The member has \ncompensated liver disease AND Pegasys (peginterferon alpha-2a) will \nbe taken in combination with ribavirin AND In members with genotypes 2 \nor 3, the member has had previous treatment, contraindication, or \nintolerance to Epclusa OR In members with genotypes 1,4,5 or 6, the \nmember has had previous treatment, contraindication, or intolerance to \nEpclusa AND Harvoni.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n12 to 120 week treatment course depending on the disease state and/or \ngenotype.\nOther Criteria\nFor all genotypes, criteria will be applied consistent with current AASLD-\nIDSA guidance.\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 320 of 497\n", "doc_id": "451e9d7f-0538-42cb-97a8-dacd4e1710cc", "embedding": null, "doc_hash": "24c5b15776826280e4e237b9adb078219cb403528fffddd85b3a442b99e83c8a", "extra_info": {"page_label": "320", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2407, "_node_type": "1"}, "relationships": {"1": "f3eabe6d-d169-4594-aef9-7f543d5556cd"}}, "__type__": "1"}, "5358de7c-6e7b-470c-8c3a-e0faf226bc0b": {"__data__": {"text": "PEGASYS\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 321 of 497\n", "doc_id": "5358de7c-6e7b-470c-8c3a-e0faf226bc0b", "embedding": null, "doc_hash": "071abb3639ac7813f0fc9ed3e89a0e7c1286bc762cec4436ffa98193e7fe22eb", "extra_info": {"page_label": "321", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 82, "_node_type": "1"}, "relationships": {"1": "8c102189-e2eb-49dc-8454-45d03575fe84"}}, "__type__": "1"}, "8f7d053c-a2d5-42fc-bbf2-1582da38ec76": {"__data__": {"text": "PEMAZYRE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experienced disease progression on Pemazyre (pemigatinib)\nRequired\nMedical\nInformation\nCholangiocarcinoma: The member has unresectable locally advanced or \nmetastatic cholangiocarcinoma and the disease is fibroblast growth \nfactor receptor 2 (FGFR2) fusion or other rearrangement as detected by \nan FDA-approved test and the member has received prior treatment \nAND Pemazyre (pemigatinib) is given as a single agent for subsequent \ntherapy.  Relapsed or refractory myeloid/lymphoid neoplasms:  the \nmember has a diagnosis of relapsed or refractory myeloid/lymphoid \nneoplasms (MLNs) AND MLNs documented as fibroblast growth factor \nreceptor 1 (FGFR1) rearrangement AND Pemazyre (pemigatinib) is \nbeing given as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 322 of 497\n", "doc_id": "8f7d053c-a2d5-42fc-bbf2-1582da38ec76", "embedding": null, "doc_hash": "091efd93d5452740028791eaedd350261991ea04076882556319316ea68e8d26", "extra_info": {"page_label": "322", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 991, "_node_type": "1"}, "relationships": {"1": "4bf88be7-80ae-40c3-a395-bda7db450141"}}, "__type__": "1"}, "7368dc06-7900-430f-bcb9-9b37abff02a3": {"__data__": {"text": "pemetrexed\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nSquamous cell non-small cell lung cancer. Creatinine clearance (CrCl) \nless than 45 ml/minute.\nRequired\nMedical\nInformation\nNon-Small Cell Lung Cancer (Nonsquamous). Diagnosis of \nnonsquamous NSCLC that is locally advanced or metastatic AND EGFR, \nALK, ROS1 BRAF negative and PD-L1 less than 1% AND one of the \nfollowing applies: Alimta is being used in combination with cisplatin or \ncarboplatin therapy for the initial treatment in members with a \nperformance status (PS) 0-2 or Alimta is being used in cisplatin or \ncarboplatin-based regimens in combination with bevacizumab product in \nmembers with PS 0-1 and no history of hemoptysis or as a single agent \nin PS 2 OR If EGFR, ALK, ROS1, BRAF positive and PD-L1 greater than \nor equal to 1% and after prior therapy AND one of the following applies: \nAlimta is being used in combination with cisplatin or carboplatin therapy \nfor the subsequent therapy in members with a performance status (PS) 0\n-2 or Alimta is being used in cisplatin or carboplatin-based regimens in \ncombination with bevacizumab product in members with PS 0-1 and no \nhistory of hemoptysis as subsequent therapy or as a single agent in PS 2 \nas subsequent therapy. OR Alimta is being used as a single agent after \nprior chemotherapy. Alimta is being used as a single agent for the \nmaintenance treatment of members whose disease has not progressed \nafter four cycles of platinum-based first-line chemotherapy OR As a \nsingle agent for recurrence or metastasis in members who achieved \ntumor response or stable disease following first-line chemotherapy with \nAlimta OR in combination with Keytruda and carboplatin or cisplatin as \nfirst line therapy for nonsquamous metastatic NSCLC followed by \nmaintenance Keytruda in combination with pemetrexed OR in \ncombination with cisplatin used as neoadjuvant or adjuvant \nchemotherapy OR Concurrent chemoradiation in combination with \ncarboplatin or cisplatin.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 323 of 497\n", "doc_id": "7368dc06-7900-430f-bcb9-9b37abff02a3", "embedding": null, "doc_hash": "09ab3bacd48b5c5ff596fe45b275dfb08d93de42f9625a020d659310a76bbb68", "extra_info": {"page_label": "323", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2149, "_node_type": "1"}, "relationships": {"1": "3ff72645-dcc6-4428-9488-3871755a0762"}}, "__type__": "1"}, "ac01f906-5f8e-4e96-8413-e02cd1b58068": {"__data__": {"text": "pemetrexed\nOther Criteria\nMalignant Pleural Mesothelioma. Diagnosis of malignant pleural \nmesothelioma AND must be using pemetrexed as induction therapy in \ncombination with cisplatin or carboplatin for medically operable clinical \nstage I-III OR must be using pemetrexed as a single agent or in \ncombination with cisplatin or carboplatin OR is using pemetrexed as \nsecond-line as a single agent if not administered first-line. OR \npemetrexed is being used in combination with bevacizumab product and \ncisplatin. Bladder Cancer: The member must have a diagnosis of \nmetastatic bladder cancer AND pemetrexed is being used as second-line \nor subsequent therapy as a single agent for metastatic disease.  Cervical \nCancer. Diagnosis of cervical cancer AND pemetrexed is being used as \na second-line or subsequent therapy as a single agent for local/regional \nrecurrence or distant metastases. Ovarian Cancer. Diagnosis of Ovarian \nCancer, or Epithelial Ovarian Cancer/Fallopian Tube Cancer/Primary \nPeritoneal Cancer AND pemetrexed is being used as a single agent for \npersistent disease or recurrence therapy. Thymic Malignancy. Diagnosis \nof thymic malignancy AND pemetrexed is being used as second-line \ntherapy as a single agent.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 324 of 497\n", "doc_id": "ac01f906-5f8e-4e96-8413-e02cd1b58068", "embedding": null, "doc_hash": "0debbafd1915553754babe49277c26bbbacc73a675bbd91f7a3fc38107d77863", "extra_info": {"page_label": "324", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1305, "_node_type": "1"}, "relationships": {"1": "48a6d3cc-7119-4a71-96db-5735901c03c8"}}, "__type__": "1"}, "3febb6a9-c76b-4c6c-a4b6-27518a474a1a": {"__data__": {"text": "pemetrexed disodium\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nSquamous cell non-small cell lung cancer. Creatinine clearance (CrCl) \nless than 45 ml/minute.\nRequired\nMedical\nInformation\nNon-Small Cell Lung Cancer (Nonsquamous). Diagnosis of \nnonsquamous NSCLC that is locally advanced or metastatic AND EGFR, \nALK, ROS1 BRAF negative and PD-L1 less than 1% AND one of the \nfollowing applies: Alimta is being used in combination with cisplatin or \ncarboplatin therapy for the initial treatment in members with a \nperformance status (PS) 0-2 or Alimta is being used in cisplatin or \ncarboplatin-based regimens in combination with bevacizumab product in \nmembers with PS 0-1 and no history of hemoptysis or as a single agent \nin PS 2 OR If EGFR, ALK, ROS1, BRAF positive and PD-L1 greater than \nor equal to 1% and after prior therapy AND one of the following applies: \nAlimta is being used in combination with cisplatin or carboplatin therapy \nfor the subsequent therapy in members with a performance status (PS) 0\n-2 or Alimta is being used in cisplatin or carboplatin-based regimens in \ncombination with bevacizumab product in members with PS 0-1 and no \nhistory of hemoptysis as subsequent therapy or as a single agent in PS 2 \nas subsequent therapy. OR Alimta is being used as a single agent after \nprior chemotherapy. Alimta is being used as a single agent for the \nmaintenance treatment of members whose disease has not progressed \nafter four cycles of platinum-based first-line chemotherapy OR As a \nsingle agent for recurrence or metastasis in members who achieved \ntumor response or stable disease following first-line chemotherapy with \nAlimta OR in combination with Keytruda and carboplatin or cisplatin as \nfirst line therapy for nonsquamous metastatic NSCLC followed by \nmaintenance Keytruda in combination with pemetrexed OR in \ncombination with cisplatin used as neoadjuvant or adjuvant \nchemotherapy OR Concurrent chemoradiation in combination with \ncarboplatin or cisplatin.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 325 of 497\n", "doc_id": "3febb6a9-c76b-4c6c-a4b6-27518a474a1a", "embedding": null, "doc_hash": "71034fc4cb806ddf3234cedbbae0646223d7e0250d18f72d5ce4487d7378d9ba", "extra_info": {"page_label": "325", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2158, "_node_type": "1"}, "relationships": {"1": "4f5d46cb-c9d7-4864-a33c-6727843ac3bc"}}, "__type__": "1"}, "020e5f41-e689-4c14-a650-2858abd353f2": {"__data__": {"text": "pemetrexed disodium\nOther Criteria\nMalignant Pleural Mesothelioma. Diagnosis of malignant pleural \nmesothelioma AND must be using pemetrexed as induction therapy in \ncombination with cisplatin or carboplatin for medically operable clinical \nstage I-III OR must be using pemetrexed as a single agent or in \ncombination with cisplatin or carboplatin OR is using pemetrexed as \nsecond-line as a single agent if not administered first-line. OR \npemetrexed is being used in combination with bevacizumab product and \ncisplatin. Bladder Cancer: The member must have a diagnosis of \nmetastatic bladder cancer AND pemetrexed is being used as second-line \nor subsequent therapy as a single agent for metastatic disease.  Cervical \nCancer. Diagnosis of cervical cancer AND pemetrexed is being used as \na second-line or subsequent therapy as a single agent for local/regional \nrecurrence or distant metastases. Ovarian Cancer. Diagnosis of Ovarian \nCancer, or Epithelial Ovarian Cancer/Fallopian Tube Cancer/Primary \nPeritoneal Cancer AND pemetrexed is being used as a single agent for \npersistent disease or recurrence therapy. Thymic Malignancy. Diagnosis \nof thymic malignancy AND pemetrexed is being used as second-line \ntherapy as a single agent.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 326 of 497\n", "doc_id": "020e5f41-e689-4c14-a650-2858abd353f2", "embedding": null, "doc_hash": "05958e6e31826b4a14b1a7250feb0f0def7cad7a7543b6931964f5e3b4e40dca", "extra_info": {"page_label": "326", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1314, "_node_type": "1"}, "relationships": {"1": "69063419-5029-4d09-8ddf-9562e50ffc45"}}, "__type__": "1"}, "5f66589c-7f61-43e4-8248-ee2ff7a82b82": {"__data__": {"text": "PERFOROMIST\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nAsthma, in the absence of concurrent medication containing inhaled \ncorticosteroid and comorbid COPD diagnosis.\nRequired\nMedical\nInformation\nChronic Obstructive Pulmonary Disease (COPD).Diagnosis of Chronic \nObstructive Pulmonary Disease (COPD), including chronic bronchitis \nand emphysema, requiring maintenance treatment of \nbronchoconstriction.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 327 of 497\n", "doc_id": "5f66589c-7f61-43e4-8248-ee2ff7a82b82", "embedding": null, "doc_hash": "b6dff4f80d5987f44de13be228dc472b2ff68b3b3e4c1152e1ddbca589942514", "extra_info": {"page_label": "327", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 610, "_node_type": "1"}, "relationships": {"1": "6dc4e23e-5da1-48c8-83b1-bd800489482c"}}, "__type__": "1"}, "4f478de9-e57b-4d8a-af10-fbc9b7a24160": {"__data__": {"text": "PERJETA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMember exceeds a total treatment of 52 weeks or 18 treatment cycles \n(applicable to neoadjuvant and/or adjuvant treatment).\nRequired\nMedical\nInformation\nMetastatic Breast Cancer. Diagnosis of metastatic breast cancer. The \nmember has a diagnosis of metastatic breast cancer and HER2 (human \nepidermal growth factor receptor2) positive disease AND one of the \nfollowing applies: will be receiving Perjeta (pertuzumab) in combination \nwith trastuzumab product and docetaxel or paclitaxel and has not \nreceived prior anti-HER2 therapy or chemotherapy for metastatic \ndisease OR the member has received prior cytotoxic therapy with or \nwithout trastuzumab product for second or subsequent line of therapy. \nEarly Stage Breast Cancer. The member has a diagnosis of locally \nadvanced, inflammatory, or early stage breast cancer (either greater than \n2 cm in diameter or node positive) and HER2 positive disease AND \nPerjeta (pertuzumab) will be used as neoadjuvant treatment as part of a \ncomplete treatment regimen and one of the following applies: in \ncombination with trastuzumab product and docetaxel or paclitaxel (after \ncompletion of combination of doxorubicin plus cyclophosphamide \nregimen) or in combination with TCH (docetaxel, carboplatin, and \ntrastuzumab product) OR The member has a diagnosis of early stage \nHER2 positive breast cancer at high risk of recurrence (e.g., node \npositive disease, hormone receptor negative, T2 non-metastatic disease) \nAND Perjeta (pertuzumab) will be used as adjuvant therapy and one of \nthe following applies: combination with trastuzumab product and \npaclitaxel or docetaxel (following doxorubicin plus cyclophosphamide \nregimen) or docetaxel plus carboplatin.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 328 of 497\n", "doc_id": "4f478de9-e57b-4d8a-af10-fbc9b7a24160", "embedding": null, "doc_hash": "171ae65bbe665b935d9645a4363068e95b16642cd26817e84967df90a80a2bc4", "extra_info": {"page_label": "328", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1970, "_node_type": "1"}, "relationships": {"1": "a2d448fd-f3cc-4816-88fd-5053e26d4105"}}, "__type__": "1"}, "488f957d-ef56-46a8-b33a-eaa62fa7df08": {"__data__": {"text": "pimecrolimus\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nMust have a diagnosis of atopic dermatitis or psoriasis have had \nprevious treatment with one of the following topical generic products: \ntriamcinolone 0.025%, 0.1%, 0.5% , mometasone, betamethasone \ndipropionate.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 329 of 497\n", "doc_id": "488f957d-ef56-46a8-b33a-eaa62fa7df08", "embedding": null, "doc_hash": "f42f60b206daab6e142700f9eda787118221e7411c2499523d7e4a299a2cabbc", "extra_info": {"page_label": "329", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 506, "_node_type": "1"}, "relationships": {"1": "12c79bfb-e559-47f6-9f99-2cf62da9e53a"}}, "__type__": "1"}, "ca485d5c-9cb2-4e0c-ae03-71bc5b759623": {"__data__": {"text": "PIQRAY\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers have severe hypersensitivity to Piqray (alpelisib). Members \nhas experienced disease progression on PIK3CA inhibitors (e.g., \nalpelisib).\nRequired\nMedical\nInformation\nBreast Cancer: The member has a diagnosis of advanced or metastatic \nhormone receptor positive, human epidermal growth factor receptor 2 \n(HER 2) negative breast cancer and PIK3CA mutated as detected by \nFDA approved test AND the member has experienced disease \nprogression on or after endocrine based therapy within one year (e.g., \nanastrozole, palbociclib) AND Piqray (alpelisib) will be given in \ncombination with fulvestrant as subsequent therapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 330 of 497\n", "doc_id": "ca485d5c-9cb2-4e0c-ae03-71bc5b759623", "embedding": null, "doc_hash": "7f680019db829cf1c7773ea82e927a2cbb1446a9c13371be7f13b1ab4c9a2f4a", "extra_info": {"page_label": "330", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 894, "_node_type": "1"}, "relationships": {"1": "e126ca03-2a60-4321-b541-e649a37ccd4f"}}, "__type__": "1"}, "7a657c28-4321-4a88-8e8c-99f05dc847ea": {"__data__": {"text": "pirfenidone\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nIdiopathic Pulmonary Fibrosis (IPF):The member meets ALL of the \nfollowing criteria: Documentation of Pulmonary Fibrosis by one of the \nfollowing:  computed tomography (CT) scan that is indicative of usual \ninterstitial pneumonia (UIP) OR surgical lung biopsy AND Has not had \nclinically significant environmental exposure or explanation for \npulmonary fibrosis or interstitial lung disease (e.g. drugs, asbestos, \nberyllium, radiation, and domestic birds, radiation, sarcoidosis, \nhypersensitivity pneumonitis, bronchiolitis, obliterans organizing \npneumonia, human immunodeficiency virus (HIV), viral hepatitis, or \ncancer).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 331 of 497\n", "doc_id": "7a657c28-4321-4a88-8e8c-99f05dc847ea", "embedding": null, "doc_hash": "56bd2efa2d7eaf0c984bafccf0c6d81105a8565c3becb0dafa3c8c8917f8cc93", "extra_info": {"page_label": "331", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 918, "_node_type": "1"}, "relationships": {"1": "b0cfcc2b-ec77-4807-a009-1c1173cbab3e"}}, "__type__": "1"}, "492c8765-cdbe-447d-b7b2-1d8ac4daefe9": {"__data__": {"text": "POLIVY\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember has experienced disease progression on Polivy (polatuzumab \nvedotin-piiq). The member has baseline Grade 2 or higher peripheral \nneuropathy. The member has active central nervous system lymphoma. \nThe member has transformation from indolent lymphoma (e.g. follicular \nlymphoma) info diffuse large B-cell lymphoma. The member has \nreceived prior allogeneic hematopoietic stem cell transplant (HSCT).\nRequired\nMedical\nInformation\nDiffuse large B-cell lymphoma: the member has a diagnosis of relapsed \nor refractory diffuse large B-cell lymphoma AND the member has \nreceived at least two prior lines of therapy AND the member will be using \nin combination with bendamustine and a rituximab product.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 332 of 497\n", "doc_id": "492c8765-cdbe-447d-b7b2-1d8ac4daefe9", "embedding": null, "doc_hash": "d34e537714e8163696682fb185af575ae2ab8c54189ccaa9cff18c46b53c1192", "extra_info": {"page_label": "332", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 959, "_node_type": "1"}, "relationships": {"1": "45009599-a8bc-43fb-9a55-6d5aa5c7c19f"}}, "__type__": "1"}, "7cfff30f-ab6d-483a-8b4d-8a08d0ac27ea": {"__data__": {"text": "POMALYST\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers receiving concomitant therapy with an immunomodulator. The \nmember has experienced disease progression while on Pomalyst \n(pomalidomide).\nRequired\nMedical\nInformation\nMultiple Myeloma: The member has a diagnosis of Multiple Myeloma \nAND The member has received at least two previous therapies AND The \nmember has demonstrated  disease progression while on Revlimid \n(lenalidomide) OR Thalomid (thalidomide) AND The member \ndemonstrated  disease progression while on a protease inhibitor (e.g. \nbortezomib, carflizomib) AND The member demonstrated disease \nprogression on or within 60 days of completion of the last therapy \nregimen [does not apply to requests for combination with Darzalex \n(daratumumab) plus dexamethasone or elotuzumab plus \ndexamethasone or Sarclisa (isatuximab) plus dexamethasone] AND The \nmember will be using Pomalyst in one of the following regimens: in \ncombination with dexamethasone and daratumumab, with \ndexamethasone and elotuzumab, with dexamethasone and ixazomib, \nwith dexamethasone and cyclophosphamide, with dexamethasone, with \ndexamethasone and bortezomib, with dexamethasone and carfilzomib, \ndexamethasone and Sarclisa (isatuximab), dexamethasone and Xpovio \n(selinexor), or as a single agent (Omission of corticosteroid from regimen \nis allowed if intolerance/contraindication).  Kaposi Sarcoma:  The \nmember has a diagnosis of AIDS-related Kaposi sarcoma after failure of \nhighly active antiretroviral therapy OR The member has a diagnosis of \nKaposi sarcoma that is HIV-negative.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 333 of 497\n", "doc_id": "7cfff30f-ab6d-483a-8b4d-8a08d0ac27ea", "embedding": null, "doc_hash": "f5ad1834936ac4747e122e5b426511cb4b59592eea089f051b3c769e5baf6013", "extra_info": {"page_label": "333", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1789, "_node_type": "1"}, "relationships": {"1": "a39e3f8e-443e-44f1-a80b-3aed7b618597"}}, "__type__": "1"}, "b42059f1-be3d-4cd2-98f0-b2908a83b1a8": {"__data__": {"text": "PORTRAZZA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on Portrazza \n(necitumumab).\nRequired\nMedical\nInformation\nNon-Small Cell Lung Cancer:The member has a diagnosis of metastatic \nsquamous non-small cell lung cancer AND The member will be initially \nusing Portrazza (necitumumab) in combination with gemcitabine and \ncisplatin AND The member will be using Portrazza (necitumumab) as \nfirst-line treatment.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nsix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 334 of 497\n", "doc_id": "b42059f1-be3d-4cd2-98f0-b2908a83b1a8", "embedding": null, "doc_hash": "38b8c353f6b635ce39afb274829d3e2fc76cf2a18da61e6a5b7dee3bc5c36f88", "extra_info": {"page_label": "334", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 672, "_node_type": "1"}, "relationships": {"1": "e4572bba-8711-43b1-9198-cd474de46866"}}, "__type__": "1"}, "3ff821f4-6d06-441a-ae6e-132645bffc43": {"__data__": {"text": "posaconazole\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nProphylaxis against Invasive Aspergillus and Candida Infections. The \nmember must be using it for prophylaxis against invasive Aspergillus or \nCandida infections, and The member must be severely \nimmunocompromised (such as hematopoietic stem cell transplant \nrecipient with graft-vs-host disease, or neutropenic patients with acute \nmyelogenous leukemia (AML) or myelodysplastic syndromes \n(MDS).Treatment of invasive Aspergillus or fungal infections caused by \nFusarium and/or Zygomycetes. The member must have documentation \nfor treatment of invasive Aspergillus or fungal infections caused by \nFusarium and/or Zygomycetes, and The member must have documented \nresistant strains of or clinically refractory to standard antifungal agents \n(e.g. voriconazole, itraconazole) or those who can not receive other \nantifungal agents due to potential toxicities, intolerance, or \ncontraindications.Treatment of Oropharyngeal or Esophageal \nCandidiasis.The member must have a diagnosis for orpharnygeal or \nesophageal candidiasis and The member has a documented inadequate \nresponse/refractory or intolerant to itraconazole and fluconazole.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 335 of 497\n", "doc_id": "3ff821f4-6d06-441a-ae6e-132645bffc43", "embedding": null, "doc_hash": "04c25104eef5bbac9194c99864f9c7a59b5cd91960dbb38d11f02c9799ceec7c", "extra_info": {"page_label": "335", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1426, "_node_type": "1"}, "relationships": {"1": "65dfb233-3dcf-4356-a908-41ef6a66f5d0"}}, "__type__": "1"}, "334a6160-c908-44bd-a54b-2211479f8fde": {"__data__": {"text": "POTELIGEO\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMember has experienced disease progression while on or following \nPoteligeo (mogamulizumab-kpkc).\nRequired\nMedical\nInformation\nMycosis fungoides or S\u00e9zary syndrome: The member has a diagnosis of \nmycosis fungoides or S\u00e9zary syndrome AND The member has relapsed \nor refractory disease AND The member will be using Poteligeo \n(mogamulizumab-kpkc) as the sole systemic therapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 336 of 497\n", "doc_id": "334a6160-c908-44bd-a54b-2211479f8fde", "embedding": null, "doc_hash": "90acf9d30a8881223e496375d7350e028052c00b74c3786deff45b6a6172729d", "extra_info": {"page_label": "336", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 643, "_node_type": "1"}, "relationships": {"1": "e1164e5b-3b62-4f61-b926-a034caa7dfea"}}, "__type__": "1"}, "3dbd59c1-579d-41ca-a5c4-fa74c8ef22d7": {"__data__": {"text": "PREVYMIS\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nProphylaxis of CMV Infection and Disease in Adult CMV Seropositive \nRecipients [R+] of an Allogenic Hematopoietic Stem Cell Transplant \n(HSCT). Member must have received an allogeneic hematopoietic stem \ncell transplant. Member must be CMV-seropositive [R+]. Prevymis \n(letermovir) must be initiated within 28 days post-transplant.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n4 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 337 of 497\n", "doc_id": "3dbd59c1-579d-41ca-a5c4-fa74c8ef22d7", "embedding": null, "doc_hash": "b41a6d232110177f288f083b0d60b2f6fab2fc8ec5228bd6d0e7136d64f9cebf", "extra_info": {"page_label": "337", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 619, "_node_type": "1"}, "relationships": {"1": "35c0bffb-7b02-40b7-bfad-f8b7d9bea40c"}}, "__type__": "1"}, "74de8415-af9b-4b8a-8618-8e1d185a71dd": {"__data__": {"text": "PROCRIT\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnemia of CKD: Diagnosis of anemia associated with chronic kidney \ndisease. Hgb level less than 10.0 g/dL or HCT less than 30- within last 4 \nweeks. Continue Therapy: Current- within last 4 weeks Hgb level less \nthan 11 g/dL OR documented dose adjustment of therapy with \ncorresponding documented Hgb levels to indicate maintenance therapy. \nAnemia in Zidovudine-treated HIV-infected: Diagnosed with HIV (and \nAZT induced anemia) and receiving zidovudine treatment corresponding \nwith HAART. Endogenous serum erythropoietin levels less than or equal \nto 500 mUnits/mL. The total zidovudine dose must not exceed \n4200mg/wk. Must have Hgb level less than or equal to 10.0 g/dL or HCT \nless than 30-within the last four weeks. Continue Therapy: Zidovudine \ndose must not exceed 4200mg/wk. Must meet one of the following \ncriteria: Current-within last 4 weeks Hgb level less than 12.0 g/dL OR \nDocumented dose adjustment of therapy with corresponding \ndocumented Hgb levels to indicate maintenance therapy. Goal Hgb level \nshould not exceed 12.0g/dL. Anemia in Chemotherapy Treated Cancer -\nfirst 4 weeks. Diagnosis with a non-myeloid, non-erythroid malignancy. \nMust be receiving concurrent chemotherapy treatment for incurable \ndisease with palliative intent. Must have Hgb level less than10.0 g/dL or \nHCT less than 30-within last 4 weeks. Maint. Phase after first 4 weeks: \nMember has responded to therapy, defined as one or more of the \nfollowing:  increase in hemoglobin of at least 1 g/dL OR An increase in \nhemoglobin to greater than or equal to 10 g/dL OR a decrease in red \nblood cell (RBC) transfusion requirements OR prescriber determines to \ncontinue therapy. Continued dosing is needed to maintain the lowest \nhemoglobin level sufficient to avoid RBC transfusion.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n3 months for chemo induced anemia,HIV,HCV,MDS,RA,surgery. 6 \nmonths for CKD, CKD reauth: Plan Year\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 338 of 497\n", "doc_id": "74de8415-af9b-4b8a-8618-8e1d185a71dd", "embedding": null, "doc_hash": "b95e3f17a4bd3f060cd9fcd613bc679cc40799e711b46d26af216ac190d11b6c", "extra_info": {"page_label": "338", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2103, "_node_type": "1"}, "relationships": {"1": "22ffd56f-6035-44b6-9570-e26b64f2ce7b"}}, "__type__": "1"}, "703883af-8bf9-4060-99dd-5bb356c95309": {"__data__": {"text": "PROCRIT\nOther Criteria\nAnemia in Surgery Members: Must be scheduled to undergo elective, \nnoncardiac, nonvascular surgery. Must have Hgb level of greater than 10 \ng/dL and less than or equal 13 g/dL (within last 4 weeks). Anemia in \nMyelodysplastic Syndromes: symptomatic anemia associated with MDS. \nMust have a serum erythropoietin level less than or equal to 500 \nmUnits/mL (unlikely to respond to ESA therapy if erythropoietin level \ngreater than 500mUnits/ml). Must have Hgb level less than or equal to \n10.0 g/dL or HCT less than 30 (within last 4 weeks). Cont. Therapy: has \nresponded to therapy, defined as one or more of the following:  An \nincrease in hemoglobin of at least 1.5 g/dL OR An increase in \nhemoglobin to greater than or equal to 10 g/dL OR a decrease in red \nblood cell (RBC) transfusion requirements, OR prescriber determines to \ncontinue therapy.   Cont. dosing is needed to maintain the lowest \nhemoglobin level (not to exceed 12 g/dL) sufficient to avoid RBC \ntransfusion. Anemia associated with Management of Hepatitis C:  \nanemia in management of chronic Hepatitis C. Receiving combination \ntreatment for chronic Hepatitis C with interferon (IFN)/ribavirin (RBV) or \npegylated (PEG) IFN/RBV. Must have Hgb level less than or equal to \n12.0 gm/dL or HCT less than 30 during combination therapy as defined \nabove(within the last 4 weeks).Continue Therapy: Must be receiving \ncombination treatment for chronic Hepatitis C with interferon \n(IFN)/ribavirin (RBV) or pegylated (PEG) IFN/RBV.Must have been able \nto maintain previous ribavirin dosing without dose reduction due to \nsymptomatic anemia. Must meet one of the following criteria: Current \n(within the last 4 weeks) Hgb level less than 12.0g/dL OR Documented \ndose adjustment of therapy with corresponding documented Hgb levels \nto indicate maintenance therapy.  Goal Hgb level should not exceed \n12.0g/dL. Anemia associated with Rheumatoid Arthritis (RA) Treatment. \nDiagnosis of anemia associated with pharmaceutical treatment of RA. \nReceiving active therapy known to cause anemia. Must have Hgb level \nless than 10 g/dL or HCT less than 30(within the last 4 weeks).Cont. \nTherapy: Receiving active RA pharmaceutical treatment. Current (within \nthe last 4 weeks) Hgb less than 11 g/dL. For listed indications: Prior to \ninitiation of therapy, other causes of anemia including iron, B-12, folate \ndeficiencies, hemolysis, and bleeding have been ruled out. Prior to \ninitiation of therapy, the member's iron scores should be evaluated. \nTransferrin saturation should be at least 20% OR ferritin at least 100 \nng/mL within the last 4 months (applies to most recent result).  Cont. of \ntherapy requires documented Transferrin saturation of at least 20% OR \nferritin of at least 100 ng/mL within the last 4 months for all indications \n(applies to most recent result).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 339 of 497\n", "doc_id": "703883af-8bf9-4060-99dd-5bb356c95309", "embedding": null, "doc_hash": "67eada0fe5b94b3421669e3084ac36a3fccda390328de4fac5a6815cdc752501", "extra_info": {"page_label": "339", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2924, "_node_type": "1"}, "relationships": {"1": "a1d7a51a-d6c8-4a1c-ad13-c1ca3d0f03de"}}, "__type__": "1"}, "b64ea6cc-5b23-4db3-a747-fa039e24db57": {"__data__": {"text": "PROLASTIN-C\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nIgA deficient members or presence of antibodies against IgA.\nRequired\nMedical\nInformation\nThe member must meet ALL of the following criteria: Diagnosis of \ncongenital alpha1-antitrypsin deficiency with clinically evident \nemphysema and chronic replacement therapy is needed AND Has an \nalpha1-antitrypsin phenotype of PiZZ, PiZ(null), or PI (null, null) or \nphenotypes associated with serum alpha 1-antitrypsin concentrations of \nless than 57mg/dL if/when measured by laboratories using nephelometry \ninstead of radial immunodiffusion. Otherwise, a deficiency is shown at \n80mg/dL. (These products should not be used in individuals with the \nPiMZ or PiMS phenotypes of alpha1-antitrypsin deficiency because \nthese individuals appear to be at small risk of developing clinically \nevident emphysema.)\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 340 of 497\n", "doc_id": "b64ea6cc-5b23-4db3-a747-fa039e24db57", "embedding": null, "doc_hash": "5ef12117dc2b31163b6896068bac0bbef8f4550f4c35252c6a8b71b36dfff619", "extra_info": {"page_label": "340", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1061, "_node_type": "1"}, "relationships": {"1": "fc8d5073-29ee-477a-b1f4-7e30307ba454"}}, "__type__": "1"}, "a631dafc-b283-451d-959c-3c709095d9b2": {"__data__": {"text": "PROMACTA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nITP members with previous documented failure of eltrombopag.\nRequired\nMedical\nInformation\nChronic Idiopathic Thrombocytopenic Purpura. Initial Approval: The \nmember has a diagnosis of relapsed/refractory chronic immune \n(idiopathic) thrombocytopenic purpura (ITP) AND The member has a \nplatelet count of less than 50 x 109/L. The member has had an \ninsufficient response or is intolerant to corticosteroids OR The member \nhas had a splenectomy with an inadequate response AND had an \ninsufficient response or is intolerant to post-splenectomy corticosteroids. \nReauthorizations. The member has a platelet count of less than 400 x \n109/L  AND The member remains at risk for bleeding complications AND \nThe member is responding to therapy as evidenced by increased platelet \ncounts. Thrombocytopenia in Patients with Hepatitis C Infection: Initial \nApproval: The member has a diagnosis of chronic hepatitis C. The \nmember has a platelet count of less than 75 x 109/L. The degree of \nthrombocytopenia is preventing the initiation of interferon therapy OR \nlimits the ability to maintain optimal interferon based therapy. \nReauthorization: The member has a platelet count of less than 400 x \n109/L AND The member is responding to therapy as evidenced by \nincreased platelet counts AND The member continues to receive \ninterferon based therapy. Aplastic Anemia: Initial Approval: The member \nhas a diagnosis of aplastic anemia AND The member will receive \nPromacta (eltrombopag) in combination with immunosuppressive \ntherapy (e.g. cyclosporine, antithymocyte immune globulin) for first-line \ntreatment of severe aplastic anemia OR Promacta (eltrombopag) is \nbeing used for the treatment of refractory severe aplastic anemia in \nmembers with an insufficient response to immunosuppressive therapy \n(e.g. cyclosporine, antithymocyte immune globulin). Reauthorization: The \nmember has a platelet count of less than 400 x 109/L AND The member \nis responding to therapy as evidenced by increased platelet counts.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 341 of 497\n", "doc_id": "a631dafc-b283-451d-959c-3c709095d9b2", "embedding": null, "doc_hash": "2fca61db99a56a79a377e625809de73c2e63fb465cb608294b7ada2b7776a3e6", "extra_info": {"page_label": "341", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2270, "_node_type": "1"}, "relationships": {"1": "a8ef26c0-cde7-48ba-ab31-90be94e7cdd9"}}, "__type__": "1"}, "ca3f54b9-5472-4cd8-bf7d-8ff8915cebe2": {"__data__": {"text": "PYRUKYND\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nHemolytic Anemia:  the member has a diagnosis of pyruvate kinase \ndeficiency with at least two mutant alleles in the PKLR gene, of which at \nleast one is missense mutation.  The member is not homozygous for the \nR479H mutation or had two non-missense, variants, without the \npresence of another missense variant in the PKLR gene.  The member \nhad a hemoglobin level less than or equal to 10g/dL.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 342 of 497\n", "doc_id": "ca3f54b9-5472-4cd8-bf7d-8ff8915cebe2", "embedding": null, "doc_hash": "58fcb8927f678e15bf03e9c71328c53ff02729825b56016881cec50527ed2d52", "extra_info": {"page_label": "342", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 684, "_node_type": "1"}, "relationships": {"1": "9b5c4d08-b6e0-4ac2-87e7-29e2923c2a2d"}}, "__type__": "1"}, "8b705786-0bfd-496f-a02c-23776027cf4c": {"__data__": {"text": "QINLOCK\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMember experiences disease progression on Qinlock (ripretinib).\nRequired\nMedical\nInformation\nGastrointestinal Stromal Tumor (GIST): The member has a diagnosis of \nadvanced GIST AND The member has received prior therapy with three \nor more kinase inhibitors, including imatinib AND Qinlock (ripretinib) is \nbeing used as monotherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 343 of 497\n", "doc_id": "8b705786-0bfd-496f-a02c-23776027cf4c", "embedding": null, "doc_hash": "02ac1ec6a4e6fb79132b63db5645b7c62a69dda6001887469b78def09b15e92f", "extra_info": {"page_label": "343", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 599, "_node_type": "1"}, "relationships": {"1": "e11fd00a-4766-4334-9313-c1f86c914a00"}}, "__type__": "1"}, "5dad3e21-e2c5-4ddf-b3f2-f78f8f83af57": {"__data__": {"text": "quinine sulfate\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nProlongation of QT interval. Glucose-6-phosphate dehydrogenase \n(G6PD) deficiency. Myasthenia gravis. Optic neuritis.\nRequired\nMedical\nInformation\nPlasmodium Falciparum Malaria: Diagnosis of uncomplicated \nchloroquine-resistant Plasmodium falciparum malaria.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 344 of 497\n", "doc_id": "5dad3e21-e2c5-4ddf-b3f2-f78f8f83af57", "embedding": null, "doc_hash": "461755b32edbe221c36c8bb86d969dca9fa2bb8121bc3bc587aae8b2c8b61946", "extra_info": {"page_label": "344", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 525, "_node_type": "1"}, "relationships": {"1": "7862bc3b-0436-4254-912e-5673e6133f39"}}, "__type__": "1"}, "bda38b47-08e2-4e79-b7cd-f1a595030b7c": {"__data__": {"text": "QULIPTA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nMigraine Prevention:  Will be utilizing Qulipta (atogepant) for the \npreventative treatment of episodic migraines AND has been unable to \nachieve at least a 2 day reduction in migraine headache days per month \nafter previous treatment (of at least 2 months) with 1 of the following oral \npreventive medications: Divalproex, Topiramate, Metoprolol, \nPropranolol, or Timolol.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 345 of 497\n", "doc_id": "bda38b47-08e2-4e79-b7cd-f1a595030b7c", "embedding": null, "doc_hash": "88741a892bf7c143adfd1d30e97719191a6faf424b0c6e37c5d162e893dde299", "extra_info": {"page_label": "345", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 661, "_node_type": "1"}, "relationships": {"1": "90e68fd0-c37f-401a-835b-c203f5995f0e"}}, "__type__": "1"}, "d28555d7-798d-43e7-8d34-6d01a498ca05": {"__data__": {"text": "rasagiline\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nMember has a diagnosis of Parkinson's disease AND has had prior \ntherapy with, contraindication, or intolerance to selegiline.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 346 of 497\n", "doc_id": "d28555d7-798d-43e7-8d34-6d01a498ca05", "embedding": null, "doc_hash": "a63f3b4349134c97c0b26d0b37a19f2d962339f9e8fcf09f8080da6ad3854742", "extra_info": {"page_label": "346", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 429, "_node_type": "1"}, "relationships": {"1": "21899607-b365-48d9-a6e7-931bda1a421e"}}, "__type__": "1"}, "002314dd-fc6b-494a-8faa-ada13e991af1": {"__data__": {"text": "REGRANEX\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nKnown neoplasm at the site of application.\nRequired\nMedical\nInformation\nMember must be using for the treatment of lower extremity diabetic \nulcers AND the ulcer extends into the subcutaneous tissue or beyond \nAND the ulcer has an adequate blood supply AND Regranex will be used \nin combination with good ulcer care practices including debridement, \npressure relief and prevention and treatment of infection.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 347 of 497\n", "doc_id": "002314dd-fc6b-494a-8faa-ada13e991af1", "embedding": null, "doc_hash": "b146119393c744a213d4c8c09da55a4a425d73e8965a7bf7b1bef88c2db1d86d", "extra_info": {"page_label": "347", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 676, "_node_type": "1"}, "relationships": {"1": "cda036b4-0f2a-4fdc-836b-152edc0f19b7"}}, "__type__": "1"}, "1c9091c8-21ce-46cf-b7f0-2fe48a5a6594": {"__data__": {"text": "REPATHA PUSHTRONEX\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nPrimary Hyperlipidemia: Repatha (evolocumab) is used as adjunctive \ntherapy to maximally tolerated high intensity statin therapy (e.g. \natorvastatin or rosuvastatin) in members that have failed to achieve goal \nLDL-C reduction OR The member is determined to have statin-\nassociated muscle symptoms (SAMs) and SAMs symptoms included \nrhabdomyolysis OR Member has failed to achieve goal LDL-C reduction \nbecause of SAMs despite both lowering of statin strength AND \nattempting a different statin OR provider attestation that statin use has \nbeen tried and failed and is not clinically appropriate due to intolerable \nadverse effects.\nAge Restriction\nMember must be 10 years of age or older for diagnosis of Primary \nHyperlipidemia.  Member must be 18 years of age or older for Clinical \nAtherosclerotic Cardiovascular Disease.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 348 of 497\n", "doc_id": "1c9091c8-21ce-46cf-b7f0-2fe48a5a6594", "embedding": null, "doc_hash": "60d14c46dc1dff225542f898f61b5810cd95eb0bd4c54a3f953e60f350329639", "extra_info": {"page_label": "348", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1069, "_node_type": "1"}, "relationships": {"1": "1e830ae7-5d66-4a7a-a47e-997f5ec4b79b"}}, "__type__": "1"}, "99e42df5-e612-4f52-aae7-91c158cd0ac9": {"__data__": {"text": "REPATHA PUSHTRONEX\nOther Criteria\nClinical Atherosclerotic Cardiovascular Disease (ASCVD): The member \nmust have documentation of an ASCVD (e.g. acute coronary syndromes, \nhistory of myocardial infarction, stable or unstable angina, coronary or \nother arterial revascularization, stroke, transient ischemic attack or \nperipheral arterial disease, all of presumed atherosclerotic origin). \nRepatha (evolocumab) is used as adjunctive therapy in members taking \nmaximally tolerated high-intensity statin therapy (e.g. atorvastatin or \nrosuvastatin) and have failed to achieve goal LDL-C OR the member is \ndetermined to have statin-associated muscle symptoms (SAMs) and \nSAMs symptoms included rhabdomyolysis OR member has failed to \nachieve goal LDL-C reduction because of SAMs despite both lowering of \nstatin strength and attempting a different statin OR provider attestation \nthat statin use has been tried and failed and is not clinically appropriate \ndue to intolerable adverse effects. Homozygous Familial \nHypercholesterolemia (HoFH): The member must have a diagnosis of \ndefinite HoFH as defined by at least one of the following: Genetic \nconfirmation of 2 mutant alleles at the LDL receptor, ApoB, PCSK9, or \nARH adaptor protein gene locus OR an untreated LDL-C greater than \n500 mg/dL ( 13 mmol/L) or treated LDL-C greater than or equal to 300 \nmg/dL (7.76 mmol/L) or treated non-HDL cholesterol greater than or \nequal to 330 mg/dL (8.5 mmol/L) with at least one of the following: \nCutaneous or tendon xanthoma before age 10 years OR Elevated LDL \ncholesterol levels before lipid-lowering consistent with HeFH in both \nparents [untreated total cholesterol greater than 290 mg/dL (7.5 mmol/L) \nor untreated LDL-C greater than 190 mg/dL (4.9 mmol/L)]. Repatha \n(evolocumab) is used as adjunctive therapy to other LDL-lowering \ntherapies (e.g. statins, ezetimibe) in members that have failed to achieve \ngoal LDL-C reduction.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 349 of 497\n", "doc_id": "99e42df5-e612-4f52-aae7-91c158cd0ac9", "embedding": null, "doc_hash": "8f26cebb78ec9605fb42a05eea9596526d4edace8cf442582dcccf5b5c07d7f5", "extra_info": {"page_label": "349", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2004, "_node_type": "1"}, "relationships": {"1": "34624f91-2ffa-4889-bdad-8284ef515811"}}, "__type__": "1"}, "4d63ebd8-77ff-49d7-b25f-9efa93afc02d": {"__data__": {"text": "REPATHA SURECLICK\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nPrimary Hyperlipidemia: Repatha (evolocumab) is used as adjunctive \ntherapy to maximally tolerated high intensity statin therapy (e.g. \natorvastatin or rosuvastatin) in members that have failed to achieve goal \nLDL-C reduction OR The member is determined to have statin-\nassociated muscle symptoms (SAMs) and SAMs symptoms included \nrhabdomyolysis OR Member has failed to achieve goal LDL-C reduction \nbecause of SAMs despite both lowering of statin strength AND \nattempting a different statin OR provider attestation that statin use has \nbeen tried and failed and is not clinically appropriate due to intolerable \nadverse effects.\nAge Restriction\nMember must be 10 years of age or older for diagnosis of Primary \nHyperlipidemia.  Member must be 18 years of age or older for Clinical \nAtherosclerotic Cardiovascular Disease.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 350 of 497\n", "doc_id": "4d63ebd8-77ff-49d7-b25f-9efa93afc02d", "embedding": null, "doc_hash": "b55a2d28b49662aa4785bebea4176c28220ded792fd3806a2f23736e60c1d5ca", "extra_info": {"page_label": "350", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1068, "_node_type": "1"}, "relationships": {"1": "9e697894-019c-4e06-9ff9-0e80c4b9d417"}}, "__type__": "1"}, "cbebd2eb-4eda-4859-8136-8253dffd49e8": {"__data__": {"text": "REPATHA SURECLICK\nOther Criteria\nClinical Atherosclerotic Cardiovascular Disease (ASCVD): The member \nmust have documentation of an ASCVD (e.g. acute coronary syndromes, \nhistory of myocardial infarction, stable or unstable angina, coronary or \nother arterial revascularization, stroke, transient ischemic attack or \nperipheral arterial disease, all of presumed atherosclerotic origin). \nRepatha (evolocumab) is used as adjunctive therapy in members taking \nmaximally tolerated high-intensity statin therapy (e.g. atorvastatin or \nrosuvastatin) and have failed to achieve goal LDL-C OR the member is \ndetermined to have statin-associated muscle symptoms (SAMs) and \nSAMs symptoms included rhabdomyolysis OR member has failed to \nachieve goal LDL-C reduction because of SAMs despite both lowering of \nstatin strength and attempting a different statin OR provider attestation \nthat statin use has been tried and failed and is not clinically appropriate \ndue to intolerable adverse effects. Homozygous Familial \nHypercholesterolemia (HoFH): The member must have a diagnosis of \ndefinite HoFH as defined by at least one of the following: Genetic \nconfirmation of 2 mutant alleles at the LDL receptor, ApoB, PCSK9, or \nARH adaptor protein gene locus OR an untreated LDL-C greater than \n500 mg/dL ( 13 mmol/L) or treated LDL-C greater than or equal to 300 \nmg/dL (7.76 mmol/L) or treated non-HDL cholesterol greater than or \nequal to 330 mg/dL (8.5 mmol/L) with at least one of the following: \nCutaneous or tendon xanthoma before age 10 years OR Elevated LDL \ncholesterol levels before lipid-lowering consistent with HeFH in both \nparents [untreated total cholesterol greater than 290 mg/dL (7.5 mmol/L) \nor untreated LDL-C greater than 190 mg/dL (4.9 mmol/L)]. Repatha \n(evolocumab) is used as adjunctive therapy to other LDL-lowering \ntherapies (e.g. statins, ezetimibe) in members that have failed to achieve \ngoal LDL-C reduction.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 351 of 497\n", "doc_id": "cbebd2eb-4eda-4859-8136-8253dffd49e8", "embedding": null, "doc_hash": "68174e1296d429ebed6130e1d0994716422dc50064357fcc42595d6c26afcf24", "extra_info": {"page_label": "351", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2003, "_node_type": "1"}, "relationships": {"1": "7b75a06d-207d-472e-a794-2d40ee948c06"}}, "__type__": "1"}, "1cda8364-b707-4155-82f0-e39516bb6b94": {"__data__": {"text": "REPATHA SYRINGE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nPrimary Hyperlipidemia: Repatha (evolocumab) is used as adjunctive \ntherapy to maximally tolerated high intensity statin therapy (e.g. \natorvastatin or rosuvastatin) in members that have failed to achieve goal \nLDL-C reduction OR The member is determined to have statin-\nassociated muscle symptoms (SAMs) and SAMs symptoms included \nrhabdomyolysis OR Member has failed to achieve goal LDL-C reduction \nbecause of SAMs despite both lowering of statin strength AND \nattempting a different statin OR provider attestation that statin use has \nbeen tried and failed and is not clinically appropriate due to intolerable \nadverse effects.\nAge Restriction\nMember must be 10 years of age or older for diagnosis of Primary \nHyperlipidemia.  Member must be 18 years of age or older for Clinical \nAtherosclerotic Cardiovascular Disease.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 352 of 497\n", "doc_id": "1cda8364-b707-4155-82f0-e39516bb6b94", "embedding": null, "doc_hash": "4bfd13253e9abc48e5724124df10804c5b00ea9178aee403a861ba9e3fdaf0f2", "extra_info": {"page_label": "352", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1066, "_node_type": "1"}, "relationships": {"1": "3065eb16-5ab7-4da7-a614-33579b5501fe"}}, "__type__": "1"}, "fc49c44b-f106-48ce-998d-8a863b34dc22": {"__data__": {"text": "REPATHA SYRINGE\nOther Criteria\nClinical Atherosclerotic Cardiovascular Disease (ASCVD): The member \nmust have documentation of an ASCVD (e.g. acute coronary syndromes, \nhistory of myocardial infarction, stable or unstable angina, coronary or \nother arterial revascularization, stroke, transient ischemic attack or \nperipheral arterial disease, all of presumed atherosclerotic origin). \nRepatha (evolocumab) is used as adjunctive therapy in members taking \nmaximally tolerated high-intensity statin therapy (e.g. atorvastatin or \nrosuvastatin) and have failed to achieve goal LDL-C OR the member is \ndetermined to have statin-associated muscle symptoms (SAMs) and \nSAMs symptoms included rhabdomyolysis OR member has failed to \nachieve goal LDL-C reduction because of SAMs despite both lowering of \nstatin strength and attempting a different statin OR provider attestation \nthat statin use has been tried and failed and is not clinically appropriate \ndue to intolerable adverse effects. Homozygous Familial \nHypercholesterolemia (HoFH): The member must have a diagnosis of \ndefinite HoFH as defined by at least one of the following: Genetic \nconfirmation of 2 mutant alleles at the LDL receptor, ApoB, PCSK9, or \nARH adaptor protein gene locus OR an untreated LDL-C greater than \n500 mg/dL ( 13 mmol/L) or treated LDL-C greater than or equal to 300 \nmg/dL (7.76 mmol/L) or treated non-HDL cholesterol greater than or \nequal to 330 mg/dL (8.5 mmol/L) with at least one of the following: \nCutaneous or tendon xanthoma before age 10 years OR Elevated LDL \ncholesterol levels before lipid-lowering consistent with HeFH in both \nparents [untreated total cholesterol greater than 290 mg/dL (7.5 mmol/L) \nor untreated LDL-C greater than 190 mg/dL (4.9 mmol/L)]. Repatha \n(evolocumab) is used as adjunctive therapy to other LDL-lowering \ntherapies (e.g. statins, ezetimibe) in members that have failed to achieve \ngoal LDL-C reduction.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 353 of 497\n", "doc_id": "fc49c44b-f106-48ce-998d-8a863b34dc22", "embedding": null, "doc_hash": "e2b3a66ea2eb342d53f2f94aa3c7a926fd815e91e4598a5d83706489ff4ba2a0", "extra_info": {"page_label": "353", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2001, "_node_type": "1"}, "relationships": {"1": "b6519bd7-7c9e-4148-91d7-af69cf468b3d"}}, "__type__": "1"}, "71546001-f484-429a-b5e8-912a20b60e0d": {"__data__": {"text": "RETACRIT\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAnemia of CKD: Diagnosis of anemia associated with chronic kidney \ndisease. Hgb level less than 10.0 g/dL or HCT less than 30- within last 4 \nweeks. Continue Therapy: Current- within last 4 weeks Hgb level less \nthan 11 g/dL OR documented dose adjustment of therapy with \ncorresponding documented Hgb levels to indicate maintenance therapy. \nAnemia in Zidovudine-treated HIV-infected: Diagnosed with HIV (and \nAZT induced anemia) and receiving zidovudine treatment corresponding \nwith HAART. Endogenous serum erythropoietin levels less than or equal \nto 500 mUnits/mL. The total zidovudine dose must not exceed \n4200mg/wk. Must have Hgb level less than or equal to 10.0 g/dL or HCT \nless than 30-within the last four weeks. Continue Therapy: Zidovudine \ndose must not exceed 4200mg/wk. Must meet one of the following \ncriteria: Current-within last 4 weeks Hgb level less than 12.0 g/dL OR \nDocumented dose adjustment of therapy with corresponding \ndocumented Hgb levels to indicate maintenance therapy. Goal Hgb level \nshould not exceed 12.0g/dL. Anemia in Chemotherapy Treated Cancer -\nfirst 4 weeks. Diagnosis with a non-myeloid, non-erythroid malignancy. \nMust be receiving concurrent chemotherapy treatment for incurable \ndisease with palliative intent. Must have Hgb level less than10.0 g/dL or \nHCT less than 30-within last 4 weeks. Maint. Phase after first 4 weeks: \nMember has responded to therapy, defined as one or more of the \nfollowing:  increase in hemoglobin of at least 1 g/dL OR An increase in \nhemoglobin to greater than or equal to 10 g/dL OR a decrease in red \nblood cell (RBC) transfusion requirements OR prescriber determines to \ncontinue therapy. Continued dosing is needed to maintain the lowest \nhemoglobin level sufficient to avoid RBC transfusion.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n3 months for chemo induced anemia,HIV,HCV,RA,MDS,surgery. 6 \nmonths for CKD, CKD reauth: Plan Year.\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 354 of 497\n", "doc_id": "71546001-f484-429a-b5e8-912a20b60e0d", "embedding": null, "doc_hash": "07c403cbe0ddb900f7413e4fc00837ab60bd49ac244f2861588e158ce4c2302c", "extra_info": {"page_label": "354", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2105, "_node_type": "1"}, "relationships": {"1": "c5b244f0-5ec1-4f82-9772-fe331a5e41f9"}}, "__type__": "1"}, "1dd0b841-be46-4692-a6e5-b5b1df298323": {"__data__": {"text": "RETACRIT\nOther Criteria\nAnemia in Surgery Members: Must be scheduled to undergo elective, \nnoncardiac, nonvascular surgery. Must have Hgb level of greater than 10 \ng/dL and less than or equal 13 g/dL (within last 4 weeks). Anemia in \nMyelodysplastic Syndromes: Diagnosis of symptomatic anemia \nassociated with MDS. Must have a serum erythropoietin level less than \nor equal to 500 mUnits/mL (unlikely to respond to ESA therapy if \nerythropoietin level greater than 500mUnits/ml). Must have Hgb level \nless than or equal to 10.0 g/dL or HCT less than 30 (within last 4 weeks). \nContinue Therapy: The member has responded to therapy, defined as \none or more of the following:  An increase in hemoglobin of at least 1.5 \ng/dL OR An increase in hemoglobin to greater than or equal to 10 g/dL \nOR a decrease in red blood cell (RBC) transfusion requirements, OR \nprescriber determines to continue therapy.   Continued dosing is needed \nto maintain the lowest hemoglobin level (not to exceed 12 g/dL) sufficient \nto avoid RBC transfusion. Anemia associated with Management of \nHepatitis C. Diagnosis of anemia in management of chronic Hepatitis C. \nReceiving combination treatment for chronic Hepatitis C with interferon \n(IFN)/ribavirin (RBV) or pegylated (PEG) IFN/RBV. Must have Hgb level \nless than or equal to 12.0 gm/dL or HCT less than 30 during combination \ntherapy as defined above (within the last 4 weeks).Continue Therapy: \nMust be receiving combination treatment for chronic Hepatitis C with \ninterferon (IFN)/ribavirin (RBV) or pegylated (PEG) IFN/RBV. Must have \nbeen able to maintain previous ribavirin dosing without dose reduction \ndue to symptomatic anemia. Must meet one of the following criteria: \nCurrent (within the last 4 weeks) Hgb level less than 12.0g/dL OR \nDocumented dose adjustment of therapy with corresponding \ndocumented Hgb levels to indicate maintenance therapy.  Goal Hgb level \nshould not exceed 12.0g/dL. Anemia associated with Rheumatoid \nArthritis (RA) Treatment. Diagnosis of anemia associated with \npharmaceutical treatment of RA. Receiving active therapy known to \ncause anemia. Must have Hgb level less than 10 g/dL or HCT less than \n30(within the last 4 weeks).Continue Therapy: Receiving active RA \npharmaceutical treatment. Current (within the last 4 weeks) Hgb less \nthan 11 g/dL. For listed indications: Prior to initiation of therapy, other \ncauses of anemia including iron, B-12, folate deficiencies, hemolysis, \nand bleeding have been ruled out. Prior to initiation of therapy, the \nmember's iron scores should be evaluated. Transferrin saturation should \nbe at least 20% OR ferritin at least 100 ng/mL within the last 4 months \n(applies to most recent result).  Continuation of therapy requires \ndocumented Transferrin saturation of at least 20% OR ferritin of at least \n100 ng/ mL within the last 4 months for all indications (applies to most \nrecent result).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 355 of 497\n", "doc_id": "1dd0b841-be46-4692-a6e5-b5b1df298323", "embedding": null, "doc_hash": "0231209d4479089131a022df86a2ab8a91058fadaa9a47a99a667cf99baf42b4", "extra_info": {"page_label": "355", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2982, "_node_type": "1"}, "relationships": {"1": "677d206f-470b-4c7e-9c04-a9c0584bf4bf"}}, "__type__": "1"}, "7eeb39da-7c98-47cd-af23-4c1018ec8264": {"__data__": {"text": "RETEVMO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experiences disease progression on Retevmo\nRequired\nMedical\nInformation\nNon-small cell lung cancer. The member has a diagnosis of metastatic \nnon-small lung cancer AND The disease is documented RET fusion \npositive AND Retevmo is being used as monotherapy. Medullary Thyroid \ncancer. The member has a diagnosis of metastatic or advanced \nmedullary thyroid cancer AND The disease is documented RET mutant \nAND Retevmo is being used as a single agent for systemic therapy. \nThyroid cancer. The member has a diagnosis of metastatic or advanced \nthyroid cancer AND The disease is documented RET fusion positive \nAND The disease is radioactive iodine refractory AND Retevmo is being \nused as a single agent for systemic therapy.  RET fusion-positive Solid \nTumors: the member has locally advanced or metastatic solid tumors \nAND the solid tumors have documented rearranged during transfection \n(RET) gene fusion positive AND the member has progressed on or \nfollowing prior systemic treatment or has no satisfactory alternative \ntreatment options AND Retevmo (selpercatinib) is being administered as \nmonotherapy.\nAge Restriction\nFor medullary thyroid cancer and thyroid cancer only: the member is 12 \nyears and older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 356 of 497\n", "doc_id": "7eeb39da-7c98-47cd-af23-4c1018ec8264", "embedding": null, "doc_hash": "76a725d20a102e1c62bdc05d6dc3d332073d90788d477b5d2fefa9204b739e3d", "extra_info": {"page_label": "356", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1462, "_node_type": "1"}, "relationships": {"1": "1e0cabdf-3fdc-473c-b71f-ea6800595025"}}, "__type__": "1"}, "28bbeee3-7a83-43bc-917a-be874b607714": {"__data__": {"text": "REXULTI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDementia-related psychosis (in the absence of an approvable diagnosis), \nfor member 65 years of age or older.\nRequired\nMedical\nInformation\nMajor depressive disorder: The member must have clinically diagnosed \nmajor depressive disorder AND The member must have documentation \nof prior therapy, intolerance, or contraindication to a generic oral atypical \nantipsychotic therapy AND Rexulti must be used as adjunctive or add-on \ntreatment to ADT and not as monotherapy. Schizophrenia:The member \nmust have clinically diagnosed schizophrenia AND The member must \nhave documentation of prior therapy, intolerance, or contraindication to \ntwo generic oral atypical antipsychotic therapies.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 357 of 497\n", "doc_id": "28bbeee3-7a83-43bc-917a-be874b607714", "embedding": null, "doc_hash": "ab703c86f8ffc12d187f0601516c26f7b8a702ebad85b5121895da966849b2dd", "extra_info": {"page_label": "357", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 942, "_node_type": "1"}, "relationships": {"1": "b1997818-dff9-4017-acf7-faf2bbc1a2d7"}}, "__type__": "1"}, "9b36f7e8-f78b-4fd7-9b97-3ca7bc28113d": {"__data__": {"text": "REZLIDHIA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember has experienced disease progression while on \nor following Rezlidhia (olutasidenib).\nRequired\nMedical\nInformation\nAcute Myeloid Leukemia - Relapsed/Refractory: The member has a \ndiagnosis of acute myeloid leukemia (AML) AND The member has \nrelapsed or refractory disease AND The member has a documented \nIDH1 mutation AND The member will be using Rezlidhia (olutasidenib) \nas monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 358 of 497\n", "doc_id": "9b36f7e8-f78b-4fd7-9b97-3ca7bc28113d", "embedding": null, "doc_hash": "1bcc1a8b95d65c755090a5a3eec59d06e2723b284f93a74a6bc133a76cc8c546", "extra_info": {"page_label": "358", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 656, "_node_type": "1"}, "relationships": {"1": "ee2a612c-1ae1-4b1d-b2c0-593ba514712a"}}, "__type__": "1"}, "3318a725-4fbd-4ee1-a2be-78a2d99b02e3": {"__data__": {"text": "REZUROCK\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on Rezurock \n(belumosudil).\nRequired\nMedical\nInformation\nChronic Graft Versus Host Disease (cGVHD):  The member has a \ndiagnosis of chronic graft vs host disease (cGVHD) AND the member \nhas been unable to achieve treatment goals with at least two prior lines \nof system therapy AND the member has a medical reason as to why \nJakafi (ruxolitinib) cannot be started or continued.  Reauthorization \nCriteria:  Physician attestation that the member has continued to receive \na clinical benefit (e.g. resolution of skin rash, reduction of GI symptoms, \nsymptom improvement).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 359 of 497\n", "doc_id": "3318a725-4fbd-4ee1-a2be-78a2d99b02e3", "embedding": null, "doc_hash": "e63f4c882ab19bad18efc360fedbcf7cbe11ef502c3843e9d087ea8c3e73c126", "extra_info": {"page_label": "359", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 885, "_node_type": "1"}, "relationships": {"1": "b6831d47-f333-4b52-b989-8fc3ae399f32"}}, "__type__": "1"}, "da28393a-c79e-498e-b579-5b62592b619f": {"__data__": {"text": "RIABNI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nHigh dose CLL therapies (doses greater than 500mg/m\n\u00b2). \nThe member \nwill be using rituximab as maintenance therapy for diffuse large B cell \nlymphoma (DLBCL).  The length of maintenance therapy exceeds 2 \nyears for low-grade non-Hodgkins lymphoma (e.g. follicular lymphoma, \nmarginal zone lymphoma). The length of maintenance therapy exceeds \n2 years for chronic lymphocytic leukemia.\nRequired\nMedical\nInformation\nFor requests for Rituxan or Truxima: member must have intolerance or \ncontraindication with Ruxience or Riabni and meet the criteria below. \nRuxience and Truxima requests are only for NHL, CLL, RA, \ngranulomatosis with polyangitis (GPA) (Wegener\n\u2019\ns Granulomatosis), and \nmicroscopic polyangitis (MPA).  Riabni requests are only for NHL, CLL, \nRA, granulomatosis with polyangitis (GPA) (Wegener\n\u2019\ns Granulomatosis), \nand microscopic polyangitis (MPA). Chronic Lymphocytic Leukemia. The \nmember has a diagnosis of CLL. Non-Hodgkin\n\u2019\ns Lymphoma (CD-20 \npositive/B-Cell). The member has a diagnosis of CD-20 positive/B-cell \nNon-Hodgkin\n\u2019\ns lymphoma. Hodgkin\n\u2019\ns Disease (Hodgkin\n\u2019\ns Lymphoma). \nThe member has a diagnosis of Hodgkin\n\u2019\ns Disease. The member will be \nusing rituximab for primary treatment or for relapsed or progressive \ndisease AND disease has confirmed CD20 positivity. Rheumatoid \nArthritis. The member has a diagnosis of moderately- to severely-active \nrheumatoid arthritis. The member has had previous treatment with, \ncontraindication, or intolerance with one of the following:  Remicade, \nInflectra, infliximab, or Simponi Aria* (previous treatment with Simponi \nAria applies to medical benefit requests only). The member must be on \nconcomitant treatment with methotrexate during rituximab therapy, \nunless contraindicated or intolerant to methotrexate.\nAge Restriction\nWegener's Granulomatosis (WG) and Microscopic Polyangiitis (MPA): \nThe member is 2 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 360 of 497\n", "doc_id": "da28393a-c79e-498e-b579-5b62592b619f", "embedding": null, "doc_hash": "58fa7d4e5be4d5863bd7b15919c28f3a13e6a9c849211dea608960e24a2f266a", "extra_info": {"page_label": "360", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2115, "_node_type": "1"}, "relationships": {"1": "1531f16e-236c-4df4-975c-cb4a1f276cae"}}, "__type__": "1"}, "cfda2ff8-f456-4133-b96a-9b4fc955aaf4": {"__data__": {"text": "RIABNI\nOther Criteria\nThe member must have a diagnosis of Waldenstram's \nmacroglobulinemia. Post-transplant lymphoproliferative disorder. The \nmember has a diagnosis of Post-transplant Lymphoproliferative disease. \nImmune or Idiopathic Thrombocytopenic Purpura. The member must \nhave a diagnosis of refractory primary immune or idiopathic \nthrombocytopenic purpura. Member has not had a splenectomy, but has \nhad an insufficient response or is intolerant to corticosteroids, AND \nimmunoglobulins (IVIG), OR has had a splenectomy with an inadequate \nresponse or is intolerant to procedure AND had an insufficient response \nor is intolerant to post-splenectomy corticosteroids. Refractory response \nis characterized as EITHER: Platelet count less than 25,000/microliter \nOR Active bleeding due to inadequate platelet function. The member \nmust have had an inadequate response to post-splenectomy \ncorticosteroid therapy for four consecutive weeks within the last three \nmonths. Diagnosis of Wegeners Granulomatosis OR Microscopic \nPolyangiitis. Must be taking rituximab in combination with \nglucocorticoids. Pemphigus Vulgaris (PV). The member must have a \ndiagnosis of moderate to severe Pemphigus Vulgaris.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 361 of 497\n", "doc_id": "cfda2ff8-f456-4133-b96a-9b4fc955aaf4", "embedding": null, "doc_hash": "ee55b778509ad531de6071d5f6fe1405a5e62badde4080bf053bf956c051b351", "extra_info": {"page_label": "361", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1281, "_node_type": "1"}, "relationships": {"1": "993d37fa-eda9-45fb-94c8-3ee57f9751b6"}}, "__type__": "1"}, "1a9cc8ee-38cd-4c7a-b9b2-622fda2d189c": {"__data__": {"text": "RINVOQ\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nRheumatoid Arthritis: The member has a diagnosis of moderate to \nseverely active rheumatoid arthritis AND the member has had prior \ntherapy, contraindication or intolerance with one or more TNF blockers \n(e.g. Humira, Enbrel).  Psoriatic Arthritis:  The member has a diagnosis \nof active psoriatic arthritis AND the member has had prior therapy, \ncontraindication or intolerance with one or more TNF blockers (e.g. \nHumira, Enbrel).  Atopic Dermatitis:  The member has a diagnosis of \nmoderate to severe atopic dermatitis AND the member has had prior \ntherapy, contraindication or intolerance with at least one other systemic \ntherapy (e.g. azathioprine, mycophenolate mofetil). Ulcerative Colitis: the \nmember has a diagnosis of moderately to severely active ulcerative \ncolitis AND the member has had prior therapy, contraindication, or \nintolerance with one or more TNF blockers (e.g. Humira). Ankylosing \nSpondylitis: the member has a diagnosis of active ankylosing spondylitis \nAND the member has had prior therapy, contrainidcation or intolerance \nwith one or more TNF blockers (e.g. Humira, Enbrel).  Non-radiographic \nAxial Spondylarthritis:  the member has a diagnosis of non-radiographic \naxial spondylarthritis with signs of inflammation AND the member has \nhad prior therapy, contraindication, or intolerance to one or more TNF \nblockers (e.g. Humira).\nAge Restriction\nRA, Psoriatic Arthritis, UC, ankylosing spondylitis, and Non-radiographic \naxial spondylarthritis: The member is 18 years of age or older. Atopic \nDermatitis: the member is 12 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 362 of 497\n", "doc_id": "1a9cc8ee-38cd-4c7a-b9b2-622fda2d189c", "embedding": null, "doc_hash": "4b79920179467f52f4c6414a99af48a3dc606b543506a99ab7e88481ec5d1b53", "extra_info": {"page_label": "362", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1850, "_node_type": "1"}, "relationships": {"1": "2cbb2d3f-68c3-49b4-8d01-f9855a055f46"}}, "__type__": "1"}, "80e74c01-f6de-40bc-8ffd-c26187bd1212": {"__data__": {"text": "ROMIDEPSIN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on \nromidepsin.Members on concomitant hypomethylator (e.g. vorinostat) \ntherapy.\nRequired\nMedical\nInformation\nCutaneous T-cell Lymphoma (CTCL). Istodax (romidepsin) is being used \nto treat cutaneous T-cell lymphoma AND one of the following applies:  \nthe member will be using Istodax (romidepsin) as primary biologic \nsystemic therapy OR the member has received at least one prior \ntherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 363 of 497\n", "doc_id": "80e74c01-f6de-40bc-8ffd-c26187bd1212", "embedding": null, "doc_hash": "6ee3196ebfc244ccdd260223377e93c27f20b591a4126f90cc2242bcffd14eaf", "extra_info": {"page_label": "363", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 706, "_node_type": "1"}, "relationships": {"1": "dfc67de1-e93d-4d04-9d1e-0d48266d789e"}}, "__type__": "1"}, "56f7a74a-ba53-4239-9362-bb28d5865ea3": {"__data__": {"text": "ROZLYTREK\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nNon-Small Cell Lung Cancer (NSCLC): The member has a diagnosis of \nmetastatic or recurrent non-small cell lung cancer (NSCLC) AND the \nmember has disease which is ROS1-positive. Solid Tumors:  the \nmember has a diagnosis of solid tumors which are metastatic AND The \nmember has a documented neurotrophic tyrosine receptor kinase \n(NTRK) gene fusion without a known acquired resistance mutation AND \nThe member is not a candidate for surgical resection AND The member's \ndisease has progressed following treatment or does not have satisfactory \nalternative therapy options. Reauthorization: The member has not \ndeveloped a known resistance to Rozlytrek (entrectinib) AND Physician \nattestation that the member has continued to receive a clinical benefit \n(e.g., complete response, partial response, stable disease) and has not \nexperienced disease progression.\nAge Restriction\nSolid tumors: member is 12 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 364 of 497\n", "doc_id": "56f7a74a-ba53-4239-9362-bb28d5865ea3", "embedding": null, "doc_hash": "b9617ea05bd6e981e2a0c47c600225c26518873be80655e5303a5f273431db84", "extra_info": {"page_label": "364", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1199, "_node_type": "1"}, "relationships": {"1": "ee1b9385-b668-4dcd-9855-43babf162488"}}, "__type__": "1"}, "487223e0-55e5-4a06-9535-a8870f47f6e4": {"__data__": {"text": "RUBRACA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on PARP \ninhibitor therapy [e.g., Rubraca (rucaparib), Lynparza (olaparib), Zejula\n(niraparib)].\nRequired\nMedical\nInformation\nOvarian Cancer, Fallopian Tube, or Peritoneal Cancer Maintenance \nTherapy: The member has a diagnosis of recurrent epithelial ovarian \ncancer, fallopian tube cancer, or primary peritoneal cancer AND The \nmember has been treated with at least two prior lines of platinum based \nchemotherapy AND The member is in complete or partial response to \ntheir last platinum regimen AND The member will utilize Rubraca \n(rucaparib) as monotherapy AND The member has a medical reason \nwhy Lynparza (olaparib) cannot be started or continued. *Discontinue \nBevacizumab product before initiating maintenance therapy with \nRubraca. Metastatic Castration-Resistant Prostate Cancer:  The member \nhas a diagnosis metastatic castration-resistant prostate cancer (mCRPC) \nAND The member has documented deleterious BRCA mutation \n(germline and/or somatic) AND The member has had prior treatment with \nandrogen receptor-directed therapy (e.g. abiraterone, Xtandi, Erleada, or \nNubeqa) and a taxane-based chemotherapy (e.g. docetaxel) AND The \nmember will use Rubraca (rucaparib) in combination with androgen \ndeprivation therapy (e.g. previous bilateral orchiectomy or concurrent \nGnRH analog).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 365 of 497\n", "doc_id": "487223e0-55e5-4a06-9535-a8870f47f6e4", "embedding": null, "doc_hash": "28989e524137fa28afe213859ed56db5da73396dbe014e3d8583fbc1562faaf9", "extra_info": {"page_label": "365", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1611, "_node_type": "1"}, "relationships": {"1": "a21c61ba-76cd-4646-83af-d52ec3cdc4af"}}, "__type__": "1"}, "0eb95164-f8df-4b01-b127-d006c3241f7e": {"__data__": {"text": "rufinamide\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nPatients with familial short QT syndrome.\nRequired\nMedical\nInformation\nLennox-Gastaut Syndrome: The member has a diagnosis of seizures \nassociated with Lennox-Gastaut Syndrome (LGS) AND the member has \nprior therapy with, contraindication or intolerance to at least one other \ndrug indicated for LGS (e.g., topiramate, lamotrogine).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 366 of 497\n", "doc_id": "0eb95164-f8df-4b01-b127-d006c3241f7e", "embedding": null, "doc_hash": "3444f3a7d730e424ee36f5b9b81848845b6ec13c8686b80e2474eb78faa3fd50", "extra_info": {"page_label": "366", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 594, "_node_type": "1"}, "relationships": {"1": "d0caeda5-7dc1-4f76-a910-0734bd5ca345"}}, "__type__": "1"}, "e482013e-5db1-48b7-b405-273d5ab147f9": {"__data__": {"text": "RUXIENCE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nHigh dose CLL therapies (doses greater than 500mg/m\n\u00b2). \nThe member \nwill be using rituximab as maintenance therapy for diffuse large B cell \nlymphoma (DLBCL).  The length of maintenance therapy exceeds 2 \nyears for low-grade non-Hodgkins lymphoma (e.g. follicular lymphoma, \nmarginal zone lymphoma). The length of maintenance therapy exceeds \n2 years for chronic lymphocytic leukemia.\nRequired\nMedical\nInformation\nFor requests for Rituxan or Truxima: member must have intolerance or \ncontraindication with Ruxience or Riabni and meet the criteria below. \nRuxience and Truxima requests are only for NHL, CLL, RA, \ngranulomatosis with polyangitis (GPA) (Wegener\n\u2019\ns Granulomatosis), and \nmicroscopic polyangitis (MPA).  Riabni requests are only for NHL, CLL, \nRA, granulomatosis with polyangitis (GPA) (Wegener\n\u2019\ns Granulomatosis), \nand microscopic polyangitis (MPA). Chronic Lymphocytic Leukemia. The \nmember has a diagnosis of CLL. Non-Hodgkin\n\u2019\ns Lymphoma (CD-20 \npositive/B-Cell). The member has a diagnosis of CD-20 positive/B-cell \nNon-Hodgkin\n\u2019\ns lymphoma. Hodgkin\n\u2019\ns Disease (Hodgkin\n\u2019\ns Lymphoma). \nThe member has a diagnosis of Hodgkin\n\u2019\ns Disease. The member will be \nusing rituximab for primary treatment or for relapsed or progressive \ndisease AND disease has confirmed CD20 positivity. Rheumatoid \nArthritis. The member has a diagnosis of moderately- to severely-active \nrheumatoid arthritis. The member has had previous treatment with, \ncontraindication, or intolerance with one of the following:  Remicade, \nInflectra, infliximab, or Simponi Aria* (previous treatment with Simponi \nAria applies to medical benefit requests only). The member must be on \nconcomitant treatment with methotrexate during rituximab therapy, \nunless contraindicated or intolerant to methotrexate.\nAge Restriction\nWegener's Granulomatosis (WG) and Microscopic Polyangiitis (MPA): \nThe member is 2 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 367 of 497\n", "doc_id": "e482013e-5db1-48b7-b405-273d5ab147f9", "embedding": null, "doc_hash": "3134b12c09bc34717cbfa08d523e39ce0cc56a0473da428566223c8439b0d0ee", "extra_info": {"page_label": "367", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2117, "_node_type": "1"}, "relationships": {"1": "09a4c596-e330-4b3e-87db-31583e9b1ff3"}}, "__type__": "1"}, "27757c46-2adb-4959-a3dd-cfd2f3a0eff3": {"__data__": {"text": "RUXIENCE\nOther Criteria\nThe member must have a diagnosis of Waldenstram's \nmacroglobulinemia. Post-transplant lymphoproliferative disorder. The \nmember has a diagnosis of Post-transplant Lymphoproliferative disease. \nImmune or Idiopathic Thrombocytopenic Purpura. The member must \nhave a diagnosis of refractory primary immune or idiopathic \nthrombocytopenic purpura. Member has not had a splenectomy, but has \nhad an insufficient response or is intolerant to corticosteroids, AND \nimmunoglobulins (IVIG), OR has had a splenectomy with an inadequate \nresponse or is intolerant to procedure AND had an insufficient response \nor is intolerant to post-splenectomy corticosteroids. Refractory response \nis characterized as EITHER: Platelet count less than 25,000/microliter \nOR Active bleeding due to inadequate platelet function. The member \nmust have had an inadequate response to post-splenectomy \ncorticosteroid therapy for four consecutive weeks within the last three \nmonths. Diagnosis of Wegeners Granulomatosis OR Microscopic \nPolyangiitis. Must be taking rituximab in combination with \nglucocorticoids. Pemphigus Vulgaris (PV). The member must have a \ndiagnosis of moderate to severe Pemphigus Vulgaris.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 368 of 497\n", "doc_id": "27757c46-2adb-4959-a3dd-cfd2f3a0eff3", "embedding": null, "doc_hash": "729515d0881f7ac58d95257a30ef531c7f42c242d6255141569e95caa717a41a", "extra_info": {"page_label": "368", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1283, "_node_type": "1"}, "relationships": {"1": "9596f487-e87b-4e2a-ac93-31e50ea1b7c8"}}, "__type__": "1"}, "a2f6ddf8-0d76-4747-ac09-b83f6d0c107b": {"__data__": {"text": "RUZURGI\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nHistory of seizures.\nRequired\nMedical\nInformation\nLambert-Eaton Myasthenic Syndrome (LEMS):  The member has a \nconfirmed diagnosis of Lambert-Eaton Myasthenic Syndrome (LEMS) by \na specialist (e.g. neurologist) AND The diagnosis is supported by results \nfrom a clinical evaluation (e.g. electromyography or the presence of \nautoantibodies directed against VGCC [voltage gated calcium \nchannels]).\nAge Restriction\nThe member is 6 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 369 of 497\n", "doc_id": "a2f6ddf8-0d76-4747-ac09-b83f6d0c107b", "embedding": null, "doc_hash": "254a0b4aaa6a91a88cc2d28676a3964e082b28e766781e24d9f3f73568ea460c", "extra_info": {"page_label": "369", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 700, "_node_type": "1"}, "relationships": {"1": "9be01ad9-3ff4-44be-aef2-dd4c7ce9f8da"}}, "__type__": "1"}, "1bf3ef12-1591-4b6f-8609-d9cdd7638adc": {"__data__": {"text": "RYBREVANT\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers who have disease progression on Rybrevant (amivantamab).\nRequired\nMedical\nInformation\nNon-small cell lung cancer (NSCLC):  The member has a diagnosis of \nlocally advanced or metastatic non-small cell lung cancer (NSCLC) and \nall the following criteria applies:  The NSCLC has documented epidermal \ngrowth factor receptor (EGFR) exon 20 insertion mutations (e.g. as \ndetected by a FDA-approved test) AND the member has documented \ndisease progression on prior platinum-based chemotherapy AND \nRybrevant (amivantamab) will be given as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 370 of 497\n", "doc_id": "1bf3ef12-1591-4b6f-8609-d9cdd7638adc", "embedding": null, "doc_hash": "0b91ebd23e5d566ffb0d98b1ae46ef5c9de1944154741bb2f9634e5b571bcb5b", "extra_info": {"page_label": "370", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 813, "_node_type": "1"}, "relationships": {"1": "15795960-3957-4a62-b842-d68025b9b0f7"}}, "__type__": "1"}, "30857626-dbc4-478c-b0de-a01b28c47be4": {"__data__": {"text": "RYDAPT\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers that have experienced disease progression while on or \nfollowing Rydapt (midostaurin), Members with a diagnosis of therapy-\nrelated acute myeloid leukemia (defined as acute myeloid leukemia due \nto prior radiation therapy or prior chemotherapy used as therapy for a \nprior disorder or malignancy), Members with a diagnosis of acute \npromyelocytic leukemia (APL), Members that are using Rydapt\n(midostaurin) for post-consolidation therapy, Members that are using \nRydapt (midostaurin) as a single agent induction therapy for acute \nmyeloid leukemia\nRequired\nMedical\nInformation\nAcute Myeloid Leukemia-Newly diagnosed: The member has newly \ndiagnosed acute myeloid leukemia (AML) AND The member has \ndocumented FLT3 mutation-positive disease AND The member will be \nusing Rydapt (midostaurin) in combination with standard cytarabine and \ndaunorubicin induction and cytarabine consolidation chemotherapy. \nSystemic Mastocytosis: The member has a diagnosis of aggressive \nsystemic mastocytosis (ASM), systemic mastocytosis with associated \nhematologic neoplasm (SM-AHN), or mast cell leukemia (MCL). Acute \nMyeloid Leukemia - Relapsed/Refractory: The member has relapsed or \nrefractory acute myeloid leukemia (AML) AND The member has \ndocumented FLT3 mutation-positive disease AND The member will be \nusing Rydapt (midostaurin) as a component of repeating the initial \nsuccessful induction regimen, if late relapse (relapse occurring later than \n12 months).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 371 of 497\n", "doc_id": "30857626-dbc4-478c-b0de-a01b28c47be4", "embedding": null, "doc_hash": "73c167d6ea64010ea35314290624882b6afe01c1bd9f57250366fb082984ce10", "extra_info": {"page_label": "371", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1727, "_node_type": "1"}, "relationships": {"1": "a483d805-ae51-4d4f-851e-f43b7694a986"}}, "__type__": "1"}, "8a0ce770-30f1-45ac-a23f-e878cc9978a7": {"__data__": {"text": "RYLAZE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers with a history of serious pancreatitis with prior asparaginase \nbased therapy.  Members with a history of serious thrombosis with prior \nasparaginase based therapy.  Members with a history of serious \nhemorrhagic events with prior asparaginase based therapy.  Members \nthat have experienced disease progression while on asparaginase based \ntherapy.\nRequired\nMedical\nInformation\nAcute Lymphoblastic Leukemia (ALL) or Lymphoblastic Lymphoma \n(LBL):  The member has a diagnosis of acute lymphoblastic leukemia \n(ALL) or Lymphoblastic lymphoma (LBL) AND The member has \ndocumented, Grade 2 \n\u2013 4 \nhypersensitivity (based on Common \nTerminology Toxicity Criteria) as a result of prior treatment with \nOncaspar (pegaspargase) ANDThe member is using Rylaze \n(asparaginase Erwinia chrysanthemi-rywn) as a component of a multi-\nagent chemotherapeutic regimen.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 372 of 497\n", "doc_id": "8a0ce770-30f1-45ac-a23f-e878cc9978a7", "embedding": null, "doc_hash": "6112d289e9499e3440ecd3fa5d54c538209140f65157795c93da8c1aff3821c8", "extra_info": {"page_label": "372", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1114, "_node_type": "1"}, "relationships": {"1": "2f301f63-42ba-48ff-b518-3a4b0331239f"}}, "__type__": "1"}, "2a4ff576-904c-45eb-a94e-25a711b69f9d": {"__data__": {"text": "sajazir\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nUse for prophylaxis of HAE attack. Evidence of autoantibodies against \nthe C1INH protein. Evidence of underlying lymphoproliferative, \nmalignant, or autoimmune disorder that causes angioedema attacks. \nUse in combination with other agents approved for acute treatment of \nHAE attack (e.g. Berinert, Kalbitor, Ruconest).\nRequired\nMedical\nInformation\nHereditary Angioedema (HAE): The member must have a diagnosis of \nhereditary angioedema (HAE) type 1 or type 2. The member must have \ndocumentation of: Low evidence of C4 level (i.e. C4 level below lower \nlimit of normal laboratory reference range) AND Low C1 inhibitor (i.e. \nC1INH level below lower limit of normal laboratory reference range) \nantigenic level (C1INH less than 19 mg/dL) OR Low C1INH functional \nlevel (i.e. functional C1INH less than 50% or below lower limit of normal \nlaboratory reference range) OR Known HAE-causing C1INH mutation. \nThe member is being treated by a specialist in hereditary angioedema \n(i.e. allergist and/or immunologist). Must provide lab report or medical \nrecord documentation which include lab values as required by policy. \nLab values must include C1q level. The member is using icatibant for \ntreatment of acute attacks of HAE.\nAge Restriction\nThe member must be 18 years or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 373 of 497\n", "doc_id": "2a4ff576-904c-45eb-a94e-25a711b69f9d", "embedding": null, "doc_hash": "07424611e0c6e04e715b3377627995b940e137d2bd9bf349a8eb549efbc0a780", "extra_info": {"page_label": "373", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1519, "_node_type": "1"}, "relationships": {"1": "a9f2669b-e1f0-4ed1-82ab-fc2ddc3176a3"}}, "__type__": "1"}, "881b16ed-cefc-4bd6-953f-38434587ab35": {"__data__": {"text": "SANDOSTATIN LAR DEPOT\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nAcromegaly: The member must have a diagnosis of Acromegaly. Must \nhave had an inadequate response to surgery/radiation or for whom \nsurgical resection/radiation is not an option.  Treatment of metastatic \ncarcinoid tumors.  Must have a diagnosis of a carcinoid tumor. Patient \nmust have severe diarrhea and flushing resulting from carcinoid tumor. \nTreatment of vasoactive intestinal peptide tumors (VIPomas). Patient \nmust be diagnosed with a vasoactive intestinal peptide tumor. Patient \nmust have diagnosis of profuse watery diarrhea associated with VIP-\nsecreting tumor. Treatment of chemotherapy or radiation induced \ndiarrhea. Patient must have grade 3 or above diarrhea according to NCI \ncommon toxicity. Patient must have NCI grade 1 or 2 diarrhea and have \nfailed treatment with loperamide or diphenoxylate and atropine. \nTreatment of severe secretory diarrhea in acquired immune deficiency \nsyndrome (AIDS) patients.  Patient must have diagnosis of severe \ndiarrhea resulting from acquired immune deficiency syndrome (AIDS). \nPatient must have tried and failed antimicrobial agents (eg. ciprofloxacin \nor metronidazole) and/or anti-motility agents (eg. loperamide or \ndiphenoxylate and atropine). Reversal of life-threatening hypotension \ndue to carcinoid crisis during induction of anesthesia. Patient must have \nlife-threatening hypotension due to carcinoid crisis.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 374 of 497\n", "doc_id": "881b16ed-cefc-4bd6-953f-38434587ab35", "embedding": null, "doc_hash": "f47afe721fb33b63ac0d0bbd6c0e32578a11a131f2423d6ce32048c7e7dcb693", "extra_info": {"page_label": "374", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1691, "_node_type": "1"}, "relationships": {"1": "72071ce9-8943-44ef-b0f4-173473900109"}}, "__type__": "1"}, "c0fbdc59-6e0b-4569-8c89-ef7957e81792": {"__data__": {"text": "sapropterin\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nInitial: The member has a diagnosis of PKU.  Reauth - The member has \ntetrahydobiopterin -(BH4) responsive PKU defined by: The member has \nachieved a greater than or equal to a 20% reduction in blood \nphenylalanine concentration from pre-treatment baseline OR the \nmember has had a clinical response (e.g., cognitive and/or behavioral \nimprovements) as determined by the prescriber.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nFirst approval: three months. if response is positive extended for plan \nyear duration.\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 375 of 497\n", "doc_id": "c0fbdc59-6e0b-4569-8c89-ef7957e81792", "embedding": null, "doc_hash": "be2501210cf0fbc4add2b20dc2c55b20f9e53a18ff56f72349ecae60eb2465b9", "extra_info": {"page_label": "375", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 755, "_node_type": "1"}, "relationships": {"1": "c2d0fa78-51a7-4f25-a286-f37e24004221"}}, "__type__": "1"}, "96fdd029-27d6-4b02-8c5b-90a3e5a6d49e": {"__data__": {"text": "SARCLISA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on or following \nan anti-CD38 inhibitor (e.g. daratumumab, isatuximab-irfc).\nRequired\nMedical\nInformation\nMultiple myeloma (third line). The member has a diagnosis of multiple \nmyeloma AND The member will be using Sarclisa (isatuximab-irfc) in \ncombination with Pomalyst (pomalidomide) and dexamethasone \n(Omission of corticosteroid from regimen is allowed if \nintolerance/contraindication) AND The member has received at least two \nprior therapies including Revlimid (lenalidomide) and a proteasome \ninhibitor (e.g. bortezomib, carfilzomib).  Multiple Myeloma (relapsed or \nrefractory):  The member has a diagnosis of relapsed or refractory \nmultiple myeloma AND The member will be using Sarclisa (isatuximab-\nirfc) in combination with carfilzomib and dexamethasone (Omission of \ncorticosteroid from regimen is allowed if intolerance/contraindication) \nAND The member has received at least one prior therapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 376 of 497\n", "doc_id": "96fdd029-27d6-4b02-8c5b-90a3e5a6d49e", "embedding": null, "doc_hash": "4554ba4b7cd2d964914925fc7452c30dd3b42413541b516251b7d01fc28ba766", "extra_info": {"page_label": "376", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1221, "_node_type": "1"}, "relationships": {"1": "463ebedf-6f3a-4a66-9c98-9167ba3904c0"}}, "__type__": "1"}, "6a9c7d86-11b6-42fc-b776-b9ce293a55bc": {"__data__": {"text": "SCEMBLIX\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on Scemblix \n(asciminib).\nRequired\nMedical\nInformation\nChronic Myeloid Leukemia (chronic phase):  The member has a \ndiagnosis of Philadelphia chromosome-positive chronic myeloid \nleukemia (Ph+ CML) in chronic phase AND One of the following applies:  \nThe member has had intolerance, resistance, or contraindication to at \nleast two available tyrosine kinase inhibitors OR The member has T315I \nmutation.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 377 of 497\n", "doc_id": "6a9c7d86-11b6-42fc-b776-b9ce293a55bc", "embedding": null, "doc_hash": "f409c3bdb7b91689b214f63c5ea40586708e2ff0933e3acf420b5d256d9fafca", "extra_info": {"page_label": "377", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 715, "_node_type": "1"}, "relationships": {"1": "37809a6f-b2f5-45db-b29c-9a55ef6e2489"}}, "__type__": "1"}, "c9f24c44-b718-43ae-a1d0-f1bb724680f2": {"__data__": {"text": "SECUADO\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nDementia related psychosis(in the absence of an approvable \ndiagnosis)for members 65 years of age or older.\nRequired\nMedical\nInformation\nSchizophrenia: The member has diagnosis of schizophrenia. The \nmember must have prior therapy or intolerance or contraindication to at \nleast two of the following: risperidone or olanzapine or quetiapine or \nziprasidone or aripiprazole.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 378 of 497\n", "doc_id": "c9f24c44-b718-43ae-a1d0-f1bb724680f2", "embedding": null, "doc_hash": "e7a5afcf0351c061e0de98d6feefd9b1b5547a2f03febe854089b97123eb123c", "extra_info": {"page_label": "378", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 641, "_node_type": "1"}, "relationships": {"1": "693eaf89-71c1-4f60-95aa-352de08cc3ad"}}, "__type__": "1"}, "c555d382-0caf-4bfe-915b-222822e41f44": {"__data__": {"text": "SIGNIFOR\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nCushings disease: Diagnosis of Cushings disease AND Pituitary surgery \nis not an option or has not been curative AND No severe hepatic \nimpairment (Child-Pugh C).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months for initial approval.\nOther Criteria\nReauthorization criteria for additional 180 days are as follows: No severe \nhepatic impairment (Child-Pugh C AND Urinary Free Cortisol (UFC) level \nhas decreased from baseline at start of Signifor (pasireotide) treatment.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 379 of 497\n", "doc_id": "c555d382-0caf-4bfe-915b-222822e41f44", "embedding": null, "doc_hash": "434e57efa6c343c3ad6147fb16815c907d893372519322b7945a4d00c30ab2d0", "extra_info": {"page_label": "379", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 685, "_node_type": "1"}, "relationships": {"1": "a635a522-9234-4c38-91b4-01eedb898e5a"}}, "__type__": "1"}, "efaab952-db8d-483a-95c7-8c21d919ce22": {"__data__": {"text": "sildenafil (pulm.hypertension)\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nPulmonary Arterial Hypertension (PAH).The member must have a \ndiagnosis of pulmonary arterial hypertension (WHO Group I) confirmed \nby right heart catheterization. The member has had prior therapy, \ncontraindication, or intolerance to a phosphodiesterase type 5 (PDE-5) \ninhibitor approved for use in PAH (e.g., sildenafil or tadalafil).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 380 of 497\n", "doc_id": "efaab952-db8d-483a-95c7-8c21d919ce22", "embedding": null, "doc_hash": "4604be88ec5203e535bb553afcfe01b42a227e1c3de6d23c2962184c2c02d4a6", "extra_info": {"page_label": "380", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 660, "_node_type": "1"}, "relationships": {"1": "fb0dcbb5-8062-4d93-96e1-513967316679"}}, "__type__": "1"}, "78ecccb7-7853-44db-a72c-bdfad171f9a7": {"__data__": {"text": "SIRTURO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nMultidrug-resistant tuberculosis (MDR-TB). The member must have a \ndiagnosis of pulmonary multidrug-resistant tuberculosis (MDR-TB) \nconfirmed by drug susceptibility testing (DST). Bedaquiline will be used \nas part of a multidrug regimen.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n24 weeks duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 381 of 497\n", "doc_id": "78ecccb7-7853-44db-a72c-bdfad171f9a7", "embedding": null, "doc_hash": "c3d2efc69222b15820106f74e4b20910a37ce0b6fc511984f65e2104511d4fa1", "extra_info": {"page_label": "381", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 525, "_node_type": "1"}, "relationships": {"1": "daad47a3-2fbe-4a84-8a66-fd8f30d37b22"}}, "__type__": "1"}, "b9f55d22-dfec-4fe5-860b-e50b4f405698": {"__data__": {"text": "SKYRIZI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nPlaque Psoriasis: The member has a diagnosis of moderate to severe \nplaque psoriasis AND the member has had prior therapy with or \nintolerance to a single conventional oral systemic treatment (e.g. \nmethotrexate, cyclosporine), or contraindication to all conventional oral \nsystemic treatments.  Psoriatic Arthritis:  The member has a diagnosis of \nactive psoriatic arthritis AND The member has had prior therapy or \nintolerance to a single DMARD (e.g. methotrexate, sulfasalazine, \nleflunomide), or contraindication with all DMARDS.  Moderately to \nseverely active Crohn\n\u2019\ns disease:  member has a diagnosis of moderately \nto severely active Crohn\n\u2019\ns disease AND the member has had prior \ntherapy, contraindication, or intolerance to a corticosteroid (e.g., \nprednisone, methylprednisolone) or an immunomodulator (e.g., \nazathioprine, 6-mercaptopurine, methotrexate).\nAge Restriction\nThe member must be 18 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 382 of 497\n", "doc_id": "b9f55d22-dfec-4fe5-860b-e50b4f405698", "embedding": null, "doc_hash": "9a2b8638a7ba7ffd53eb6ad1814cd5cca6d7987114d5525b2cf27b44d3e802bb", "extra_info": {"page_label": "382", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1202, "_node_type": "1"}, "relationships": {"1": "382dc190-350c-471a-bf5e-29f3d21b4183"}}, "__type__": "1"}, "54276fe0-90bb-4c71-9727-6a0b66d964f5": {"__data__": {"text": "sodium oxybate\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nNarcolepsy with Cataplexy: The member has a diagnosis of narcolepsy \nwith cataplexy.  Reauthorization: Documentation must be provided \ndemonstrating a reduction in frequency of cataplexy attacks associated \nwith Xyrem (sodium oxybate) therapy. Narcolepsy with excessive \ndaytime sleepiness: The member has a diagnosis of narcolepsy \naccording to ICSD-3 or DSM-5 criteria AND the member has condition of \nexcessive daytime sleepiness (EDS) associated with narcolepsy as \nconfirmed by documented sleep testing (e.g. polysomnography, multiple \nsleep latency test) AND previous treatment, intolerance, or \ncontraindication to at least one CNS stimulant (e.g. methylphenidate, \namphetamine salt combination immediate release, or \ndextroamphetamine) and modafinil. Prerequisite therapy required only \nfor diagnosis of narcolepsy with excessive daytime sleepiness. \nReauthorization: Documentation must be provided demonstrating a \nreduction in symptoms of EDS associated with Xyrem (sodium oxybate) \ntherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial authorization: 3 months. Reauthorization: 6 months.\nOther Criteria\nThe member will be using no more than one of the following products at \nany given time: Xyrem (sodium oxybate), Xywav (calcium magnesium, \npotassium, and sodium oxybates), Sunosi (solriamfetol), or Wakix \n(pitolisant).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 383 of 497\n", "doc_id": "54276fe0-90bb-4c71-9727-6a0b66d964f5", "embedding": null, "doc_hash": "7ac3217da9c03d9e8d702816666e0170632bca0939ada251612a6a923c97eef3", "extra_info": {"page_label": "383", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1556, "_node_type": "1"}, "relationships": {"1": "b19860d0-a8b2-4fd8-a497-08317d6b458e"}}, "__type__": "1"}, "a594843e-1ae9-453f-b28b-35307515e532": {"__data__": {"text": "SOMATULINE DEPOT\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nDiagnosis of acromegaly. The patient has a diagnosis of acromegaly. \nThe patient has had an inadequate response to or cannot be treated with \nsurgical resection OR The patient has had an inadequate response to or \ncannot be treated with radiation therapy.  Gastroenteropancreatic \nNeuroendocrine Tumors (GEP-NETs): The member has a diagnosis of \nunresectable, well- or moderately-differentiated, locally advanced, or \nmetastatic gastroenteropancreatic neuroendocrine tumors.  Carcinoid \nSyndrome: The member has a diagnosis of carcinoid syndrome with \nsymptoms of flushing and/or diarrhea.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 384 of 497\n", "doc_id": "a594843e-1ae9-453f-b28b-35307515e532", "embedding": null, "doc_hash": "2a3a08e56f0c3d81b1fe6aa7fd570c9a0cf23e0c092b908857e1257cc25d60cb", "extra_info": {"page_label": "384", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 898, "_node_type": "1"}, "relationships": {"1": "76b417b2-e951-4961-bb01-f9a807cb1fdb"}}, "__type__": "1"}, "e08f3971-3b5c-4d66-a61e-4e8694313af5": {"__data__": {"text": "SOMAVERT\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAcromegaly. The member must have a diagnosis of acromegaly. The \nmember had inadequate response to surgery or radiation therapy, AND \none dopamine agonists (i.e. bromocriptine)or one somatostatin \nanalogues (i.e. octreotide, Somatuline depot).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 385 of 497\n", "doc_id": "e08f3971-3b5c-4d66-a61e-4e8694313af5", "embedding": null, "doc_hash": "25a9d4ed71ff7a2d5c6d8bf9753714ba66d036a232542bcbb5bedcac2810378b", "extra_info": {"page_label": "385", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 532, "_node_type": "1"}, "relationships": {"1": "4603de5a-4ed7-4aca-bff8-efbad600648b"}}, "__type__": "1"}, "37f2a501-e4a8-4408-818c-8b45783e333d": {"__data__": {"text": "sorafenib\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors. Members that have \nexperienced disease progression while on Nexavar (sorafenib).\nRequired\nMedical\nInformation\nRenal Cell Carcinoma: Diagnosis of advanced renal cell carcinoma \n(stage IV) AND the member has experienced intolerance, \ncontraindication, or unable to achieve treatment goals with Cabometyx \n(cabozantinib) as second line therapy (e.g., severe \nhypertension/hypertensive crisis, cardiac failure, venous thromboembolic \nevent within the last 6 months, arterial thromboembolic event within the \nlast 12 months, severe hemorrhage, reversible posterior \nleukoencephalopathy, unmanageable fistula/GI perforation, nephrotic \nsyndrome). Liver Carcinoma: Diagnosis of unresectable hepatocellular \n(liver) carcinoma. Thyroid Carcinoma. Diagnosis of advanced metastatic \nmedullary carcinoma (thyroid carcinoma) OR The member has a \ndiagnosis of advanced, clinically progressive and/or symptomatic \npapillary carcinoma, follicular carcinoma or Hurthle cell carcinoma AND \nTumors are not responsive to radio-iodine treatment. Gastrointestinal \nstromal tumor (GIST). Diagnosis of gastrointestinal stromal tumor (GIST) \nAND The member experienced disease progression with imatinib or \nSutent (sunitinib) or Stivarga (regorafenib).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 386 of 497\n", "doc_id": "37f2a501-e4a8-4408-818c-8b45783e333d", "embedding": null, "doc_hash": "fc906645e3f5b54a4bc2d2742ddba5611f9a6f655cdbaf5a39a1b570821a8e37", "extra_info": {"page_label": "386", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1538, "_node_type": "1"}, "relationships": {"1": "460b2792-0635-425e-a325-1cfbaabea87c"}}, "__type__": "1"}, "f367f092-50a9-4277-885d-ce111fa10f75": {"__data__": {"text": "SPRYCEL\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors, Members that have \nexperienced disease progression while on dasatinib. For ALL and CML: \nThe member has one of the following mutations: T315I/A, F317L/V/I/C or \nV299L.\nRequired\nMedical\nInformation\nChronic Myelogenous Leukemia (CML): The member has a diagnosis of \nPh+ chronic myeloid leukemia (CML) and one of the following applies: \nThe member has accelerated or blast phase CML OR The member has a \ndiagnosis of chronic phase CML that has not been previously treated and \none of the following applies: Intermediate- or high-risk score for disease \nprogression and has contraindication to, intolerance to, or unable to \nachieve treatment goals with Bosulif (bosutinib) OR Low risk score for \ndisease progression and has contraindication to, intolerance to, or \nunable to achieve treatment goals with imatinib and Bosulif (bosutinib)  \nOR The member has a diagnosis of chronic phase CML that has \nreceived previous treatment AND Low, intermediate-, or high-risk score \nfor disease progression and has contraindication to, intolerance to, or \nunable to achieve treatment goals with Bosulif (bosutinib). Acute \nLymphoblastic Leukemia (ALL): The member has ALL (Philadelphia \nChromosome positive)and Sprycel is being used for induction or \nconsolidation treatment in combination with chemotherapy or \ncorticosteroids OR treatment is for maintenance therapy or the treatment \nof members with resistance or intolerance to prior therapy. Advanced \nGastrointestinal Stromal Tumor (GIST): The member has a diagnosis of \nadvanced unresectable GIST.The member has progressive disease or is \nintolerant to prior therapy with Gleevec (imatinib) or Sutent (sunitinib)or \nStivarga. [Pediatric] Chronic Myelogenous Leukemia (CML). The \nmember has a diagnosis of chronic myeloid leukemia (CML) that is \nPhiladelphia chromosome positive (Ph+) AND the member is in chronic \nphase. [Pediatric] Acute lymphoblastic leukemia (ALL).  The member has \na diagnosis of acute lymphoblastic leukemia (ALL) AND the member has \nPhiladelphia chromosome positive (Ph+) disease AND the member has \nnewly-diagnosed disease AND The member will be using Sprycel in \ncombination with chemotherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 387 of 497\n", "doc_id": "f367f092-50a9-4277-885d-ce111fa10f75", "embedding": null, "doc_hash": "233718b6baa9bde1b28b0485de3b395b623e6dc17cc4e6c91e6e083317834fde", "extra_info": {"page_label": "387", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2456, "_node_type": "1"}, "relationships": {"1": "230b0a18-d3d4-4add-ad16-c7d1796f37e1"}}, "__type__": "1"}, "f1c430d6-b694-42fb-bc25-fc7ce19b9094": {"__data__": {"text": "SPRYCEL\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 388 of 497\n", "doc_id": "f1c430d6-b694-42fb-bc25-fc7ce19b9094", "embedding": null, "doc_hash": "790bc96839b5160e1289f7d59a866eb7bc60e03ce6d217abb146fca13a815eed", "extra_info": {"page_label": "388", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 82, "_node_type": "1"}, "relationships": {"1": "41859b7c-0fe0-4414-881e-5e1e5dee2e25"}}, "__type__": "1"}, "1f079a5c-f225-4f2b-a1e7-0d60ad4d866f": {"__data__": {"text": "STELARA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nModerate to severe chronic plaque psoriasis (SC formulation only): The \nmember must have a diagnosis of moderate to severe chronic plaque \npsoriasis AND The member has had proir therapy or intolerance to one \nor more oral systemic tretaments (e.g. methotrexate, cyclosporine) or \ncontraindication to all conventional oral systemic treatments. Psoriatic \narthritis (SC formulation only):  The member must have a diagnosis of \nactive psoriatic arthritis AND the member has had prior therapy or \nintolerance to a single DMARD (e.g. methotrexate, sulfasalazine, \nhydroxychoroquine, leflunomide), or contraindication with all DMARDS. \nModerately to severely active Crohn's disease (IV and SC formulations). \nThe member must have a diagnosis of moderately to severely active \nCrohn's disease AND the member has had prior therapy, \ncontraindication, or intolerance to a corticosteroid (e.g. prednisone, \nmethylprednisolone) or an immunomodulator (e.g. azathioprine, 6-\nmercaptopurine, methotrexate). The member must have a diagnosis of \nmoderately to severely active ulcerative colitis AND the member has had \nprior therapy, contraindication, or intolerance to one or more of the \nfollowing conventional therapies: 5-aminosalicylic acids (5-ASAs) (e.g. \nmesalamine, balsalazide) OR Corticosteroids (e.g. prednisone, \nmethylpredisolone) PR immunomodulators (e.g. azathioprine, 6-\nmercaptopurine).\nAge Restriction\nModerate to severe chronic plaque psoriasis and psoriatic arthritis: The \nmember must be 6 years of age or older. For all other indications: Must \nbe 18 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 389 of 497\n", "doc_id": "1f079a5c-f225-4f2b-a1e7-0d60ad4d866f", "embedding": null, "doc_hash": "9c1b8f3bda3630f4b86f6088fa6ffe451e0509bbafda40c615920605602560cc", "extra_info": {"page_label": "389", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1852, "_node_type": "1"}, "relationships": {"1": "1c6a9a9d-ffd2-42c1-88cb-6576f7270649"}}, "__type__": "1"}, "22715473-75d4-4d1b-8f7b-fb1bf3830f48": {"__data__": {"text": "STIVARGA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on Stivarga \n(regorafenib).Members on concomitant tyrosine kinase inhibitors.\nRequired\nMedical\nInformation\nMetastatic Colorectal Cancer. The member has a diagnosis of metastatic \ncolorectal cancer AND The member is using Stivarga (regorafenib) as \nmonotherapy AND The member has documented intolerance, \ncontraindication or has failed previous treatment with ALL of the \nfollowing therapies: fluoropyrimidine (regimens include 5-\nFU/capecitabine),oxaliplatin-based chemotherapy, irinotecan-based \nchemotherapy, and anti-VEGF therapy (e.g., bevacizumab, ziv-\naflibercept) AND If the member is RAS wild-type and has documented \nintolerance, contraindication or has failed previous treatment with anti-\nEGFR therapy (e.g., cetuximab, panitumumab).Gastrointestinal Stromal \nTumor. The member has a diagnosis of locally advanced, unresectable \nor metastatic gastrointestinal stromal tumor  AND The member has \nexperienced disease progression, intolerance, or contraindication with \nimatinib mesylate and sunitinib malate.  Hepatobiliary Cancers: The \nmember has a diagnosis of hepatocellular carcinoma AND Stivarga \n(regorafenib) is being given as monotherapy AND The member has \nexperienced progression after first line theapy (e.g., sorafenib).  Soft \nTissue sarcoma. Diagnosis of advanced or metastatic soft tisuse \nsarcoma (e.g., angiosarcoma, non-adipocytic sarcoma, pleomorphic \nrhabdomyosarcoma) AND Stivarga (regorafenib) is being given as a \nsingle agent.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Month Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 390 of 497\n", "doc_id": "22715473-75d4-4d1b-8f7b-fb1bf3830f48", "embedding": null, "doc_hash": "c98e16a3a1880c00d9a971bd65c092bebba4ff543b57396dd448abb81a529d65", "extra_info": {"page_label": "390", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1770, "_node_type": "1"}, "relationships": {"1": "31c2981a-30ed-4cf1-8620-e284f5c1a9f7"}}, "__type__": "1"}, "fcb29b46-7831-47e2-a56a-4daa0336ec26": {"__data__": {"text": "STRENSIQ\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nHypophosphatasia (HPP):The member must have a diagnosis of \nperinatal-onset, infantile-onset, or juvenile onset hypophosphatasia. \nHypophosphatasia (HPP):The member must have a diagnosis of \nperinatal-onset, infantile-onset, or juvenile-onset hypophosphatasia \ndefined by:Low total serum alkaline phosphatase (ALP) activity \ndetermined by the gender- and age-specific reference range, AND  \nElevated urine concentration of phosphoethanolamine (PEA) determined \nby age-specific reference range, OR Elevated serum pyridoxal \n5\u2019-\nphosphate (PLP) level (normal range 5 \n\u2013 50 \nmcg/L), OR Documented \ngene mutation of tissue-nonspecific alkaline phosphatase (TNSALP).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial Auth: 6 months. Reauth: Plan Year Duration.\nOther Criteria\nContinuation of Therapy:  The member is experiencing clinical benefit \nfrom Strensiq therapy (e.g. improvement in skeletal manifestations, \ngait/mobility, growth, etc).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 391 of 497\n", "doc_id": "fcb29b46-7831-47e2-a56a-4daa0336ec26", "embedding": null, "doc_hash": "f318707125ad37c20dc4ec9e396f811487a59df8b47f257faff32ac98f5ea229", "extra_info": {"page_label": "391", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1161, "_node_type": "1"}, "relationships": {"1": "c725e63d-eb03-45ef-b8dd-2ac5513d0869"}}, "__type__": "1"}, "62a8be04-fb96-45de-93c1-be8276e889ac": {"__data__": {"text": "sunitinib malate\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors.Members that have \nexperienced disease progression while on Sutent (sunitinib). Member not \nto exceed a total treatment of 54 weeks (applicable to adjuvant therapy \nfor renal cell carcinoma).\nRequired\nMedical\nInformation\nGastrointestinal stromal tumor (GIST). Diagnosis of gastrointestinal \nstromal tumor (GIST)AND the member has disease progression on or \nintolerance to imatinib mesylate. Advanced renal cell carcinoma\n(RCC).Diagnosis of advanced renal cell carcinoma (stage IV). Renal Cell \nCarcinoma (RCC) Adjuvant Therapy. The member has high risk (i.e. \ntumor stage T3 or higher, regional lymph node metastases, or both) of \nrecurrent RCC following nephrectomy AND Sutent (sunitinib) will be used \nas a single agent as adjuvant treatment. Pancreatic neuroendocrine \ntumors (PNET). Diagnosis of Progressive, well-differentiated pancreatic \nneuroendocrine tumors (pNET) AND The member has unresectable \nlocally advanced or metastatic disease. Advanced Thyroid Carcinoma. \nDiagnosis of advanced/metastatic  follicular carcinoma, Hurthle cell \ncarcinoma, papillary (types of thyroid carcinoma) and are not responsive \nto radio-iodine treatment and clinical trials are not available or \nappropriate.  OR The member has a diagnosis of advanced medullary \ncarcinoma-disseminated symptomatic disease (type of thyroid \ncarcinoma) and has disease progression or has an intolerance to \nCaprelsa (vandetanib) or Cometriq (cabozantinib). Soft Tissue sarcoma. \nDiagnosis of soft tisuse sarcoma (Angiosarcoma or Solitary Fibrous \nTumor or Alveolar soft part sarcoma) AND Sutent (sunitinib) is being \nutilized as a single agent/monotherapy (without concomitant \nchemotherapy or biologics).Thymomas/thymic carcinoma: The member \nwill be using as monotherapy in the second line.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 392 of 497\n", "doc_id": "62a8be04-fb96-45de-93c1-be8276e889ac", "embedding": null, "doc_hash": "24b206312102ae5a927b65bb220af138a484ef86622d6db74904c466551f7df0", "extra_info": {"page_label": "392", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2083, "_node_type": "1"}, "relationships": {"1": "d16ab139-677f-446d-bd7d-c91cb4b4ea09"}}, "__type__": "1"}, "19265670-4059-4ee1-88d9-65deeb407c8e": {"__data__": {"text": "SYLVANT\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nMulticentric Castleman\n\u2019\ns Disease:The member has a diagnosis of \nmember has a diagnosis of multicentric Castleman\n\u2019\ns disease.The \nmember is human immunodeficiency (HIV) and human herpes virus \n(HHV-8) negative.The member has an absolute neutrophil count greater \nthan or equal to 1.0 x 109/L, a platelet count of greater than or equal to \n75 x 109, and hemoglobin level less than 17 g/dL.Reauthorization \nCriteria:The approval duration may be continued for 6 additional months \nif benefit is shown via no evidence of disease progression/treatment \nfailure and the following laboratory parameters are met: The member \nhas an absolute neutrophil count greater than or equal 1.0 x 109/L, a \nplatelet count of greater than or equal 50 x 109, and hemoglobin level \nless than 17 g/dL.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 393 of 497\n", "doc_id": "19265670-4059-4ee1-88d9-65deeb407c8e", "embedding": null, "doc_hash": "80f8e3462741c5ebb304be6f1b7d56c13b5df484567d4bb8d945dcad0f3f540e", "extra_info": {"page_label": "393", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1075, "_node_type": "1"}, "relationships": {"1": "cc4733cf-c374-4ab9-ac86-2c2d349f460b"}}, "__type__": "1"}, "fae6e2a5-e636-4989-9a4f-f5e11563f325": {"__data__": {"text": "SYMDEKO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nCystic Fibrosis: The member must meet ALL of the following criteria: \nDiagnosis of Cystic Fibrosis AND submission of lab testing with \ndocumentation of a mutation in the CFTR gene that is responsive to \ntherapy based on clinical literature and/or in vitro assay data.\nAge Restriction\nPrescriber\nRestriction\nThe member is being treated by or in consultation with a specialist (e.g. \npulmonologist).\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 394 of 497\n", "doc_id": "fae6e2a5-e636-4989-9a4f-f5e11563f325", "embedding": null, "doc_hash": "13dca6a8be47fe675822876fb2e023aa8af80ba59d1c73f3d596c9c72f012778", "extra_info": {"page_label": "394", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 624, "_node_type": "1"}, "relationships": {"1": "3215ecd1-ac16-4bdc-b6ab-67c0522f8f39"}}, "__type__": "1"}, "aae2a2e3-fec3-4e1f-b490-ba46e5160abe": {"__data__": {"text": "SYMPAZAN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nLennox-Gastaut Syndrome:  The member has a diagnosis of Lennox-\nGastaut Syndrome AND the member will be taking at least one \nconcomitant anti-epileptic medication therapy AND the member has had \nprior therapy AND has a documented contraindication (e.g. dysphagia) to \nBOTH a generic clobazam tablet AND oral suspension formulation.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 395 of 497\n", "doc_id": "aae2a2e3-fec3-4e1f-b490-ba46e5160abe", "embedding": null, "doc_hash": "ac1a73c518e7b33955a258c805558af1c08c2c00716734dda4f641c7e482d761", "extra_info": {"page_label": "395", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 620, "_node_type": "1"}, "relationships": {"1": "d141ff33-267c-419e-be58-effb86936228"}}, "__type__": "1"}, "6c6bf142-58e3-4cd0-85c7-42a0ac4358e6": {"__data__": {"text": "SYNRIBO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors.Members that have \nexperienced disease progression while on Synribo (omacetaxine \nmepesuccinate).\nRequired\nMedical\nInformation\nChronic Myelogenous Leukemia. The member has a diagnosis of \nchronic or accelerated phase chronic myeloid leukemia AND one of the \nfollowing applies: The member has had prior therapy, intolerance, or \nresistance to at least two of the following tyrosine kinase inhibitors: \nimatinib, Sprycel, Tasigna, or Bosulif OR The member has a \ndocumented T315I mutation.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 396 of 497\n", "doc_id": "6c6bf142-58e3-4cd0-85c7-42a0ac4358e6", "embedding": null, "doc_hash": "e910b4fff59e67e2e3a796c642992fd95b59fbd989680caf2e245dc11a8e02f8", "extra_info": {"page_label": "396", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 794, "_node_type": "1"}, "relationships": {"1": "5efcbdbe-63d7-474c-933a-f574e37660ee"}}, "__type__": "1"}, "0518bd10-110d-4fff-8c52-805f5ea01252": {"__data__": {"text": "TABRECTA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMember experiences disease progression on Tabrecta (capmatinib).\nRequired\nMedical\nInformation\nNon-Small Lung Cell Cancer (NSCLC):  The member has a diagnosis of \nmetastatic NSCLC AND the disease is documented MET exon 14 \nskipping positive AND Tabrecta (capmatinib) is being used as \nmonotherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 397 of 497\n", "doc_id": "0518bd10-110d-4fff-8c52-805f5ea01252", "embedding": null, "doc_hash": "2048706dd58fb34513489356aedb54f13141a88ffdd637996adff6ea3ac713a8", "extra_info": {"page_label": "397", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 564, "_node_type": "1"}, "relationships": {"1": "4ed5e69b-0198-4c78-8bf1-9259f274f6e9"}}, "__type__": "1"}, "5673735d-95d3-4166-a509-f118055eb917": {"__data__": {"text": "tadalafil (pulm. hypertension)\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nPulmonary Arterial Hypertension (PAH). The member must have a \ndiagnosis of pulmonary arterial hypertension (WHO Group I) confirmed \nby right heart catheterization.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 398 of 497\n", "doc_id": "5673735d-95d3-4166-a509-f118055eb917", "embedding": null, "doc_hash": "d969aa76be6087a64982bd18ad7600dbc14e21ed155c46e668638450d68779fd", "extra_info": {"page_label": "398", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 487, "_node_type": "1"}, "relationships": {"1": "8fc317ad-54a4-4fb2-81de-b2c218683806"}}, "__type__": "1"}, "3ba2197a-e29a-4d18-a103-dbcecaf8c455": {"__data__": {"text": "TAFINLAR\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers on concomitant Yervoy (ipilimumab), Zelboraf (vemurafenib), \nOpdivo (nivolumab), Keytruda (pembrolizumab) Cotellic (cobimetinib), \nBraftovi (encorafenib), or Mektovi (binimetinib). Members that have \nexperienced disease progression while on Tafinlar (dabrafenib).  \nMembers that have experienced disease progression while on prior anti-\nBRAF/MEK combination therapy [e.g. Cotellic (cobimetinib) with Zelboraf \n(vemurafenib) or Tafinlar (dabrafenib) with Mekinst (trametinib)]. \nAdjuvant melanoma only: member is taking Tafinlar (dabrafenib) total \ntreatment for more than one year.\nRequired\nMedical\nInformation\nMelanoma-Unresectable or Metastatic: The member has a diagnosis of \nunresectable or stage IV metastatic melanoma AND The member has a \ndocumented BRAF V600 activating mutation AND The member will be \nusing Tafinlar (dabrafenib) as monotherapy OR in combination with \nMekinist (trametinib). Non-small cell lung cancer: The member has a \ndiagnosis of recurrent or metastatic non-small cell lung cancer (NSCLC) \nAND The member has a documented BRAF V600E mutation AND The \nmember will be using Tafinlar (dabrafenib) in combination with Mekinist \n(trametinib). Melanoma - Adjuvant. The member has a diagnosis of stage \nIII melanoma AND The member has undergone lymph node resection of \ninvolved lymph nodes AND The member has a documented BRAF V600 \nactivating mutation AND The member will be using Tafinlar (dabrafenic) \nin combination with Mekinist (trametinib) for adjuvant treatment. \nAnaplastic Thyroid Cancer. The member has a diagnosis of locally \nadvanced or metastatic anaplastic thyroid cancer AND The member has \na documented V600E mutation AND The member has no satisfactory \nlocoregional treatment options AND The member will be using Tafinlar \n(dabrafenib) in combination with Mekinist (trametinib). Metastatic Solid \nTumors: the member has a diagnosis of unresectable or metastatic solid \ntumors with documented BRAF V600E mutation AND the member has \ndisease that has progressed on prior therapy and has no satisfactory \nalternative treatments AND Tafinlar is given in combination with Mekinist.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 399 of 497\n", "doc_id": "3ba2197a-e29a-4d18-a103-dbcecaf8c455", "embedding": null, "doc_hash": "707bd56329e3d2109e03552c25c93059272e4671d7ccdcf7cdb0d5653576f133", "extra_info": {"page_label": "399", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2385, "_node_type": "1"}, "relationships": {"1": "a0f7551e-0226-47d3-8902-27475db55773"}}, "__type__": "1"}, "8f95cfe2-7bb8-4540-80f2-ef20818bfcf9": {"__data__": {"text": "TAGRISSO\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors. Members who have \ndisease progression on Tagrisso (osimertinib).  Total treatment exceeds \nthree years (applicable to adjuvant therapy in NSCLC).\nRequired\nMedical\nInformation\nNon small cell lung cancer NSCLC:The member has a diagnosis of \nmetastatic non small cell lung cancer (NSCLC) and the following criteria \napplies: The member has documented sensitizing EGFR mutations \n(exon 19 deletions or exon 21 L858R) AND Tagrisso (osimertinib) is \nbeing used as single agent for first line therapy OR The member has a \ndocumented epidermal growth factor receptor (EGFR) T790M mutation \nAND Tagrisso (osimertinib) is used as monotherapy after progression of \nEGFR inhibitors (e.g., erlotinib, gefitinib).  Non-small cell lung cancer \n(NSCLC) [Adjuvant therapy]:  The member has a diagnosis of NSCLC \n(i.e., Stage Ib- IIIA) AND The member has documented sensitizing \nEGFR mutations (exon 19 deletions or exon 21 L858R) AND The tumor \nhas been resected AND Member will taking (osimertinib) as a single \nagent for adjuvant therapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 400 of 497\n", "doc_id": "8f95cfe2-7bb8-4540-80f2-ef20818bfcf9", "embedding": null, "doc_hash": "552547722e9f210f34973ef266f8021aeffd4a2f1cf39d93aaf4f15544b9d1f0", "extra_info": {"page_label": "400", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1343, "_node_type": "1"}, "relationships": {"1": "816dfe9f-d71a-404f-acb2-2e62cc31c9fc"}}, "__type__": "1"}, "b3c9a1dc-ac0f-4bcc-85fe-d762b488cc3d": {"__data__": {"text": "TALZENNA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers have experienced disease progression while on or following \nPARP inhibitor therapy (eg, olaparib).\nRequired\nMedical\nInformation\nBreast Cancer. Member has a diagnosis of locally advanced or \nmetastatic, HER-2 negative breast cancer AND Member has \ndocumented deleterious germline or suspected germline BRCAmutated \ndisease AND if member has hormone receptor positive disease then is \nendocrine refractory AND Talzenna (talazoparib) will be used as \nmonotherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 401 of 497\n", "doc_id": "b3c9a1dc-ac0f-4bcc-85fe-d762b488cc3d", "embedding": null, "doc_hash": "4e9e2f1531811041586166453c82b2118a35985f4bf11219a40bfdb63810e219", "extra_info": {"page_label": "401", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 734, "_node_type": "1"}, "relationships": {"1": "47c5846a-8764-4cea-8c73-fe7222394144"}}, "__type__": "1"}, "5e0654b1-7304-4898-945d-b4f359a0aadc": {"__data__": {"text": "TARGRETIN\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers that are pregnant. Members on concomitant retinoid therapy.\nRequired\nMedical\nInformation\nCutaneous T-cell Lymphoma (CTCL). Targretin (bexarotene) capsules). \nThe member will be using Targretin as primary treatment  OR Member \nhas experienced disease progression, contraindication, or intolerance to \nat least one prior systemic therapy for cutaneous manifestations of \ncutaneous T-cell lymphoma. Cutaneous T-cell Lymphoma. Targretin \n(bexarotene) 1% topical gel/jelly). The member will be using Targretin as \nprimary treatment OR Member has experienced disease progression, \ncontraindications, or intolerance to at least one prior CTCL therapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 402 of 497\n", "doc_id": "5e0654b1-7304-4898-945d-b4f359a0aadc", "embedding": null, "doc_hash": "dea1e9547148de7c0e1796c73959ec16daf58f58ee4a945096250f65d7019c22", "extra_info": {"page_label": "402", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 922, "_node_type": "1"}, "relationships": {"1": "1c075cc5-b177-466d-9fa4-08b5459bde7d"}}, "__type__": "1"}, "d176515d-5618-4171-a7eb-fa4c019ba968": {"__data__": {"text": "TASIGNA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors.Members that have \nexperienced disease progression while on Tasigna (nilotinib).  For ALL \nand CML: The member has one of the following mutations: T315I, \nY253H, E255K/V, F359V/C/I or G250E.\nRequired\nMedical\nInformation\nChronic Myelogenous Leukemia (CML). The member has a diagnosis of \nPhiladelphia chromosome positive chronic myeloid leukemia (CML) AND \nOne of the following applies: The member has accelerated or blast \nphase CML OR  The member has a diagnosis of chronic phase CML that \nhas not been previously treated, and one of the following applies: \nIntermediate- or high-risk score for disease progression and has \ncontraindication to, intolerance to, or unable to achieve treatment goals \nwith Bosulif (bosutinib) OR Low-risk score for disease progression and \nhas contraindication to, intolerance to, or unable to achieve treatment \ngoals with imatinib and Bosulif (bosutinib) OR The members has a \ndiagnosis of chronic phase CML that has received previous treatment \nAND: Low, Intermediate-, or high-risk score for disease progression and \nhas contraindication to, intolerance to, or unable to achieve treatment \ngoals with Bosulif (bosutinib). Advanced Gastrointestinal Stromal Tumor \n(GIST). Diagnosis of advanced unresectable GIST.The member has \nprogressive disease or is intolerant to prior therapy with Gleevec \n(imatinib), Sutent (sunitinib),or Stivarga.Acute Lymphoblastic Leukemia \n(ALL). The member has diagnosis of Philadelphia positive acute \nlymphoblastic leukemia. Pediatric CML: Diagnosis of chronic phase Ph+ \nchronic myeloid leukemia (CML) OR Diagnosis of accelerated phase Ph\n+ chronic myeloid leukemia (CML) AND resistance, intolerance, or \ncontraindication to prior TKI therapy.\nAge Restriction\nPediatric CML- member is greater than or equal to 1 year of age.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 403 of 497\n", "doc_id": "d176515d-5618-4171-a7eb-fa4c019ba968", "embedding": null, "doc_hash": "39d0e6072a5840b04818278205b101491407157253ca2899ef2c4475fd0cc3ef", "extra_info": {"page_label": "403", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2085, "_node_type": "1"}, "relationships": {"1": "543d46f6-df78-4208-a7e2-19eac4abe0a1"}}, "__type__": "1"}, "7d8534db-dc8c-4e21-b99d-9227f8b41b38": {"__data__": {"text": "tasimelteon\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nNon-24-Hour Sleep-Wake Disorder. The member must utilize Hetlioz \n(tasimelteon) for the treatment of Non-24-Hour Sleep-Wake Disorder. \nSmith-Magenis Syndrome (SMS): The member has a documented \ndiagnosis of SMS and documented evidence of nighttime sleep \ndisturbances associated with SMS.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 404 of 497\n", "doc_id": "7d8534db-dc8c-4e21-b99d-9227f8b41b38", "embedding": null, "doc_hash": "34b86c5e69640547f444e70f1392a72b60abf92b4607add0a6c1b570531120f9", "extra_info": {"page_label": "404", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 580, "_node_type": "1"}, "relationships": {"1": "c5f27eb3-1472-4f01-b1b7-a9f2c59a6e14"}}, "__type__": "1"}, "2af7ceca-3bf3-4ed4-b501-80c0b08aee25": {"__data__": {"text": "tazarotene\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nCosmetic indications including solar lentigines, wrinkles, or roughness of \nthe skin in the absence of an approvable indication described in the \ncoverage determination section.\nRequired\nMedical\nInformation\nThe treatment of acne vulgaris: The member must have a documented \ndiagnosis of acne vulgaris AND The member must have had previous \ntreatment, or intolerance to generic topical tretinoin (non-micro)*. The \ntreatment of stable plaque psoriasis: The member must have a \ndocumented diagnosis of stable plaque psoriasis AND The member must \nhave had previous treatment , intolerance, or contraindication with \ntopical betamethasone dipropionate or triamcinolone 0.5%. *Generic \ntopical tretinoin (non-micro) has additional prior authorization \nrequirements.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 405 of 497\n", "doc_id": "2af7ceca-3bf3-4ed4-b501-80c0b08aee25", "embedding": null, "doc_hash": "5e06f2bea334f13bdc681fcb1494a1773e2bc90a17aed4a6750c6ebfd641abe6", "extra_info": {"page_label": "405", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1023, "_node_type": "1"}, "relationships": {"1": "63f6f599-08d0-41f1-aa0b-7853d37680de"}}, "__type__": "1"}, "225deadd-845e-475b-b26f-64101ab30e28": {"__data__": {"text": "TAZVERIK\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member experiences disease progression on Tazverik\nRequired\nMedical\nInformation\nEpithelioid Sarcoma: The member has a diagnosis of metastatic or \nlocally advanced epithelioid sarcoma not eligible for complete resection \nAND Tazverik will be given as monotherapy.  Follicular lymphoma:  The \nmember has a diagnosis of relapsed/refractory follicular lymphoma AND \none of the following applies:  The member has a documented EZH2 \nmutation by an FDA approved test and the member has received at least \ntwo prior therapies and the member will be using Tazverik (tazemetostat) \nas monotherapy OR The member has no satisfactory alternative \ntreatment options and The member will be using Tazverik (tazemetostat) \nas monotherapy.\nAge Restriction\nThe member is 16 years of age or older\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 406 of 497\n", "doc_id": "225deadd-845e-475b-b26f-64101ab30e28", "embedding": null, "doc_hash": "65a42f87b43a785273d73eb999ac542885078291ca640544ce03f8f5c8a35172", "extra_info": {"page_label": "406", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1030, "_node_type": "1"}, "relationships": {"1": "0f2f3811-f208-48a3-a8bd-ee2235511082"}}, "__type__": "1"}, "f3afb49e-5381-4446-ae5d-d514e63015b3": {"__data__": {"text": "TECENTRIQ\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDisease progression while on or following anti-PD-1/PD-L1 therapy (e.g. \nOpdivo [nivolumab], Keytruda [pembrolizumab], Tecentriq \n[atezolizumab], Bavencio [avelumab]).  Adjuvant setting for Non-Small \nCell Lung Cancer: member is taking Tecentriq (atezolizumab) total \ntreatment for more than one year.\nRequired\nMedical\nInformation\nNon-Small Cell Lung Cancer (advanced or metastatic): The member has \na diagnosis of advanced or metastatic NSCLC AND member has \ndisease with no EGFR or ALK genomic tumor aberrations and one of the \nfollowing scenarios is applied: The member has non-squamous cell \nhistology AND Tecentriq will be given as a component of one of the two \ncombo regimens: in combination with carboplatin and paclitaxel and \nBevacizumab Product as first line therapy followed by maintenance \ntherapy with combination Tecentriq and Bevacizumab Product OR in \ncombo with Abraxane (nabpaclitaxel) and carboplatin as first line \ntherapy. OR Disease has high PD-L1 expression [PD-L1 stained greater \nthan or equal to 50% of tumor cells OR PD-L1 stained tumor-infiltrating \nimmune cells covering greater than or equal to 10% of the tumor area] \nAND PD-L1 tumor expression is determined by an FDA-approved test \nAND will be given as first-line therapy AND The member will be using as \nmonotherapy. OR The member has experienced disease progression on \nor after chemotherapy and EGFR inhibitor or ALK inhibitor (post \nconfirmed EGFR or ALK genomic tumor aberration positivity) AND The \nmember will be using Tecentriq as monotherapy. Alveolar Soft Part \nSarcoma (ASPS): The member has a diagnosis of unresectable or \nmetastatic alveolar soft part sarcoma AND The member will be using \nTecentriq as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 407 of 497\n", "doc_id": "f3afb49e-5381-4446-ae5d-d514e63015b3", "embedding": null, "doc_hash": "7513ad48164857dea3bc0c7aa7b06dec4df6c0c64b1b1505596029a5b93229fb", "extra_info": {"page_label": "407", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1934, "_node_type": "1"}, "relationships": {"1": "f903908a-bc35-4bec-abc6-893a7361d491"}}, "__type__": "1"}, "82cc373f-7ec2-477d-aefb-736e26e2c7b3": {"__data__": {"text": "TECENTRIQ\nOther Criteria\nSmall Cell Lung Cancer: The member has a diagnosis of extensive-stage \nsmall cell lung cancer AND Tecentriq will be given in combination with \netoposide and carboplatin as first line therapy followed by maintenance \ntherapy with Tecentriq.  Heptatocellular Carcinoma:  The member has a \ndiagnosis of unresectable or metastatic hepatocellular carcinoma AND \nTecentriq (atezolizumab) will be used as first line therapy in combination \nwith bevacizumab.  Melanoma:  The member has a diagnosis of \nunresectable or metastatic melanoma AND The member has a \ndocumented BRAF V600 activating mutation AND the member will use \nTecentriq in combination with Cotellic (cobimetinib) and Zelboraf \n(vemurafenib).  Non-Small Cell Lung Cancer (Adjuvant):  The member \nmust have a diagnosis of Stage II to IIIA non-small cell lung cancer AND \nThe disease has expression of PD-L1 on greater than or equal to 1% of \ntumor cells as determined by an FDA-approved test AND The member is \npost complete surgical resection and adjuvant platinum-based \nchemotherapy AND The member will be using Tecentriq (atezolizumab) \nas monotherapy in the adjuvant setting.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 408 of 497\n", "doc_id": "82cc373f-7ec2-477d-aefb-736e26e2c7b3", "embedding": null, "doc_hash": "ff7bd90c0f762daceaf87cb8223874574359d5c0cdcaad1f0787f6ea7962adf9", "extra_info": {"page_label": "408", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1236, "_node_type": "1"}, "relationships": {"1": "0559c94e-060e-4999-951e-d90b6b4ec9a2"}}, "__type__": "1"}, "c5604f4d-a6e1-476c-a478-cba1fe857d95": {"__data__": {"text": "TECVAYLI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on bispecific B-\ncell maturation antigen (BCMA)-directed CD3 T-cell engager-containing \nregimen.\nRequired\nMedical\nInformation\nMultiple Myeloma. The member has a diagnosis of multiple myeloma \nAND the member has relapsed/refractory disease AND the member has \nreceived at least four prior lines of therapy, including an anti-CD38 \nmonoclonal antibody (e.g. daratumumab), a proteasome inhibitor (e.g. \nbortezomib), and an immunomodulatory agent (e.g. lenalidomide) AND \nthe member is using Tecvayli (teclistamab-cqyv) as a single agent.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 409 of 497\n", "doc_id": "c5604f4d-a6e1-476c-a478-cba1fe857d95", "embedding": null, "doc_hash": "56301e58c4bdef5e4b09a97579037f315a15e77497ef5018f3d0083974f1601c", "extra_info": {"page_label": "409", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 847, "_node_type": "1"}, "relationships": {"1": "a9a5525c-0cd9-44d3-b2f4-91409f2af742"}}, "__type__": "1"}, "ffc7d5ec-e5a8-4808-b499-5a6f8e9b4bfd": {"__data__": {"text": "temsirolimus\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nPatients that have experienced disease progression while on \ntemsirolimus.\nRequired\nMedical\nInformation\nThe member has a diagnosis of advanced/metastatic renal cell \ncarcinoma (stage IV). Endometrial cancer: The member has a diagnosis \nof endometrial cancer AND the member has been surgically staged and \nfound to be stage IIIA-IVB and Torisel will be used as adjuvant therapy \nOR Torisel (temsirolimus) will be used as  primary treatment. OR The \nmember has a diagnosis of recurrent or metastatic endometrial cancer.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 410 of 497\n", "doc_id": "ffc7d5ec-e5a8-4808-b499-5a6f8e9b4bfd", "embedding": null, "doc_hash": "4b5fe6eedd897892484041daee1936e8f54d2cc882bc525f5edd7164a9248cec", "extra_info": {"page_label": "410", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 789, "_node_type": "1"}, "relationships": {"1": "1e2056f2-499e-45b5-8779-8eabe6734ecf"}}, "__type__": "1"}, "5fbbe4c8-77da-449e-8ca6-2ec2cebbf472": {"__data__": {"text": "TEPMETKO\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member experiences disease progression on MET inhibitor (e.g., \nTabrecta, Tepmetko).\nRequired\nMedical\nInformation\nNon-small cell lung cancer. The member has a diagnosis of metastatic \nNSCLC AND The disease is documented MET exon 14 skipping positive \nAND The member has a medical reason as to why Tabrecta (capmatinib) \ncannot be started or continued AND Tepmetko (tepotinib) is being used \nas monotherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 411 of 497\n", "doc_id": "5fbbe4c8-77da-449e-8ca6-2ec2cebbf472", "embedding": null, "doc_hash": "0ccd6d52858c8a618685abf33f85fd916cc8d46fc329804d59a6555e194c0e22", "extra_info": {"page_label": "411", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 680, "_node_type": "1"}, "relationships": {"1": "e878de0e-a3d9-4d63-a971-4cd1b5803615"}}, "__type__": "1"}, "2e43c1b1-154a-47dd-ac7e-f2639b14bee8": {"__data__": {"text": "teriflunomide\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers with severe hepatic impairment (e.g. Child-Pugh Class C).\nRequired\nMedical\nInformation\nThe member has a diagnosis of a relapsing form of multiple sclerosis, to \ninclude relapsing-remitting or active secondary progressive disease, OR \nthe member has a diagnosis of clinically isolated syndrome (CIS).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 412 of 497\n", "doc_id": "2e43c1b1-154a-47dd-ac7e-f2639b14bee8", "embedding": null, "doc_hash": "b6946abf763e295c9ccbf3a3face7db0e721b87eb472c67465f0bad3a1b315fc", "extra_info": {"page_label": "412", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 572, "_node_type": "1"}, "relationships": {"1": "81669650-a9ba-4971-abe1-0ccebe3dd724"}}, "__type__": "1"}, "18af92ce-f91e-4fa7-9588-caad85a9c511": {"__data__": {"text": "testosterone\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nMember has one of the following diagnoses: Primary hypogonadism: \ntesticular failure due to cryptorchidism, bilateral torsion, orchitis, \nvanishing testis syndrome, orchiectomy, Klinefelter's syndrome, \nchemotherapy, or toxic damage from alcohol or heavy metals OR \nHypogonadotropic hypogonadism: idiopathic gonadotropin or luteinizing \nhormone-releasing hormone (LHRH) deficiency or pituitary-hypothalamic \ninjury from tumors, trauma, or radiation AND Member has had one of the \nfollowing: Documentation of two morning serum testosterone levels (total \nor free) that are less than the reference range for the lab, taken at \nseparate times, prior to treatment OR Documentation of a serum \ntestosterone level (total or free) that is less than or within the reference \nrange for the lab, when already on treatment.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 413 of 497\n", "doc_id": "18af92ce-f91e-4fa7-9588-caad85a9c511", "embedding": null, "doc_hash": "fb3f37474e54277604d81346b81a37a8973e24f2f151db04256ab5587c0f76c6", "extra_info": {"page_label": "413", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1117, "_node_type": "1"}, "relationships": {"1": "377c898d-7e9f-4bf1-826e-85fda05e57a2"}}, "__type__": "1"}, "bda4f18b-a7df-42a5-8f91-3e8a58055249": {"__data__": {"text": "tetrabenazine\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nDiagnosis of chorea associated with Huntington's disease.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 414 of 497\n", "doc_id": "bda4f18b-a7df-42a5-8f91-3e8a58055249", "embedding": null, "doc_hash": "07f4a356ea24973c87a632e12fa1be1bdf7f33f52a90647fe3e5210ad4d6e76b", "extra_info": {"page_label": "414", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 351, "_node_type": "1"}, "relationships": {"1": "c55afdb3-1a01-4b96-b04c-f20047f90e8c"}}, "__type__": "1"}, "f0b15c18-fba5-427e-b526-d96bcc8e830e": {"__data__": {"text": "THALOMID\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers on concomitant Revlimid (lenalidomide) or Pomalyst \n(pomalidomide). Members that have experienced disease progression \nwhile on thalidomide.\nRequired\nMedical\nInformation\nThalomid (thalidomide) will require prior authorization and may be \nconsidered medically necessary when the following criteria are met for \nthe following indication(s):Erythema Nodosum Leprosum (ENL).The \nmember is currently having acute cutaneous manifestations of moderate \nto severe erythema nodosum leprosum (ENL) OR Thalomid \n(thalidomide) is prescribed for maintenance therapy for prevention and \nsuppression of the cutaneous manifestations of (ENL) \nrecurrence.Multiple Myeloma.The member has a diagnosis of Multiple \nMyeloma. Waldenstrom's Macroglobulinemia.The member has a \ndiagnosis of Waldenstrom's macroglobulinemia or lymphoplasmacytic \nlymphoma AND Thalomid (thalidomide) is being used for primary \ntherapy, progressive or relapsed disease or salvage therapy for disease \nthat does not respond to primary therapy AND Thalomid (thalidomide) is \nbeing used as monotherapy or in combination with a rituximab product.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 415 of 497\n", "doc_id": "f0b15c18-fba5-427e-b526-d96bcc8e830e", "embedding": null, "doc_hash": "e610a450bced5ccf55cfa563d45c03153591190ff0f8a60e372781d8696d6cb9", "extra_info": {"page_label": "415", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1365, "_node_type": "1"}, "relationships": {"1": "ba6f5e33-35c8-496a-b13a-1cb45e6e9d26"}}, "__type__": "1"}, "61e05fd5-4415-4e25-bcb5-fcede87483f6": {"__data__": {"text": "TIBSOVO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember has experienced disease progression while on or following \nTibsovo (ivosedinib).\nRequired\nMedical\nInformation\nAcute Myeloid Leukemia- Relapsed/Refractory: The member has a \ndiagnosis of acute myeloid leukemia (AML) AND The member has \nrelapsed or refractory disease AND The member has a documented \nIDH1 mutation AND one of the following applies: The member will be \nusing Tibsovo (ivosedinib) as monotherapy OR the member will be using \nTibsovo as a component of repeating the initial successful induction \nregimen, if late relapse (relapse occurring later than 12 months).  Acute \nMyeloid Leukemia \n\u2013 \nNewly diagnosed:  The member has a diagnosis of \nacute myeloid leukemia (AML) AND the member has newly diagnosed \ndisease AND one of the following applies:  the member is 60 years of \nage or older and is not a candidate for intensive induction therapy due to \ncomorbidities OR the member is 60 years of age or older and the \nmember declines intensive induction therapy OR the member is 75 years \nof age or older.  The member has a documented IDH1 mutation as \ndetected by an FDA-approved test AND the member will be using \nTibsovo as monotherapy or in combination with azactidine.  \nCholangiocarcinoma:  The member has locally advanced or metastatic \ncholangiocarcinoma AND the disease has documented isocitrate \ndehydrogenate-1 (IDH1) mutation AND Tibsovo (ivosedinib) will be a \nsubsequent therapy and used as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 416 of 497\n", "doc_id": "61e05fd5-4415-4e25-bcb5-fcede87483f6", "embedding": null, "doc_hash": "c626386253694e4f2bfffe88c64946218d4ea3eadb59d5e440555a9ee0cbb1dc", "extra_info": {"page_label": "416", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1693, "_node_type": "1"}, "relationships": {"1": "d5ff17a3-c856-4373-a805-fe3005eb7a71"}}, "__type__": "1"}, "5452d07a-d1b4-4975-a7b8-8dcb99b1c843": {"__data__": {"text": "TIVDAK\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experiences disease progression on Tivdak (tisotumab vedotin-\ntftv).\nRequired\nMedical\nInformation\nRecurrent/ Metastatic Cervical Cancer:  The member has recurrent or \nmetastatic cervical cancer AND The member experienced disease \nprogression after chemotherapy AND If the disease expresses CPS \nscore of greater than equal to 1 AND The member has a medical reason \nwhy Keytruda (pembrolizumab) cannot be initiated as subsequent \ntherapy AND Tivdak (tisotumab vedotin-tftv) is administered as \nmonotherapy as subsequent therapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 417 of 497\n", "doc_id": "5452d07a-d1b4-4975-a7b8-8dcb99b1c843", "embedding": null, "doc_hash": "a0d2080bd6862146fa4aa4dd40f4e91602910680af587ce334ab5bb58edc3660", "extra_info": {"page_label": "417", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 792, "_node_type": "1"}, "relationships": {"1": "dcff5e19-8243-48c8-8fdb-a69f22bce720"}}, "__type__": "1"}, "974615f5-007a-4a88-8f0f-ccaa7e5ddc5b": {"__data__": {"text": "tobramycin\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nPatients with a forced expiratory volume in one second (FEV1) less than \n25% or greater than 80% predicted. Patients colonized with Burkholderia \ncepacia.\nRequired\nMedical\nInformation\nCystic Fibrosis or Bronchiectasis: The member has a diagnosis of cystic \nfibrosis (CF) or Bronchiectasis. The member is colonized with \nP.aeruginosa.\nAge Restriction\nMust be 6 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 418 of 497\n", "doc_id": "974615f5-007a-4a88-8f0f-ccaa7e5ddc5b", "embedding": null, "doc_hash": "b2cd5dc7ded7a87dd1930dc5331642aeacea49d4cd94f580e3569cdc64fdd240", "extra_info": {"page_label": "418", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 634, "_node_type": "1"}, "relationships": {"1": "cba15e6b-ac48-4d01-92bd-11198429ce24"}}, "__type__": "1"}, "42cebb9f-6bb7-46ca-b9de-e8b76fc88686": {"__data__": {"text": "tobramycin with nebulizer\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nPatients with a forced expiratory volume in one second (FEV1) less than \n25% or greater than 80% predicted. Patients colonized with Burkholderia \ncepacia.\nRequired\nMedical\nInformation\nCystic Fibrosis or Bronchiectasis: The member has a diagnosis of cystic \nfibrosis (CF) or Bronchiectasis. The member is colonized with \nP.aeruginosa.\nAge Restriction\nMust be 6 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 419 of 497\n", "doc_id": "42cebb9f-6bb7-46ca-b9de-e8b76fc88686", "embedding": null, "doc_hash": "f21d8c187db5eb4a9f197b7c5c1ce491c9af849054e387452041dceb2b0ee513", "extra_info": {"page_label": "419", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 649, "_node_type": "1"}, "relationships": {"1": "47ed7d38-b865-4b68-b694-6fef2ad83a7f"}}, "__type__": "1"}, "c861fb02-29ed-4342-b10a-fecb03df7c32": {"__data__": {"text": "TRAZIMERA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nFor Herceptin (trastuzumab), Ogivri, Herzuma or Ontruzant requests: \nmember must have an intolerance or contraindication Trazimera \n(trastuzumab-qyyp) OR Kanjinti (trastuzumab-anns) and meets below \ncriteria: Breast Cancer: The member has a diagnosis of breast cancer \nand HER2 (human epidermal growth factor receptor2) positive disease. \nGastric Cancer: The member has a diagnosis of advanced, gastric \ncancer or gastroesophageal adenocarcinoma and HER2 positive \ndisease AND trastuzumab is being used in combination with cisplatin \nand fluorouracil or capecitabine.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 420 of 497\n", "doc_id": "c861fb02-29ed-4342-b10a-fecb03df7c32", "embedding": null, "doc_hash": "83dc4d63e73d9c034e327d81bbfe9e4df87bbef4fe72129bf40bb797f6e1343f", "extra_info": {"page_label": "420", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 856, "_node_type": "1"}, "relationships": {"1": "063b52cb-0999-4696-a03e-954fc0cc234a"}}, "__type__": "1"}, "5a7ff84d-f018-42f6-ba40-4c35572a5f39": {"__data__": {"text": "TREANDA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers who experience disease progression on bendamustine \ncontaining regimens.\nRequired\nMedical\nInformation\nChronic Lymphocytic Leukemia (CLL). The member has a diagnosis of \nCLL AND bendamustine is being used for relapsed or refractory disease \nor as first line therapy. Multiple Myeloma (MM). The member has a \ndiagnosis of MM AND bendamustine is being used for disease relapse or \nfor progressive or refractory disease. Non-Hodgkin\n\u2019\ns Lymphoma: The \nmember has a diagnosis of follicular lymphoma, gastric MALT lymphoma \nor nongastric MALT lymphoma and is using Bendamustine. The member \nhas a diagnosis of mantle cell lymphoma and bendamustine is being \nused as one of the following: Less aggressive induction therapy OR \nSecond-line therapy for relapsed, refractory or progressive disease. The \nmember has a diagnosis of primary cutaneous B-cell lymphoma (primary \ncutaneous marginal zone or follicle center B-cell lymphoma) and \nbendamustine is being used as a single agent or in combination with a \nrituximab product in one of the following: Refractory generalized \ncutaneous disease OR generalized extracutaneous disease as initial \ntherapy or for relapse. The member has a diagnosis of splenic marginal \nzone lymphoma and bendamustine is being used as one of the following: \nFirst-line therapy for disease progression following initial treatment for \nsplenomegaly OR Second-line or subsequent therapy for progressive \ndisease. The member has a diagnosis of diffuse large B-cell lymphoma \nand bendamustine is being used as second-line therapy or subsequent \ntherapy .The member has a diagnosis of AIDS-related B-cell lymphoma \nand bendamustine is being used as second-line therapy or subsequent \ntherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration.\nOther Criteria\nWaldenstroms Macroglobulinemia:The member has Waldenstroms \nmacroglobulinemia or lymphoplasmacytic lymphoma and bendamustine \nis being used as one of the following: Primary therapy OR Progressive or \nrelapsed disease. Hodgkin Lymphoma: The member has a diagnosis of \nclassical Hodgkin lymphoma AND bendamustine will be used as \nsubsequent therapy for relapsed or refractory disease.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 421 of 497\n", "doc_id": "5a7ff84d-f018-42f6-ba40-4c35572a5f39", "embedding": null, "doc_hash": "772126c0c4d37784f501ca5f336760c67a898047ad1927f112746886ad414a2a", "extra_info": {"page_label": "421", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2356, "_node_type": "1"}, "relationships": {"1": "cbaa77d4-c12e-49f0-98ed-265aa167838e"}}, "__type__": "1"}, "b30e144f-2952-4298-93c7-ed980670eb36": {"__data__": {"text": "TRELSTAR\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with other LHRH agonists.\nRequired\nMedical\nInformation\nProstate Cancer.The patient has a diagnosis of advanced prostate \ncancer or has a high risk of disease recurrence.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 422 of 497\n", "doc_id": "b30e144f-2952-4298-93c7-ed980670eb36", "embedding": null, "doc_hash": "b92be0f701a1e1675897753d56e72e01cc823b7fcc56f10e7efd3192e02f99c1", "extra_info": {"page_label": "422", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 454, "_node_type": "1"}, "relationships": {"1": "cb151eb1-aa1a-41c0-b412-c0412a1a4ed9"}}, "__type__": "1"}, "8b152745-7bfe-4763-9578-0f269bc292fe": {"__data__": {"text": "tretinoin\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nApproval will be given to all members using this agent for medically \nnecessary, FDA approved, or compendia supported, non-cosmetic \nindications including but not limited to the following:  Acne:  the member \nhas a diagnosis of acne vulgaris, Actinic Keratosis: the member has a \ndiagnosis of actinic keratosis.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 423 of 497\n", "doc_id": "8b152745-7bfe-4763-9578-0f269bc292fe", "embedding": null, "doc_hash": "2b1f1968d15e170078941ce4ab021c79e8de776b75f024dbecaa726c2a2db52c", "extra_info": {"page_label": "423", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 601, "_node_type": "1"}, "relationships": {"1": "79b48b04-8ebd-4436-8714-a18e48155ba4"}}, "__type__": "1"}, "38fd24f9-55f8-4eda-a85e-bf3017577b42": {"__data__": {"text": "TRIKAFTA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nCystic Fibrosis: The member must meet ALL of the following criteria: \nDiagnosis of Cystic Fibrosis AND submission of lab testing with \ndocumentation of a mutation in the CFTR gene that is responsive to \ntherapy based on clinical literature and/or in vitro assay data.\nAge Restriction\nPrescriber\nRestriction\nThe member is being treated by or in consultation with a specialist (e.g. \npulmonologist).\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 424 of 497\n", "doc_id": "38fd24f9-55f8-4eda-a85e-bf3017577b42", "embedding": null, "doc_hash": "05eded15faf496181767681bcf7b9521c2278631478e9e7fef70123b0da17338", "extra_info": {"page_label": "424", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 625, "_node_type": "1"}, "relationships": {"1": "9d4d3440-2785-4647-9312-c96b2ef9036a"}}, "__type__": "1"}, "4cea0fdd-a19c-4ff5-9d1a-aee8f847968d": {"__data__": {"text": "TRISENOX\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nAcute Promyelocytic Leukemia (APL). The member has a diagnosis of \nacute promyelocytic leukemia AND the member will be using Trisenox \n(arsenic trioxide) for induction therapy, consolidation therapy, or relapsed \ndisease.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 425 of 497\n", "doc_id": "4cea0fdd-a19c-4ff5-9d1a-aee8f847968d", "embedding": null, "doc_hash": "39589dbc9af8d1512520083d9b4f238facb7d0e31008f6c1f5eae918c54be9b2", "extra_info": {"page_label": "425", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 518, "_node_type": "1"}, "relationships": {"1": "9b9c3b6d-cfaa-40d0-8560-a57ba65fc468"}}, "__type__": "1"}, "63a8a489-8aba-4af8-a6e8-726df0cc8e66": {"__data__": {"text": "TRODELVY\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers experienced disease progression on Trodelvy (sacituzumab \ngovitecan-hziy)\nRequired\nMedical\nInformation\nBreast Cancer: The member has unresectable locally advanced or \nmetastatic triple negative breast cancer AND The member has received \nat least two prior therapies, where one was administered for metastatic \ndisease AND Trodelvy (sacituzumab govitecan-hziy) is given as single \nagent as subsequent therapy.  Urothelial cancer:  The member has \nlocally advanced or metastatic urothelial cancer AND The member has \nreceived prior platinum containing chemotherapy AND The member has \nreceived prior PD-1 or PD-L1 inhibitor AND Trodelvy (sacituzumab \ngovitecan-hziy) is given as single agent as subsequent therapy. Breast \ncancer (Hormone Receptor (HR)- positive): The member has a diagnosis \nof unresectable locally advanced or metastatic hormone receptor (HR)- \npositive, human epidermal growth factor receptor 2 (HER2)-negative \n(e.g., IHC 0, IHC 1+ or IHC 2+/ISH\n\u2013) \nbreast cancer AND The member \nhas received endocrine-based therapy AND The member has received \nat least two additional systemic therapies in the metastatic setting (e.g. \ntaxane) AND Trodelvy will be used as a single agent for subsequent \ntherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 426 of 497\n", "doc_id": "63a8a489-8aba-4af8-a6e8-726df0cc8e66", "embedding": null, "doc_hash": "14a396ac44f3a661cb3ff421b2cb6ddab4a3ca36235d7ec548e6aad477faae8b", "extra_info": {"page_label": "426", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1485, "_node_type": "1"}, "relationships": {"1": "a54a31d8-ad0e-43a0-ad86-2d27768cb95c"}}, "__type__": "1"}, "e9f6e980-d6c0-4c03-9bd8-a5ab037702e4": {"__data__": {"text": "TRUSELTIQ\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experienced disease progression on FGFR2 inhibitors (e.g., \ninfigratinib, pemigatinib).\nRequired\nMedical\nInformation\nCholangiocarcinoma:  The member has unresectable locally advanced \nor metastatic cholangiocarcinoma AND The cholangiocarcinoma is \nfibroblast growth factor receptor 2 (FGFR2) fusion or other \nrearrangement as detected by an FDA-approved test AND The member \nhas received prior treatment AND Truseltiq (infigratinib) is given as a \nsingle agent for subsequent therapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 427 of 497\n", "doc_id": "e9f6e980-d6c0-4c03-9bd8-a5ab037702e4", "embedding": null, "doc_hash": "a8511e002fb339de4d6bb649ef8f4cd6fd96f308064b87a2db2e7477a1a7d548", "extra_info": {"page_label": "427", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 751, "_node_type": "1"}, "relationships": {"1": "31298161-4dc4-450a-9497-ba577031a9f0"}}, "__type__": "1"}, "f3a6e4e9-66f3-4a01-9d11-85c7b2883922": {"__data__": {"text": "TUKYSA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experiences disease progression on Tukysa (tucatinib)\nRequired\nMedical\nInformation\nBreast Cancer. The member has metastatic or advanced unresectable \nHER 2 positive breast cancer (inclusive of brain metastases) and all of \nthe following apply: Member has received one or more prior anti-HER2 \nbased regimen in the metastatic setting AND Tukysa is given in \ncombination with trastuzumab product and capecitabine as subsequent \ntherapy. Colorectal cancer. The member has a diagnosis of RAS wild-\ntype HER2-positive unresectable or metastatic colorectal cancer AND \nThe member has progressed following treatment with fluoropyrimidine-, \noxaliplatin-, and irinotecan-based chemotherapy AND Tuksya will be \ngiven in combination with trastuzumab product.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 428 of 497\n", "doc_id": "f3a6e4e9-66f3-4a01-9d11-85c7b2883922", "embedding": null, "doc_hash": "8be8631b8e65d438728e2e236792edc05b167808e9843de4fbc9acf209d521fc", "extra_info": {"page_label": "428", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1013, "_node_type": "1"}, "relationships": {"1": "be33ca8e-f443-4cff-8917-48d588d3090b"}}, "__type__": "1"}, "bf506543-6cdb-43f2-b736-0218e509d707": {"__data__": {"text": "TURALIO\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nSymptomatic Tenosynovial Giant Cell Tumor:  The member has \nsymptomatic tenosynovial giant cell tumor (TGCT) and the disease is \nassociated with severe morbidity or functional limitations and the disease \nis not amenable to improvement with surgery and Turalio (pexidartinib) \nwill be used as monotherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 429 of 497\n", "doc_id": "bf506543-6cdb-43f2-b736-0218e509d707", "embedding": null, "doc_hash": "b57004d802ccb317d618e58091784c137d7121863397bd8c47cfb8ba7ed3847f", "extra_info": {"page_label": "429", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 604, "_node_type": "1"}, "relationships": {"1": "ebc0fad6-6550-44d4-b789-a9231f27064c"}}, "__type__": "1"}, "449b48b7-a228-4736-8d23-d3aba6abaf5d": {"__data__": {"text": "TYMLOS\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nThe member has a diagnosis of osteoporosis. The member is at high risk \nfor osteoporotic fracture as evident by the following: The member has a \nhistory of osteoporotic fracture OR The member has new fractures or \nsignificant loss of bone mineral density despite previous treatment, \ncontraindication or intolerance with an oral OR intravenous \nbisphosphonate (e.g. alendronate).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 430 of 497\n", "doc_id": "449b48b7-a228-4736-8d23-d3aba6abaf5d", "embedding": null, "doc_hash": "7fb39d89759a4d00f24c75f04295e3fa7a8c9f15211aa6cb7f6dcbb1b8968551", "extra_info": {"page_label": "430", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 666, "_node_type": "1"}, "relationships": {"1": "7084a685-83d8-4166-aa96-392f356434a5"}}, "__type__": "1"}, "259c8441-f1c3-4684-84bb-3b0a4a69db07": {"__data__": {"text": "UBRELVY\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nAcute Migraine: The member will be utilizing Ubrelvy (ubrogepant) for \nthe acute treatment of migraines AND The member has had previous \ntreatment, intolerance, or contraindication to two of the following: \nnaratriptan, rizatriptan, sumatriptan.\nAge Restriction\nThe member is 18 years of age or older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 431 of 497\n", "doc_id": "259c8441-f1c3-4684-84bb-3b0a4a69db07", "embedding": null, "doc_hash": "f71067d04689e486c8716735cbbc82da6b6695a8c0a2cb4b18a1c22a206c43c7", "extra_info": {"page_label": "431", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 582, "_node_type": "1"}, "relationships": {"1": "f1bcfd1c-0e47-46b8-a3f2-c8e297c38e95"}}, "__type__": "1"}, "970a332d-aa27-4f81-a75f-7a923e2514cc": {"__data__": {"text": "UDENYCA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant use with filgrastim, biosimilar filgrastim (e.g. filgastrim-sndz \nor filgastrim-aafi), tbo-filgratim, sargramostim (unless part of stem cell \nmobilization protocol), pegfilgrastim (within seven days of pegfilgrastim \ndose), or biosimiliar pegfilgrastim (e.g. pegfilgrastim-jmbd or \npegfilgastrim-cbqv, within seven days of pegfilgrastim dose). Same day \nadministration with myelosuppressive chemotherapy or therapeutic \n(Administration of pegfilgrastim occurs no less than 24 hours following \nmyelosuppressive chemotherapy).  Cannot be given more than once per \nchemotherapy cycle.\nRequired\nMedical\nInformation\nFebrile Neutropenia Prophylaxis. The member must have a diagnosis of \nnon-myeloid malignancy (e.g. solid tumors) AND The member has \nreceived or will receive pegfilgrastim product 24-72 hours after the \nadministration of myelosuppressive chemotherapy AND The member \nmust also meet ONE OR MORE of the following criteria: A risk of febrile \nneutropenia (FN) of greater than 20% based on current chemotherapy \nregimen (as listed in current ASCO and NCCN guidelines for myeloid \ngrowth factors) OR A risk of febrile neutropenia of 10-20% based on \nchemotherapy regimen, and one or more of the following risk factors \napply: Prior chemotherapy or radiation therapy OR Persistent \nneutropenia (defined as neutrophil count less than 500 neutrophils/mcL \nor less than 1,000 neutrophils/mcL and a predicted decline to less than \nor equal to 500 neutrophils/mcL over next 48 hours) OR Bone marrow \ninvolvement by tumor OR Recent surgery and/or open wounds OR Liver \ndysfunction (bilirubin greater than 2.0 mg/dL) OR Renal dysfunction \n(creatinine clearance less than 50 mL/min) OR Age greater than 65 \nreceiving full chemotherapy dose intensity OR Previous neutropenic \nfever complication or dose-limiting neutropenic event from a prior cycle \nof similar chemotherapy OR The member is receiving a dose-dense \nchemotherapy regimen OR As secondary prophylaxis in the curative \nsetting to maintain dosing schedule and/or intensity.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n4 months duration\nOther Criteria\nHematopoietic Subsyndrome of Acute Radiation Syndrome. The \nmember has been acutely exposed to myelosuppressive doses of \nnontherapeutic radiation.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 432 of 497\n", "doc_id": "970a332d-aa27-4f81-a75f-7a923e2514cc", "embedding": null, "doc_hash": "f3843f85deb3bd1cb4a7667cb9d23befa35b483fa0d94764317afe6a87810bb7", "extra_info": {"page_label": "432", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2448, "_node_type": "1"}, "relationships": {"1": "57fb5e34-7f4e-492a-ba50-00850d2825ed"}}, "__type__": "1"}, "31642533-dc57-4b59-a4d9-4c453ddff48f": {"__data__": {"text": "UDENYCA AUTOINJECTOR\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant use with filgrastim, biosimilar filgrastim (e.g. filgastrim-sndz \nor filgastrim-aafi), tbo-filgratim, sargramostim (unless part of stem cell \nmobilization protocol), pegfilgrastim (within seven days of pegfilgrastim \ndose), or biosimiliar pegfilgrastim (e.g. pegfilgrastim-jmbd or \npegfilgastrim-cbqv, within seven days of pegfilgrastim dose). Same day \nadministration with myelosuppressive chemotherapy or therapeutic \n(Administration of pegfilgrastim occurs no less than 24 hours following \nmyelosuppressive chemotherapy).  Cannot be given more than once per \nchemotherapy cycle.\nRequired\nMedical\nInformation\nFebrile Neutropenia Prophylaxis. The member must have a diagnosis of \nnon-myeloid malignancy (e.g. solid tumors) AND The member has \nreceived or will receive pegfilgrastim product 24-72 hours after the \nadministration of myelosuppressive chemotherapy AND The member \nmust also meet ONE OR MORE of the following criteria: A risk of febrile \nneutropenia (FN) of greater than 20% based on current chemotherapy \nregimen (as listed in current ASCO and NCCN guidelines for myeloid \ngrowth factors) OR A risk of febrile neutropenia of 10-20% based on \nchemotherapy regimen, and one or more of the following risk factors \napply: Prior chemotherapy or radiation therapy OR Persistent \nneutropenia (defined as neutrophil count less than 500 neutrophils/mcL \nor less than 1,000 neutrophils/mcL and a predicted decline to less than \nor equal to 500 neutrophils/mcL over next 48 hours) OR Bone marrow \ninvolvement by tumor OR Recent surgery and/or open wounds OR Liver \ndysfunction (bilirubin greater than 2.0 mg/dL) OR Renal dysfunction \n(creatinine clearance less than 50 mL/min) OR Age greater than 65 \nreceiving full chemotherapy dose intensity OR Previous neutropenic \nfever complication or dose-limiting neutropenic event from a prior cycle \nof similar chemotherapy OR The member is receiving a dose-dense \nchemotherapy regimen OR As secondary prophylaxis in the curative \nsetting to maintain dosing schedule and/or intensity.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n4 months duration\nOther Criteria\nHematopoietic Subsyndrome of Acute Radiation Syndrome. The \nmember has been acutely exposed to myelosuppressive doses of \nnontherapeutic radiation.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 433 of 497\n", "doc_id": "31642533-dc57-4b59-a4d9-4c453ddff48f", "embedding": null, "doc_hash": "53703e258dd7c538f431c8deea1c85dd527c02512140d85830d7956885631342", "extra_info": {"page_label": "433", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2461, "_node_type": "1"}, "relationships": {"1": "fa9bea77-18b4-4d86-885e-66739e3ab9f8"}}, "__type__": "1"}, "9ae50e80-72eb-4fd0-8908-9b8a9652c5f4": {"__data__": {"text": "UNITUXIN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers receiving Unituxin (dinutuximab)as monotherapy.Members that \nhave experienced disease progression while on Unituxin (dinutuximab).\nRequired\nMedical\nInformation\nHigh-risk neuroblastoma:The member has a diagnosis of high-risk \nneuroblastoma ANDUnituxin (dinutuximab) will be used in combination \nwith isotretinoin AND Unituxin (dinutuximab) will be used in alternating \ncycles of Leukine (sargramostim) and Proleukin (aldesleukin) AND The \nmember has achieved at least a partial response to the following: \nInduction combination chemotherapy AND Maximum feasible surgical \nresection The member has had the previous procedure/therapy: \nMyeloablative consolidation chemotherapy followed by autologous stem \ncell transplantation AND Radiation therapy to residual soft tissue \ndisease.\nAge Restriction\nMemebr must be 18 years of age or younger.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 434 of 497\n", "doc_id": "9ae50e80-72eb-4fd0-8908-9b8a9652c5f4", "embedding": null, "doc_hash": "e3aa1d1141f91417755d9b0692de3886c89409faa637bb98998c54ecf5413791", "extra_info": {"page_label": "434", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1093, "_node_type": "1"}, "relationships": {"1": "f1afef2e-28ea-4a5c-bf4d-34fa7874eed8"}}, "__type__": "1"}, "c4007f61-fe21-4224-a719-377f57f96ca0": {"__data__": {"text": "VALCHLOR\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers that have experienced disease progression while on Valchlor \n(mechlorethamine).\nRequired\nMedical\nInformation\nCutaneous T-Cell Lymphoma: The member has a diagnosis of \nfungoides-type cutaneous T-cell lymphoma AND The member has had \nprior therapy with skin-directed therapy or using as primary treatment.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 435 of 497\n", "doc_id": "c4007f61-fe21-4224-a719-377f57f96ca0", "embedding": null, "doc_hash": "df70882a2347d8f11bf441fc4dd2ada43d47c372dae19d6d014bd4427b4a6568", "extra_info": {"page_label": "435", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 580, "_node_type": "1"}, "relationships": {"1": "95e7d944-bb77-4e58-a666-6474b8bcf00b"}}, "__type__": "1"}, "339a7d48-f745-4580-824a-3af9545ef028": {"__data__": {"text": "valrubicin\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member has an active urinary tract infection (UTI). The member has \nperforated bladder or compromised bladder mucosa. The member has \nsmall bladder capacity (unable to tolerate a 75 mL instillation).\nRequired\nMedical\nInformation\nBladder Cancer:  The member has recurrent or persistent carcinoma in \nsitu of the urinary bladder(Cis). The member has experienced disease \nprogression, intolerance or has a contraindication to BCG therapy. The \nmember is not a candidate for immediate cystectomy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 436 of 497\n", "doc_id": "339a7d48-f745-4580-824a-3af9545ef028", "embedding": null, "doc_hash": "e0fcfa6da8dad008fae0d43ee6fa14df29491fc8e1369cda3b31268389c0bd4e", "extra_info": {"page_label": "436", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 766, "_node_type": "1"}, "relationships": {"1": "2f63ee3e-f938-4ea3-bf53-8d3b11cde4a6"}}, "__type__": "1"}, "2cf83360-c4d3-48da-8429-3714b050dcfa": {"__data__": {"text": "VALSTAR\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nThe member has an active urinary tract infection (UTI). The member has \nperforated bladder or compromised bladder mucosa. The member has \nsmall bladder capacity (unable to tolerate a 75 mL instillation).\nRequired\nMedical\nInformation\nBladder Cancer:  The member has recurrent or persistent carcinoma in \nsitu of the urinary bladder(Cis). The member has experienced disease \nprogression, intolerance or has a contraindication to BCG therapy. The \nmember is not a candidate for immediate cystectomy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 437 of 497\n", "doc_id": "2cf83360-c4d3-48da-8429-3714b050dcfa", "embedding": null, "doc_hash": "1d076b715623a820c73ec3710f639caa3345c3e4052cf14dfd838f4fc3206569", "extra_info": {"page_label": "437", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 763, "_node_type": "1"}, "relationships": {"1": "ecefb3dc-9971-446d-ac1b-859dc79a46c8"}}, "__type__": "1"}, "7bb82104-ad72-4dd1-93cd-402d3754fde8": {"__data__": {"text": "vancomycin\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nC. difficile-associated diarrhea: The member must have a diagnosis of  \nC. difficile-associated diarrhea. Enterocolitis caused by staphylococcus \naureus (including methicillin-resistant strains): The member must have a \ndiagnosis of enterocolitis caused by staphylococcus aureus (including \nmethicillin-resistant strains).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 438 of 497\n", "doc_id": "7bb82104-ad72-4dd1-93cd-402d3754fde8", "embedding": null, "doc_hash": "0a12e0421867097d0b219327bb9fa7dbcd3f8cdadf47b7f6b875d533e167c268", "extra_info": {"page_label": "438", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 625, "_node_type": "1"}, "relationships": {"1": "3ed2688a-a340-48f7-b8e0-290364f4523e"}}, "__type__": "1"}, "d51871a8-6afd-481f-91a9-376f60cf94fc": {"__data__": {"text": "VARIZIG\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nVaricella Zoster: The member is using Varizig (varicella zoster immune \nglobulin)for post-exposure prophylaxis of varicella zoster. The member is \nat high risk for the development of varicella zoster infection. High risk \nindividuals include: Immunocompromised children and adults. Newborns \nof mothers with varicella shortly before or after delivery. Premature \ninfants. Neonates and infants less than one year of age. Adults without \nevidence of immunity. Pregnant members.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 439 of 497\n", "doc_id": "d51871a8-6afd-481f-91a9-376f60cf94fc", "embedding": null, "doc_hash": "4e285f1dafc2603df70cddfaf16cd0f68033e77a617bc94723ae19b9887b4102", "extra_info": {"page_label": "439", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 772, "_node_type": "1"}, "relationships": {"1": "038bf8e0-7cef-4b5c-9eb8-27e6892cd040"}}, "__type__": "1"}, "7ab6a887-19e9-4bba-ba4f-555b8530cce8": {"__data__": {"text": "VECTIBIX\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMetastatic colorectal cancer members with RAS-mutant mCRC or for \nwhom RAS mutation status is unknown. Member has had disease \nprogression on Vectibix (panitumumab) or Erbitux (cetuximab).Vectibix \n(panitumumab) may not be used in conjunction with Erbitux(cetuximab), \nTarceva (erlotinib),or Iressa (gefitinib).Vectibix (panitumumab) may not \nbe used in conjunction with bevacizumab product (based on the results \nfrom the PACCE trial).\nRequired\nMedical\nInformation\nMetastatic Colorectal Cancer. Diagnosis of Metastatic (stage IV) \nColorectal Cancer AND the member has mCRC that expresses verified \nwild-type RAS (defined as KRAS and NRAS). RAS testing should be \nperformed for all mCRC members that are potential candidates for \npanitumumab or cetuximab therapy. Applies to new starts only. And one \nof the following applies .The member had disease progression on or \nfollowing fluoropyrimidine (generally Xeloda/capecitabine/5-\nFU/fluorouracil), oxaliplatin, and irinotecan containing chemotherapy \nregimens. OR Using Vectibix (panitumumab) in combination with \nFOLFOX or FOLFIRI as first-line treatment OR using Vectibix \n(panitumumab) concurrently with irinotecan-based therapy in mCRC \nmembers.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 440 of 497\n", "doc_id": "7ab6a887-19e9-4bba-ba4f-555b8530cce8", "embedding": null, "doc_hash": "dfd618d377db11a335a16ae62a360cac3017d9183b5564e6cc8e96cac746135b", "extra_info": {"page_label": "440", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1467, "_node_type": "1"}, "relationships": {"1": "a59ea249-c96c-4e51-a549-78207b5a38bf"}}, "__type__": "1"}, "0b9a3017-6fdc-46ad-a3fa-a66975f3fbc2": {"__data__": {"text": "VENCLEXTA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on Venclexta \n(venetoclax).\nRequired\nMedical\nInformation\nChronic Lymphocytic Leukemia (CLL):The member has a diagnosis of \nChronic Lymphocytic Leukemia (CLL)  and one of the following applies:  \nhas received at least one prior therapy AND the member is using \nVenclexta (venetoclax) as monotherapy or in combination with rituximab \nOR the request is for first-line therapy AND the member is using \nVenclexta (venetoclax) in combination with Gazyva (obinutuzumab). \nMantle Cell Lymphoma: The member has a diagnosis of MCL AND The \nmember is using Venclexta (venetoclax) as monotherapy or in \ncombination with a rituximab product AND The member meets one of the \nfollowing:  relapsed, refractory, or progressive disease OR Stable \ndisease or partial response after induction therapy. Acute Myeloid \nLeukemia - Newly Diagnosed: The member has a diagnosis of newly-\ndiagnosed acute myeloid leukemia (AML) AND one of the following \napplies: member is 75 years or older OR member has comorbidities that \npreclude the use of intensive induction chemotherapy (e.g. baseline \nEastern Cooperative Oncology Group (ECOG) performance status of 2-\n3, severe cardiac or pulmonary comorbidity, moderate hepatic \nimpairment, or creatinine clearance less than 45 ml/min).  The member \nwill be using Venclexcta (ventoclax) in combination with azacitidine, or \ndecitabine, or low-dose cytarabine.  Acute Myeloid Leukemia, \nrelapsed/refractory: The member has a diagnosis of acute myeloid \nleukemia (AML) AND The member has relapsed/refractory disease AND \nOne of the following applies: As a component of repeating the initial \nsuccessful induction regimen if late relapse (greater than or equal to 12 \nmonths since induction regimen) AND Venclexta (venetoclax) has not \nbeen administered continuously AND Venclexta (venetoclax) was not \nstopped due to the development of clinical resistance OR The member \nwill be using Venclexta (venetoclax) in combination with azacitidine, or \ndecitabine, or low-dose cytarabine.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 441 of 497\n", "doc_id": "0b9a3017-6fdc-46ad-a3fa-a66975f3fbc2", "embedding": null, "doc_hash": "575664585e0d6c45ba9095381d5b580cb5e79b60143a803281f4608b83e11bf7", "extra_info": {"page_label": "441", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2288, "_node_type": "1"}, "relationships": {"1": "66c60223-5c98-4811-8c80-751e492bee12"}}, "__type__": "1"}, "edf4db94-a109-43bd-9197-622efcbf2954": {"__data__": {"text": "VENCLEXTA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 442 of 497\n", "doc_id": "edf4db94-a109-43bd-9197-622efcbf2954", "embedding": null, "doc_hash": "a8d5e0e0703dc9360115fb4c21d1b87b9208e5ecf7b1db6cfaf5e46a4d1c5d55", "extra_info": {"page_label": "442", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 84, "_node_type": "1"}, "relationships": {"1": "5fbaf4a9-bb83-4705-b764-7fa18079d8cb"}}, "__type__": "1"}, "b652e2a0-225b-4105-affc-3405a5ceda4d": {"__data__": {"text": "VENCLEXTA STARTING PACK\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on Venclexta \n(venetoclax).\nRequired\nMedical\nInformation\nChronic Lymphocytic Leukemia (CLL):The member has a diagnosis of \nChronic Lymphocytic Leukemia (CLL)  and one of the following applies:  \nhas received at least one prior therapy AND the member is using \nVenclexta (venetoclax) as monotherapy or in combination with rituximab \nOR the request is for first-line therapy AND the member is using \nVenclexta (venetoclax) in combination with Gazyva (obinutuzumab). \nMantle Cell Lymphoma: The member has a diagnosis of MCL AND The \nmember is using Venclexta (venetoclax) as monotherapy or in \ncombination with a rituximab product AND The member meets one of the \nfollowing:  relapsed, refractory, or progressive disease OR Stable \ndisease or partial response after induction therapy. Acute Myeloid \nLeukemia - Newly Diagnosed: The member has a diagnosis of newly-\ndiagnosed acute myeloid leukemia (AML) AND one of the following \napplies: member is 75 years or older OR member has comorbidities that \npreclude the use of intensive induction chemotherapy (e.g. baseline \nEastern Cooperative Oncology Group (ECOG) performance status of 2-\n3, severe cardiac or pulmonary comorbidity, moderate hepatic \nimpairment, or creatinine clearance less than 45 ml/min).  The member \nwill be using Venclexcta (ventoclax) in combination with azacitidine, or \ndecitabine, or low-dose cytarabine.  Acute Myeloid Leukemia, \nrelapsed/refractory: The member has a diagnosis of acute myeloid \nleukemia (AML) AND The member has relapsed/refractory disease AND \nOne of the following applies: As a component of repeating the initial \nsuccessful induction regimen if late relapse (greater than or equal to 12 \nmonths since induction regimen) AND Venclexta (venetoclax) has not \nbeen administered continuously AND Venclexta (venetoclax) was not \nstopped due to the development of clinical resistance OR The member \nwill be using Venclexta (venetoclax) in combination with azacitidine, or \ndecitabine, or low-dose cytarabine.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 443 of 497\n", "doc_id": "b652e2a0-225b-4105-affc-3405a5ceda4d", "embedding": null, "doc_hash": "51024e9ba7c9d09bb7adf8becbad52a055eedbc5df232bb38f00f5f6ad0b223f", "extra_info": {"page_label": "443", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2302, "_node_type": "1"}, "relationships": {"1": "70af5338-1745-4bca-aa86-7844d2eec1d4"}}, "__type__": "1"}, "2e9f3c74-6543-4ea6-a98c-66fde8ca147e": {"__data__": {"text": "VENCLEXTA STARTING PACK\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 444 of 497\n", "doc_id": "2e9f3c74-6543-4ea6-a98c-66fde8ca147e", "embedding": null, "doc_hash": "4add8b21deae4e4a6c4819989800a2128244e2dacd4e49f20e97d8b7ef8a4e36", "extra_info": {"page_label": "444", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 98, "_node_type": "1"}, "relationships": {"1": "7c3ead24-69b6-4d90-8d03-758c13653368"}}, "__type__": "1"}, "ef1df2ab-a61a-42ee-9a3a-6fa244902196": {"__data__": {"text": "VENTAVIS\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nPulmonary Arterial Hypertension (WHO GROUP I):The member must \nhave a diagnosis of pulmonary arterial hypertension (WHO Group I) \nconfirmed by right heart catheterization with WHO/NYHA Function Class \nIII-IV symptoms OR the member must have had prior therapy, \nintolerance to, or contraindication to ONE Phosphodiesterase type 5 \n(PDE-5) inhibitor approved for use in PAH (e.g., sildenafil or tadalafil) or \nAdempas (riociguat) AND ONE Endothelin receptor antagonist [e.g., \nambrisentan, bosentan, Opsumit [macitentan]) approved for use in PAH.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 445 of 497\n", "doc_id": "ef1df2ab-a61a-42ee-9a3a-6fa244902196", "embedding": null, "doc_hash": "0fcba8ed48f0ae12d2bcb5633b70fa8518f805c19c7637cb4c16071ce8f98484", "extra_info": {"page_label": "445", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 833, "_node_type": "1"}, "relationships": {"1": "5e2cbb88-6965-4df3-8963-b213aa51d63c"}}, "__type__": "1"}, "a8cd47ee-eb41-401b-8bb1-b388b31b6204": {"__data__": {"text": "VERSACLOZ\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDementia-related psychosis (in the absence of an approvable diagnosis), \nfor member 65 years of age or older.\nRequired\nMedical\nInformation\nThe member must be using clozapine orally disintegrating tablet for \ntreatment-resistant schizophrenia.The member must have had prior \ntherapy or intolerance to generic clozapine.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 446 of 497\n", "doc_id": "a8cd47ee-eb41-401b-8bb1-b388b31b6204", "embedding": null, "doc_hash": "7baec82d760bfb84d3164ea2275601d29865aaf6b140ee4eb20f06379c727e69", "extra_info": {"page_label": "446", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 585, "_node_type": "1"}, "relationships": {"1": "9505e518-cc79-4165-8303-86dd9d256127"}}, "__type__": "1"}, "b989716e-ed9a-4cd0-91a1-b8feab4c4d48": {"__data__": {"text": "VERZENIO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember has experienced disease progression on Faslodex (fulvestrant) \n[applies to combination therapy with Faslodex (fulvestrant)]. Member has \nexperienced disease progression on CDK 4/6 inhibitor (e.g., palbociclib, \nribociclib). Member exceeds two years of total Verzenio (abemaciclib) \nbased treatment (applicable only to early breast cancer).\nRequired\nMedical\nInformation\nMetastatic Breast cancer- initial endocrine based therapy. The member \nhas a diagnosis of advanced or metastatic hormone receptor (HR)-\npositive and human epidermal growth factor receptor 2 (Her2neu)-\nnegative breast cancer AND Verzenio (abemaciclib) is given in \ncombination with an aromatase inhibitor (e.g., letrozole) as first line \nendocrine based therapy. Metastatic breast cancer combination therapy \nwith Faslodex (fulvestrant). The member has diagnosis of advanced or \nmetastatic hormone receptor (HR) positive human epidermal growth \nfactor receptor 2 (HER2) negative breast cancer AND The member has \nexperienced disease progression on endocrine therapy (e.g., \nanastrazole) AND Verzenio (abemaciclib) is given in combination with \nFaslodex (fulvestrant). Metastatic breast cancer monotherapy: The \nmember has diagnosis of advanced or metastatic HR positive, HER2 \nnegative breast cancer AND the member has experienced disease \nprogression on endocrine therapy (e.g., anastrazole) and chemotherapy \nin the metastatic setting AND Verzenio (abemaciclib) is being used as \nmonotherapy.  Early Breast cancer - combination therapy:  The member \nhas a diagnosis of HR positive, HER2 negative, node positive, early \nbreast cancer at high risk of recurrence AND Verzenio (abemaciclib) is \ngiven in combination with tamoxifen or aromatase inhibitor.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 447 of 497\n", "doc_id": "b989716e-ed9a-4cd0-91a1-b8feab4c4d48", "embedding": null, "doc_hash": "d6f09ce442626bc9f3ae8afcfe78c432842048a55d2841db5bda6707d95e9038", "extra_info": {"page_label": "447", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1986, "_node_type": "1"}, "relationships": {"1": "92e4c537-733c-4e23-adca-4c8103d9d2e4"}}, "__type__": "1"}, "e0637e71-58db-4ab2-b31a-c2896a334e8b": {"__data__": {"text": "vigabatrin\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nComplex Partial Seizure: Documented diagnosis of refractory complex \npartial seizure. Unsuccessful treatment with at least two concomitant \nantiepileptic drugs (AEDs) (e.g. carbamazepine, lamotrigine, \nlevetiracetam, topiramate).  Infantile Spasms:  Documented diagnosis of \ninfantile spasms.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 448 of 497\n", "doc_id": "e0637e71-58db-4ab2-b31a-c2896a334e8b", "embedding": null, "doc_hash": "d9a0d252a6de62eea346dc72938cd4e9003031fd9de0cfc73c34dd9659dc2462", "extra_info": {"page_label": "448", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 595, "_node_type": "1"}, "relationships": {"1": "c50d516c-91dd-42be-b02f-5891c960b1be"}}, "__type__": "1"}, "61eab87a-bbba-4713-a9b7-10dd4ce722f1": {"__data__": {"text": "vigadrone\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nComplex Partial Seizure: Documented diagnosis of refractory complex \npartial seizure. Unsuccessful treatment with at least two concomitant \nantiepileptic drugs (AEDs) (e.g. carbamazepine, lamotrigine, \nlevetiracetam, topiramate).  Infantile Spasms:  Documented diagnosis of \ninfantile spasms.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 449 of 497\n", "doc_id": "61eab87a-bbba-4713-a9b7-10dd4ce722f1", "embedding": null, "doc_hash": "8990a534f265746de82af5c077bea21b1edf41841e85dc3db0e3e81c318d2cef", "extra_info": {"page_label": "449", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 594, "_node_type": "1"}, "relationships": {"1": "cfb83702-5ed4-4e1a-a30b-70165a53212d"}}, "__type__": "1"}, "ba555a6d-062d-477e-8774-463328a5d449": {"__data__": {"text": "VIIBRYD\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nThe member must be utilizing Viibryd (vilazodone) for treatment of major \ndepressive disorder. For new starts only: The member must have a \ndocumentation of prior therapy, intolerance, or contraindication to a \nselective serotonin reuptake inhibitor (SSRI) AND a generic bupropion \nproduct (75mg/100mg IR, 100mg/150mg/200mg SR, or 150mg/300mg \nXL) or mirtazapine.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 450 of 497\n", "doc_id": "ba555a6d-062d-477e-8774-463328a5d449", "embedding": null, "doc_hash": "a1d55b0b9cd18ffa5757ee5f483aa3eb2a2651614b6f06e715252f80b0401eb4", "extra_info": {"page_label": "450", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 663, "_node_type": "1"}, "relationships": {"1": "4bfc9a7e-5144-47c7-9fc0-e3fe8c05c137"}}, "__type__": "1"}, "e4e68299-2544-414e-a336-cde553ffea37": {"__data__": {"text": "vilazodone\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nThe member must be utilizing Viibryd (vilazodone) for treatment of major \ndepressive disorder. For new starts only: The member must have a \ndocumentation of prior therapy, intolerance, or contraindication to a \nselective serotonin reuptake inhibitor (SSRI) AND a generic bupropion \nproduct (75mg/100mg IR, 100mg/150mg/200mg SR, or 150mg/300mg \nXL) or mirtazapine.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 451 of 497\n", "doc_id": "e4e68299-2544-414e-a336-cde553ffea37", "embedding": null, "doc_hash": "7dfec5b3863bff86dcda62a5ec91abba8423f24d2dfb1a3c0698c8cac0a2bbbd", "extra_info": {"page_label": "451", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 666, "_node_type": "1"}, "relationships": {"1": "8f1e0af0-532f-410f-a28c-1954f6c7e031"}}, "__type__": "1"}, "0e5b7bb7-e9fa-4643-8944-b646baf33dcd": {"__data__": {"text": "VITRAKVI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nSolid Tumors. Member has been diagnosed with advanced or metastatic \nsolid tumor AND Member has a documented neurotrophic receptor \ntyrosine kinase (NTRK) gene fusion without a known resistance mutation \nAND Member is not a candidate for surgical resection AND Member is \nnot a candidate for or does not have alternative systemic therapy \ntreatment options. Reauthorization: Member has not developed a known \nresistance mutation to Vitrakvi (larotrectinib) AND Physician attestation \nthat the member has continued to receive a clinical benefit (e.g., \ncomplete response, partial response, stable disease) and has not \nexperienced disease progression.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial authorization: 90 days. Reauthorization: Six month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 452 of 497\n", "doc_id": "0e5b7bb7-e9fa-4643-8944-b646baf33dcd", "embedding": null, "doc_hash": "632d9259386e117f704a65245b474bd809255e8f1d38491ffa6ab7cdf5210fde", "extra_info": {"page_label": "452", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 997, "_node_type": "1"}, "relationships": {"1": "7407440f-62eb-48b3-9d34-8a6ba12532cb"}}, "__type__": "1"}, "c18aab26-a58f-4b28-b1cd-ce6f44b10ee6": {"__data__": {"text": "VIZIMPRO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers on concomitant tyrosine kinase inhibitors.\nRequired\nMedical\nInformation\nNon-small cell lung cancer (NSCLC). The member has a diagnosis of \nmetastatic non-small cell lung cancer (NSCLC) AND the following criteria \napplies: The member has a documented epidermal growth factor \nreceptor (EGFR) exon 19 deletion or exon 21 (L858R) substitution \nmutation AND The member is using Vizimpro (dacomitinib) as a single \nagent for first line therapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 453 of 497\n", "doc_id": "c18aab26-a58f-4b28-b1cd-ce6f44b10ee6", "embedding": null, "doc_hash": "a10e5bf581bb2499cbe5e1361be778ca285e50c419d01b4ae25841652130921f", "extra_info": {"page_label": "453", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 713, "_node_type": "1"}, "relationships": {"1": "c6c39b15-a458-4fe8-8a59-d3b7b79641ef"}}, "__type__": "1"}, "e7fadaa2-1098-4632-be64-1ed38a44ff18": {"__data__": {"text": "VONJO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on Vonjo \n(pacritinib).\nRequired\nMedical\nInformation\nMyelofibrosis:  The member has a diagnosis of primary myelofibrosis or \nsecondary myelofibrosis (i.e. post-polycythemia vera or post-essential \nthrombocythemia) AND The member has one of the following risk \ncategories, as defined by accepted risk stratification tools for \nmyelofibrosis (e.g. International Prognostic Scoring System (IPSS), \nDynamic International Prognostic Scoring System (DIPSS), or DIPSS-\nPLUS):  Intermediate-risk disease OR High-risk disease AND The \nmember will be using Vonjo (pacritinib) as monotherapy AND The \nmember has a platelet count below 50 x 109/L.  Reauthorization criteria:  \nPhysician attestation that the member has continued to receive a clinical \nbenefit (e.g. spleen volume reduction from baseline, symptom \nimprovement) AND Physician attestation that the member has not \nexperienced unacceptable toxicities.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial Authorization: 6 months duration. Reauthorization: 6 months \nduration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 454 of 497\n", "doc_id": "e7fadaa2-1098-4632-be64-1ed38a44ff18", "embedding": null, "doc_hash": "46b0e8ba0e4c3181c4e048c4f1e7fc5f77ed5c523b13b2fce01c329a4772ef1f", "extra_info": {"page_label": "454", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1274, "_node_type": "1"}, "relationships": {"1": "1745d44f-99d0-4d3e-b055-92b27e5ecb7d"}}, "__type__": "1"}, "8cb2ac7b-4fab-4994-b543-9fb80e3fc16c": {"__data__": {"text": "voriconazole\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAntifungal Prophylaxis in members undergoing bone marrow transplants. \nAntifungal Prophylaxis in members who are intermediate or high risk of \ndeveloping cancer-related fungal infections.  Prophylaxis of Aspergillus \nspecies in post-heart transplantation patients should meet one of the \nfollowing: CMV disease,Isolation of Aspergillus species in respiratory \ntract cultures,Post-transplant hemodialysis or Reoperation, Existence of \nan episode of invasive aspergillosis in heart transplant program two \nmonths before or after heart transplant.Prophylaxis of both Candida and \nAspergillus species in high risk post-liver transplant patients should meet \none of the following criteria: Local epidemiology, Renal failure needing \nhemodialysis or continuous venovenous dialysis pre- or post-\ntransplantation, Reoperation involving thoracic or abdominal cavity \n(exploratory laparotomy, or intrathoracic surgery), Retransplantation OR \nTransplantation for fulminant hepatic failure. Prophylaxis of invasive \naspergillosis in post-lung transplantation,Treatment of invasive \naspergillosis, Treatment of chronic cavitary or necrotizing pulmonary \naspergillosis and/or Serious fungal infections cause by Scedosporium \napiospermum and Fusarium spp. including Fusarium solani, in patients \nintolerant of other therapy OR Empiric therapy of suspected invasive \nCandidiasis or Aspergillosis in high risk patients with febrile neutropenia \ndespite receiving broad-spectrum antibiotic therapy. Diagnosis of one of \nthe following fungal infections and failed to achieve clinical response or \nhas contraindications to fluconazole or itraconazole for sensitive (non-\nkrusei, non-glabrata) candida infections: Esophageal candidiasis, \nOropharyngeal candidiasis,Candidemia in nonneutropenic patients \nand/or The following Candida infections: disseminated infections in skin \nand infections in abdomen, kidney, bladder wall, and/or wounds.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 455 of 497\n", "doc_id": "8cb2ac7b-4fab-4994-b543-9fb80e3fc16c", "embedding": null, "doc_hash": "ee953b73c944db50b24d8fe367bdc2e6b4c4772ca14074f14ed7ffa018bee1ae", "extra_info": {"page_label": "455", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2213, "_node_type": "1"}, "relationships": {"1": "7c8017f2-b028-4e02-83de-fd7ad7e10925"}}, "__type__": "1"}, "2989b029-076c-4d3d-920a-78cc08f4c2b7": {"__data__": {"text": "VOSEVI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nRetreatment of Chronic Hepatitis C. The member must have a diagnosis \nof chronic hepatitis C (HCV). The member must have HCV genotype \ndocumented prior to therapy. Baseline HCV RNA must be documented. \nMember must be tested for the presence of HBV by screening for the \nsurface antigen of HBV (HBsAg) and anti-hepatitis B core total \nantibodies (anti-HBc) prior to initiation of therapy. The member has \nrelapsed after completing a full course of or has a contraindication to: \nGenotypes 1, 4, 5, and 6: Harvoni OR Epclusa. Genotypes 2 and 3:  The \nmember has relapsed after completing a full course of or has a \ncontraindication to Epclusa.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n12 weeks depending on disease state and genotype based on AASLD \ntreatment guidelines for HCV.\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 456 of 497\n", "doc_id": "2989b029-076c-4d3d-920a-78cc08f4c2b7", "embedding": null, "doc_hash": "11cca91ae4c075448850fb69292ff42b5e2068c91c3b7fb51ed7a1aea5faa82b", "extra_info": {"page_label": "456", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1004, "_node_type": "1"}, "relationships": {"1": "5db5bced-031e-4adc-bc4d-17634d2ccec5"}}, "__type__": "1"}, "65881e5f-a03c-4ae2-9e39-f1bd6430fe9f": {"__data__": {"text": "VOTRIENT\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on previous \npazopanib therapy.\nRequired\nMedical\nInformation\nAdvanced Renal Cell Carcinoma RCC).The member has a diagnosis of \nadvanced renal cell carcinoma (stage IV). First-line therapy as a single \nagent for relapsed or unresectable stage IV disease with predominant \nclear cell histology OR as subsequent therapy as a single agent for \nrelapsed or unresectable stage IV disease with predominant clear cell \nhistology in members who have progressed on prior first-line \ntherapy.Soft Tissue Sarcoma. The member has a diagnosis of soft tissue \nsarcoma AND The member has progressed after prior chemotherapy. \nThyroid Carcinoma: The member has a diagnosis of advanced or \nmetastatic radio-iodine refractory follicular carcinoma, Hurthle cell \ncarcinoma, papillary and disease is progressive OR The member has a \ndiagnosis of advanced medullary carcinoma and has disease \nprogression on or intolerance to Caprelsa (vandetanib) or Cometriq \n(cabozantinib).  Ovarian Cancer. The member has a diagnosis of \nepithelial ovarian, fallopian tube, or primary peritoneal cancer. Uterine \nNeoplasms. The member has a diagnosis of stage II, III, IV, or advanced \nmetastatic uterine neoplasm sarcoma and disease is not suitable for \nprimary surgery AND Votrient (pazopanib) will be used as a single agent.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 month duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 457 of 497\n", "doc_id": "65881e5f-a03c-4ae2-9e39-f1bd6430fe9f", "embedding": null, "doc_hash": "25bbec73623aaa76845b70cfad0de5b5cee4c166dc5239cccd8d19c05c4bbbb6", "extra_info": {"page_label": "457", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1606, "_node_type": "1"}, "relationships": {"1": "4bfdd0b3-18b8-405d-84fb-ccfc5f48490b"}}, "__type__": "1"}, "e2da1f4f-b365-4b3d-bf0f-94085b7d8767": {"__data__": {"text": "VRAYLAR\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nDementia-related psychosis (in the absence of an approvable diagnosis), \nfor member 65 years of age or older.\nRequired\nMedical\nInformation\nSchizophrenia/ Bipolar I Disorder, manic or mixed episode: The member \nmust be utilizing Vraylar for the treatment of schizophrenia or bipolar I \ndisorder AND The member must have documentation of prior therapy, \nintolerance, or contraindication to at least 2 of the following: risperidone, \nolanzapine, quetiapine, ziprasidone or aripiprazole.  Bipolar 1 Disorder \n(Bipolar Depression): The member must have a diagnosis of bipolar 1 \ndisorder (bipolar depression) and the member must have documentation \nof prior treatment, intolerance, or contraindication to quetiapine. Major \nDepressive Disorder: The member has a clinical diagnosis of major \ndepressive disorder (MDD) as defined by DSM-5 criteria and/or \nappropriate depression rating scale (e.g. PHQ-9, Clinically Useful \nDepression Outcome Scale, Quick Inventory of Depressive \nSymptomatology-Self Report 16 Item, MADRS, HAM-D) AND The \nmember has had previous treatment, contraindication, or intolerance to \nat least one antidepressants of adequate dose (i.e. as determined by the \ntreating provider based on individual patient characteristics) and duration \n(i.e. at least 8 weeks) used as monotherapy for MDD AND The member \nmust have documentation of prior therapy, intolerance, or \ncontraindication to at least one other generic oral atypical antipsychotic \ntherapy that has been used as adjunctive (i.e. add-on) to antidepressant \ntherapy AND Vraylar must be used as adjunctive treatment to \nantidepressant therapy and not as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 458 of 497\n", "doc_id": "e2da1f4f-b365-4b3d-bf0f-94085b7d8767", "embedding": null, "doc_hash": "0d478f8d29da3042898dbf60d4287f9e65857da2ce1c087c5b00025dcc5b38aa", "extra_info": {"page_label": "458", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1899, "_node_type": "1"}, "relationships": {"1": "5e0f0676-70ca-4f35-bf2a-7471428972f1"}}, "__type__": "1"}, "b2e98b18-e002-4330-aca8-85decb6f077f": {"__data__": {"text": "VUMERITY\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nThe member has a diagnosis of a relapsing form of multiple sclerosis, to \ninclude relapsing-remitting or active secondary progressive disease OR \nthe member has a diagnosis of a clinically isolated syndrome (CIS).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 459 of 497\n", "doc_id": "b2e98b18-e002-4330-aca8-85decb6f077f", "embedding": null, "doc_hash": "3c74330254a1d820985dabcb527216cb2d9e6523c4f47ce04d5917341809fdab", "extra_info": {"page_label": "459", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 502, "_node_type": "1"}, "relationships": {"1": "02c3045e-942e-4fed-9d9a-205bf3708177"}}, "__type__": "1"}, "e726f119-fc84-4a3e-ba05-9356c690e380": {"__data__": {"text": "VYNDAMAX\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nCardiomyopathy of Transthyretin-Mediated Amyloidosis (ATTR-CM): \nMember has a history of NYHA Class I through III Heart Failure AND \nMember has a diagnosis of ATTR-CM defined as:  Significant cardiac \ninvolvement (e.g. substantial ventricular wall thickening or elevated intra-\ncardiac filling pressures) on echocardiography or cardiac MRI and one of \nthe following:  Medical records indicate presence of transthyretin \nprecursor protein confirmed on immunohistochemical analysis, \nscintigraphy, or mass spectrometry using Technescan PYP (PYP \nScreening) or Medical records indicate presence of amyloid deposits on \nanalysis of biopsy specimens. The member does not have a history of \nany of the following:  Liver Transplant, Heart Transplant without evidence \nof further amyloid deposits post-transplant, Left Ventricular Assist Device \n(LVAD), Current Pregnancy. Reauthorization:  Member has evidence of \nslowing of clinical decline (e.g., decrease in number of hospitalizations, \nimprovement or stabilization of the 6-minute walk test, stable or \nimprovement in KCCQ-OS).\nAge Restriction\nThe member is 18 years of age or older.\nPrescriber\nRestriction\nThe member is being treated by a specialist (e.g. cardiologist).\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 460 of 497\n", "doc_id": "e726f119-fc84-4a3e-ba05-9356c690e380", "embedding": null, "doc_hash": "d563f56ae41068e65ff5a42fb37ba46fe1e86631c807ebfd85a4e44d401a0b2b", "extra_info": {"page_label": "460", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1446, "_node_type": "1"}, "relationships": {"1": "ac22a433-f284-4c89-8527-9c97f81dcabe"}}, "__type__": "1"}, "66ad97a3-e34b-4a06-bbde-238dbe33c11c": {"__data__": {"text": "VYNDAQEL\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nCardiomyopathy of Transthyretin-Mediated Amyloidosis (ATTR-CM): \nMember has a history of NYHA Class I through III Heart Failure AND \nMember has a diagnosis of ATTR-CM defined as:  Significant cardiac \ninvolvement (e.g. substantial ventricular wall thickening or elevated intra-\ncardiac filling pressures) on echocardiography or cardiac MRI and one of \nthe following:  Medical records indicate presence of transthyretin \nprecursor protein confirmed on immunohistochemical analysis, \nscintigraphy, or mass spectrometry using Technescan PYP (PYP \nScreening) or Medical records indicate presence of amyloid deposits on \nanalysis of biopsy specimens. The member does not have a history of \nany of the following:  Liver Transplant, Heart Transplant without evidence \nof further amyloid deposits post-transplant, Left Ventricular Assist Device \n(LVAD), Current Pregnancy. Reauthorization:  Member has evidence of \nslowing of clinical decline (e.g., decrease in number of hospitalizations, \nimprovement or stabilization of the 6-minute walk test, stable or \nimprovement in KCCQ-OS).\nAge Restriction\nThe member is 18 years of age or older.\nPrescriber\nRestriction\nThe member is being treated by a specialist (e.g. cardiologist).\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 461 of 497\n", "doc_id": "66ad97a3-e34b-4a06-bbde-238dbe33c11c", "embedding": null, "doc_hash": "53074d04ecf18eeb4662efae4ffe72c442d37dac57b44bf82f98678164232617", "extra_info": {"page_label": "461", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1446, "_node_type": "1"}, "relationships": {"1": "776c361f-2d56-4134-92d6-721b1a74b7bb"}}, "__type__": "1"}, "01e86f14-1724-4843-a94c-f9a43cc9ae80": {"__data__": {"text": "VYXEOS\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember has experienced disease progression on Vyxeos (daunorubicin \nand cytarabine). Member has experienced disease progression on \nconventional daunorubicin and cytarabine regimen (e.g. \n\u201c\n7+3\n\u201d)\nRequired\nMedical\nInformation\nAcute Myeloid Leukemia: The member has a diagnosis of therapy-\nrelated acute myeloid leukemia (t-AML) or AML with myelodysplasia-\nrelated changes (AML-MRC) AND one of the following applies: The \nmember has newly diagnosed disease OR the member is using Vyxeos \n(daunorubicin and cytarabine) as post-remission therapy (if given in \ninduction) OR the member is using Vyxeos (daunorubicin and \ncytarabine) as re-induction (if given in induction).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 462 of 497\n", "doc_id": "01e86f14-1724-4843-a94c-f9a43cc9ae80", "embedding": null, "doc_hash": "d0c7357468198ab11970db85c4a13a79a90ce9b3602145e6ae68ac627638d499", "extra_info": {"page_label": "462", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 932, "_node_type": "1"}, "relationships": {"1": "bcc9205d-6149-40b2-b74e-ef50462d9f59"}}, "__type__": "1"}, "a0f064ca-c352-405c-9383-98183dd38259": {"__data__": {"text": "WELIREG\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experiences disease progression on Welireg (belzutifan).\nRequired\nMedical\nInformation\nvon Hippel Lindau VHL disease:  The member has von Hippel Lindau \n(VHL) disease and the member does not require immediate surgery and \nThe member requires treatment for: associated renal cell carcinoma \n(RCC) OR associated central nervous system hemangioblastomas OR \npancreatic neuroendocrine tumors and Welireg (belzutifan) is \nadministered as monotherapy.  Reauthorization criteria:  Physician \nattestation that the member has continued to receive a clinical benefit \n(e.g., response of lesions by imaging).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial authorization: 6 months duration.  Reauthorization: plan year \nduration.\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 463 of 497\n", "doc_id": "a0f064ca-c352-405c-9383-98183dd38259", "embedding": null, "doc_hash": "d744c3fbfd6a92f12e5db5a4c192f524f7e98f4b65c1c840e53668c1fae286ea", "extra_info": {"page_label": "463", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 924, "_node_type": "1"}, "relationships": {"1": "0565530d-301c-45ac-aaa0-44b1d8cdb36a"}}, "__type__": "1"}, "e7943ad1-c579-410f-b708-90ac4b982722": {"__data__": {"text": "XALKORI\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers using Xalkori (crizotinib) for adjuvant therapy.  Member is \ntaking concomitant tyrosine kinase inhibitors.\nRequired\nMedical\nInformation\nNon-small Cell Lung Cancer (NSCLC). The member has a diagnosis of \nmetastatic or recurrent non-small cell lung cancer (NSCLC) and The \nmember will be using Xalkori (crizotinib) as monotherapy and one of the \nfollowing applies: The member has documented anaplastic lymphoma \nkinase (ALK)-positive NSCLC disease AND the member has a medical \nreason as to why Alecensa (alectinib) or Alunbrig (brigatinib) cannot be \nstarted or continued OR the member has disease which is ROS1 \npositive.  Anaplastic large cell lymphoma (ALCL):  The member has a \ndiagnosis of relapsed or refractory, systemic ALCL AND the disease has \ndocumented ALK-positivity AND Xalkori (crizotinib) is given as \nmonotherapy.  Inflammatory myofibroblastic tumor (IMT):  the member \nhas a diagnosis of unresectable, recurrent, or refractory IMT AND the \ndisease has documented ALK-positivity AND Xalkori (crizotinib) is given \nas monotherapy.\nAge Restriction\nALCL:  The member is greater than 1 year of age up to young adult (21 \nyears of age).  IMT:  The member is greater than 1 year of age and older.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 464 of 497\n", "doc_id": "e7943ad1-c579-410f-b708-90ac4b982722", "embedding": null, "doc_hash": "e2f6492fca845a26822431a54ca9eeac7976a6cd00d7b8f1f2958af0ee5bea3c", "extra_info": {"page_label": "464", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1457, "_node_type": "1"}, "relationships": {"1": "90473aca-452d-468f-92dd-bb27d3d4191b"}}, "__type__": "1"}, "07e8fd14-7ba1-458a-a807-83894f081c06": {"__data__": {"text": "XATMEP\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that are pregnant or nursing. Members with disease \nprogression on Xatmep (methotrexate)(applies to acute lymphoblastic \nleukemia only).\nRequired\nMedical\nInformation\nAcute Lymphoblastic Leukemia (ALL): The member has a diagnosis of \nacute lymphoblastic leukemia AND The member will be using Xatmep \n(methotrexate) as part of a multi-phase, combination chemotherapy \nmaintenance regimen AND The member has had previous treatment or \nintolerance to generic methotrexate. Polyarticular Juvenile Idiopathic \nArthritis (pJIA): The member has a diagnosis of active polyarticular \njuvenile idiopathic arthritis (pJIA) AND The member has had an \ninsufficient therapeutic response to previous treatment, or is intolerant of, \nor had an inadequate response to first-line therapy (e.g. non-steroidal \nanti-inflammatory agents (NSAIDs)) as determined by prescriber AND \nThe member has had previous treatment or intolerance to generic \nmethotrexate.\nAge Restriction\nThe member is less than 18 years of age.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 465 of 497\n", "doc_id": "07e8fd14-7ba1-458a-a807-83894f081c06", "embedding": null, "doc_hash": "c076e491d9e7d8b5d8672a47a151c15f0d424b84e1f489bb7e2d5058b73f98f0", "extra_info": {"page_label": "465", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1242, "_node_type": "1"}, "relationships": {"1": "4d91befa-f6ff-4a94-8f35-8d9d70194f8e"}}, "__type__": "1"}, "cfc5e652-a898-4df8-9021-d17b21bf39fa": {"__data__": {"text": "XGEVA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nUncorrected Pre-existing hypocalcemia. Concurrent use of \nbisphosphonate therapy (e.g., zoledronic acid, pamidronate)\nRequired\nMedical\nInformation\nOsteolytic Bone Metastases of Solid Tumors. The member has a \ndiagnosis of solid tumor cancer (such as breast cancer, prostate cancer, \nor other solid tumor). The member must have documented bone \nmetastases. The member has experienced disease progression, \nintolerance or contraindication following treatment with zoledronic acid or \npamidronate (disease progression, intolerance or contraindication \nfollowing treatment with pamidronate or zoledronic acid does not apply \nfor prostate cancer). Multiple Myeloma:  The member has a diagnosis of \nmultiple myeloma AND the member has experienced disease \nprogression, intolerance or contraindication following treatment with \nzoledronic acid or pamidronate. Giant Cell tumor of Bone: Diagnosis of \ngiant cell tumor of bone. Hypercalcemia of malignancy: The member has \nhypercalcemia of malignancy, defined as an albumin-corrected calcium \nof greater than 12.5 mg/dL AND The member has had prior therapy with \nintravenous bisphosphonate therapy (e.g. pamidronate or zoledronic \nacid).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n1\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 466 of 497\n", "doc_id": "cfc5e652-a898-4df8-9021-d17b21bf39fa", "embedding": null, "doc_hash": "0ed87e30e093f7d2db735b4da9021827a4c8369e5960956c2498de553b03e4ca", "extra_info": {"page_label": "466", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1435, "_node_type": "1"}, "relationships": {"1": "40811b3b-4b90-44cd-8288-a0e58a632068"}}, "__type__": "1"}, "1beb2649-3411-480f-b14d-faf250b75df1": {"__data__": {"text": "XIFAXAN\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nTreatment of traveler's diarrhea complicated by fever or bloody stools.\nRequired\nMedical\nInformation\nTraveler's diarrhea: Member must have traveler's diarrhea caused by \nnon-invasive strains of Escherichia Coli. Member has previous \ntreatment, intolerance or contraindication to ciprofloxacin, levofloxacin, or \nazithromycin. Hepatic encephalopathy prophylaxis: Member must have \nhepatic encephalopathy. Member has previous treatment, intolerance or \ncontraindication to lactulose or neomycin. Irritable bowel syndrome with \ndiarrhea (IBS-D): Diagnosis of Irritable bowel syndrome with diarrhea \n(IBS-D).\nAge Restriction\nMust be age 12 or older for Travelers Diarrhea, Age 18 or older for \nHepatic encephalopathy prophylaxis and IBS-D.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year for Hepatic Encephalopathy, 30 days for traveler's diarrhea, \nand 3 months for IBS-D.\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 467 of 497\n", "doc_id": "1beb2649-3411-480f-b14d-faf250b75df1", "embedding": null, "doc_hash": "0899c451d3e4fdb6d228191ca30e5031437f8577d6b2d02bec9b06ab1720031c", "extra_info": {"page_label": "467", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1055, "_node_type": "1"}, "relationships": {"1": "f18533ec-40f7-4f2e-bb74-f837928f1582"}}, "__type__": "1"}, "faeaf271-1f84-416c-874e-72cfe9d8a296": {"__data__": {"text": "XOLAIR\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nChronic Idiopathic Urticaria. Member has a diagnosis of chronic \nidiopathic urticaria. Member has remained symptomatic despite at least \n2 weeks of H1 antihistamine therapy, unless contraindicated. Member \nwill continue to receive H1 antihistamine therapy while on Xolair,unless \ncontraindicated. Diagnosis of moderate or severe persistent asthma, \nFEV1, allergic sensitivity skin or blood test, baseline serium IgE. \nOmalizumab may be considered medically necessary when the following \ncriteria are met for the following indication: Moderate or Severe \npersistent asthma. The patient has a diagnosis of moderate or severe \npersistent asthma.The patient has evidence of specific allergic sensitivity \nconfirmed by positive skin test (i.e. prick/puncture test) or blood test (i.e. \nRAST) for a specific IgE or in vitro reactivity to a perennial aeroallergen. \nFor ages 12 and older,  patient must have a baseline serum IgE between \n30 IU/ml and 700 IU/ml. For ages 6 years old to less than 12 years old: \nmust have baseline serum IgE between 30 IU/ml and 1300 IU/ml.  The \npatient has inadequately controlled asthma despite the use of: Inhaled \nCorticosteroids.\nAge Restriction\nThe patient is 12 years of age or older for diagnosis of chronic idiopathic \nurticaria.  The patient is 6 years of age or older for moderate to severe \npersistent asthma.  The patient is 18 years of age or older for nasal \npolyps.\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 468 of 497\n", "doc_id": "faeaf271-1f84-416c-874e-72cfe9d8a296", "embedding": null, "doc_hash": "897139a0abad3b9528e3bc871eaa59090e8d9820346267cc9b51c143dcfcfa30", "extra_info": {"page_label": "468", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1646, "_node_type": "1"}, "relationships": {"1": "93bf7c7a-d3c9-4d3f-89dc-36e0225a6131"}}, "__type__": "1"}, "f4eee52f-55e1-41cb-8e3f-a664c9fa9b86": {"__data__": {"text": "XOLAIR\nOther Criteria\nContinuation of therapy:  Member is currently stable on Xolair therapy. \nMember will continue on asthma controller inhalers: inhaled \ncorticosteroids with or without a long-acting beta2-agonist (e.g. Flovent \nHFA/Diskus, Arnuity Ellipta, Serevent Diskus, Striverdi Respimat, Advair \nDiskus, Breo Ellipta, Symbicrt HFA, Dulera HFA, Asmanex HFA, \nAsmanex Twisthaler or available generic versions of these agents).  \nNasal Polyps - Initial Review:  The member must meet all of the following \ncriteria:  have a diagnosis of nasal polyps (e.g., Chronic Rhinosinusitis \nwith Nasal Polyposis [CRSwNP]) AND Xolair will be used in combination \nwith a daily intranasal corticosteroid spray AND is unable to achieve \nadequate control of symptoms with maximum tolerated intranasal \ncorticosteroid therapy.  Reauthorization:  The member must meet ALL of \nthe following criteria: Had a sustained improvement in symptoms (e.g., \ndecrease in nasal congestion, decrease in polyp size, improvement in \nability to smell) AND will continue intranasal corticosteroid spray therapy.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 469 of 497\n", "doc_id": "f4eee52f-55e1-41cb-8e3f-a664c9fa9b86", "embedding": null, "doc_hash": "3c701b228971c8737843f7d44b09f8625730c9837d02d8d24ba725765a1f6d1b", "extra_info": {"page_label": "469", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1157, "_node_type": "1"}, "relationships": {"1": "da28e9b1-4c67-4b7d-a3b7-02c716f15884"}}, "__type__": "1"}, "40a3aa91-c52a-4960-b069-43f68ad04b9e": {"__data__": {"text": "XOSPATA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nAcute Myeloid Leukemia. The member has a diagnosis of acute myeloid \nleukemia AND The member has relapsed or refractory disease AND The \nmember has documented FLT3 mutation positive disease AND The \nmember will be using Xospata (gilteritinib) as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 470 of 497\n", "doc_id": "40a3aa91-c52a-4960-b069-43f68ad04b9e", "embedding": null, "doc_hash": "fc6bf8509971c46cff29c30fa69704247e3cc185f4ce2c4d5d50a22a92cf7ebd", "extra_info": {"page_label": "470", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 545, "_node_type": "1"}, "relationships": {"1": "ae4a396c-fd92-497c-b2ce-50ceba4cd2ca"}}, "__type__": "1"}, "4909a2d9-84a2-45d3-a887-acba255a5c34": {"__data__": {"text": "XPOVIO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression on Xpovio \n(selinexor).\nRequired\nMedical\nInformation\nMultiple Myeloma: The member has a diagnosis of multiple myeloma \nAND The member has received at least one prior therapy AND The \nmember will be using Xpovio in combination with dexamethasone and \nbortezomib (unless documented intolerance/contraindication to \ncorticosteroid) OR The member has a diagnosis of multiple myeloma \nAND The member has received at least four prior therapies AND The \nmember's disease is refractory to at least two proteasome inhibitors, at \nleast two immunomodulatory agents and an anti-CD38 monoclonal \nantibody AND The member will be using Xpovio (selinexor) in \ncombination with dexamethasone (unless documented \nintolerance/contraindication to corticosteroid). Diffuse large B-cell \nlymphoma:  The member has a diagnosis of relapsed or refractory \ndiffuse large B-cell lymphoma (DLBCL), not otherwise specified, \nincluding DLBCL arising from follicular lymphoma AND The member has \nreceived at least two prior lines of systemic therapy AND The member \nwill be using Xpovio (selinexor) as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 471 of 497\n", "doc_id": "4909a2d9-84a2-45d3-a887-acba255a5c34", "embedding": null, "doc_hash": "9eeea49d9e91dfa2c58dbb8f63776eb66d391aa676460bab96f464b64b0fbd03", "extra_info": {"page_label": "471", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1389, "_node_type": "1"}, "relationships": {"1": "f0175172-52d1-4e1f-b9ce-3653697804d2"}}, "__type__": "1"}, "8cd09970-fb68-48cf-ab76-b3e6adbe9f0d": {"__data__": {"text": "XTANDI\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nConcomitant use with Erleada (apalutamide), abiraterone \nacetate,Provenge(sipuleucel-T),Taxotere(docetaxel)or Jevtana\n(cabazitaxel)is not recommended at this time due to lack of evidence \nsupporting safety and efficacy. Members that have experienced disease \nprogression while on Xtandi (enzalutamide).\nRequired\nMedical\nInformation\nProstate Cancer (metastatic castration-resistant). The member has \nmetastatic (stage IV) castration-resistant prostate cancer (CRPC). \nProstate Cancer (non-metastatic castration-resistant). The member has \na diagnosis of non-metastatic castration-resistant prostate cancer AND \nThe member will use Xtandi (enzalutamide) in combination with \nandrogen deprivation therapy (e.g. previous bilateral orchiectomy or \nGnRH analog).  Prostate Cancer (metastatic castration-sensitive):  the \nmember has a diagnosis of metastatic castration-sensitive prostate \ncancer AND the member will use Xtandi (enzalutamide) in combination \nwith androgen deprivation therapy (e.g. previous bilateral orchiectomy or \nGnRH analog).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 472 of 497\n", "doc_id": "8cd09970-fb68-48cf-ab76-b3e6adbe9f0d", "embedding": null, "doc_hash": "3d72f9dafcfce14970e113c9f3d1a3813a852e7078d89aaf3a8482f635957440", "extra_info": {"page_label": "472", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1306, "_node_type": "1"}, "relationships": {"1": "6fc42ca3-9179-403d-adc1-34d1a2cac95d"}}, "__type__": "1"}, "ebee5cca-c5a3-43e4-99ac-63a889a9bdd7": {"__data__": {"text": "XYREM\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nNarcolepsy with Cataplexy: The member has a diagnosis of narcolepsy \nwith cataplexy.  Reauthorization: Documentation must be provided \ndemonstrating a reduction in frequency of cataplexy attacks associated \nwith Xyrem (sodium oxybate) therapy. Narcolepsy with excessive \ndaytime sleepiness: The member has a diagnosis of narcolepsy \naccording to ICSD-3 or DSM-5 criteria AND the member has condition of \nexcessive daytime sleepiness (EDS) associated with narcolepsy as \nconfirmed by documented sleep testing (e.g. polysomnography, multiple \nsleep latency test) AND previous treatment, intolerance, or \ncontraindication to at least one CNS stimulant (e.g. methylphenidate, \namphetamine salt combination immediate release, or \ndextroamphetamine) and modafinil. Prerequisite therapy required only \nfor diagnosis of narcolepsy with excessive daytime sleepiness. \nReauthorization: Documentation must be provided demonstrating a \nreduction in symptoms of EDS associated with Xyrem (sodium oxybate) \ntherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nInitial authorization: 3 months. Reauthorization: 6 months.\nOther Criteria\nThe member will be using no more than one of the following products at \nany given time: Xyrem (sodium oxybate), Xywav (calcium magnesium, \npotassium, and sodium oxybates), Sunosi (solriamfetol), or Wakix \n(pitolisant).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 473 of 497\n", "doc_id": "ebee5cca-c5a3-43e4-99ac-63a889a9bdd7", "embedding": null, "doc_hash": "60a4cc61d1a860402afd1e11ca7b47a00a347ab9357761624ae5cbf64c739961", "extra_info": {"page_label": "473", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1547, "_node_type": "1"}, "relationships": {"1": "a28ba738-07a6-4228-a914-c5333d4b10d1"}}, "__type__": "1"}, "29c2bbb5-c96e-4856-aeae-2b3df7b557b8": {"__data__": {"text": "YERVOY\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant Zelboraf (vemurafenib), Tafinlar (dabrafenib), Cotellic \n(cobimetnib) or Mekinist (trametinib) therapy. The member has had \nprogression of disease on adjuvant therapy with Yervoy (ipilimumab).\nRequired\nMedical\nInformation\nMelanoma.The member has a diagnosis of unresectable or metastatic \nmelanoma OR Adjuvant treatment of cutaneous melanoma with \npathologic involvement of regional lymph nodes of more than 1 \nmillimeter who have undergone complete resection, including total \nlymphadenectomy. The member is naive to Yervoy (ipilimumab).The \nmember has an Eastern Cooperative Oncology Group (ECOG) \nperformance status of 0-2.Melanoma - Reauthorization Criteria \nMelanoma.The member had stable disease, partial response or \ncomplete response for greater than 3 months following the completion of \ninitial induction (completion of four cycles within a 16 week period. \nMembers who were unable to tolerate or receive the complete induction \nregimen within 16 weeks of initiation will not receive approval). AND The \nmember has progressive disease, necessitating reinduction therapy with \nYervoy (ipilimumab). AND The member has an Eastern Cooperative \nOncology Group (ECOG) performance status of 0-2.  Reauth adjuvant \ntreatment of cutaneous melanoma. The member has not had disease \nrecurrence or unacceptable toxicity with Yervoy (ipilimumab) AND The \ntotal duration of treatment is less than 3 years AND The member has an \nECOG performance status of 0-2.  Renal Cell Carcinoma. The member \nhas a diagnosis of advanced renal cell carcinoma (RCC) AND The \nmember has intermediate or poor risk disease, based on International \nMetastatic Renal Cell Carcinoma Database Consortium (IMDC) Criteria \nAND The member has predominant clear cell histology AND The \nmember will be using Yervoy (ipilimumab) in combination with Opdivo \n(nivolumab) AND The member will be using for first line therapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n4 Months Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 474 of 497\n", "doc_id": "29c2bbb5-c96e-4856-aeae-2b3df7b557b8", "embedding": null, "doc_hash": "442804c8ed22224524abadee7e197aced090ee64815dbde449601fff4241613d", "extra_info": {"page_label": "474", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2119, "_node_type": "1"}, "relationships": {"1": "a465c11b-032f-4d8a-84e6-475f5e026c12"}}, "__type__": "1"}, "3b1a94cf-f216-4965-9590-5ad7855752ca": {"__data__": {"text": "YERVOY\nOther Criteria\nMicrosatellite Instability-High (MSI-H) or Mismatch Repair Deficient \n(dMMR) Metastatic Colorectal Cancer. The member has a diagnosis of \nunresectable or metastatic colorectal cancer with documented \nmicrosatellite instability-high (MSI-H) or mismatch repair deficient \n(dMMR) AND The member will be using Yervoy (ipilimumab) in \ncombination with Opdivo (nivolumab) AND One of the following applies: \nThe member has disease that has progressed following treatment with \noxaliplatin-, irinotecan-, or fluoropyrimidine-based therapy OR The \nmember has unresectable metachronous metastases and previously \nreceived adjuvant FOLFOX (fluorouracil, leucovorin, and oxaliplatin) or \nCapeOX (capecitabine and oxaliplatin) within the past 12 months.   \nHepatocellular carcinoma: The member has a diagnosis of \nhepatocellular carcinoma AND The member has received prior treatment \nwith a first line therapy (i.e., sorafenib) AND The member will be using \nYervoy (ipilimumab) in combination with Opdivo (nivolumab).  Non-small \ncell lung cancer (NSCLC) -- First Line Therapy:  The member must have \na diagnosis of metastatic non-small cell lung cancer (NSCLC) AND one \nof the following applies:  Disease with PD-L1 expression greater than or \nequal to 1% with no EGFR or ALK genomic tumor aberrations and given \nas first line therapy AND Tumor expresses PD-L1 as determined by an \nFDA-approved test AND Will be used in combination with Opdivo \n(nivolumab) OR Disease with no EGFR or ALK genomic tumor \naberrations and given as first line therapy AND Will be used in \ncombination with Opdivo (nivolumab) AND Will be used in combination \nwith two cycles of platinum doublet chemotherapy.  Malignant pleural \nmesothelioma:  The member has a diagnosis of unresectable malignant \npleural mesothelioma AND The member will be using for first-line or \nsubsequent treatment, if not administered first-line AND Yervoy \n(ipilimumab) will be used in combination with Opdivo (nivolumab).  \nEsophageal Cancer (squamous cell carcinoma):  the member has \nunresectable advanced, recurrent, or metastatic squamous cell \ncarcinoma of the esophagus AND Yervoy will be given as first line \ntreatment in combination with Opdivo.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 475 of 497\n", "doc_id": "3b1a94cf-f216-4965-9590-5ad7855752ca", "embedding": null, "doc_hash": "98d2207458764b3143163eef478c03aeda5790cbc6ad761802694514cb4a6ee9", "extra_info": {"page_label": "475", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2292, "_node_type": "1"}, "relationships": {"1": "66bfe2ad-b7c3-4a94-b565-31f95ccda9ae"}}, "__type__": "1"}, "91bf2d06-bad1-4f73-b81f-9dd024642cb0": {"__data__": {"text": "YONDELIS\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMember experiences disease progression on Yondelis (trabectedin)\nRequired\nMedical\nInformation\nLiposarcoma/Leiomyosarcoma:The member has unresectable or \nmetastatic liposarcoma or leiomyosarcoma AND The member has \nreceived prior anthracycline (e.g., doxorubicin) containing regimen. Soft \nTissue Sarcoma. Yondelis (trabectedin) will be used as monotherapy for \npalliative treatment and one of the following applies: The member has a \ndiagnosis of unresectable or progressive retroperitoneal or \nintraabdominal soft tissue sarcoma OR the member has a diagnosis of \nangiosarcoma or rhabdomyosarcoma OR the member has a diagnosis \nstage IV soft tissue sarcoma of the extremity/superficial trunk, \nhead/neck, or recurrent disease with disseminated metastases.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nsix month duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 476 of 497\n", "doc_id": "91bf2d06-bad1-4f73-b81f-9dd024642cb0", "embedding": null, "doc_hash": "f9ad5753de66af7171a87f3839b769e5c6ab4a01a6ac2614fe929e56366777ed", "extra_info": {"page_label": "476", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1021, "_node_type": "1"}, "relationships": {"1": "4f410207-d907-4f28-b2b3-10f9973edbae"}}, "__type__": "1"}, "85a3bdf8-8eca-4217-adad-fd8b5246d572": {"__data__": {"text": "ZALTRAP\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers receiving concomitant therapy with bevacizumab product. The \nmember has experienced disease progression while on Zaltrap.\nRequired\nMedical\nInformation\nMetastatic Colorectal Cancer: The member has a diagnosis of metastatic \ncolorectal cancer AND The member is using Zaltrap in combination with \nirinotecan or FOLFIRI (leucovorin, irinotecan, 5-fluorouracil) \nchemotherapy AND At least one of the following applies: Zaltrap is being \nused as second line therapy AND The member experienced disease \nprogression or resistance with an Oxaliplatin containing regimen OR The \nmember has unresectable metachronous metastases and has received \nprevious adjuvant FOLFOX (fluorouracil, leucovorin, and oxaliplatin) or \nCapeOX(capecitabine and oxaliplatin)\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 477 of 497\n", "doc_id": "85a3bdf8-8eca-4217-adad-fd8b5246d572", "embedding": null, "doc_hash": "772d3bc56acc1f54e293cbebfaddb84002f6b02c0b0bb30a714a8a64b54ca0fb", "extra_info": {"page_label": "477", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1021, "_node_type": "1"}, "relationships": {"1": "970fdd93-4f95-465e-b78f-23f9a42f749f"}}, "__type__": "1"}, "c906778d-79fe-4013-ad07-5e1cba35663d": {"__data__": {"text": "ZARXIO\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nConcomitant use with filgrastim, biosimilar filgrastim (e.g. filgrastim-sndz \nor filgrastim-aafi), tbo-filgrastim, sargramostim (unless part of stem cell \nmobilization protocol), pegfilgrastim (within seven days of pegfilgrastim \ndose), or biosimiliar pegfilgrastim (e.g. pegfilgrastim-jmbd or \npegfilgastrim-cbqv, within seven days of pegfilgrastim dose).\nRequired\nMedical\nInformation\nNeutropenia in Myelodysplastic Syndromes. The member must have a \ndiagnosis of neutropenia associated with myelodysplastic syndrome.  \nTreatment of Febrile Neutropenia:  The member must have a diagnosis \nof febrile neutropenia AND filgrastim product must be used in adjunct \nwith appropriate antibiotics in high risk members. Febrile Neutropenia \nProphylaxis, In non-myeloid malignancies following myelosuppressive \nchemotherapy: The member must have a diagnosis of non-myeloid \nmalignancy (e.g. breast cancer, lung cancer) AND The member has \nreceived or will receive filgrastim product 24-72 hours after the \nadministration of  myelosuppressive chemotherapy AND The member \nmust also meet ONE OR MORE of the following criteria:  A risk of febrile \nneutropenia (FN) of greater than 20% based on current chemotherapy \nregimen (as listed in current ASCO and NCCN guidelines for myeloid \ngrowth factors) OR A risk of febrile neutropenia of 10-20% based on \nchemotherapy regimen and one or more of the following risk factors \napply:  Prior chemotherapy or radiation therapy, Persistent neutropenia \n(defined as neutrophil count less than 500 neutrophils/mcL or less than \n1,000 neutrophils/mcL and a predicted decline to less than or equal to \n500 neutrophils/mcL over next 48 hours), Bone marrow involvement by \ntumor, Recent surgery and/or open wounds, Liver dysfunction (bilirubin \ngreater than 2.0 mg/dL), Renal dysfunction (creatinine clearance less \nthan 50 mL/min), Age greater than 65 receiving full chemotherapy dose \nintensity OR Previous neutropenic fever complication or dose-limiting \nneutropenic event from a prior cycle of similar chemotherapy OR The \nmember is receiving a dose-dense chemotherapy regimen OR As \nsecondary prophylaxis in the curative setting to maintain dosing \nschedule and/or intensity\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n4 Months Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 478 of 497\n", "doc_id": "c906778d-79fe-4013-ad07-5e1cba35663d", "embedding": null, "doc_hash": "2f5b5ee36a9b76eda21b4e1a1305d4e633c43ce0b06922327d0cabcdd0b9f7b9", "extra_info": {"page_label": "478", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2421, "_node_type": "1"}, "relationships": {"1": "e373ec7a-cf77-4dbe-8ac0-87e1def9cb7e"}}, "__type__": "1"}, "0e5d033b-e77c-46eb-8259-31c939356e34": {"__data__": {"text": "ZARXIO\nOther Criteria\nFebrile Neutropenia Prophylaxis, in members with acute myeloid \nleukemia receiving chemotherapy:  The member must have a diagnosis \nAcute Myeloid Leukemia (AML). The member must be receiving either \ninduction chemotherapy OR consolidation Chemotherapy AND The \nmember is not administering filgrastim product earlier than 24 hours after \ncytotoxic chemotherapy or within 24 hours before chemotherapy. Febrile \nNeutropenia Prophylaxis, In non-myeloid malignancies following \nHematopoietic Stem Cell Transplant (HCST):  The member must have \nhad a Hematopoietic Stem Cell Transplant (HCST) (e.g. bone marrow \ntransplant, peripheral-blood progenitor cell (PBPC) transplant) for a non-\nmyeloid malignancy AND The member is not administering filgrastim \nproduct earlier than 24 hours after cytotoxic chemotherapy or within 24 \nhours before chemotherapy Harvesting of peripheral blood stem \ncells.The member must be scheduled for autologous peripheral-blood \nstem cell (PBSC) transplantation, storing cells for a possible future \nautologous transplant, or donating stem cells for an allogeneic or \nsyngeneic PBSC transplant. Neutropenic disorder, chronic (Severe), \nSymptomatic:  The member must have a diagnosis of congenital, cyclic, \nor idiopathic neutropenia. Neutropenia in AIDS patients. The member \nmust have a diagnosis of AIDS with neutropenia. Treatment of Aplastic \nAnemia. The member must have a diagnosis of Aplastic Anemia. \nTreatment of Agranulocytosis.The member must have a diagnosis of \ncongenital or drug induced agranulocytosis. Hematopoietic Syndrome of \nAcute radiation syndrome. The member has been acutely exposed to \nmyelosuppressive doses of radiation.\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 479 of 497\n", "doc_id": "0e5d033b-e77c-46eb-8259-31c939356e34", "embedding": null, "doc_hash": "de1ad28a33d541a01f4c0ab797f622e3edbf023ce08b52e2240a64745cd0373f", "extra_info": {"page_label": "479", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1768, "_node_type": "1"}, "relationships": {"1": "7463f9c0-325e-47b9-a5de-fc6dd92946bd"}}, "__type__": "1"}, "94b380e6-4e5b-407b-ad79-b0349e20b077": {"__data__": {"text": "ZEJULA\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers that have experienced disease progression while on or \nfollowing PARP inhibitor therapy [e.g., Rubraca (rucaparib), Lynparza \n(olaparib), Zejula (niraparib)].\nRequired\nMedical\nInformation\nEpithelial Ovarian Cancer, Fallopian Tube, or Peritoneal Cancer \nsubsequent line maintenance therapy: The member has a diagnosis of \nrecurrent epithelial ovarian cancer, fallopian tube cancer, or primary \nperitoneal cancer AND The member has been treated with at least two \nprior lines of platinum based chemotherapy AND The member is in \ncomplete or partial response to their last platinum regimen AND The \nmember will utilize Zejula (niraparib) as a monotherapy AND The \nmember has a medical reason why Lynparza (olaparib) cannot be \nstarted or continued. *Discontinue Bevacizumab product before initiating \nmaintenance therapy with Zejula. Advanced Ovarian Cancer, Fallopian \nTube, or Peritoneal Cancer First Line Maintenance Therapy: member \nhas a diagnosis of advanced epithelial ovarian, fallopian tube, or primary \nperitoneal cancer AND member is in complete response or partial \nresponse to first line treatment with platinum based chemotherapy AND \nmember will utilize Zejula (niraparib) capsules as monotherapy AND \nmember has a medical reason why Lynparza (olaparib) cannot be \nstarted or continued when member's disease is associated with \nhomologous recombination deficiency (HRD) positive status. HRD is \ndefined as defined as deleterious or suspected deleterious BRCA \nmutation or genomic instability. Homologous recombination proficient \n(HRP) does not apply to step.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 480 of 497\n", "doc_id": "94b380e6-4e5b-407b-ad79-b0349e20b077", "embedding": null, "doc_hash": "af552d9e792e4f16f2c2507ec6d7a729395a9547322ef9d23227ed80058c99a8", "extra_info": {"page_label": "480", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1836, "_node_type": "1"}, "relationships": {"1": "0c863ddf-b040-489b-907e-1b3cabea62e7"}}, "__type__": "1"}, "aacd5263-fd60-4e6b-b43d-533c753928af": {"__data__": {"text": "ZELBORAF\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nMembers on concomitant Yervoy (ipilimumab), Opdivo (nivolumab), \nKeytruda (pembrolizumab), Tafinlar (dabrafenib), Mekinist (trametinib), \nBraftovi (encorafenib), or Mektovi (binimetinib). Members that have \nexperienced disease progression while on Zelboraf (vemurafenib). \nMembers that have experienced disease progression while on prior anti-\nBRAF/MEK combination therapy [e.g. Cotellic (cobimetinib) with Zelboraf \n(vemurafenib) or Tafinlar (dabrafenib) with Mekinst (trametinib)].\nRequired\nMedical\nInformation\nMelanoma: The member has a diagnosis of Unresectable or Stage IV \nMetastatic melanoma.The member has a documented BRAF V600 \nactivating mutation.The member will be using Zelboraf (vemurafenib) as \nmonotherapy OR in combination with Cotellic (cobimetnib). Erdheim-\nChester Disease: The member has a diagnosis of Erdheim-Chester \nDisease AND The member has a documented BRAF V600 mutation \nAND The member will be using Zelboraf (vemurafenib) as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 481 of 497\n", "doc_id": "aacd5263-fd60-4e6b-b43d-533c753928af", "embedding": null, "doc_hash": "ed3c809c92ec0b5437d67743bbe39961f8d39e5967abbcb83b33a77b236b5994", "extra_info": {"page_label": "481", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1227, "_node_type": "1"}, "relationships": {"1": "134da570-79fa-4e90-8ac6-1fc22abbd5bb"}}, "__type__": "1"}, "aca4d2be-d4a3-4450-8641-6bc7353ce19a": {"__data__": {"text": "ZEPZELCA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMember experiences disease progression on Zepzelca (lurbinectedin).\nRequired\nMedical\nInformation\nSmall cell lung cancer:  The member has a diagnosis of metastatic small \ncell lung cancer AND The member had progression on or after treatment \nwith platinum-based chemotherapy AND Zepzelca (lurbinectedin) will be \nused as a single agent.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 482 of 497\n", "doc_id": "aca4d2be-d4a3-4450-8641-6bc7353ce19a", "embedding": null, "doc_hash": "36c9530a07b8c0f04eb24c245a4405cacad3552ec6acf60ba14e14dde1643297", "extra_info": {"page_label": "482", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 603, "_node_type": "1"}, "relationships": {"1": "5daeb425-4a9f-4bd8-9174-758c37177f13"}}, "__type__": "1"}, "2b0d3255-0492-41f9-8ecf-7691a3294b87": {"__data__": {"text": "ZIRABEV\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nUsed in lung cancer members that have small cell or squamous cell \ndisease, recent hemoptysis, history of bleeding, continuing \nanticoagulation, or as a single agent (unless maintenance as described \nin Coverage Determinations). Should not be initiated in members with \nrecent hemoptysis. Should not be used in members who experience a \nsevere arterial thromboembolic event. Should not be used in members \nwith gastrointestinal perforation. Bevacizumab should not be used in \nmembers with fistula formation involving internal organs. Bevacizumab \nshould not be used in members experiencing a hypertensive crisis or \nhypertensive encephalopathy. Bevacizumab should not be used for at \nleast 28 days following major surgery or until surgical incision is fully \nhealed. Bevacizumab may not be used in conjunction with Vectibix. \nBevacizumab may not be used in conjunction with Erbitux. Bevacizumab \nmay not be used in the adjuvant or neoadjuvant setting (except in \nepithelial ovarian, fallopian tube, or primary peritoneal cancer adjuvant \nsetting). Bevacizumab should not be continued or restarted after disease \nprogression with the exception of metastatic colorectal cancer.\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 483 of 497\n", "doc_id": "2b0d3255-0492-41f9-8ecf-7691a3294b87", "embedding": null, "doc_hash": "356b0f60650ce90192222fe8dabc845fdb056fa785099269e7ac1fcfc8aceb23", "extra_info": {"page_label": "483", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1298, "_node_type": "1"}, "relationships": {"1": "47277464-fb86-42b1-a160-a0cf8235ec95"}}, "__type__": "1"}, "8321c303-5b62-4904-891e-8c8c1deffedd": {"__data__": {"text": "ZIRABEV\nRequired\nMedical\nInformation\nAvastin (bevacizumab), Alymsys (bevacizumab-\nmaly) and Vegzelma (bevacizumab-adcd) oncology requests: must have \nan intolerance or contraindication with Mvasi or Zirabev. Metastatic \ncolorectal cancer: metastatic colorectal cancer AND 1 of the following \napply: using bevacizumab in combo with fluoropyrimidine (e.g., 5-\nfluorouracil or capecitabine) based chemo for 1st or 2nd-line therapy OR \nin combo with fluoropyrimidine-irinotecan or fluoropyrimidine-oxaliplatin-\nbased chemo for 2nd-line therapy in patients who have progressed on \n1st-line bevacizumab-containing regimens. Non-small cell lung cancer \n(non-squamous cell histology). NSCLC with non-squamous cell histology \nAND using bevacizumab in combo with cisplatin or carboplatin based \nregimens for unresectable, locally advanced, recurrent, or metastatic \nNSCLC AND 1 of the following apply: for 1st line therapy OR as \nsubsequent therapy immediately after 1 of the following situations:  \nEGFR mutation-positive tumors after prior therapy [if cytotoxic therapy \nnot previously given] OR ALK-positive tumors after prior therapy [if \ncytotoxic therapy not previously given] OR ROS-1 positive disease after \nprior therapy [if cytotoxic therapy not previously given] OR \nPembrolizumab (with PD-L1 expression of greater than or equal to 1%) \nadministered as 1st line therapy and EGFR, ALK, BRAF V600E, and \nROS1 negative tumors (if cytotoxic therapy not previously given) OR has \nBRAF V600E positive disease (if cytotoxic therapy not previously given) \nOR using bevacizumab as single-agent continuation maintenance \ntherapy if bevacizumab was used as 1st line treatment for recurrence or \nmetastasis OR has disease with no EGFR or ALK genomic tumor \naberrations AND bevacizumab will be given in combo with carboplatin \nand paclitaxel and Tecentriq as 1st line therapy followed by maintenance \ntherapy with combo Tecentriq and bevacizumab. Hepatocellular \ncarcinoma:  unresectable or metastatic HCC AND used will be used as \n1st line therapy in combo with Tecentriq.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 Months Duration. Ocular indications: Plan Year Duration\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 484 of 497\n", "doc_id": "8321c303-5b62-4904-891e-8c8c1deffedd", "embedding": null, "doc_hash": "17d816d449d5de47b76ee1a49469af36676f8e8da4cde83b731602d5d541f6f0", "extra_info": {"page_label": "484", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2250, "_node_type": "1"}, "relationships": {"1": "9fef27f8-1a57-4fa2-bd44-289942713981"}}, "__type__": "1"}, "c6a41617-96ed-4094-ad7e-5d3a6e9aa71a": {"__data__": {"text": "ZIRABEV\nOther Criteria\nMetastatic breast cancer (Effectiveness based on improvement in \nprogression-free survival. No data available demonstrating improvement \nin disease-related symptoms or survival with bevacizumab). Member has \nmetastatic HER-2 negative breast cancer AND is using bevacizumab in \ncombo with paclitaxel. Recurrent Ovarian Cancer. Bevacizumab is being \nused to treat recurrent or persistent ovarian cancer for 1 of the following \nsituations: in combo with liposomal doxorubicin or weekly paclitaxel or \ntopotecan for platinum resistant disease or as monotherapy or in combo \nwith carboplatin and gemcitabine for platinum sensitive disease. Stage \nIV/Metastatic (Unresectable) RCC. Member has RCC and is using \nbevacizumab to treat stage IV unresectable kidney cancer in combo with \ninterferon alpha OR is using bevacizumab as systemic therapy for non-\nclear cell histology. Recurrent Primary CNS Tumor (including \nGlioblastoma multiforme). Diagnosis of progressive or recurrent \nglioblastoma or anaplastic glioma AND Bevacizumab is being used as a \nsingle agent or in combo with irinotecan, carmustine, lomustine or \ntemozolomide. Member does not have a CNS hemorrhage. Soft Tissue \nSarcoma. Diagnosis of angiosarcoma and bevacizumab is being used as \na single agent OR member has a diagnosis of solitary fibrous tumor and \nhemangiopericytoma and bevacizumab is being used in combo with \ntemozolomide. Macular Retinal Edema. Avastin is being used to treat \ncentral or branch retinal vein occlusion with macular retinal edema. \nCervical Cancer: member has recurrent, or metastatic cervical cancer \nAND Bevacizumab will be used in combo with paclitaxel and cisplatin or \ncarboplatin and paclitaxel or paclitaxel and topotecan as first line \ntherapy. Endometrial Cancer: progressive endometrial cancer AND \nBevacizumab will be used as a single-agent.  Malignant Pleural \nMesothelioma. Diagnosis of unresectable malignant pleural \nmesothelioma and bevacizumab will be used in combo with cisplatin and \npemetrexed followed by bevacizumab monotherapy for maintenance \ntherapy (for responders). Epithelial ovarian, fallopian tube, or primary \nperitoneal cancer:  Diagnosis of epithelial ovarian, fallopian tube or \nprimary peritoneal cancer AND has Stage III or IV disease AND \nbevacizumab is initially being given in combo with carboplatin and \npaclitaxel after initial surgical resection followed by bevacizumab \nmonotherapy OR advanced epithelial ovarian, fallopian tube or primary \nperitoneal cancer AND disease is associated with homologous \nrecombination deficiency (HRD) positive status defined by either: a \ndeleterious or suspected deleterious BRCA mutation OR genomic \ninstability as defined by FDA approved test AND Member is in complete \nresponse or partial response to 1st line treatment with platinum-based \nchemo AND Bevacizumab is given in combo with Lynparza. Age Related \nMacular Degeneration (Avastin requests only). Diabetic Macular Edema \n(Avastin requests only).\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 485 of 497\n", "doc_id": "c6a41617-96ed-4094-ad7e-5d3a6e9aa71a", "embedding": null, "doc_hash": "3db2cf027c722413b3200f2964d6858cf1a5b85566fbc5a0914bc92fcece5af5", "extra_info": {"page_label": "485", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 3070, "_node_type": "1"}, "relationships": {"1": "95cf5097-407a-4607-96d5-e471e34174fb"}}, "__type__": "1"}, "4c2aaba9-6fe7-4ead-9fd8-ace3849c66ba": {"__data__": {"text": "ZOKINVY\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nProgeroid Laminopathies:  Member must meet ALL of the following \ncriteria: Diagnosis of one of the following: Hutchinson-Gilford Progeria \nsyndrome OR Progeroid Laminopathies with either Heterozygous LMNA \nmutation with progerin-like protein accumulation OR Homozygous or \nCompound Heterozygous ZMPTSTE24 mutations. AND Body Surface \nArea of 0.39 meters squared or greater.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 486 of 497\n", "doc_id": "4c2aaba9-6fe7-4ead-9fd8-ace3849c66ba", "embedding": null, "doc_hash": "157bbb6080c315366196f1a4da4bdc4196146f6a83016e288dd29afcf309ce14", "extra_info": {"page_label": "486", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 673, "_node_type": "1"}, "relationships": {"1": "fb4b34d3-279e-4b6a-916e-e2c1ae1676c9"}}, "__type__": "1"}, "1581619a-81ea-4812-9521-8c2cc3bd3a73": {"__data__": {"text": "ZOLADEX\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nZoladex should not be continued or restarted after malignant disease \nprogression(Exception is Prostate Cancer). Concomitant use with other \nLHRH agents. Abnormal vaginal bleeding of unknown etiology.\nRequired\nMedical\nInformation\nProstate Cancer. The patient has a diagnosis of advanced prostate \ncancer or has a high risk of disease recurrence. Breast Cancer. The \npatient must be pre- or perimenopausal. The patient must have a \ndiagnosis of hormone receptor (ER and/or PR +) positive breast cancer. \nEndometriosis. The patient must have a diagnosis of endometriosis. The \npatient has had an inadequate pain control response or intolerance to: \nDanazol,Combination Oral Contraceptives, Progesterone Only \nProducts.Endometrial Thinning. The patient is scheduled for endometrial \nablation.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n2 months for endometrial hyperplasia\nOther Criteria\nApproval Durations. Advanced Prostate Cancer or Invasive Breast \nCancer is 12 months. Endometriosis is six months. Endometrial \nHyperplasia is two months\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 487 of 497\n", "doc_id": "1581619a-81ea-4812-9521-8c2cc3bd3a73", "embedding": null, "doc_hash": "6bc151ca046ad8ccafd16855f09b6b46255f715f8cb856a7688e516a351b8979", "extra_info": {"page_label": "487", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1226, "_node_type": "1"}, "relationships": {"1": "a61514eb-9daf-49b6-90fb-58e4585e5e36"}}, "__type__": "1"}, "3343a8b4-0b58-4781-a514-278fdee4890a": {"__data__": {"text": "zoledronic acid-mannitol-water\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nSevere renal impairment (creatinine clearance less than 35 mL/min). \nEvidence of acute renal failure.Patients with Hypocalcemia.\nRequired\nMedical\nInformation\nOsteoporosis:  The member has a diagnosis of osteoporosis. Has new \nfractures or significant loss of bone mineral density despite previous \ntreatment, contraindication, or intolerance with an oral OR IV \nbisphosphonate (ALENDRONATE, IBANDRONATE, PAMIDRONATE). \nOsteoporosis Prophylaxis in postmenopausal members: The member is \npostmenopausal. Has new fractures or significant loss of bone mineral \ndensity despite previous treatment, contraindication, or intolerance with \nan oral OR IV bisphosphonate (ALENDRONATE, IBANDRONATE, \nPAMIDRONATE). Glucocorticoid induced Osteoporosis in men and \nwomen taking systemic glucocorticoids: Diagnosis of glucocorticoid \ninduced osteoporosis or is either initiating or continuing systemic \nglucocorticoids with a daily dosage equivalent of 7.5 mg or greater of \nprednisone and is expected to remain on glucocorticoids for at least 12 \nmonths AND has new fractures or significant loss of bone mineral \ndensity despite previous treatment, contraindication, or intolerance with \nan oral OR IV bisphosphonate (ALENDRONATE, IBANDRONATE, \nPAMIDRONATE). Paget\n\u2019\ns Disease: Diagnosis of Paget\n\u2019\ns disease. The \nmember has continued elevation(s) in serum alkaline phosphatase \n(SAP) of two times or higher than the upper limit of normal despite \nprevious treatment, contraindication, or intolerance with an oral OR IV \nbisphosphonate (ALENDRONATE, PAMIDRONATE). And the member: \nIs symptomatic OR is at risk for complications from their disease, to \ninduce remission, or to normalize serum alkaline phosphatase. Brand \nReclast request only: Members must have previous treatment, \ncontraindication, or intolerance to generic Zoledronic acid (generic \nReclast).\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 488 of 497\n", "doc_id": "3343a8b4-0b58-4781-a514-278fdee4890a", "embedding": null, "doc_hash": "915138058ae45c5744b2a84f257a09ffd3206bc3a7a9685acbcd152d0dc1cb4c", "extra_info": {"page_label": "488", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2136, "_node_type": "1"}, "relationships": {"1": "75f9b52e-83bb-4c03-a327-a65faf58304b"}}, "__type__": "1"}, "c8057314-74ba-4c0c-8007-8412e5aaef37": {"__data__": {"text": "ZOLINZA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMembers that have experienced disease progression while on Zolinza \n(vorinostat).\nRequired\nMedical\nInformation\nCutaneous T-Cell Lymphoma (CTCL).The member has a diagnosis of \nprogressive, persistent, or recurrent disease or The member hwill be \nusing Zolinza as primary treatment or adjuvant therapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 489 of 497\n", "doc_id": "c8057314-74ba-4c0c-8007-8412e5aaef37", "embedding": null, "doc_hash": "7bd07f1086ecf855592d70eb751e695882d8fa0610712eeb7e1c2e441f76dae6", "extra_info": {"page_label": "489", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 568, "_node_type": "1"}, "relationships": {"1": "4335e411-a543-41c2-bf42-364a8c482cf8"}}, "__type__": "1"}, "9ad23b6a-90ed-485f-b1d9-a9c0a1857919": {"__data__": {"text": "ZONISADE\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nAllergy or hypersensitivity to sulfonamides.\nRequired\nMedical\nInformation\nPartial-onset Seizures:  member must have a diagnosis of partial-onset \nseizures AND will be used in combination with at least one other \nmedication that treats partial-onset seizures AND member has had prior \ntherapy with or cannot use zonisamide capsules AND member has had \nprior therapy with at least one of the following:  levetiracetam, \ntopiramate, carbamazepine, gabapentin, divalproex, or lamotrigine.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 490 of 497\n", "doc_id": "9ad23b6a-90ed-485f-b1d9-a9c0a1857919", "embedding": null, "doc_hash": "fc64e9ed99b30d56c13d796bcef96b7a2e7dd27d19649fe87713c2f05bc6b099", "extra_info": {"page_label": "490", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 744, "_node_type": "1"}, "relationships": {"1": "d815c595-b5d1-4918-94da-e8f92bf2d95b"}}, "__type__": "1"}, "01cf9e2a-9851-4eb6-bc8c-21ad39d03540": {"__data__": {"text": "ZTALMY\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nSeizures associated with Cyclin-dependent Kinase-Like 5 (CDKL5) \nDeficiency Disorder (CDD):  the member has a diagnosis of cyclin-\ndependent kinase-like 5 CDKL5) deficiency disorder (CDD) AND the \nmember continues to experience seizures while on current therapy AND \nthe member has previous treatment, contraindication, or intolerance to at \nleast one broad-spectrum antiepileptic medication.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 491 of 497\n", "doc_id": "01cf9e2a-9851-4eb6-bc8c-21ad39d03540", "embedding": null, "doc_hash": "68ac1b36385193eed3f8bb9f999a78ebce82e2fb79ff8b5949993a9319a600c6", "extra_info": {"page_label": "491", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 679, "_node_type": "1"}, "relationships": {"1": "31ba72e0-0cb9-45fb-bdf8-37d3661d7afe"}}, "__type__": "1"}, "128330ab-6690-4d66-a373-a8d07ff72d5e": {"__data__": {"text": "ZYDELIG\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nThe member has experienced disease progression while on or following \na PI3K inhibitor (e.g. idelalisib, copanlisib).\nRequired\nMedical\nInformation\nChronic Lymphocytic Leukemia (CLL): The member must have a \ndiagnosis of relapsed OR refractory chronic lymphocytic leukemia (CLL).\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan Year Duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 492 of 497\n", "doc_id": "128330ab-6690-4d66-a373-a8d07ff72d5e", "embedding": null, "doc_hash": "c052ba1f16504a41f35822ee942fed2c232233710406bd62188b26ffb3f69e96", "extra_info": {"page_label": "492", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 537, "_node_type": "1"}, "relationships": {"1": "9e1c853b-10c6-4a43-892a-404777e6f766"}}, "__type__": "1"}, "edaf5f55-2173-4996-9c3f-63554ea61be5": {"__data__": {"text": "ZYKADIA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nNA\nRequired\nMedical\nInformation\nNon-small Cell Lung Cancer (NSCLC): The member has a diagnosis of \nmetastatic and documented anaplastic lymphoma kinase (ALK)-positive \nnon-small cell lung cancer (NSCLC) AND the member has a medical \nreason as to why Alecensa (alectinib) OR Alunbrig (brigatinib)  cannot be \nstarted or continued AND  member will be using Zykadia (ceritinib) as \nmonotherapy.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\n6 months duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 493 of 497\n", "doc_id": "edaf5f55-2173-4996-9c3f-63554ea61be5", "embedding": null, "doc_hash": "d44497bcda5f16d86836ca65959df35bdd9692b8babd4287cc1ffd93dca7c92c", "extra_info": {"page_label": "493", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 658, "_node_type": "1"}, "relationships": {"1": "6654c66c-1993-47ff-9a43-d03f063dd893"}}, "__type__": "1"}, "7aa8349e-2408-4801-a065-aa726eac7eb1": {"__data__": {"text": "ZYNLONTA\nPA Criteria\nCriteria Details\nOff-Label Uses\nNA\nExclusion\nCriteria\nMember experienced disease progression on Zynlonta (loncastuximab \ntesirine-Ipyl).\nRequired\nMedical\nInformation\nB-cell Lymphoma:  The member has a diagnosis of one of the following: \ndiffuse large B-cell lymphoma (DLBCL) otherwise not specified, DLBCL \narising from a low grade lymphoma (e.g. follicular lymphoma) OR a \ndiagnosis of high-grade B-cell lymphoma (HGBL) not otherwise specified \nor with translocations AND The member has relapsed or refractory \ndisease AND The member has had two or more lines of systemic therapy \nAND The member will be using Zynlonta as a single agent.\nAge Restriction\nNA\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nPlan year duration\nOther Criteria\nNA\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 494 of 497\n", "doc_id": "7aa8349e-2408-4801-a065-aa726eac7eb1", "embedding": null, "doc_hash": "180a6426cdad69fc04af4ed92fb40efb3ea6ffb99616ca1ee6e3674ce0170e7c", "extra_info": {"page_label": "494", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 853, "_node_type": "1"}, "relationships": {"1": "85d680ec-46d5-4908-bee2-5b642800c54a"}}, "__type__": "1"}, "59bacfc6-e309-4f69-b0bc-339d51a689c7": {"__data__": {"text": "ZYNYZ\nPA Criteria\nCriteria Details\nOff-Label Uses\nExclusion\nCriteria\nRequired\nMedical\nInformation\nMerkel Cell Carcinoma: The member has a diagnosis of recurrent locally \nadvanced or metastatic merkel cell carcinoma AND Zynyz (retifanlimab-\ndlwr) will be used as monotherapy.\nAge Restriction\nPrescriber\nRestriction\nLicensed Practitioner\nCoverage\nDuration\nSix months duration\nOther Criteria\nPart B \nPrerequisite\n0\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 495 of 497\n", "doc_id": "59bacfc6-e309-4f69-b0bc-339d51a689c7", "embedding": null, "doc_hash": "a4e50d66415fd12403d7817d796efd6fbd0369ca80c2e90c261402f94fa33250", "extra_info": {"page_label": "495", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 463, "_node_type": "1"}, "relationships": {"1": "01591232-3e55-487b-819e-5433b570998f"}}, "__type__": "1"}, "1b532328-bf14-4e7b-a869-c88f54e20daa": {"__data__": {"text": "The following drugs are subject to a Medicare Part B or D authorization depending upon the \ncircumstances. Information may need to be submitted describing the use and setting of the \ndrug to make the determination.\nPART B VERSUS PART D\nProducts Affected\n\u2022  \nAkynzeo (netupitant) 300 mg-0.5 mg capsule\n\u2022  \nAnzemet 50 MG; tablet\n\u2022  \naprepitant 125 mg (1)-80 mg (2) capsules in \na dose pack\n\u2022  \naprepitant 125 MG; 125 mg (1)- 80 MG (2); \n40 MG; 80 MG; capsule\n\u2022  \nAstagraf XL 0.5 MG; 1 MG; 5 MG; \ncapsule,extended release\n\u2022  \nAzasan 100 MG; 75 MG; tablet\n\u2022  \nazathioprine 100 MG; 50 MG; 75 MG; tablet\n\u2022  \nCellCept 200 MG/ML; 250 MG; 500 MG; \ncapsule\n\u2022  \nCellCept 200 MG/ML; 250 MG; 500 MG; oral \nsuspension\n\u2022  \nCellCept 200 MG/ML; 250 MG; 500 MG; \ntablet\n\u2022  \nCellCept Intravenous 500 MG; intravenous \nsolution\n\u2022  \nchlorpromazine 10 MG; 25 MG; tablet\n\u2022  \nCompazine 10 MG; 5 MG; tablet\n\u2022  \ncyclosporine 100 MG; 25 MG; capsule\n\u2022  \ncyclosporine modified 100 MG; 100 MG/ML; \n25 MG; 50 MG; capsule\n\u2022  \ncyclosporine modified 100 MG; 100 MG/ML; \n25 MG; 50 MG; oral solution\n\u2022  \ndronabinol 10 MG; 2.5 MG; 5 MG; capsule\n\u2022  \nEmend 125 mg (1)- 80 MG (2); 125 mg (25 \nmg/ ML FINAL CONC.); 80 MG; capsule\n\u2022  \nEmend 125 mg (1)-80 mg (2) capsules in a \ndose pack\n\u2022  \nEmend 125 mg (25 mg/mL final conc.) oral \nsuspension\n\u2022  \nEnvarsus XR 0.75 MG; 1 MG; 4 MG; \ntablet,extended release\n\u2022  \neverolimus (immunosuppressive) 0.25 MG; \n0.5 MG; 0.75 MG; 1 MG; tablet\n\u2022  \nGengraf 100 MG; 100 MG/ML; 25 MG; \ncapsule\n\u2022  \nGengraf 100 MG; 100 MG/ML; 25 MG; oral \nsolution\n\u2022  \ngranisetron HCl 1 MG; tablet\n\u2022  \nImuran 50 MG; tablet\n\u2022  \nMarinol 10 MG; 2.5 MG; 5 MG; capsule\n\u2022  \nMedrol 16 MG; 2 MG; 32 MG; 4 MG; 8 MG; \ntablet\n\u2022  \nmethotrexate sodium 2.5 MG; tablet\n\u2022  \nmethylprednisolone 16 MG; 32 MG; 4 MG; 8 \nMG; tablet\n\u2022  \nMillipred 5 MG; tablet\n\u2022  \nmycophenolate 500 MG; intravenous \nsolution\n\u2022  \nmycophenolate mofetil 200 MG/ML; 250 \nMG; 500 MG; capsule\n\u2022  \nmycophenolate mofetil 200 MG/ML; 250 \nMG; 500 MG; oral suspension\n\u2022  \nmycophenolate mofetil 200 MG/ML; 250 \nMG; 500 MG; tablet\n\u2022  \nmycophenolate sodium 180 MG; 360 MG; \ntablet,delayed release\n\u2022  \nMyfortic 180 MG; 360 MG; tablet,delayed \nrelease\n\u2022  \nNeoral 100 MG; 100 MG/ML; 25 MG; \ncapsule\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 496 of 497\n", "doc_id": "1b532328-bf14-4e7b-a869-c88f54e20daa", "embedding": null, "doc_hash": "954f5e179191ede242cc6fc3fd5a97e982bd6c939806918f275ec4923a18afd6", "extra_info": {"page_label": "496", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 2267, "_node_type": "1"}, "relationships": {"1": "7c461718-0a2c-4d28-a6c2-54cddbbe36fa"}}, "__type__": "1"}, "1eb7c451-a607-427b-bc2c-235b4364d433": {"__data__": {"text": "\u2022  \nNeoral 100 MG; 100 MG/ML; 25 MG; oral \nsolution\n\u2022  \nondansetron 4 MG; 8 MG; disintegrating \ntablet\n\u2022  \nondansetron HCl 4 MG; 4 MG/5 ML; 8 MG; \noral solution\n\u2022  \nondansetron HCl 4 MG; 4 MG/5 ML; 8 MG; \ntablet\n\u2022  \nprednisolone 5 MG; tablet\n\u2022  \nprednisone 1 MG; 10 MG; 2.5 MG; 20 MG; 5 \nMG; 5 MG/5 ML; 50 MG; oral solution\n\u2022  \nprednisone 1 MG; 10 MG; 2.5 MG; 20 MG; 5 \nMG; 5 MG/5 ML; 50 MG; tablet\n\u2022  \nPrednisone Intensol 5 MG/ML; oral \nconcentrate\n\u2022  \nprochlorperazine maleate 10 MG; 5 MG; \ntablet\n\u2022  \nPrograf 0.2 MG; 0.5 MG; 1 MG; 5 MG; \ncapsule\n\u2022  \nPrograf 0.2 MG; 0.5 MG; 1 MG; 5 MG; oral \ngranules in packet\n\u2022  \nRapamune 0.5 MG; 1 MG; 1 MG/ML; 2 MG; \noral solution\n\u2022  \nRapamune 0.5 MG; 1 MG; 1 MG/ML; 2 MG; \ntablet\n\u2022  \nRayos 1 MG; 2 MG; 5 MG; tablet,delayed \nrelease\n\u2022  \nSandimmune 100 MG; 100 MG/ML; 25 MG; \ncapsule\n\u2022  \nSandimmune 100 MG; 100 MG/ML; 25 MG; \noral solution\n\u2022  \nsirolimus 0.5 MG; 1 MG; 1 MG/ML; 2 MG; \noral solution\n\u2022  \nsirolimus 0.5 MG; 1 MG; 1 MG/ML; 2 MG; \ntablet\n\u2022  \nSyndros 5 MG/ML; oral solution\n\u2022  \ntacrolimus 0.5 MG; 1 MG; 5 MG; capsule, \nimmediate-release\n\u2022  \nTigan 300 MG; capsule\n\u2022  \nTrexall 10 MG; 15 MG; 5 MG; 7.5 MG; tablet\n\u2022  \ntrimethobenzamide 300 MG; capsule\n\u2022  \nVarubi 90 MG; tablet\n\u2022  \nXatmep 2.5 MG/ML; oral solution\n\u2022  \nZofran 4 MG; tablet\n\u2022  \nZortress 0.25 MG; 0.5 MG; 0.75 MG; 1 MG; \ntablet\n\u2022  \nZuplenz 4 MG; 8 MG; oral soluble film\nY0040_ GHHJPMNES_C\nUpdated 06/2023\nPage 497 of 497\n", "doc_id": "1eb7c451-a607-427b-bc2c-235b4364d433", "embedding": null, "doc_hash": "7055025b7e69fa2703a7c9a024886571b141e41f54f30815848119b35970aaf9", "extra_info": {"page_label": "497", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1428, "_node_type": "1"}, "relationships": {"1": "a6176669-729e-43df-9c4d-3e9938a9d8b2"}}, "__type__": "1"}, "a2ebfc14-7106-4532-9788-60e121b83c4c": {"__data__": {"text": "  GHHLNNXEN 0522Important _____________________________________________________________________\nAt Humana, it is important you are treated fairly. \nHumana Inc. and its subsidiaries do not discriminate or exclude people because of their race, \ncolor, national origin, age, disability, sex, sexual orientation, gender, gender identity, ancestry, \nethnicity, marital status, religion, or language. Discrimination is against the law. Humana and \nits subsidiaries comply with applicable federal civil rights laws. If you believe that you have \nbeen discriminated against by Humana or its subsidiaries, there are ways to get help. \n\u2022   You may file a complaint, also known as a grievance:  \nDiscrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618  \nIf you need help filing a grievance, call 1-877-320-1235  or if you use a TTY, call 711.\n\u2022   You can also file a civil rights complaint with the U.S. Department of Health and Human \nServices , Office for Civil Rights electronically through their Complaint Portal, available at \nhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf , or at U.S. Department of Health and Human \nServices , 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201, \n1-800-368-1019 , 800-537-7697 (TDD) . Complaint forms are available at  \nhttps://www.hhs.gov/ocr/office/file/index.html .\n\u2022   California residents:  You may also call the California Department of Insurance toll-free \nhotline number: 1-800-927-HELP (4357) , to file a grievance.\nAuxiliary aids and services, free of charge, are available to you.  \n1-877-320-1235 (TTY: 711)\nHumana provides free auxiliary aids and services, such as qualified sign language  \ninterpreters, video remote interpretation, and written information in other formats  \nto people with disabilities when such auxiliary aids and services are necessary to  \nensure an equal opportunity to participate. ", "doc_id": "a2ebfc14-7106-4532-9788-60e121b83c4c", "embedding": null, "doc_hash": "d6587ca452c15ee5e10e60aa96435645dfc9114cda7141f58715264c3d14528a", "extra_info": {"page_label": "498", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1885, "_node_type": "1"}, "relationships": {"1": "0766d2d3-fc00-416f-bd84-d51be4430048"}}, "__type__": "1"}, "1c956516-bf64-49e7-98ea-20ab4dd87258": {"__data__": {"text": "  GHHLNNXEN 0522Multi-Language Insert  \nMulti-language Interpreter Services\nEnglish: We have free interpreter services to answer any questions you may have \nabout our health or drug plan. To get an interpreter, just call us at 1-877-320-1235 \n(TTY: 711). Someone who speaks English can help you. This is a free service.\nSpanish:  Tenemos servicios de int\u00e9rprete sin costo alguno para responder \ncualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. \nPara hablar con un int\u00e9rprete, por favor llame al 1-877-320-1235 (TTY: 711). Alguien \nque\u00a0hable espa\u00f1ol le podr\u00e1 ayudar. Este es un servicio gratuito.\nChinese Mandarin:\u202f \u6211\u4eec\u63d0\u4f9b\u514d\u8d39\u7684\u7ffb\u8bd1\u670d\u52a1\uff0c\u5e2e\u52a9\u60a8\u89e3\u7b54\u5173\u4e8e\u5065\u5eb7\u6216\u836f\u7269\u4fdd\u9669\u7684\u4efb\u4f55\u7591\u95ee\u3002\u5982\u679c\n\u60a8\u9700\u8981\u6b64\u7ffb\u8bd1\u670d\u52a1\uff0c\u8bf7\u81f4\u7535  1-877-320-1235 (TTY: 711) \u3002\u6211\u4eec\u7684\u4e2d\u6587\u5de5\u4f5c\u4eba\u5458\u5f88\u4e50\u610f\u5e2e\u52a9\u60a8\u3002\u8fd9\u662f\n\u4e00\u9879\u514d\u8d39\u670d\u52a1\u3002\nChinese Cantonese: \u202f\u60a8\u5c0d\u6211\u5011\u7684\u5065\u5eb7\u6216\u85e5\u7269\u4fdd\u96aa\u53ef\u80fd\u5b58\u6709\u7591\u554f \uff0c\u70ba\u6b64\u6211\u5011\u63d0\u4f9b\u514d\u8cbb\u7684\u7ffb\u8b6f\u670d\u52d9 \u3002  \n\u5982\u9700\u7ffb\u8b6f\u670d\u52d9 \uff0c\u8acb\u81f4\u96fb  1-877-320-1235 (TTY: 711) \u3002\u6211\u5011\u8b1b\u4e2d\u6587\u7684\u4eba\u54e1\u5c07\u6a02\u610f\u70ba\u60a8\u63d0\u4f9b\u5e6b\u52a9 \u3002\u9019\u662f\n\u4e00\u9805 \u514d \u8cbb \u670d \u52d9\u3002\nTagalog:  Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot \nang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan \no panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa \n1-877-320-1235 (TTY: 711). Maaari kayong tulungan ng isang nakakapagsalita \nng\u00a0Tagalog. Ito ay libreng serbisyo.\nFrench:  Nous proposons des services gratuits d\u2019interpr\u00e9tation pour r\u00e9pondre \u00e0 \ntoutes vos questions relatives \u00e0 notre r\u00e9gime de sant\u00e9 ou d\u2019assurance-m\u00e9dicaments. \nPour acc\u00e9der au service d\u2019interpr\u00e9tation, il vous suffit de nous appeler au \n1-877-320-1235 (TTY: 711). Un interlocuteur parlant Fran\u00e7ais pourra vous aider. \nCe\u00a0service est gratuit.\nVietnamese:  Ch\u00fang t\u00f4i c\u00f3 d\u1ecbch v\u1ee5 th\u00f4ng d\u1ecbch mi\u1ec5n ph\u00ed \u0111\u1ec3 tr\u1ea3 l\u1eddi c\u00e1c c\u00e2u h\u1ecfi v\u1ec1 \nch\u01b0\u01a1ng s\u1ee9c kh\u1ecfe v\u00e0 ch\u01b0\u01a1ng tr\u00ecnh thu\u1ed1c men. N\u1ebfu qu\u00ed v\u1ecb c\u1ea7n th\u00f4ng d\u1ecbch vi\u00ean xin \ng\u1ecdi\u00a01-877-320-1235 (TTY: 711) s\u1ebd c\u00f3 nh\u00e2n", "doc_id": "1c956516-bf64-49e7-98ea-20ab4dd87258", "embedding": null, "doc_hash": "b326b768afc66a6cf9ebc571bd4eb8e3afecb93225c6ae338033458bc2507c38", "extra_info": {"page_label": "499", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 1761, "_node_type": "1"}, "relationships": {"1": "66cd6f43-e0e2-4e31-91a3-6af0685ad24e", "3": "5ccac1c4-d6f1-4c65-9d4a-bc837cd8a778"}}, "__type__": "1"}, "5ccac1c4-d6f1-4c65-9d4a-bc837cd8a778": {"__data__": {"text": "(TTY: 711) s\u1ebd c\u00f3 nh\u00e2n vi\u00ean n\u00f3i ti\u1ebfng Vi\u1ec7t gi\u00fap \u0111\u1ee1 qu\u00ed v\u1ecb. \u0110\u00e2y l\u00e0 \nd\u1ecbch v\u1ee5 mi\u1ec5n ph\u00ed.\nGerman:  Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu \nunserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie \nunter 1-877-320-1235 (TTY: 711). Man wird Ihnen dort auf Deutsch weiterhelfen. \nDieser Service ist kostenlos.\nKorean:  \ub2f9\uc0ac\ub294 \uc758\ub8cc \ubcf4\ud5d8 \ub610\ub294 \uc57d\ud488 \ubcf4\ud5d8\uc5d0 \uad00\ud55c \uc9c8\ubb38\uc5d0 \ub2f5\ud574 \ub4dc\ub9ac\uace0\uc790 \ubb34\ub8cc \ud1b5\uc5ed \uc11c\ube44\uc2a4\ub97c \uc81c\uacf5\ud558\uace0 \n\uc788\uc2b5\ub2c8\ub2e4. \ud1b5\uc5ed \uc11c\ube44\uc2a4\ub97c \uc774\uc6a9\ud558\ub824\uba74 \uc804\ud654  1-877-320-1235 (TTY: 711) \ubc88\uc73c\ub85c \ubb38\uc758\ud574 \uc8fc\uc2ed\uc2dc\uc624 . \n\ud55c\uad6d\uc5b4\ub97c \ud558\ub294 \ub2f4\ub2f9\uc790\uac00 \ub3c4\uc640 \ub4dc\ub9b4 \uac83\uc785\ub2c8\ub2e4. \uc774 \uc11c\ube44\uc2a4\ub294 \ubb34\ub8cc\ub85c \uc6b4\uc601\ub429\ub2c8\ub2e4.  ", "doc_id": "5ccac1c4-d6f1-4c65-9d4a-bc837cd8a778", "embedding": null, "doc_hash": "a92e54fbdccb9e5369216707c5376e21d1924ff1757c58f5964457db35fcc1f0", "extra_info": {"page_label": "499", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 1740, "end": 2257, "_node_type": "1"}, "relationships": {"1": "66cd6f43-e0e2-4e31-91a3-6af0685ad24e", "2": "1c956516-bf64-49e7-98ea-20ab4dd87258"}}, "__type__": "1"}, "52ef6ef9-8905-4547-a1e1-30e04b8a36d1": {"__data__": {"text": "  GHHLNNXEN 0522Russian:  \u0415\u0441\u043b\u0438 \u0443 \u0432\u0430\u0441 \u0432\u043e\u0437\u043d\u0438\u043a\u043d\u0443\u0442 \u0432\u043e\u043f\u0440\u043e\u0441\u044b \u043e\u0442\u043d\u043e\u0441\u0438\u0442\u0435\u043b\u044c\u043d\u043e \u0441\u0442\u0440\u0430\u0445\u043e\u0432\u043e\u0433\u043e \u0438\u043b\u0438 \n\u043c\u0435\u0434\u0438\u043a\u0430\u043c\u0435\u043d\u0442\u043d\u043e\u0433\u043e \u043f\u043b\u0430\u043d\u0430, \u0432\u044b \u043c\u043e\u0436\u0435\u0442\u0435 \u0432\u043e\u0441\u043f\u043e\u043b\u044c\u0437\u043e\u0432\u0430\u0442\u044c\u0441\u044f \u043d\u0430\u0448\u0438\u043c\u0438 \u0431\u0435\u0441\u043f\u043b\u0430\u0442\u043d\u044b\u043c\u0438 \n\u0443\u0441\u043b\u0443\u0433\u0430\u043c\u0438 \u043f\u0435\u0440\u0435\u0432\u043e\u0434\u0447\u0438\u043a\u043e\u0432. \u0427\u0442\u043e\u0431\u044b \u0432\u043e\u0441\u043f\u043e\u043b\u044c\u0437\u043e\u0432\u0430\u0442\u044c\u0441\u044f \u0443\u0441\u043b\u0443\u0433\u0430\u043c\u0438 \u043f\u0435\u0440\u0435\u0432\u043e\u0434\u0447\u0438\u043a\u0430, \n\u043f\u043e\u0437\u0432\u043e\u043d\u0438\u0442\u0435 \u043d\u0430\u043c \u043f\u043e \u0442\u0435\u043b\u0435\u0444\u043e\u043d\u0443 1-877-320-1235 (TTY: 711). \u0412\u0430\u043c \u043e\u043a\u0430\u0436\u0435\u0442 \u043f\u043e\u043c\u043e\u0449\u044c \n\u0441\u043e\u0442\u0440\u0443\u0434\u043d\u0438\u043a, \u043a\u043e\u0442\u043e\u0440\u044b\u0439 \u0433\u043e\u0432\u043e\u0440\u0438\u0442 \u043f\u043e-p\u0443\u0441\u0441\u043a\u0438. \u0414\u0430\u043d\u043d\u0430\u044f\u00a0\u0443\u0441\u043b\u0443\u0433\u0430 \u0431\u0435\u0441\u043f\u043b\u0430\u0442\u043d\u0430\u044f.\n\u0625\u0646\u0646\u0627 \u0646\u0642\u062f\u0645 \u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0645\u062a\u0631\u062c\u0645 \u0627\u0644\u0641\u0648\u0631\u064a \u0627\u0644\u0645\u062c\u0627\u0646\u064a\u0629 \u0644\u0644\u0625\u062c\u0627\u0628\u0629 \u0639\u0646 \u0623\u064a \u0623\u0633\u0626\u0644\u0629 \u062a\u062a\u0639\u0644\u0642 \u0628\u0627\u0644\u0635\u062d\u0629  :Arabic\n\u0623\u0648 \u062c\u062f\u0648\u0644 \u0627\u0644\u0623\u062f\u0648\u064a\u0629 \u0644\u062f\u064a\u0646\u0627. \u0644\u0644\u062d\u0635\u0648\u0644 \u0639\u0644\u0649 \u0645\u062a\u0631\u062c\u0645 \u0641\u0648\u0631\u064a\u060c \u0644\u064a\u0633 \u0639\u0644\u064a\u0643 \u0633\u0648\u0649 \u0627\u0644\u0627\u062a\u0635\u0627\u0644 \u0628\u0646\u0627\n\u0633\u064a\u0642\u0648\u0645 \u0634\u062e\u0635 \u0645\u0627 \u064a\u062a\u062d\u062f\u062b \u0627\u0644\u0639\u0631\u0628\u064a\u0629 \u0628\u0645\u0633\u0627\u0639\u062f\u062a\u0643. \u0647\u0630\u0647 . 1-877-320-1235 (TTY: 711)  \u0639\u0644\u0649\n\u062e\u062f\u0645\u0629 \u0645\u062c\u0627\u0646\u064a\u0629.\nHindi:  \u0939\u092e\u093e\u0930\u0947 \u0938\u094d\u093e\u0938\u094d\u0925\u094d\u092f \u0925\u094d\u092f\u093e \u0926\u094d\u093e \u0915\u0940 \u0925\u094d\u092f\u094b\u091c\u0928\u093e \u0915 \u0947  \u092c\u093e\u0930\u0947 \u092e\u0947\u0902 \u0906\u092a\u0915 \u0947  \u0915\u0915\u0938\u0940 \u092d\u0940 \u092a\u094d\u0930\u0936\u094d\u0928 \u0915 \u0947  \u091c\u094d\u093e\u092c \u0926\u0947\u0928\u0947 \u0915 \u0947  \u0932\u093f\u090f \u0939\u092e\u093e\u0930\u0947 \u092a\u093e\u0938 \u092e\u0941\u092b\u094d\u0924 \n\u0926\u0941\u092d\u093e\u0915\u093f\u0925\u094d\u092f\u093e \u0938\u0947\u094d\u093e\u090f\u0901 \u0909\u092a\u093f\u092c\u094d\u0927 \u0939\u0948\u0902. \u090f\u0915 \u0926\u0941\u092d\u093e\u0915\u093f\u0925\u094d\u092f\u093e \u092a\u094d\u0930\u093e\u092a\u094d\u0924 \u0915\u0930\u0928\u0947 \u0915 \u0947  \u0932\u093f\u090f, \u092c\u0938 \u0939\u092e\u0947\u0902  1-877-320-1235 (TTY: 711) \u092a\u0930 \n\u092b\u094b\u0928 \u0915\u0930\u0947\u0902. \u0915\u094b\u0908 \u0935\u094d\u092f\u0932\u0924\u093f \u091c\u094b \u0915\u0939\u0928 \u0926\u0926\u0940 \u092c\u094b\u093f\u094d\u0924\u093e \u0939\u0948 \u0906\u092a\u0915\u0940 \u092e\u0926\u0926 \u0915\u0930 \u0938\u0915\u094d\u0924\u093e \u0939\u0948. \u0925\u094d\u092f\u0939 \u090f\u0915 \u092e\u0941\u092b\u094d\u0924 \u0938\u0947\u094d\u093e \u0939\u0948. ", "doc_id": "52ef6ef9-8905-4547-a1e1-30e04b8a36d1", "embedding": null, "doc_hash": "512a5810cd2cd149af0070379cd7bf701ec506a22aa0faf5fa50af5a9cdf531a", "extra_info": {"page_label": "500", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 0, "end": 909, "_node_type": "1"}, "relationships": {"1": "febd6f07-4102-4322-a244-85c462a8074e", "3": "06735e6a-5bf2-4f45-b83e-a374fdff67ca"}}, "__type__": "1"}, "06735e6a-5bf2-4f45-b83e-a374fdff67ca": {"__data__": {"text": "\nItalian:  \u00c8 disponibile un servizio di interpretariato gratuito per rispondere a \neventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, \ncontattare il numero 1-877-320-1235 (TTY: 711). Un nostro incaricato che parla \nItalianovi fornir\u00e0 l\u2019assistenza necessaria. \u00c8\u00a0un servizio gratuito.\nPortugues:  Dispomos de servi\u00e7os de interpreta\u00e7\u00e3o gratuitos para responder \na\u00a0qualquer quest\u00e3o que tenha acerca do nosso plano de sa\u00fade ou de medica\u00e7\u00e3o. \nPara obter um int\u00e9rprete, contacte-nos atrav\u00e9s do n\u00famero 1-877-320-1235 \n(TTY:\u00a0711). Ir\u00e1 encontrar algu\u00e9m que fale\u00a0o idioma Portugu\u00eas para o ajudar. \nEste\u00a0servi\u00e7o \u00e9\u00a0gratuito.\nFrench Creole:  Nou genyen s\u00e8vis ent\u00e8pr\u00e8t gratis pou reponn tout kesyon ou ta \ngenyen kons\u00e8nan plan medikal oswa dw\u00f2g nou an. Pou jwenn yon ent\u00e8pr\u00e8t, jis rele \nnou nan 1-877-320-1235 (TTY: 711). Yon moun ki pale Krey\u00f2l kapab ede w. Sa a se \nyon s\u00e8vis ki gratis.\nPolish:  Umo\u017cliwiamy bezp\u0142atne skorzystanie z us\u0142ug t\u0142umacza ustnego, kt\u00f3ry \npomo\u017ce w\u00a0uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania \nlek\u00f3w. Aby skorzysta\u0107 z pomocy t\u0142umacza znaj\u0105cego j\u0119zyk polski, nale\u017cy zadzwoni\u0107 \npod numer 1-877-320-1235 (TTY: 711). Ta\u00a0us\u0142uga jest bezp\u0142atna.\nJapanese  :\u00a0\u5f53\u793e\u306e\u5065\u5eb7\u5065\u5eb7\u4fdd\u967a\u3068\u85ac\u54c1\u51e6\u65b9\u85ac\u30d7\u30e9\u30f3\u306b\u95a2\u3059\u308b\u3054\u8cea\u554f\u306b\u304a\u7b54\u3048\u3059\u308b\u305f\u3081\u306b\u200c\u3001\u7121\u6599\u306e\u901a\u8a33\n\u30b5\u200c\u30fc\u30d3\u30b9\u304c\u3042\u308a\u307e\u3059\u3054\u3056\u3044\u307e\u3059\u200c\u3002\u901a\u8a33\u3092\u3054\u7528\u547d\u306b\u306a\u308b\u306b\u306f\u200c\u3001 1-877-320-1235 (TTY : 711 )\u306b\u304a\u96fb\u8a71\u304f\u3060\n\u3055\u3044\u200c\u3002\u65e5\u672c\u8a9e\u3092\u8a71\u3059\u4eba\u8005\u304c\u652f\u63f4\u3044\u305f\u3057\u307e\u3059\u200c\u3002\u3053\u308c\u306f\u7121\u6599\u306e\u30b5\u200c\u30fc\u30d3\u30b9\u3067\u3059\u200c\u3002", "doc_id": "06735e6a-5bf2-4f45-b83e-a374fdff67ca", "embedding": null, "doc_hash": "ff4cc29c72602e99cf77e9724e786266f27d3cd0cba1eadc8975dfa991cab904", "extra_info": {"page_label": "500", "file_name": "pre-authorization required.pdf"}, "node_info": {"start": 910, "end": 2264, "_node_type": "1"}, "relationships": {"1": "febd6f07-4102-4322-a244-85c462a8074e", "2": "52ef6ef9-8905-4547-a1e1-30e04b8a36d1"}}, "__type__": "1"}}, "docstore/ref_doc_info": {"4536c7a5-f8a1-49c6-a684-2bc5c5c8b362": {"doc_ids": ["d309e2b0-159c-4762-811e-5dc5f466c4a4"], "extra_info": {"page_label": "1", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "b8e0fd88-9c5c-4bee-8d5f-34c7cfddf61b": {"doc_ids": ["7b470071-5400-423e-bb72-46aafe894580"], "extra_info": {"page_label": "2", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "dcb8d134-6b29-4205-9f66-2571af10521a": {"doc_ids": ["5bf2afcc-9668-499c-a8c4-3425fb05394b"], "extra_info": {"page_label": "3", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "44e6b813-b597-4855-8c73-abd185bdc9ab": {"doc_ids": ["4e4d811d-b2e0-43ad-8e12-5f28d42c3a10"], "extra_info": {"page_label": "4", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "090f6cbd-7594-4c59-ab80-cdfa9103caf3": {"doc_ids": ["6f5993d5-50dc-4fad-a6d3-6b599a2d3ae1"], "extra_info": {"page_label": "5", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "4828d225-5d1f-4e35-b4fd-717e3351c219": {"doc_ids": ["aa3ef838-0ecc-4ef0-858a-0978e528c581"], "extra_info": {"page_label": "6", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "7078060a-ea3a-4282-9c23-db78c9d21dff": {"doc_ids": ["9127f353-b2b0-4728-a732-0de7296c043e"], "extra_info": {"page_label": "7", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "1484d1dd-5f29-4f11-927c-a575f7810445": {"doc_ids": ["54a534e1-3c1c-466c-90da-a09a3870ebd9"], "extra_info": {"page_label": "8", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "1c2ffb2b-2ff1-4786-8c1e-6a2206ee767b": {"doc_ids": ["c3b5ee34-c8dc-465c-b9df-b4711eaa07fb"], "extra_info": {"page_label": "9", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "37543027-c634-4a4f-91cc-dfdaff6de13a": {"doc_ids": ["7f8a6a0b-f398-400d-83c1-7f638c5ea1ed"], "extra_info": {"page_label": "10", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "f7ba0b1a-e60e-4015-b8de-4b4ff07d3b44": {"doc_ids": ["9bb4d2df-62b3-4dda-b8e3-4eac95e186d6"], "extra_info": {"page_label": "11", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "16f976f9-6952-4ce8-b03b-fcb350f08f01": {"doc_ids": ["0e7c5f44-aeb1-423b-b605-3fc02cf668e9"], "extra_info": {"page_label": "12", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "5dd7398c-23f1-4e80-92e9-da81baaa2f7f": {"doc_ids": ["81a30b8e-c842-4830-8055-cb1d206eb2f1"], "extra_info": {"page_label": "13", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "2fad2dca-54a6-4c85-b947-124bf62f5a6d": {"doc_ids": ["638c9691-c4ca-4365-a7de-942ffb3c8c1b"], "extra_info": {"page_label": "14", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "24880012-18f6-456d-af2b-076a33f5067c": {"doc_ids": ["2d88d7ca-4e2a-432a-9583-e8fd6c76fabf"], "extra_info": {"page_label": "15", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "63719f8c-6ce3-4d45-b06a-14e0f1334343": {"doc_ids": ["5944387b-7d5c-43c7-8959-a83970997ecb"], "extra_info": {"page_label": "16", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "d68c272e-e910-4430-bd9d-5a33c35064fe": {"doc_ids": ["9dbfdb02-df96-4cad-a69d-3cedcbdb99df"], "extra_info": {"page_label": "17", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "1a41dd19-ac4c-4f83-bd47-daf1a2d21ef6": {"doc_ids": ["f7fe4a39-6a00-414f-b7f6-826a11a87b72"], "extra_info": {"page_label": "18", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "e6f86a9a-b581-495f-8243-5ea667154734": {"doc_ids": ["a7fe926c-482d-4374-a1ef-8f171e038f8e"], "extra_info": {"page_label": "19", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "2ae52e95-7e2b-44bf-97fd-e28f183ecf1d": {"doc_ids": ["74dea28b-9c0a-4217-8cc4-67cb46b92759"], "extra_info": {"page_label": "20", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "b1065af6-39c3-4a18-9bdb-7c6c134d20d9": {"doc_ids": ["1b5c4a5e-7d87-4769-a332-2899afb908dd"], "extra_info": {"page_label": "21", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "eb66606e-d697-4ccc-ad77-d8228b4bb745": {"doc_ids": ["aedecc0e-3e40-4d09-bb60-e571a0263a24"], "extra_info": {"page_label": "22", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "ddde86fc-815b-4682-8fad-1f5189243770": {"doc_ids": ["a10a9382-80b9-4e23-95bb-f87e667dc552"], "extra_info": {"page_label": "23", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "477640e2-4f9b-4613-962b-409368857896": {"doc_ids": ["86e02bec-5f67-451f-8bf1-c551a48c700c"], "extra_info": {"page_label": "24", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "59d84232-09ab-4b2e-8973-665b464d8278": {"doc_ids": ["5f7c8912-8806-4f1f-9f0a-b5723b6eec7c"], "extra_info": {"page_label": "25", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "4a42ac7a-14b5-4066-849f-68b1bd25395d": {"doc_ids": ["e603d02d-ae0e-4b9c-a562-c688baef6385"], "extra_info": {"page_label": "26", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "1b061e34-9fa7-4aa7-8fce-b16fb7f0617e": {"doc_ids": ["9494501e-3430-4719-844e-2da439a99205"], "extra_info": {"page_label": "27", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "b327e644-bfa6-4c8d-8917-1952346384a5": {"doc_ids": ["9c77689a-846d-4edf-a0bc-3de6ca2e40fb"], "extra_info": {"page_label": "28", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "3b80bc31-f6d5-45ee-8d44-54714a155751": {"doc_ids": ["9960b106-e385-4f4f-af51-12442ac44635", "d75c3b67-8eab-4785-be62-69533a8cf716"], "extra_info": {"page_label": "29", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "c863b8d5-e3fd-4a57-9c4e-0ed9cc10fae5": {"doc_ids": ["5e3f4c80-e66c-4242-91e1-e55f0777e9bb"], "extra_info": {"page_label": "30", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "01db5cee-01e4-435b-ba79-11ad2dcc85a1": {"doc_ids": ["e1462f50-d16f-4dfa-b286-72062460870c"], "extra_info": {"page_label": "31", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "bc5bdfd5-1f27-4c78-8c43-05609d3dd81c": {"doc_ids": ["53354811-2f7e-4efa-bf1b-b38c21f6d882"], "extra_info": {"page_label": "32", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "e3c1a094-d8a2-47cf-b4bf-cfa98da8ef0e": {"doc_ids": ["11f9c439-458b-4c05-bab9-d5b7bb85ff07"], "extra_info": {"page_label": "35", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "e4ae379f-9d63-413b-8afa-afc20b5d0840": {"doc_ids": ["52f3c867-069f-43ff-9e8d-28427e4b4ac0"], "extra_info": {"page_label": "36", "file_name": "ANOC - Humana Gold Plus SNP-DE (HMO-POS D-SNP).pdf"}}, "0902737a-cecc-43dc-a42c-f1170e797f3e": {"doc_ids": ["f50ec48a-2bd6-493d-afad-aa8d488b4e1e"], "extra_info": {"page_label": "1", "file_name": "DucDetails.pdf"}}, "1dd89492-3c6b-45cf-bf4c-0f0846bd5e6a": {"doc_ids": ["5a064a9e-3536-496a-a879-dcedb35b0f66"], "extra_info": {"page_label": "1", "file_name": "GirishDetails.pdf"}}, "453afa2a-95c5-464a-ab4c-71d860b2f67e": {"doc_ids": ["2abb7291-582b-482a-9690-d68abd48619e"], "extra_info": {"page_label": "1", "file_name": "Humana Gold Plus (HMO) - CMS Plan Rating.pdf"}}, "5dbde026-bebb-42ed-b237-366ab5b3815d": {"doc_ids": ["3d82f039-4ee2-452d-b6a7-d5561e2854cc"], "extra_info": {"page_label": "2", "file_name": "Humana Gold Plus (HMO) - CMS Plan Rating.pdf"}}, "4bc1f1b7-8730-4a4f-8e64-705677c17aad": {"doc_ids": ["65d6c4c8-708b-4cee-a3e1-79b9d88e6a46", "96ae10a3-3e55-434a-a9fc-29bf3994780f"], "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus (HMO) - CMS Plan Rating.pdf"}}, "86c64624-4863-40cf-a897-99aada3d293e": {"doc_ids": ["e056ae5f-1b79-4e74-8fda-d124bf45f28d", "1787b3bf-8484-42f5-9e3c-123532075e09"], "extra_info": {"page_label": "4", "file_name": "Humana Gold Plus (HMO) - CMS Plan Rating.pdf"}}, "ead21676-478c-4016-8130-55d7a1b30667": {"doc_ids": ["d7f2211e-3ab3-4cdb-bcaa-0834dc35de19"], "extra_info": {"page_label": "1", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "07bf2223-6f67-4480-9464-061c9446a7ba": {"doc_ids": ["6f7923d3-d1f3-4acc-9ff5-c8fd6a3b0aa6"], "extra_info": {"page_label": "2", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "3e310d24-ca9b-406d-afa6-ca08e60a881f": {"doc_ids": ["72900278-f191-49f6-abfd-117594e73859"], "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "a7edf12c-ddf8-4bd2-9d1e-74fe6714b246": {"doc_ids": ["b28491b4-a24c-4960-a6f8-3a607e4bf97e"], "extra_info": {"page_label": "5", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "1cd7ed3d-28fc-486b-a305-fe41714edd67": {"doc_ids": ["9ff278e1-9fa8-4fdf-9cb0-681c4435c7c2"], "extra_info": {"page_label": "6", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "9a45a111-0d63-4a6d-a051-ef74ab85bd94": {"doc_ids": ["0ade37bd-3aaa-4a62-93ae-bd818203bd28"], "extra_info": {"page_label": "7", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "5727633c-2a70-4b63-850e-f9a827e549c2": {"doc_ids": ["11f88103-34d2-44ab-ac8b-7e9e1738f9f2"], "extra_info": {"page_label": "8", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "3301a21a-1eac-4e82-a4f8-d1a7799151ac": {"doc_ids": ["6a7619ee-346c-4a47-931a-cf535877e28f"], "extra_info": {"page_label": "9", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "8577f61f-7da5-4b39-aa64-93207290cb2f": {"doc_ids": ["7d176641-205b-4e70-95e0-11dabb434b0b"], "extra_info": {"page_label": "10", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "7d021290-03b8-4928-ae52-30e37ea681e1": {"doc_ids": ["ec2b1ff7-edf0-45f2-9a4f-5e5b05ec5821"], "extra_info": {"page_label": "11", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "04296aab-2a9d-4182-80b0-9d6fd5485bfa": {"doc_ids": ["842b0cef-7ec7-439c-a04b-fbbbae3da790"], "extra_info": {"page_label": "12", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "13f8f39f-0fd5-4540-9645-4f5c7e4dca54": {"doc_ids": ["7609548b-f30b-41e5-afcc-8b6b8e2aedcd"], "extra_info": {"page_label": "13", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "752f075f-b7f3-446d-83b1-9aa5b36e58a3": {"doc_ids": ["9b06b38a-6cbe-465f-9e35-a4db146f5a89"], "extra_info": {"page_label": "14", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "1b057de8-418b-45c3-945b-de77c1d90051": {"doc_ids": ["898b42c3-5d28-4e96-90b9-e5b5aeecb592"], "extra_info": {"page_label": "15", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "5e3b5a88-532c-4bf3-a6de-2e3ba09049a4": {"doc_ids": ["e8353196-347b-418d-992d-8746e5a407ed"], "extra_info": {"page_label": "16", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "d4f7dce2-6393-4313-bc0c-2cdfebe762cc": {"doc_ids": ["23e195e2-4f0f-492e-9a5f-f8bd0294ab20"], "extra_info": {"page_label": "17", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "cccd72e1-8f73-41d2-b15e-b5ec34e88f6e": {"doc_ids": ["925343d8-a08d-47f7-8440-e30cf09cc867"], "extra_info": {"page_label": "18", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "e187c352-dbdc-4526-8a11-acb8819f1e88": {"doc_ids": ["518dce73-3313-4479-aaaa-5bb55ef71efc"], "extra_info": {"page_label": "19", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "f2316407-e14b-4c19-be75-42bc7b59b074": {"doc_ids": ["835d7195-762f-4f3c-8014-83d4520db493"], "extra_info": {"page_label": "20", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "2777322f-b9ce-46e2-b8d4-c17b971e1b72": {"doc_ids": ["ddc948bb-5fc7-4fbd-9aa2-895943dd2f07"], "extra_info": {"page_label": "21", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "85466ec0-cd68-485a-ac5a-e4faa41257bd": {"doc_ids": ["ed87ddb3-110c-4ea5-984e-98d31f33b6d3"], "extra_info": {"page_label": "22", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "6a785e8e-6fcb-4f83-93e9-663da5167de6": {"doc_ids": ["000b7117-126c-403a-abed-aa13b0a0d299"], "extra_info": {"page_label": "23", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "5f614161-3f67-43c0-84fd-d1814299e861": {"doc_ids": ["8264139e-4817-4af1-8158-2d444714022d"], "extra_info": {"page_label": "24", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "cb003932-8052-4708-a030-7392202b9adf": {"doc_ids": ["81e0b601-5751-4cf3-b905-845d4661f46d"], "extra_info": {"page_label": "25", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "04edc4bb-4ad9-4bd4-a7dd-93add88a3521": {"doc_ids": ["072c7972-46a3-46c6-8d7c-926dfb698e7b"], "extra_info": {"page_label": "26", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "b564ceac-4cef-4a26-9c80-a23be11dc10b": {"doc_ids": ["0a0e1fa2-4b1d-4741-9dd7-11aacc076305"], "extra_info": {"page_label": "27", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "32cc05f1-2a71-4f76-a2dd-21b48a0f732f": {"doc_ids": ["13f557cd-d4d4-4908-ad7c-82603d0bc21b"], "extra_info": {"page_label": "28", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "f2589de3-8eaf-4cb4-aa97-0364ffa07d21": {"doc_ids": ["b8d5a8bf-ed1a-4499-9d67-f2c0c0da3889"], "extra_info": {"page_label": "29", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "cce6f646-7384-487c-b324-309fc6affb77": {"doc_ids": ["16f515ca-0dd5-4dca-85ab-7e7e85e0977d"], "extra_info": {"page_label": "30", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "b6bad8bd-bdbb-4ad6-a3b0-4b2f6c32cc30": {"doc_ids": ["f90568da-45a5-413e-9db0-5c55f1f40766"], "extra_info": {"page_label": "31", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "3554f076-0cf7-4007-872e-53ad1157c837": {"doc_ids": ["f7af7fa3-0968-46bf-8e5d-bd93caa02d5b"], "extra_info": {"page_label": "32", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "1ab8f553-673b-4e15-a1b3-9ce906842891": {"doc_ids": ["65bb1aaa-83fb-48b3-8e44-0302c2011fe3"], "extra_info": {"page_label": "33", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "d987d3a4-06d7-4953-9805-66d59b44e91c": {"doc_ids": ["99d5bb5b-f7c2-4f9f-874e-53ec082be9b2"], "extra_info": {"page_label": "34", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "7bf72344-40b0-469b-b6ee-81ad3c35aa5a": {"doc_ids": ["1cf03328-e574-43a5-a3cc-ece84c14fa1e"], "extra_info": {"page_label": "35", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "c14d73e6-7c07-489d-a20c-b75f6cdb00c3": {"doc_ids": ["890049a7-f634-4c57-84d6-09709e3d5823"], "extra_info": {"page_label": "36", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "f336b233-6662-4dd3-9adb-17a39907b54f": {"doc_ids": ["2c0c93e2-99a9-488f-a364-be8a10159c85"], "extra_info": {"page_label": "37", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "82429d40-80fd-4194-bfee-b641afe43cdf": {"doc_ids": ["8a64f27d-be93-40f9-a922-11f1879a4d9d"], "extra_info": {"page_label": "38", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "ef6a1017-7adc-4f8f-82fa-3b8a87431952": {"doc_ids": ["2a7f6739-0a1e-471e-b6e8-e0b3b4b69f23"], "extra_info": {"page_label": "39", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "13d1e588-85e5-4d85-a5fb-c9e94b74d89c": {"doc_ids": ["884aabff-0470-4f2c-a48d-725bd776eee9"], "extra_info": {"page_label": "40", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "9ef26203-762a-4b72-8726-f5367480317d": {"doc_ids": ["5837d3dc-1bf6-40ed-abce-b23d102a9aca"], "extra_info": {"page_label": "41", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "10c41412-5362-413a-ac6d-784a2258db5b": {"doc_ids": ["171c3ced-5bcf-41bd-8367-fe16e37d118f"], "extra_info": {"page_label": "42", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "8acec875-a1d0-4812-87c9-12141bdcde8c": {"doc_ids": ["210f3d60-6df3-42fe-b51a-d948e60dfecf"], "extra_info": {"page_label": "43", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "a306a787-2b16-4671-b764-4821848409fe": {"doc_ids": ["67c5a110-26ed-43ac-8964-667debcb272c"], "extra_info": {"page_label": "44", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "95582803-7714-4dfc-a935-817b5ddb574f": {"doc_ids": ["e25e6f70-00fd-4f99-878f-2adb5797e7f7"], "extra_info": {"page_label": "45", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "83d42ba2-d396-45ff-97a2-1a713a34b7a2": {"doc_ids": ["ada70517-d3a1-42ff-9533-c94cc25f5dc0"], "extra_info": {"page_label": "46", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "8ffd8653-1c20-45b5-a9d6-2444054ff836": {"doc_ids": ["23fd8d25-1218-4ea1-9031-8e866813b324"], "extra_info": {"page_label": "47", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "f0533645-d4d0-4a93-a302-190251cd23a2": {"doc_ids": ["ad48ecd1-f18c-4d01-95db-b4c60873d1f7"], "extra_info": {"page_label": "48", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "ef8895c9-e158-4328-8bb0-2808888628e9": {"doc_ids": ["ec586ece-4aed-4be5-be92-145c68956464"], "extra_info": {"page_label": "49", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "a738b865-19f4-40ae-8ecd-17704b1880a0": {"doc_ids": ["1d0953af-8efa-4a68-8a8f-9043546bbc9c"], "extra_info": {"page_label": "50", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "74b9126a-4fcc-4a57-88ca-2afc34d8526d": {"doc_ids": ["0fffa81d-2126-40d7-a32a-66055ae15991"], "extra_info": {"page_label": "51", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "cbdccf59-e8d9-424b-8ca6-f7a16e015737": {"doc_ids": ["c8f5991d-ca30-4f36-8e4d-9491f3c015c7"], "extra_info": {"page_label": "52", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "d1cdb3d5-03f1-41f6-ad61-3bb8d2200581": {"doc_ids": ["d8619a5d-3bbe-4475-8baa-727716389c54"], "extra_info": {"page_label": "53", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "885b3087-a36d-442c-9748-d0dc6c9d6dfa": {"doc_ids": ["9ea4855d-88a4-41d5-b917-23f3228c7140"], "extra_info": {"page_label": "54", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "61671732-245a-4392-b420-0ba6ad322ff3": {"doc_ids": ["ff559108-9ae7-44a9-8f1f-f56a73a6f845"], "extra_info": {"page_label": "55", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "9775e379-01ee-4811-afca-34f66c2ce5cf": {"doc_ids": ["3ea709c6-8702-45d5-8628-edf4341bb8a7"], "extra_info": {"page_label": "56", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "dacf3b98-0f27-48b1-8f36-c5876bc493aa": {"doc_ids": ["f120f79a-a0c3-4f8b-8ed0-180a56f83c44"], "extra_info": {"page_label": "57", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "c4bbe220-e335-42fd-8d45-3babaf36e6d7": {"doc_ids": ["336b7d6e-2727-4270-9311-65f938627af3", "87820f8d-32cc-4c8a-b0c3-887a40b52943"], "extra_info": {"page_label": "58", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "fe2c398a-a70a-480e-a9ba-5c310d24d1d3": {"doc_ids": ["009e0002-e57e-4029-a725-45b6d512eacb"], "extra_info": {"page_label": "59", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "0c348d79-8048-43a4-afe6-1923171d4c80": {"doc_ids": ["dbd48933-4c27-4c91-bace-3562cb0abf7a"], "extra_info": {"page_label": "60", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "bf1e24a4-fa67-4d33-b1f8-86f8cf06c7db": {"doc_ids": ["8d4ab7c9-516d-4a13-88dd-4ee847b5a1b7"], "extra_info": {"page_label": "61", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "30ec26a6-82c1-4566-bcdf-1452c417d567": {"doc_ids": ["7566accb-13b5-4f67-ad12-d34dc83d8690"], "extra_info": {"page_label": "62", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "9fcb5435-78c7-46ac-bdcb-690fec057055": {"doc_ids": ["c6157a54-a39c-46cd-868e-0cdedf70d707"], "extra_info": {"page_label": "63", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "f017f507-17d9-4e64-ac1e-3056163f7b08": {"doc_ids": ["db933f85-1138-4661-818c-8d795b12d1cc"], "extra_info": {"page_label": "64", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "eefc82cc-e904-4d89-a023-bca35633a97d": {"doc_ids": ["3e3c1613-f69e-4958-84e5-39656662cb81"], "extra_info": {"page_label": "65", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "09e818fc-385c-40cb-93f7-712fdc1b278c": {"doc_ids": ["58687f56-e150-4871-80ad-949c9fec49ab"], "extra_info": {"page_label": "66", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "30edcdcf-0697-41f2-9946-196bc9ba443d": {"doc_ids": ["f0d6ae37-fe7a-4230-b381-9b4b54f17336"], "extra_info": {"page_label": "67", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "1a6cdde4-18c3-4946-a53f-dae2a6d0f588": {"doc_ids": ["f9ae405e-8bbf-4bb6-a374-55ac499efff3"], "extra_info": {"page_label": "68", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "ad2cfc73-37bb-4b7b-8287-97522bc256f6": {"doc_ids": ["efec72e5-115f-4a57-b63c-70d72eb5fb0c"], "extra_info": {"page_label": "69", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "e60b55ef-bf2a-4951-b66e-a215a4162631": {"doc_ids": ["154e534d-9007-413b-ad76-31a27c70c1a4"], "extra_info": {"page_label": "70", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "9e7d1fd9-0ab5-423c-b6fb-10464d6473dc": {"doc_ids": ["6472b42d-1fc2-4204-a085-a91e9e3e77fd"], "extra_info": {"page_label": "71", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "a4dcecf6-1b5e-4629-823c-f817d01251cc": {"doc_ids": ["a5e294a6-d3f6-4560-a5d6-eb01847c4275"], "extra_info": {"page_label": "72", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "02911eb1-2714-4d45-bf2a-4fe19fc55871": {"doc_ids": ["8fedf6c8-e429-4977-8b3e-668544d9716b"], "extra_info": {"page_label": "73", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "6f6de8f1-566a-4a1a-bc12-b7a11691b387": {"doc_ids": ["73f306e7-edf9-4126-98ad-923a8e39022f"], "extra_info": {"page_label": "74", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "49a431a9-503f-4da5-8753-d2ddf82c09c0": {"doc_ids": ["03df2935-407d-427e-a42e-a3fd633559cf"], "extra_info": {"page_label": "75", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "309537af-1378-4104-8f65-94d2640eb42c": {"doc_ids": ["f91f877c-47fd-4727-80b9-11b0855096a6"], "extra_info": {"page_label": "76", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "b7bb677d-5c59-4983-b2b6-c2b90239a7d2": {"doc_ids": ["4ee02e6a-4e64-469b-bec0-23f120bd140a"], "extra_info": {"page_label": "77", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "2de9dc72-a627-458f-9305-fe7108028a51": {"doc_ids": ["ebb702b1-bf3d-4ebc-9803-f3d64062d14c"], "extra_info": {"page_label": "78", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "c6dc1253-7056-4dd8-a98d-da1ea0cabc43": {"doc_ids": ["45407d03-1f95-4dfe-85b9-8aad40068924"], "extra_info": {"page_label": "79", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "833bb4ed-8f5b-4f6e-98a2-8981f3fcd4f3": {"doc_ids": ["013cbf3b-168f-43e5-988c-0c119b990d7a"], "extra_info": {"page_label": "80", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "facdb65f-d37a-40ad-8360-87994a1e99f2": {"doc_ids": ["b1dba3cb-33ab-431f-b2c8-55d2dc74a442"], "extra_info": {"page_label": "81", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "d2f989bf-23df-4a52-aca4-fdaf3c61e40c": {"doc_ids": ["112d3444-8043-4126-9254-6140993fc310"], "extra_info": {"page_label": "82", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "859dcc04-6c25-4e38-a92e-ab31569fb10e": {"doc_ids": ["071edec4-d744-431b-86ec-9db1db5c5aef"], "extra_info": {"page_label": "83", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "a0758f96-3e2a-484b-96db-7cde00181ef7": {"doc_ids": ["c914225a-7fe2-437f-9100-e91a8d5edc00"], "extra_info": {"page_label": "84", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "19f9203a-c83f-454f-98c4-7fda199da842": {"doc_ids": ["e76ed89d-629a-4d20-88cd-531dddf6eb41"], "extra_info": {"page_label": "85", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "57837dcc-6cb4-4636-bd65-75849f1527b8": {"doc_ids": ["220bc180-6b42-44b7-8024-d0a1b9f93173"], "extra_info": {"page_label": "86", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "01fc81ba-2b6f-494d-a19e-5ff325ee76d2": {"doc_ids": ["f0a30b99-16e7-41b7-b3b6-ef30e67777ce", "5253cfee-3f87-45b1-adc8-6976c33ab3c7"], "extra_info": {"page_label": "87", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "9ed539ad-4de5-49be-b369-8be2de44fb0a": {"doc_ids": ["5eb2d40d-0b6d-4dfd-b345-52988e864863"], "extra_info": {"page_label": "88", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "bc786873-541c-4b3f-85c7-0955ad2f451d": {"doc_ids": ["6bc29b05-15b2-4b2e-acd5-85d808044379"], "extra_info": {"page_label": "89", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "e87cca45-641c-4d94-86e0-edc884c57306": {"doc_ids": ["b748a419-773b-42f4-a160-81034e18d135"], "extra_info": {"page_label": "90", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "26f23882-bf36-452b-af54-54b53ed5960a": {"doc_ids": ["fea787c6-736a-4c2f-9b44-d47778cac787"], "extra_info": {"page_label": "91", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "4ae098b9-96ea-4d5f-8223-bcfb092929cd": {"doc_ids": ["179b3807-9368-44f0-af1e-af74a1faca28"], "extra_info": {"page_label": "92", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "3903c9a9-23fc-4532-ab00-8b72b2b6c86d": {"doc_ids": ["60b8661c-efd8-432d-a143-8ecfbbf3edcd"], "extra_info": {"page_label": "93", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "4bdaae58-2b10-452b-aafb-2f17de3f6bbf": {"doc_ids": ["23f95865-cf3a-4d94-b3ed-87e0a00d5299", "11d2a024-ac9d-4451-ae00-146eb1a781d5"], "extra_info": {"page_label": "94", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "49c4b941-19bc-478d-909e-9a948b55b01f": {"doc_ids": ["2690e8f1-0d9d-48fe-9464-64e9be7f2fdf"], "extra_info": {"page_label": "95", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "654bd8d8-b21f-4ffb-bfd6-72213b3647d7": {"doc_ids": ["a4538c45-9cc6-4cde-9176-f5d8ef9d641c"], "extra_info": {"page_label": "96", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "080d7dbc-6178-4cd6-af31-e968bc1c3968": {"doc_ids": ["4979f2f0-b279-495f-b7ba-d66e56e902d1"], "extra_info": {"page_label": "97", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "10bb9270-5549-4eb1-a5f9-a531e9b25c0c": {"doc_ids": ["f769df96-a3c8-4aed-9271-4a5f9bdaf536"], "extra_info": {"page_label": "98", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "ef4ecd3b-89e2-4a16-a5ef-20558ce1fc7d": {"doc_ids": ["759ce702-6918-4bb3-ae74-f21c19f78a8a"], "extra_info": {"page_label": "99", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "61773825-8cb5-4f7d-b774-aa1b4f79353f": {"doc_ids": ["9d2d8d50-c7d1-4645-8d13-9f83c1400161"], "extra_info": {"page_label": "100", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "384c3c45-4c1e-4d8f-8008-4a5a3d99a820": {"doc_ids": ["0b7622e2-aa2f-48e6-8942-f5d76b87da44"], "extra_info": {"page_label": "101", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "b4a2fcfb-fa1c-429b-ad31-67e32e895782": {"doc_ids": ["f508d885-8a23-4195-bf24-c1cd60e2063c"], "extra_info": {"page_label": "102", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "19245fe9-5920-4588-b097-3e3037210b38": {"doc_ids": ["c3faa421-db77-4c2e-83d5-bfd28e3e4e11"], "extra_info": {"page_label": "103", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "0222444a-79c4-409b-ab08-8cc11b5350d1": {"doc_ids": ["38acc63e-1d3b-4bf8-a406-a3eccd07da18"], "extra_info": {"page_label": "104", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "381adc2c-39d4-496a-b659-c8f9e006baf9": {"doc_ids": ["eeb21716-7d5b-4820-be79-1c896039f5ff"], "extra_info": {"page_label": "105", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "e669b8a5-8b94-401c-87ca-c455bec2cccf": {"doc_ids": ["87abc490-c3bd-4135-8ccb-7b01e64b9dce"], "extra_info": {"page_label": "106", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "04e0ee8e-1549-4fd0-81b5-8362d5063f1c": {"doc_ids": ["22e02dd4-7e74-4b48-9cef-362395414e29"], "extra_info": {"page_label": "107", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "fa3dd9c2-37d8-4212-98bc-ff33a78d13ef": {"doc_ids": ["a36ac4df-bee2-4a9e-b518-ce9c1611c037"], "extra_info": {"page_label": "108", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "e6f6cb78-0499-45b4-b641-dcf9ec1313c9": {"doc_ids": ["dacaac01-2f84-44ba-8426-4e8694381653"], "extra_info": {"page_label": "109", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "1051bc8e-760f-458d-a7c3-8607998f6544": {"doc_ids": ["b2d761a4-a95c-4224-8cf1-ec16720bf831"], "extra_info": {"page_label": "110", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "3716dcb5-ef79-418e-9cef-fc42d6698941": {"doc_ids": ["fd3f0856-28df-4ba9-ac9a-210687af160f"], "extra_info": {"page_label": "111", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "a9ad9932-f173-42bf-a2a0-274329934761": {"doc_ids": ["484ac50d-ff47-4260-b14f-2717093fafcb"], "extra_info": {"page_label": "112", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "23b4b4d3-c20a-4125-aaa3-3001c1391991": {"doc_ids": ["ab95a1b6-f6a2-43ab-ad33-dbb78c6c0d04"], "extra_info": {"page_label": "113", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "36983539-293c-4fb5-ba1c-498c660d378c": {"doc_ids": ["da9de516-30a6-40d7-bbf1-252182cc593d"], "extra_info": {"page_label": "114", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "4e41c544-0e85-4158-9a71-03caf334c5d1": {"doc_ids": ["8f1eb2f7-4888-46a0-b529-4a7eb3d5fa25"], "extra_info": {"page_label": "115", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "0fbb0971-ca86-4553-99fd-24290ea96b73": {"doc_ids": ["31cc5e95-0380-4683-83e0-de0839d844ce"], "extra_info": {"page_label": "116", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "5ac865b7-d61c-40e1-a8bd-193b81176674": {"doc_ids": ["62ac95de-0c07-49a1-948b-c7830e94a273"], "extra_info": {"page_label": "117", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "bc5e2b1f-acd1-4d64-8129-5adf07008f1a": {"doc_ids": ["0d57ff7b-7339-4911-841a-8bf0148067f4"], "extra_info": {"page_label": "118", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "e5acc09e-b152-4060-9ac6-7b1db967cca3": {"doc_ids": ["f42c6431-d698-48a9-82f2-b6c69ca42235"], "extra_info": {"page_label": "119", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "050dc063-032a-4c64-a2af-45edc8873841": {"doc_ids": ["5dc98b08-ceae-479b-8827-f1abc460c90f"], "extra_info": {"page_label": "120", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "6f4e2028-596c-4f3a-9e3e-2554cd28a671": {"doc_ids": ["a878079b-f288-422a-874c-7dbea044a803"], "extra_info": {"page_label": "121", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "225e94cf-350e-405a-b3e2-61df0ec86773": {"doc_ids": ["3aebffd5-5f9b-4f75-9c1b-fe6cf474a26e"], "extra_info": {"page_label": "122", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "6d6c2bfa-f8d2-45aa-bf85-01619cc04fc9": {"doc_ids": ["f1622148-d0dc-4719-a93b-03b6c14603ff"], "extra_info": {"page_label": "123", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "467a2faa-e226-478e-a1af-a51c2b915c56": {"doc_ids": ["ec3fb8c8-6feb-4e67-8b96-c3df4f051896"], "extra_info": {"page_label": "124", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "9295b091-d5ea-4707-90d4-5ee7c350b671": {"doc_ids": ["ba0cbae4-fa99-403b-889d-23e7125a701b"], "extra_info": {"page_label": "125", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "ffaf2043-50a9-4108-892e-686ccc034040": {"doc_ids": ["2259b1f7-ee78-4467-ad1e-59d7afe9f521"], "extra_info": {"page_label": "126", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "311b2664-abdf-4d5a-8a5c-bcd3d84dad1b": {"doc_ids": ["8ac91f58-2f65-4ef0-a3be-57b8f184922a"], "extra_info": {"page_label": "127", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "1aaf53aa-d230-4f36-98df-5dcbf12a7122": {"doc_ids": ["325cd1de-ecc7-40b3-9dba-5576cfecb4c7", "129b86bc-f928-43d3-a81b-ed56094a5fb7"], "extra_info": {"page_label": "128", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "186aae32-e1a3-40db-b9a8-1a5546a1c5d6": {"doc_ids": ["44b1842b-bdef-48c4-baa0-4d3ec8d67778"], "extra_info": {"page_label": "129", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "bbf2c993-92ac-4d0a-a0e3-9abca7772803": {"doc_ids": ["8556cc11-140c-4e2c-8597-8d0b17924cef"], "extra_info": {"page_label": "130", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "3f359dd5-73f9-41b9-a83f-52233b605e52": {"doc_ids": ["46073802-2153-4625-8066-84f5759459d9"], "extra_info": {"page_label": "131", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "6967c86c-1a7a-4622-b37d-c149cb25b9a4": {"doc_ids": ["1e584c9e-9282-4090-a4b6-53b7e6e85283"], "extra_info": {"page_label": "132", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "ca796061-17d2-4a54-8690-7a689866464c": {"doc_ids": ["4cacccf6-32b8-49d8-ae5c-611df2293acd"], "extra_info": {"page_label": "133", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "c36bf82a-afcf-435b-a3d0-a2da3b23dfec": {"doc_ids": ["0f8b91ef-d661-4b3d-a30f-b1fc1685c398"], "extra_info": {"page_label": "134", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "784e52ed-599c-4027-af5e-595073e8c393": {"doc_ids": ["6b8f034e-ad9a-4543-9af9-54c6bf4874a7"], "extra_info": {"page_label": "135", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "07a5fd13-ba12-4aea-b14e-520f3bbd5ad7": {"doc_ids": ["9d216aad-8fc4-43b8-8ede-8a5498b9f123"], "extra_info": {"page_label": "136", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "9f269857-45fc-46a1-bf17-446c6772f562": {"doc_ids": ["8a6c743b-2d3c-418c-ba56-4c42fca45a19"], "extra_info": {"page_label": "137", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "0330562b-976d-4a14-8514-faadd4b93e9c": {"doc_ids": ["3f447eb0-f55a-4e82-9c57-9639348c2062"], "extra_info": {"page_label": "138", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "223d09d7-7f17-4a4c-9b8f-38a5a78bf3fd": {"doc_ids": ["4917786c-3b91-4bc7-989b-40c6bbe8d73c"], "extra_info": {"page_label": "139", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "bab5d1ee-f912-489c-802e-f05a01e9e615": {"doc_ids": ["2a44c392-fb76-4735-9e81-6ab41fdda4f9"], "extra_info": {"page_label": "140", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "add48fdb-f87c-4242-afbf-d6c5855f31a1": {"doc_ids": ["a6862ba4-21fc-4b4f-8f7c-3a0e1111a7b3"], "extra_info": {"page_label": "141", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "22a839b0-dd01-46cb-b359-e664363c7b65": {"doc_ids": ["e45b2d47-3ad0-4906-b6a4-dab3a2f99b34"], "extra_info": {"page_label": "142", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "8205764f-8b54-4ccc-bc44-d96bec6e74e6": {"doc_ids": ["9c1bd46e-70bc-4fdf-9a8f-3500f6bf7ba0"], "extra_info": {"page_label": "143", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "e17503da-2fe7-4b9e-ab95-ec5cd4adef92": {"doc_ids": ["fb8a82a1-2a91-45c9-bcdd-9f6de6df59bd"], "extra_info": {"page_label": "144", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "16ac06f2-a3b4-43e8-b3d1-5f3690d392d8": {"doc_ids": ["f6531598-96b4-43cd-a905-41c98c647d1c"], "extra_info": {"page_label": "145", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "4098719c-bc0b-43dc-a9a9-8dec11ca74ea": {"doc_ids": ["2f8e5cbc-d709-4f97-9eb3-c33c4f6089b5"], "extra_info": {"page_label": "146", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "db0f6059-bc1e-4c5e-9470-6d80717499c4": {"doc_ids": ["aba44502-f6a3-445c-b105-92557e2cb376"], "extra_info": {"page_label": "147", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "395d74e0-4a3d-4909-af58-21190d5aac47": {"doc_ids": ["ac9137ef-7c1e-46e3-9143-beafcd3da67a"], "extra_info": {"page_label": "148", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "6eec134f-e7e0-4127-9590-0435c418ab26": {"doc_ids": ["c292920c-cb99-4c20-8d68-9dcb732d5bac"], "extra_info": {"page_label": "149", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "8e68cf70-da3d-430c-8652-0dfc6b229d81": {"doc_ids": ["9eb68db3-8351-4f6a-8d06-e7feef6f823c"], "extra_info": {"page_label": "150", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "5c91be46-4c92-468a-a62e-5a58aa1ed438": {"doc_ids": ["9e11a70c-7933-49b4-a24e-f25595f47383"], "extra_info": {"page_label": "151", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "aff23f75-465e-4de4-9621-545c33fd25db": {"doc_ids": ["c03da7b4-34e5-49da-bfbb-c4ce47db7701"], "extra_info": {"page_label": "152", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "31f40556-d89e-4618-a099-21378c60ab41": {"doc_ids": ["22584e2e-1751-4180-9ea8-cccd1ce346d7"], "extra_info": {"page_label": "153", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "515ce81b-4cb9-4c33-8692-d963dc07dd1a": {"doc_ids": ["c795783e-813d-4782-ad07-1d63c3c0a16a"], "extra_info": {"page_label": "154", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "cf7dffa8-b7ae-4665-b417-e3c40fbe1eae": {"doc_ids": ["cd1c2873-0830-4be7-bb76-f2bd378549be"], "extra_info": {"page_label": "155", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "2ce169af-9c75-4954-bd8c-61e9e547d4d8": {"doc_ids": ["be998169-9cb9-44d2-981d-3b067fcb16da"], "extra_info": {"page_label": "156", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "88efc990-3a38-4ce1-bcbc-e0dcc9dbf796": {"doc_ids": ["88bb1d0d-10f9-47af-98bd-7b2ebca567a0"], "extra_info": {"page_label": "157", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "9e7f1bb1-68c7-46e9-a1cf-6bbacc756325": {"doc_ids": ["d3687edb-7690-4a3d-81a9-fc5713f3ae3b"], "extra_info": {"page_label": "158", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "f2e4249d-e15d-405f-97f6-d8018e31a218": {"doc_ids": ["69f65619-31a5-436e-8514-5a3358d7cc8a"], "extra_info": {"page_label": "159", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "df0bc6fe-91d7-4636-8ca4-3cb82145452c": {"doc_ids": ["a339d175-9f2f-4286-8df8-b827aa8052e4"], "extra_info": {"page_label": "160", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "1b6692f0-8a9d-41a3-a424-2ab79a89e903": {"doc_ids": ["5c356633-8bd2-4c3b-96cd-dc3090a51ee2"], "extra_info": {"page_label": "161", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "4532fb0b-cf8b-4269-b405-503f8fb21bfb": {"doc_ids": ["d035fb34-e0bd-4473-b28c-e077f6366d26"], "extra_info": {"page_label": "162", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "ca0defeb-721d-472e-ba3e-e8c97b63728d": {"doc_ids": ["4d64e628-d162-4f7f-b951-aab596d6ac8a"], "extra_info": {"page_label": "163", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "a7a37174-b2de-4619-83cb-e3b5b2880308": {"doc_ids": ["315b0654-5bc1-4674-8414-2c3e87a31f7a"], "extra_info": {"page_label": "164", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "a650ba24-99fa-4529-a655-6a9758b749b4": {"doc_ids": ["3d0ba866-d086-4bd5-870d-5b2f92d40455"], "extra_info": {"page_label": "165", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "9aaafd07-0dbe-46de-a807-db2bddb5a1ef": {"doc_ids": ["6582dcb7-595e-40a3-a6c0-1aadef7ddf84"], "extra_info": {"page_label": "166", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "a7bd2634-f8bb-4d1b-ac1b-35dfa5812c95": {"doc_ids": ["c1e0c52a-c5b5-4370-b827-d53c2b3a867c"], "extra_info": {"page_label": "167", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "d34d95b8-067b-42f3-b33c-37f03d4c5084": {"doc_ids": ["6a611048-b180-40c6-bd2a-02336d3e8f15"], "extra_info": {"page_label": "168", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "c5600311-5653-473d-9907-f058f7dc1ef7": {"doc_ids": ["350e660c-cc0a-4404-9499-c244ad0d4894"], "extra_info": {"page_label": "169", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "f82acea8-6960-4f77-a05c-8f0c29235005": {"doc_ids": ["02b27095-f917-4771-a801-c877a05f42cd"], "extra_info": {"page_label": "170", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "80a4a387-9259-4822-833d-f441f61427c0": {"doc_ids": ["3ac32094-2721-4188-99f0-daeee4218072"], "extra_info": {"page_label": "171", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "5042599c-c5b2-41c4-865f-294fd1925747": {"doc_ids": ["5ddd90b6-0ef1-4a86-b1bc-866f8a652e91"], "extra_info": {"page_label": "172", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "2e6e0ddb-3fb5-43f6-8ff2-6ff2db2bc415": {"doc_ids": ["6d31e838-0687-4217-bea7-3fb781aa3955"], "extra_info": {"page_label": "173", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "97fe2a42-c7f5-4791-ad62-fed15a8a09af": {"doc_ids": ["086d644f-2fa3-4f06-89a8-eaed7cd72d66"], "extra_info": {"page_label": "174", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "c47da29f-03e2-4faf-8ef2-3ac153b0b948": {"doc_ids": ["46b636c7-e330-44a9-9aa0-780a8766a29f"], "extra_info": {"page_label": "175", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "921179c8-13e4-4498-a53e-7da71168f8c1": {"doc_ids": ["cd21c50f-3f89-4a54-b70f-7407feb6c49d"], "extra_info": {"page_label": "176", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "820b7bb8-8cc0-4e8c-8361-b073814eccf6": {"doc_ids": ["0d9138ab-2b79-408f-9a80-d54b2858e3c0"], "extra_info": {"page_label": "177", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "1a5bd254-3c5f-49e4-9bfa-0ea7c3d3b5d6": {"doc_ids": ["2b8574ae-5832-4318-9b35-9bfe1848d4d3"], "extra_info": {"page_label": "178", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "9e634128-7380-4a31-a476-e59b006ae219": {"doc_ids": ["048e91f7-1f34-4108-8461-7357f411ec8c"], "extra_info": {"page_label": "179", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "c95dadce-0036-46f6-b922-f1f7b144ab7b": {"doc_ids": ["fdb3d070-5f97-42dc-b203-42e13a390eb3"], "extra_info": {"page_label": "180", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "b282b006-a3a4-4a9a-9568-1d3813d96331": {"doc_ids": ["79964e7d-753c-4bcf-9ccc-0857a8ec6fdd"], "extra_info": {"page_label": "181", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "5083885a-9e33-4ae2-be1f-52c17e1fa7f8": {"doc_ids": ["36599981-7c10-4754-bcbc-fa8c3a4c5250"], "extra_info": {"page_label": "182", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "09a94798-b5dd-4e28-9466-2b11935e44c6": {"doc_ids": ["768cde1b-338a-449b-ae05-e9bf33a98c95"], "extra_info": {"page_label": "183", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "a85ae421-1251-43ab-8257-3fab2e49558d": {"doc_ids": ["437ca213-3e31-4af5-a4af-ba1545617685"], "extra_info": {"page_label": "184", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "4f75d18a-c65d-463d-9461-119a7a3b82fe": {"doc_ids": ["208ec19a-4dd1-4e8f-808b-3ee20326c850"], "extra_info": {"page_label": "185", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "f716064f-54d7-4f7c-870d-db6731765726": {"doc_ids": ["dba5a09e-73ff-4b8a-8324-6d947a264f4d"], "extra_info": {"page_label": "186", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "74b779e1-c56e-49a1-8d6f-f85520d7b423": {"doc_ids": ["146f4ac1-4a75-400e-b4ed-a42d86c03abb"], "extra_info": {"page_label": "187", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "da89ba99-0217-4f36-bd95-dec10a8a8807": {"doc_ids": ["afbdbf0b-6cb8-4278-a79c-ebba78488041"], "extra_info": {"page_label": "188", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "fe17b061-dbd2-4cf9-a76d-aed523ba3e70": {"doc_ids": ["9c3c0c97-2d33-42b1-8414-2833b98aa0a0"], "extra_info": {"page_label": "189", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "d2de1fa2-3ff9-47cf-a2e0-0ebc5f0b3ab6": {"doc_ids": ["ac44f9b3-890c-48cb-9525-3c59b89daa19"], "extra_info": {"page_label": "190", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "884cb8a4-2841-4183-b584-7ff5cda2f74e": {"doc_ids": ["bd98800b-5875-4fb6-9ab1-4824d1d8fd91"], "extra_info": {"page_label": "191", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "3c8f4483-6048-46d5-934b-4b032c978045": {"doc_ids": ["effa2022-a3d1-4a01-93b9-897f0367d2b4"], "extra_info": {"page_label": "192", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "4b4ab300-c2c6-4867-a345-ebee1456000d": {"doc_ids": ["88c0f168-4f42-4fd8-8cdd-2252ca91cb35"], "extra_info": {"page_label": "193", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "43eaba79-dcfc-43a2-86d9-e67d4fe5b27a": {"doc_ids": ["56690117-6aed-43c0-baf0-21866cdea389"], "extra_info": {"page_label": "194", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "af36c7fe-2446-4921-9a75-d542a14d1818": {"doc_ids": ["a2e94e84-706f-4a8e-84f0-76447c6ade76"], "extra_info": {"page_label": "195", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "807f6830-5174-48b0-85e2-1e4e94baf25e": {"doc_ids": ["d48b967d-868b-453b-94ba-7d2db382b54f"], "extra_info": {"page_label": "196", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "4deca681-0f42-45ca-864c-a891f789d3a0": {"doc_ids": ["ce03992b-30f2-42f4-aa58-5e12f9caca19"], "extra_info": {"page_label": "197", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "a3c57a4f-3b7f-4752-854e-1402f2d8e1fe": {"doc_ids": ["0a3db01c-a9db-471c-bab3-85a7345788c0"], "extra_info": {"page_label": "198", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "cecc755e-4e1f-4326-b872-70d8416a8089": {"doc_ids": ["e116152e-ccd1-4eed-aa75-3f3b9803e491"], "extra_info": {"page_label": "199", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "d6cd24f2-26db-4ed8-a41c-977b84d21f43": {"doc_ids": ["8ef4c21e-70d7-4943-a4b8-cd45d2202813"], "extra_info": {"page_label": "203", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "3cab2bf7-6485-4244-a1f2-66a920a972d5": {"doc_ids": ["36039e26-b65d-4e63-8df1-9e8924b4c2d3"], "extra_info": {"page_label": "204", "file_name": "Humana Gold Plus (HMO) - Evidence of Coverage.pdf"}}, "b545e59c-7d2e-4083-942b-1bb5a07252d9": {"doc_ids": ["399e1b13-9b90-4a13-ba9d-7e770c8316b8"], "extra_info": {"page_label": "1", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "174a73e0-48ee-464f-b096-d42386dce72b": {"doc_ids": ["5146e307-0663-4bd3-a4b0-2a78e3c6b455"], "extra_info": {"page_label": "2", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "b4256e63-cadc-4267-9e50-0d9a3ac6e583": {"doc_ids": ["2dce3d28-64d9-4aec-b228-7be44916c007"], "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "58a98e6c-6583-4c89-9d2a-4f6e3470136c": {"doc_ids": ["054cc4bc-ca4e-4932-8ed2-f176ac82593c"], "extra_info": {"page_label": "5", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "dedd53a2-9955-43a4-b487-b2079a3558eb": {"doc_ids": ["582fe9b4-52be-4449-a8bb-1b0c9424c05a"], "extra_info": {"page_label": "7", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "5f68319b-4c0d-4d78-8e72-fdaffcc68721": {"doc_ids": ["25954946-06bd-44e0-85d5-cbfa29f7b6b8"], "extra_info": {"page_label": "8", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "10c3b9d1-171d-47f2-8fa3-91ed85d01645": {"doc_ids": ["97d8ef1b-2cdb-4bbb-bb15-0b00107dee59"], "extra_info": {"page_label": "9", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "544f69fa-b053-4b1c-9703-fa89c2a02c28": {"doc_ids": ["d7d70d22-97a1-4573-9ecf-253d1d3bf1e0"], "extra_info": {"page_label": "10", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "fd7499f4-2259-44b6-9b27-42746c425901": {"doc_ids": ["d1bbf49b-2281-451a-b7fc-e320974bf014"], "extra_info": {"page_label": "11", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "966bacbe-d9e7-4dda-b7ff-7e730254403e": {"doc_ids": ["6218d87e-b417-4a6f-a01e-a0d228cdd9d4"], "extra_info": {"page_label": "12", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "ef812af2-ba1c-4900-82b0-4ff292578afe": {"doc_ids": ["c8c48b14-9549-469e-a855-d6ca729d02c4"], "extra_info": {"page_label": "13", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "510c1dcf-5ff9-407d-a25b-6f6fce06cb11": {"doc_ids": ["aaa35494-00df-482c-ae36-408b50eeba13"], "extra_info": {"page_label": "14", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "8a81d30a-fb05-46f2-b486-3923c7966585": {"doc_ids": ["c086ed68-dc79-4426-a026-ca1d4361b5c3"], "extra_info": {"page_label": "15", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "45bbce71-1d4f-4777-9b76-469978086d5f": {"doc_ids": ["f2ec1d4d-ef35-4f48-960e-14ff324b773b"], "extra_info": {"page_label": "16", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "31f37692-0992-49b9-8919-c24d914a667f": {"doc_ids": ["a3651ada-701c-43c1-81c1-c68827a22ba9"], "extra_info": {"page_label": "17", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "c6f9c487-c132-4e8f-9115-a0247c8a6bb0": {"doc_ids": ["6524a92b-3aa7-4d49-aab4-b26473ecb489"], "extra_info": {"page_label": "18", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "6c73d408-bf30-454d-876c-020652c30d26": {"doc_ids": ["e04a8cff-3fc4-49b4-ab5e-ae34962a56f7"], "extra_info": {"page_label": "19", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "e5fdc819-83a7-4408-b9b3-d9603860111a": {"doc_ids": ["292ebe4d-026c-4028-9f7b-d8e70bf4dc26"], "extra_info": {"page_label": "20", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "7c0e5279-d099-49a9-a1a5-c6bbc4de70dd": {"doc_ids": ["1875fec4-33f1-439b-8717-6d8abeaa6b35"], "extra_info": {"page_label": "21", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "9b745e95-5f45-484e-a2cb-f1f51ec7d7c9": {"doc_ids": ["3def36cc-7ce6-4b6a-8073-a398a5ba7416"], "extra_info": {"page_label": "22", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "dacde70f-6303-498f-88c4-228258ad41d6": {"doc_ids": ["c865e206-e2c6-41bf-ad98-e9132218de45"], "extra_info": {"page_label": "23", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "c643571a-869b-41aa-b4b7-642c04a97188": {"doc_ids": ["0aa5601a-76f6-4cba-8d45-a59a9c7487ce"], "extra_info": {"page_label": "24", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "544b24e7-9c5b-4ad5-b763-a94d9c2f994c": {"doc_ids": ["266f9258-2e26-41bb-98b5-148e40dbddd2"], "extra_info": {"page_label": "28", "file_name": "Humana Gold Plus H0028-014 (HMO) - Summary of Benefits.pdf"}}, "4ac916dc-319f-4d53-98fc-291a6745fcd1": {"doc_ids": ["c4662c05-8b90-4253-afa8-deb2f3bf7d04"], "extra_info": {"page_label": "1", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - CMS Plan Rating.pdf"}}, "4b3cc256-c207-4841-aaf4-6aeb02f3594e": {"doc_ids": ["cba63cd8-c1e7-4c53-9efc-ad0c6248575b"], "extra_info": {"page_label": "2", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - CMS Plan Rating.pdf"}}, "6510f538-9d4d-445f-8c3e-8beac6916d13": {"doc_ids": ["8e9a420c-457a-4ccc-8fef-a33a80b742ef", "a4d96eca-a09e-4053-adf2-909de068a966"], "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - CMS Plan Rating.pdf"}}, "482d3eae-6f93-424b-a9bd-f48f4f155571": {"doc_ids": ["0ce22cc3-d2f0-4f13-aaa7-a6499b2e5c66", "83ca32df-ebb5-439e-9950-9d1b38d734e0"], "extra_info": {"page_label": "4", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - CMS Plan Rating.pdf"}}, "3b3bae26-2679-4d69-b4ac-241fad854b4a": {"doc_ids": ["7c6df006-37c7-4905-b5e8-862cd798a946"], "extra_info": {"page_label": "1", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "b96b03ce-619e-4b51-a791-a81aeedb0b2e": {"doc_ids": ["ed5c060f-3acd-4c08-b953-cfd0ffc4eb7f"], "extra_info": {"page_label": "2", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "0f560b38-6656-42ea-9cac-25ac01665a69": {"doc_ids": ["4f19a4dd-2c70-498a-8739-6f7347008a6d"], "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "9219484d-514f-46a0-99fa-8a83302f3717": {"doc_ids": ["1c4df0fc-d6c1-46a0-b2f0-b0048b80b31d"], "extra_info": {"page_label": "5", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "03bbb391-4b4b-4d5d-a7fb-4563444c9d3c": {"doc_ids": ["770b0281-0bc7-453c-bfde-45051bf615f4"], "extra_info": {"page_label": "6", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "59d89076-9535-4e90-b0bd-1f17a9a40fd5": {"doc_ids": ["e9f2d3c1-ea76-4ef5-9b7b-6a4dd16b1460"], "extra_info": {"page_label": "7", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "5ced7010-2d4c-47d3-a51f-4f9d3c421a23": {"doc_ids": ["ef65b35f-6994-41d8-9b53-d42c9d901d82"], "extra_info": {"page_label": "8", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "a706f6f5-e5ee-4ff7-830a-4ee3707013f4": {"doc_ids": ["9c14e2fa-59f4-4276-a693-040506d7a050"], "extra_info": {"page_label": "9", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "4805c533-3b25-4edc-bf61-49a4bccb5ecb": {"doc_ids": ["3917d8fb-1219-42f9-bfff-a8c4fd32de3a"], "extra_info": {"page_label": "10", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "e52e8c07-f7f5-48a8-ac35-02b9add8bd47": {"doc_ids": ["1bd2f048-fa74-4899-afb8-6cf350ad8360"], "extra_info": {"page_label": "11", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "9c59b63c-fe5e-4b6f-9fd5-b1049d2baa06": {"doc_ids": ["11552297-9775-4182-877c-cdd447200c6a"], "extra_info": {"page_label": "12", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "a7efc45e-2821-4e4e-993b-36224131874a": {"doc_ids": ["5359b1df-7b03-4348-858d-0f38480af92b"], "extra_info": {"page_label": "13", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "8aef6527-0a81-4f37-bee1-eec9b48a2eb6": {"doc_ids": ["acec41fc-1d9c-4fa6-825a-f4af1b11cc95"], "extra_info": {"page_label": "14", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "81eecd6b-b598-47bb-b934-87e50e9ec70d": {"doc_ids": ["ba0ffb7b-ba0a-4742-b09e-29a347f58953"], "extra_info": {"page_label": "15", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "84cb59ad-8699-4c1f-a8d3-5c769454edd0": {"doc_ids": ["bf856344-20bc-4910-8446-84ac2d0af108"], "extra_info": {"page_label": "16", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "fa4c7ccf-727f-401a-93e5-7211d33e0564": {"doc_ids": ["16bea5c7-26b3-45f3-a36e-d40916854ca7"], "extra_info": {"page_label": "17", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "4b842583-60ab-45f8-9251-7bcc388758a7": {"doc_ids": ["23627685-7dd3-422b-a345-ed6ce85f3dd1"], "extra_info": {"page_label": "18", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "b9346e9d-e13f-4afd-bdca-adeedfd3fc61": {"doc_ids": ["ebfad792-9703-435e-97a1-29407e16dcdd"], "extra_info": {"page_label": "19", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "436fda78-8e7b-4ded-a029-eb6d6a121339": {"doc_ids": ["19cb383a-6e7d-45e7-9a77-5d34751699ec"], "extra_info": {"page_label": "20", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "a775a1dd-094f-4d00-8f39-f1cc79afe210": {"doc_ids": ["cf2802a1-d684-46d9-9c84-564caff4eaba"], "extra_info": {"page_label": "21", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "a383b9ee-818d-443b-aedc-6a61db937df1": {"doc_ids": ["62594afb-fb73-48bf-a325-b47fe8340cfd"], "extra_info": {"page_label": "22", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "6373c8a1-70fa-4cf0-8028-a46de1e70f13": {"doc_ids": ["968bea49-ccdf-437f-bd83-1ed8e24a6c35"], "extra_info": {"page_label": "23", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "11eaf81e-caac-43ec-817b-ff6cfc101f98": {"doc_ids": ["d036c21c-9f61-4b53-8c16-36a7d3f915f1"], "extra_info": {"page_label": "24", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "56282b31-05c6-4fad-b366-5c27e8e7705d": {"doc_ids": ["71bdcd9a-c8b2-44be-a385-de930f68a9b6"], "extra_info": {"page_label": "25", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "40ffceba-1735-4058-881d-47ed34d9435d": {"doc_ids": ["ef9029fd-114b-43c6-a537-77f1fec04d95"], "extra_info": {"page_label": "26", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "f7d2b211-732f-4d96-af71-8f3d76bcec6f": {"doc_ids": ["62cdc4a0-c6ad-431f-8f82-cba2dcdc15bd"], "extra_info": {"page_label": "27", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "ccd87f54-0401-44d3-a6d9-4e7d0f15e92e": {"doc_ids": ["f82596c3-c19f-40f7-8828-b84ffe88b6fc"], "extra_info": {"page_label": "28", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "bcfcbb84-3773-418d-b919-584da9309e02": {"doc_ids": ["93596e62-e3be-4ed1-bfc4-94a314039bf6"], "extra_info": {"page_label": "29", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "e961ed54-2513-4b47-8af9-3d930b6c4c2a": {"doc_ids": ["3b357ffc-b856-4212-81b5-0609dabab13b"], "extra_info": {"page_label": "30", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "c88d1f96-f076-400d-b3f8-d2aa917ed864": {"doc_ids": ["ae916781-e6be-4272-9c54-45db2b9a664a"], "extra_info": {"page_label": "31", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "23bd0390-9873-4f79-b39d-7986091b95c9": {"doc_ids": ["c08db8e3-ab5a-4c10-a9ee-e2bb85709daa"], "extra_info": {"page_label": "32", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "e4cb947a-e679-4dc4-8731-da11ef37cf79": {"doc_ids": ["9a36e625-f683-4a1b-bbec-697b992794f7"], "extra_info": {"page_label": "33", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "ffd50294-da1f-49db-a69d-b11603a71f48": {"doc_ids": ["33a25cd7-cf85-4263-a8f7-102d86cfdadd"], "extra_info": {"page_label": "34", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "61965537-de19-451e-a2b8-9a50a00ea209": {"doc_ids": ["7fd25ab4-ea61-47f9-9033-ea67f0d49324"], "extra_info": {"page_label": "35", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "3cfd0ae8-d695-43f3-b76d-e9aad7687d5f": {"doc_ids": ["75a33a43-b930-4877-846f-c5d310c1c613"], "extra_info": {"page_label": "36", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "66b580d7-8fc7-4173-a9b0-017b9f33f715": {"doc_ids": ["7720db1a-981a-439b-910c-7610f516658c"], "extra_info": {"page_label": "37", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "0d870915-aac8-4d37-b3a2-5d0d8e5684fa": {"doc_ids": ["67261a6f-041a-4255-ac1a-372398279eb4"], "extra_info": {"page_label": "38", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "250c7ab8-5d0d-4b6e-8f13-ddf200acb4de": {"doc_ids": ["057d0cc5-390c-42a0-9179-9aa280b54655"], "extra_info": {"page_label": "39", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "0b4c10e3-330e-4e9d-abb6-2270e73d033c": {"doc_ids": ["b830e29f-0025-40bf-871f-5a248ee05e11"], "extra_info": {"page_label": "40", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "218850bc-f4bb-4d34-9605-5e32f0eed11b": {"doc_ids": ["f82950aa-13a3-4d92-8581-3f337b8ca2b3"], "extra_info": {"page_label": "41", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "3d966de5-0ad6-4fc5-afa8-d5fb5bea8dea": {"doc_ids": ["92714847-823d-4e9b-a692-ae772e3100ef"], "extra_info": {"page_label": "42", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "d46063ca-d326-4e2e-8d41-3d1e45e3e916": {"doc_ids": ["fe6acd69-aeca-49b2-8e58-abb529861667"], "extra_info": {"page_label": "43", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "618f0b0e-0280-4ebd-b425-573356244342": {"doc_ids": ["ea08f880-5959-4f42-843a-759909ba4627"], "extra_info": {"page_label": "44", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "6b93020e-4ea3-4496-99e1-afbfeaa282c2": {"doc_ids": ["6bdce02d-1170-4c34-bccc-cb1ce2ee6e95"], "extra_info": {"page_label": "45", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "04411f5b-c85d-4e3a-afbb-8f8ca753af40": {"doc_ids": ["4af395e5-fbed-48ef-a802-384fc9e326b8"], "extra_info": {"page_label": "46", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "89279d59-07b1-459f-bed9-7601d10cf5ff": {"doc_ids": ["2354cce8-c467-4733-8f9b-7a8e46a8902c"], "extra_info": {"page_label": "47", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "ef37630a-9d87-4041-8339-9d48ef7f8923": {"doc_ids": ["c8df2a36-4b2c-421d-8de4-58bc4ff3a7b0"], "extra_info": {"page_label": "48", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "7fe7fa3e-23a2-4076-bdf8-e92d32af9bfe": {"doc_ids": ["9dd70010-7db0-4566-875e-8974383537b8"], "extra_info": {"page_label": "49", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "26aad095-9fe3-487b-b7cd-233458e193e1": {"doc_ids": ["b785d575-d7a2-472c-8328-30337dedc998"], "extra_info": {"page_label": "50", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "94cc97c7-300c-4ecd-a8a8-afd424e6fe58": {"doc_ids": ["7459cb47-7189-47c2-a2e6-f9e8ad28f77c"], "extra_info": {"page_label": "51", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "32e6b1a4-8f47-4d5e-ac52-0b5af7f73a06": {"doc_ids": ["3e0c3e02-8db7-4ea5-b8c3-05cec088f1e3"], "extra_info": {"page_label": "52", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "cf9febae-13d4-4a70-bcbd-b5b361261269": {"doc_ids": ["da8fad0b-a3e2-43b1-b2db-0cc2680e9654"], "extra_info": {"page_label": "53", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "f843f40c-ec1f-4f08-aae5-447eb2f53fd0": {"doc_ids": ["34f48f9b-b30a-40d4-8b21-d1df1f577275"], "extra_info": {"page_label": "54", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "afb7f9b4-0557-4b6c-abde-0615f548a017": {"doc_ids": ["cf3addc8-8a38-442f-8b55-0a9bc128f7e7"], "extra_info": {"page_label": "55", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "44cf9109-923b-4e43-a620-986b8a529727": {"doc_ids": ["d436f246-9f9a-4f36-a242-1dc088c921b4"], "extra_info": {"page_label": "56", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "2017b307-5093-44d6-bcdd-85767ec7023e": {"doc_ids": ["69b170a8-a1f5-4ca8-aaf9-82fed26ce484"], "extra_info": {"page_label": "57", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "a13f7229-c6d5-421c-b873-6f6ba0ea357f": {"doc_ids": ["b745cec2-2f12-41ec-8bb2-9369706c16e2"], "extra_info": {"page_label": "58", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "258369db-6c9c-40de-9132-6b93d5c87879": {"doc_ids": ["0e3720f2-238e-4ad1-98df-2e3216f0877a"], "extra_info": {"page_label": "59", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "d60374bd-9b21-4e85-8ae9-70ec300ee0d4": {"doc_ids": ["e9baef76-3520-4219-b948-3749a65f49ab"], "extra_info": {"page_label": "60", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "16e4c4dc-0fd1-41a0-a1de-8edcfbe03f0d": {"doc_ids": ["771ec08a-ead4-4e8c-9fa2-d371b0c0747a"], "extra_info": {"page_label": "61", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "0576b29b-5e00-4809-90de-a5d8d4ed643e": {"doc_ids": ["25291b76-c034-4202-b772-b21b04a00398"], "extra_info": {"page_label": "62", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "62f5c672-f3bf-4871-9ba5-1fab45527137": {"doc_ids": ["92ff0a4c-3152-4152-871d-2ce28215f8e7"], "extra_info": {"page_label": "63", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "59e085da-64aa-48e3-8376-04ff018abdcf": {"doc_ids": ["2a657811-d7b6-4d58-8bfa-d2938b2a519b"], "extra_info": {"page_label": "64", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "6c1b0711-7477-47a6-b17d-b611cc0e5ee7": {"doc_ids": ["70345a82-0217-471c-9031-5119e047d3a1"], "extra_info": {"page_label": "65", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "0ceaf771-8c0c-4a33-a6f5-f5456143c647": {"doc_ids": ["b04974f1-8e5e-439b-9d24-f6ae9b26b059"], "extra_info": {"page_label": "66", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "e0b19272-5427-47cb-9bb9-95139ad8c3fc": {"doc_ids": ["5b8b1ec9-54a3-4031-8944-f5c76a2b07ec"], "extra_info": {"page_label": "67", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "360f886a-27c3-40fe-83bf-2306d46050a1": {"doc_ids": ["e302e844-2ebe-433c-b00e-7b25cebe466d"], "extra_info": {"page_label": "68", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "5c49e22a-64eb-48d5-8876-811a6a5d8da6": {"doc_ids": ["a1f2a676-06df-4fc9-a467-6660c1abebed"], "extra_info": {"page_label": "69", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "59813012-8b2e-4709-863d-a9216907ec7b": {"doc_ids": ["babd7430-5d88-48a5-ba0b-769f201af186"], "extra_info": {"page_label": "70", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "934b3f04-0fd5-415c-b746-ad733055737a": {"doc_ids": ["0de7fc24-190c-493e-ae68-fdba07b744d1"], "extra_info": {"page_label": "71", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "749d9153-134e-40c8-8fe7-cd55fc8e56d9": {"doc_ids": ["5ebc8cc2-b0c1-40be-b08c-f63e1bf12ee0"], "extra_info": {"page_label": "72", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "84e62828-a4af-46e5-b397-637ebe5c1f77": {"doc_ids": ["8ba6fb9f-3903-4293-9514-9eb8adb0f1a0"], "extra_info": {"page_label": "73", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "d2b7d5a7-f229-44ec-bb73-a1f5acd69a3d": {"doc_ids": ["cd9203a0-bbad-4dd4-97b1-7747acb75b4b"], "extra_info": {"page_label": "74", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "97ea8c55-3378-42a5-8d9c-d8a90eb5bf38": {"doc_ids": ["8cc2d788-d523-48d7-87ec-40546b6a86f0"], "extra_info": {"page_label": "75", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "6bbb5786-d069-4820-8cfb-ef41df5ebaf5": {"doc_ids": ["1867fd7b-0296-4971-bfdc-a5288f55211b"], "extra_info": {"page_label": "76", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "bff0204d-9979-4181-9a8b-13f87a5515dc": {"doc_ids": ["f6dacc57-4ba9-460f-a22b-74d8d1aa919c"], "extra_info": {"page_label": "77", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "1849de7d-16ee-43e9-a046-b93ae74bd7c9": {"doc_ids": ["37acf63e-e4ef-4feb-9786-bb13dc868781"], "extra_info": {"page_label": "78", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "8f90fb16-e21e-420d-a1f1-2a1a328443e1": {"doc_ids": ["2e04d189-3a71-4b4d-9ae4-8d1c837f4d39"], "extra_info": {"page_label": "79", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "45e3b0aa-015a-49fe-a240-fea8a328564b": {"doc_ids": ["3eab93a1-37e0-42f4-b0bc-cbacb783683e"], "extra_info": {"page_label": "80", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "b9b2128b-d471-41b7-8004-9fb4f8c646b4": {"doc_ids": ["3da22e1a-3ecd-44c8-8b67-c4f3fa32fbfd"], "extra_info": {"page_label": "81", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "f9e923bd-c5c7-45b9-827c-077cebe35dac": {"doc_ids": ["c827e761-8ff6-4a77-8916-ff445c0ae97f"], "extra_info": {"page_label": "82", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "44d3251a-2d18-44bd-855d-d8cd31ac32c9": {"doc_ids": ["65e3eab6-3a3f-4c9d-87fb-a8934fc64a02"], "extra_info": {"page_label": "83", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "c4bb568f-006a-4adc-a56f-5ec5b54f3438": {"doc_ids": ["f9e86776-5bfe-4cde-b500-95eca73208e6"], "extra_info": {"page_label": "84", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "e31c649e-73b0-453e-8092-0f94482cd098": {"doc_ids": ["77ef3256-49b7-4f23-8640-a3a986a374bb"], "extra_info": {"page_label": "85", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "b99d4fc7-9452-4a88-a056-e71f2e9c8bfd": {"doc_ids": ["7cbe2f49-3d38-4f08-953a-54ff912c91d8"], "extra_info": {"page_label": "86", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "29a23499-5b04-4646-b1ec-73d6ea9241ca": {"doc_ids": ["8bcfff8e-b465-40a1-a6a5-77110cf7f91c"], "extra_info": {"page_label": "87", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "416e82dd-6bc0-4ce3-97ef-ea6400ede39a": {"doc_ids": ["f2ef8d67-7f54-4bdc-9e43-9ce946af1b6b"], "extra_info": {"page_label": "88", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "5b8f4140-266d-400b-8e44-0a1add4f54ce": {"doc_ids": ["a3d30657-60cc-4250-be6a-7fba88f9dbe0"], "extra_info": {"page_label": "89", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "42bfff9b-9c25-4385-acf4-244125f691e8": {"doc_ids": ["b720dfda-1526-4c85-81e2-46b4aad1de7f"], "extra_info": {"page_label": "90", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "2ccd8a58-b19c-4aa3-bcc2-c8b922fc1694": {"doc_ids": ["8a4dd8a2-747a-404b-9513-4fe7830d30f4", "3abc471b-6f18-4eac-b6ea-c18b4ec1a19a"], "extra_info": {"page_label": "91", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "9d57e201-fe3c-46ba-85d6-f7559fbb1d0c": {"doc_ids": ["a4c9f06a-62d0-4080-aaf2-760c78cf0400"], "extra_info": {"page_label": "92", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "ebff97c3-a7e0-4422-a33d-ec441c202fc3": {"doc_ids": ["554aeb20-bd3b-4e16-b481-6498d189933f"], "extra_info": {"page_label": "93", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "f7b53843-b7ad-494a-b357-28eda3ae9bc7": {"doc_ids": ["704aea51-1dac-4b3e-8f7d-e569d47bceb0"], "extra_info": {"page_label": "94", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "cf8444cc-83bf-4fb5-824a-9311ba0090ab": {"doc_ids": ["fbce9b0d-19e5-43b2-a508-d1880a608def"], "extra_info": {"page_label": "95", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "6cc43358-0eec-49fd-b048-dbc55893946f": {"doc_ids": ["437e32e8-aa13-4b29-9877-c683b522e84a"], "extra_info": {"page_label": "96", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "1918193b-cc28-4ce8-bf80-30cc3f5c6c6f": {"doc_ids": ["f244d19d-0a15-422a-9e61-3065b17cf690"], "extra_info": {"page_label": "97", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "837f3afc-a706-47d5-9f1d-10d0b84b427a": {"doc_ids": ["e31a00a8-2539-4b3a-9754-64267526b91b"], "extra_info": {"page_label": "98", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "8461dade-a8c0-4999-8679-7110164daafc": {"doc_ids": ["6225ff2c-d242-4f5b-a40b-e2217e03a1a7"], "extra_info": {"page_label": "99", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "6f5e62fb-5ea4-4e2e-9826-12f28138f0ab": {"doc_ids": ["2e76d6bc-049b-40d1-9ca3-f969631c63b0"], "extra_info": {"page_label": "100", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "56776356-42dc-468d-8fa1-bf8805380591": {"doc_ids": ["5942814d-cd56-47d3-8982-29bfe3186185"], "extra_info": {"page_label": "101", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "47792a3d-13a2-4ab1-8dd2-137025fe3bfe": {"doc_ids": ["65415d54-9f43-43a6-85a1-48bf1e9d6212"], "extra_info": {"page_label": "102", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "e093c856-b912-422e-813e-50e2b05f092b": {"doc_ids": ["41599352-2737-4c08-84c4-e2bf85bccad4"], "extra_info": {"page_label": "103", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "1411bed5-47b7-4ef0-8938-f750b1ce02cc": {"doc_ids": ["39c6f6f6-c75c-4b2a-9e20-401866e441ec"], "extra_info": {"page_label": "104", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "abf5a3d4-e5ee-40c4-8c58-acb5e30c45c0": {"doc_ids": ["fed53ac8-ba52-4852-b451-2607b685d940"], "extra_info": {"page_label": "105", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "2effd3c2-524f-445e-9ba4-82c6a58828b2": {"doc_ids": ["3f8c937e-de43-4299-bb46-41244b9da479"], "extra_info": {"page_label": "106", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "7104ddbd-03f5-4a85-9515-a888ea1d0515": {"doc_ids": ["1159d90e-6316-4341-aabe-d1c0bae59e41"], "extra_info": {"page_label": "107", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "5ba809d3-89d1-41c0-9909-d1133f1bcfae": {"doc_ids": ["84a4427c-5493-436b-84fb-3f058676a05e"], "extra_info": {"page_label": "108", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "2fe869cf-e6cc-4ddb-b046-c581b98dc151": {"doc_ids": ["6745e4fc-928e-43cc-a218-ef44b8df1cf6"], "extra_info": {"page_label": "109", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "c5fbd5a8-c1f1-4f2c-a045-cfcb044df77c": {"doc_ids": ["8d69574d-6e2c-4683-b6f2-8c6988e9587e"], "extra_info": {"page_label": "110", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "e6007b0b-793f-433e-a0fa-f93addf09297": {"doc_ids": ["85ccc68a-0ab0-413d-8a3d-b2f911747cba"], "extra_info": {"page_label": "111", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "641ee814-2572-41d2-b321-e25ad41c3bc6": {"doc_ids": ["4f344f1a-0f87-4601-a5bc-ff5dddee4ad6"], "extra_info": {"page_label": "112", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "d004f951-b0b3-4224-91c4-bf85499b7d94": {"doc_ids": ["3549f939-c86b-48a7-bb0f-f31ce6a19f3a"], "extra_info": {"page_label": "113", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "4f833ec8-0fae-4892-ba47-eeca1f1902d4": {"doc_ids": ["2d77d51f-5986-4466-b65f-528d8fdf5342"], "extra_info": {"page_label": "114", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "9f5de443-543b-4b9d-b700-59fad19d7868": {"doc_ids": ["d0e5f6a4-ed7e-4391-8565-725b90229ab7"], "extra_info": {"page_label": "115", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "d9f8bddd-72e3-46b7-b52a-77642dffc75d": {"doc_ids": ["b79cc9c9-5c3b-479d-9562-4f02faaa730f"], "extra_info": {"page_label": "116", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "080cfcdc-cdca-4926-82e5-f8cd1f79dc37": {"doc_ids": ["d9be35e0-ab5b-4242-8b16-49179da3d0e1"], "extra_info": {"page_label": "117", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "32288a3b-aae2-4dc0-a4a3-b98e9bce57a0": {"doc_ids": ["09a606ca-d949-4811-b9ad-b9dd8c113d01"], "extra_info": {"page_label": "118", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "8ef8f965-8653-401f-9fa8-637eb4fe33e9": {"doc_ids": ["220b96c2-9a76-488c-8457-6f25391d39a4"], "extra_info": {"page_label": "119", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "71407cce-75d1-4a79-8154-a6b18d91f9da": {"doc_ids": ["9dc15862-6691-4c7a-8219-11a627df5bd2", "34034b7d-2c67-4d2e-9c4e-eb7624f5f729"], "extra_info": {"page_label": "120", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "955870ca-cea4-4b08-80cd-025aca2b84f4": {"doc_ids": ["cdd23294-2f78-49a7-9a07-4fc8f9424ce6"], "extra_info": {"page_label": "121", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "0d3f70c7-c292-423d-8064-a7053216c696": {"doc_ids": ["bb4bc1d2-d443-4ce5-9645-9c0b84e37509"], "extra_info": {"page_label": "122", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "35cb2e3e-6a10-47a9-8ab8-ab061f10a990": {"doc_ids": ["39e9e6f2-3334-4914-99d7-cf6c5e0bc4a5"], "extra_info": {"page_label": "123", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "ca1a4570-f7ed-46e7-8254-4c674ec8a5cf": {"doc_ids": ["4904b475-fa7b-4706-8738-f464032dca15"], "extra_info": {"page_label": "124", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "4afc3a2d-9cf7-49d8-a199-49157562715c": {"doc_ids": ["29662bd4-7ed3-47ba-8534-8ce0bec03f77"], "extra_info": {"page_label": "125", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "b0e5d0dd-0cb4-4ad4-a216-7b6fc7dd9993": {"doc_ids": ["f26681f5-fc07-4a13-a5f4-59af4ac8a224"], "extra_info": {"page_label": "126", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "f0854f3a-1b23-410e-bbee-8bbcb3a95b43": {"doc_ids": ["1ecdef50-d72e-4f5b-baf6-7ca6efe32c48"], "extra_info": {"page_label": "127", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "56a34ccb-1230-4398-a1be-4047b59759f4": {"doc_ids": ["00ed1be2-3370-4ac1-b265-8a1f2d26609e"], "extra_info": {"page_label": "128", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "118f0783-de88-4784-88d5-e6569a952627": {"doc_ids": ["b6145b9a-7f0c-460a-82b9-4e90dc6fe9f9"], "extra_info": {"page_label": "129", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "588789f3-a7a3-4a83-a060-9cbd07ea0570": {"doc_ids": ["e74199be-f8be-4647-8dc9-663184b01061"], "extra_info": {"page_label": "130", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "84a4b8c7-feb1-405b-ae25-381c480e5879": {"doc_ids": ["fd29379e-dffc-4ab1-9368-624ccf9e0459"], "extra_info": {"page_label": "131", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "e3b0d3e7-f660-4b82-9078-d74ebcd64c49": {"doc_ids": ["5cf7a6c1-c544-47c5-bbe0-3718b56d3b05"], "extra_info": {"page_label": "132", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "a961b99b-1ffc-4136-9c88-d0210f832534": {"doc_ids": ["4d128bce-5e7a-423b-9cef-30322a6a5317"], "extra_info": {"page_label": "133", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "d15252dd-f92c-4529-9570-fb05f318160a": {"doc_ids": ["a2010ea5-3d5c-4356-bbb8-f529d87eb631"], "extra_info": {"page_label": "134", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "cb3ceb9a-38a3-4639-8970-f43b4b0531b1": {"doc_ids": ["7c6a516f-c027-4dcb-9535-f51590333168"], "extra_info": {"page_label": "135", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "19e41f82-7ad5-46e5-8be5-0bca1d7dc047": {"doc_ids": ["42f88e03-98d5-4c8b-8408-b1da23346926"], "extra_info": {"page_label": "136", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "b41f90d9-db7a-4d0e-b68f-9ba91b67d8a9": {"doc_ids": ["cd32f49e-5ea2-473f-baac-516dd5474591"], "extra_info": {"page_label": "137", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "af45d2f4-a6cd-4e50-87b3-6dde7094047e": {"doc_ids": ["c3aeee3b-f4f7-4446-8936-0a81647cf243"], "extra_info": {"page_label": "138", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "5eca12dc-cab1-4271-bbe9-d6e0d19058f1": {"doc_ids": ["84216000-3711-4ffe-b8cb-13db9ec15e03"], "extra_info": {"page_label": "139", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "31453792-fe49-4abe-a39e-fabc3df8f5de": {"doc_ids": ["bc7533d6-01e1-4728-bb88-a45a5155dd1d"], "extra_info": {"page_label": "140", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "cd6e6069-8236-4141-b1d9-e425e4df6260": {"doc_ids": ["0d47bc0c-e5d8-465e-8e47-100e25880498"], "extra_info": {"page_label": "141", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "0cd937f5-7c18-459f-8ecb-2f7a0e6d68a7": {"doc_ids": ["38255058-e2c7-4956-bf79-a65765fa792c"], "extra_info": {"page_label": "142", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "36e6279b-6442-4137-ae8a-3811045f78d7": {"doc_ids": ["9b00abd3-5df0-4641-9803-38e3f4e805d9"], "extra_info": {"page_label": "143", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "d886fb8f-e41c-4d5e-932c-b34d342149d4": {"doc_ids": ["7e39ea01-fa49-4469-b181-8f768118c04a"], "extra_info": {"page_label": "144", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "cf6c7754-2bf2-4c11-b784-bb3cb24be9ca": {"doc_ids": ["b72fa594-82ae-4802-83cd-93fd89b9e746"], "extra_info": {"page_label": "145", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "2f4b08a4-94c9-4b13-85c1-af90c0027bb6": {"doc_ids": ["d0c0e1b0-a723-4421-ab83-87e870ce6cd5"], "extra_info": {"page_label": "146", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "f77a0e64-a9f2-44f0-b89f-cedfbef10fe2": {"doc_ids": ["c0c8d48a-575d-40f1-920c-8d380e89ca45"], "extra_info": {"page_label": "147", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "0bba286e-cb34-4520-98f9-10da3bfd851e": {"doc_ids": ["3a39838b-7d47-4c33-988f-9d8f4aa99a4e"], "extra_info": {"page_label": "148", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "a99c9c94-831e-43ca-99ad-2215ae11f7ad": {"doc_ids": ["19670c68-a810-4000-839b-4140f28e6bcc"], "extra_info": {"page_label": "149", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "bcff4d9f-5fe1-4fee-be8b-dc7f31c150df": {"doc_ids": ["09b23eb6-db52-4b2b-b416-35c480ed479c"], "extra_info": {"page_label": "150", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "15010ef0-c017-44da-9b50-b2a34972e3b0": {"doc_ids": ["92ea0eab-6000-43c9-84af-69b9d0df0334"], "extra_info": {"page_label": "151", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "d79e78f9-6978-4ab8-8a86-d729d345e751": {"doc_ids": ["0f26c1c1-a7f2-412a-9944-d649961b9f6e"], "extra_info": {"page_label": "152", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "4bfc82ca-f567-42d4-95e5-b3c63ecfed6c": {"doc_ids": ["dd95c1a9-f26a-4793-acd8-a1f771ad1f29"], "extra_info": {"page_label": "153", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "17358d04-2a13-450d-8d23-17f1e0fcc891": {"doc_ids": ["5b823ed9-a08a-40b5-8f18-c1c1d6fc2cca"], "extra_info": {"page_label": "154", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "590250cd-1555-4994-8c35-cb304b1c97d6": {"doc_ids": ["087dfdac-5912-4754-8220-85c06326c33e"], "extra_info": {"page_label": "155", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "a7eb9891-3e6f-45f6-8ffd-6a7eba663823": {"doc_ids": ["35dbbaec-1000-4614-962e-1693ce8a5617"], "extra_info": {"page_label": "156", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "290bf3d4-2eac-43c0-8719-0913776aeb58": {"doc_ids": ["ff45f6f4-c140-4a3c-b3f2-976f68362bc6"], "extra_info": {"page_label": "157", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "f2979cca-f3f1-4c85-9dc7-6b71909e5c11": {"doc_ids": ["21fe6da2-3ffa-41c4-ab0a-c6ba0758eb95"], "extra_info": {"page_label": "158", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "2f7566b9-b47d-4f73-b863-f0675de59f27": {"doc_ids": ["5db1624f-4c2e-4def-85e6-cd469831783f"], "extra_info": {"page_label": "159", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "93fda818-e244-4274-8a21-6eac4fc8af1a": {"doc_ids": ["5cef2e1c-3a6b-46b4-ae02-8f3c2b8f3f03"], "extra_info": {"page_label": "160", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "d08e6245-3ca4-43c1-9ea1-1d826c39ab76": {"doc_ids": ["c1c88df8-94e5-46b0-970d-fec734b6a456"], "extra_info": {"page_label": "161", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "c287ac8e-5547-4afc-85a2-55c18929302e": {"doc_ids": ["037ff7cd-faf9-4039-b272-002847098c25"], "extra_info": {"page_label": "162", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "0295e345-ddfa-4a1b-8eff-425927b618e9": {"doc_ids": ["2e29f716-3177-4d18-81fe-b32ff6cd0d42"], "extra_info": {"page_label": "163", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "5ae8a322-d326-4a55-8302-b1faff5a537a": {"doc_ids": ["1ef58c11-1c14-482b-8b62-370669a9a15c"], "extra_info": {"page_label": "164", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "8582b286-0da6-4138-ad08-3107ffd7f79a": {"doc_ids": ["3840c9a8-bb2f-435a-bce4-f2518e2298be"], "extra_info": {"page_label": "165", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "95099e15-a51c-4805-b7b5-a42074066edf": {"doc_ids": ["e110b059-13fd-4311-bd10-e0f6a7cead5d"], "extra_info": {"page_label": "166", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "6b777d8d-aef8-4d8e-bebe-a087999fbd2f": {"doc_ids": ["2d4e8f86-d9f8-428b-81b2-507a024bc577"], "extra_info": {"page_label": "167", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "fe58eac7-671d-41e3-a5a1-fc342d177fe8": {"doc_ids": ["ff5edc85-32f4-408e-89b9-0fa7f16c65d7"], "extra_info": {"page_label": "168", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "9ece048d-fe7a-4e23-89c9-3aa0e609a4d9": {"doc_ids": ["bb068039-d703-4177-bcd7-cfaf2ba87af6"], "extra_info": {"page_label": "169", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "d6a934ec-1504-4a8e-b92d-a15167b22b64": {"doc_ids": ["bafd7fe2-9f21-481d-9e6d-0421a103b230"], "extra_info": {"page_label": "170", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "5ff7e443-9744-483a-b578-aa5a0d27ac6e": {"doc_ids": ["2e10f53b-680d-4721-b124-8a90470bf9e1"], "extra_info": {"page_label": "171", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "631f9317-f065-47d7-8911-eb035681c3c4": {"doc_ids": ["1ed8d1ae-6f9a-438d-82a6-3176fcf15f7c"], "extra_info": {"page_label": "172", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "e5ec2d86-962c-4ade-a6c0-31b4412b800b": {"doc_ids": ["5e94b18e-d90d-4287-b91b-14420ca0c388"], "extra_info": {"page_label": "173", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "ef9fb24d-3767-4090-be5b-8220237b7c08": {"doc_ids": ["c34a5a78-09cb-40e9-9a41-38ed6cf6a093"], "extra_info": {"page_label": "174", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "13f9dcfb-473a-4a25-88cc-a3645d3b6bef": {"doc_ids": ["884cf616-caaf-437b-a58d-a869d578c1d1"], "extra_info": {"page_label": "175", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "e754db18-3a4e-42f0-a851-9eb873b16211": {"doc_ids": ["ecb2f3d8-14d9-4929-9e00-f7b2c22bcf15"], "extra_info": {"page_label": "176", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "64b810b6-fb40-4562-86f3-39406f51d672": {"doc_ids": ["bcddde01-8764-41de-9b6e-6fad27bf1b0d"], "extra_info": {"page_label": "177", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "12c0f22c-492d-45bb-adb3-2195637e15f5": {"doc_ids": ["1c0a927f-a2a9-4277-b944-8f01e0a3fafd"], "extra_info": {"page_label": "178", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "8da80870-f31e-46d9-99d6-dce3b78796f4": {"doc_ids": ["47063983-667a-4ebe-a082-e053b0472887"], "extra_info": {"page_label": "179", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "37d4574e-cad4-48bb-8b69-db9c5a148303": {"doc_ids": ["99e40e95-7ad7-458c-a9c9-7d3637373c43"], "extra_info": {"page_label": "180", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "f69c2141-d86e-4bdc-925c-6d8f9931b193": {"doc_ids": ["f3937a51-edd5-49c2-ad76-baeeddbb98ae"], "extra_info": {"page_label": "181", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "b7f1b4b8-4e57-4dd7-8c25-03bca6ecdb2c": {"doc_ids": ["251dbc5f-be3d-46c5-b787-eb912317726d"], "extra_info": {"page_label": "182", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "51da49e5-6763-4acb-87cf-876d154928d9": {"doc_ids": ["9f6b5c3a-aa0c-43cb-896a-c87f0ef71104"], "extra_info": {"page_label": "183", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "9cee441f-2b4e-445e-8fae-3115bc05d523": {"doc_ids": ["805b6d5f-1dec-4763-bf3d-318df8061aa3"], "extra_info": {"page_label": "184", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "28c40e9c-1430-48ac-88ea-6ab22cad52d2": {"doc_ids": ["bac08d9e-9d1d-4bf2-a234-aae972675994"], "extra_info": {"page_label": "185", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "ac3462f8-06a2-4f85-ac0e-e0653d1b4538": {"doc_ids": ["6dc6e153-30b0-4a10-bc23-4b20495e0431"], "extra_info": {"page_label": "186", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "14d54e81-6d48-4813-81d2-158dc456e8de": {"doc_ids": ["42cb96d2-bf79-4acf-b708-cc0fb03ea4bf"], "extra_info": {"page_label": "187", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "7f82ba6f-0fd0-4977-87eb-b14ed646812d": {"doc_ids": ["b62e5a4b-d542-44e8-bfdd-389780c87a95"], "extra_info": {"page_label": "188", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "8790262d-3f30-468b-9bff-de566cb7c570": {"doc_ids": ["7c33220a-e72f-4a21-9153-075a124a07ff"], "extra_info": {"page_label": "189", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "8ac6cb8e-d80a-4c22-8d7b-35f2cd0b7500": {"doc_ids": ["6a47ec3c-5055-4089-96d5-169ae3f4ab3e"], "extra_info": {"page_label": "190", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "f9b74f6c-594f-43b3-be3c-2636b36f7b74": {"doc_ids": ["ba6e6b92-0baa-49cb-94dd-312564b564b8"], "extra_info": {"page_label": "191", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "e860fbb1-9133-4256-8a33-592f8e569053": {"doc_ids": ["a7730fca-47c4-43d4-bde4-e3e92e2ca435"], "extra_info": {"page_label": "192", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "fd951588-6bb7-40b9-b69c-66e04fd7b003": {"doc_ids": ["9f733625-5e72-4c55-8cce-bbbd92dfa9df"], "extra_info": {"page_label": "193", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "71f392a5-e16e-4f81-8ae2-c4aeb18934c2": {"doc_ids": ["1f95c5d5-a972-45a3-b432-1992a5791ec0"], "extra_info": {"page_label": "196", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "5028fb87-dec4-49f9-8d6a-0ee4ac093852": {"doc_ids": ["efc52289-b9a4-4d1e-8a5d-4d34e31d44b7"], "extra_info": {"page_label": "197", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "1a2b86bd-c055-4719-8917-2d16ddfdf24d": {"doc_ids": ["c45cbb7e-c0bc-4880-b1b3-0249d30cc7c4"], "extra_info": {"page_label": "198", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "d679c472-50fc-4e97-85c1-0cb5f883b2aa": {"doc_ids": ["18997e9f-1a64-4181-ba31-3411692b1280"], "extra_info": {"page_label": "199", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "aa5cbdf4-77d8-456e-ac32-af1f6abed965": {"doc_ids": ["dc66946a-e8dc-4c79-9ff5-78c72ce07ef4"], "extra_info": {"page_label": "200", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Evidence of Coverage.pdf"}}, "9be79619-07c4-4908-86f5-c7786f59947a": {"doc_ids": ["c0f4ba56-8deb-45fa-abfd-d896a4fc85a7"], "extra_info": {"page_label": "1", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "229b6e18-913f-47ba-bb26-64b19bc43908": {"doc_ids": ["8c63957e-caf8-468e-92ca-c9bffa87bc37"], "extra_info": {"page_label": "2", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "4fec7fff-df34-44b5-819d-092f564fa704": {"doc_ids": ["b6490be2-c886-4817-9564-6e844c819768"], "extra_info": {"page_label": "3", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "6cde3203-80af-4131-8e27-81093c08dc77": {"doc_ids": ["58be316f-9724-43f6-b92f-9216f49c519e", "e06bdb89-aff3-40b9-ac7f-98446cbfd50b"], "extra_info": {"page_label": "5", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "ba921fee-9b6f-4645-852f-24c24af62ee5": {"doc_ids": ["112efbfe-7845-4273-9609-d13137a2b4da"], "extra_info": {"page_label": "6", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "975bea42-71b8-47ff-a7c6-52c6da9a3c2f": {"doc_ids": ["285ea26c-c168-48d1-a567-80254914332f"], "extra_info": {"page_label": "7", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "d113bb4e-601b-472f-b90d-44e6fb8d5c86": {"doc_ids": ["a1e47307-802a-443c-a3c5-5b879b52cc46"], "extra_info": {"page_label": "8", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "ba5a5093-94a6-4c1a-8ce1-c49f79347ea6": {"doc_ids": ["008ac8f6-b876-493d-8c16-69ac59680201"], "extra_info": {"page_label": "9", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "6bf9a1ad-c76b-4a70-9040-736af6596ceb": {"doc_ids": ["54415658-387a-4a4e-b1df-ba3d8cf13d4a"], "extra_info": {"page_label": "10", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "752815e2-3e43-4b09-a7fb-3f3afe863afd": {"doc_ids": ["bd4256fa-cedf-40cd-8f57-8685d9cb76bd"], "extra_info": {"page_label": "11", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "52b78121-7e7e-47da-b0eb-6dd474368b36": {"doc_ids": ["7a359c96-1f90-4392-857e-74ff5a025294"], "extra_info": {"page_label": "12", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "bd81c912-bb20-4178-b1e3-0df87dde5426": {"doc_ids": ["b92a7b28-9f3c-471b-a3a8-89aa972e75ba"], "extra_info": {"page_label": "13", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "b2fe87d3-280d-4abd-8d2f-30bc085b2c9a": {"doc_ids": ["0d388ed5-60c8-4c76-8666-fbc2a6257e5a"], "extra_info": {"page_label": "14", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "7716f194-2b56-4220-9c4e-430c96d738f5": {"doc_ids": ["996c0089-e096-40fc-90e6-a649439f172e"], "extra_info": {"page_label": "15", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "20023176-6484-4ab5-8d9e-1c664e10ce79": {"doc_ids": ["826b90ae-3086-43db-b6e9-5b93cf3a4dbb"], "extra_info": {"page_label": "16", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "d8c1c01e-7575-43d4-927d-a9c532a0273d": {"doc_ids": ["3a03e341-ab40-498c-8a34-a8cac64d97e6"], "extra_info": {"page_label": "17", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "49e850e8-753d-4145-b36a-2329929af481": {"doc_ids": ["44f4e8f1-eb3f-4679-af65-e1f9405fd1ca"], "extra_info": {"page_label": "18", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "5f9601e8-0495-40eb-92a4-7ac4e58aac0b": {"doc_ids": ["87a08bb9-7c8a-4d98-abfe-7d4ecd3f558d"], "extra_info": {"page_label": "19", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "adaa0fef-b347-4421-8220-cba702dd4083": {"doc_ids": ["f2755fa0-28cf-43b1-9f87-9df9be602eda"], "extra_info": {"page_label": "20", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "393cb6ec-d3a9-4529-a177-0980283db340": {"doc_ids": ["e051d8c0-7178-4216-8d9c-99a6a749d131"], "extra_info": {"page_label": "21", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "117b5627-6afa-46df-a9ac-b69ca5c1e556": {"doc_ids": ["b3db7605-335f-4e53-a772-ad893c07fa62"], "extra_info": {"page_label": "22", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "374ba5d2-d1ed-4668-983b-799dcddeae27": {"doc_ids": ["67cb04fc-08f4-4f16-a639-748e1c3b4840"], "extra_info": {"page_label": "24", "file_name": "Humana Gold Plus SNP-DE (HMO-POS D-SNP) - Summary of Benefits.pdf"}}, "29c9ab5d-8207-4f5f-98d9-df267fdb5c6e": {"doc_ids": ["966e5bec-4129-4d2f-9e25-74860e7731bd"], "extra_info": {"page_label": "1", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "4cf51b1a-4278-4234-9894-d38a43ed9a90": {"doc_ids": ["039eab44-b642-42c4-81ab-cd82828751c0"], "extra_info": {"page_label": "2", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "6b150add-7ab4-4461-97f0-5a9b956647e2": {"doc_ids": ["3bf2a62e-f064-4e5a-9d27-9ed92d13e16e"], "extra_info": {"page_label": "3", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "357511cc-c2d4-426a-b505-dcb29f767522": {"doc_ids": ["19a70e81-b38a-4d02-b6ea-134cb2de6e02"], "extra_info": {"page_label": "5", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "15cb8b30-b27c-42dd-91f9-6577da4086ce": {"doc_ids": ["197460a7-3d41-4746-ad27-0c6f6e6a1ea7"], "extra_info": {"page_label": "6", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "18258d2e-8b7c-43a5-8b4a-cf3210934de6": {"doc_ids": ["398513cb-b3f0-498e-9991-1d97093cbbfc"], "extra_info": {"page_label": "7", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "2c3f08e2-b793-44a7-8ac2-afa86a417673": {"doc_ids": ["cfde4bef-448b-41a3-8e10-1735dd7af95a"], "extra_info": {"page_label": "8", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "13f93e02-1bad-4e25-935a-7dd90e472053": {"doc_ids": ["da5e955d-6ef6-4ce0-b4a5-5034597a9b23"], "extra_info": {"page_label": "9", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "20617c36-7f56-4245-8ca9-106687b9e4ed": {"doc_ids": ["2a1c59dd-31fb-4379-848c-897872c8e515"], "extra_info": {"page_label": "10", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "beea1a87-03ff-4e35-a7d7-cd1efb664e32": {"doc_ids": ["b20126be-997f-45b2-b3d0-08856a278747"], "extra_info": {"page_label": "11", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "680d946f-6933-4e2a-906a-654d78d485c6": {"doc_ids": ["6eb4f5da-c68d-4086-bf6b-e52fb3754a39"], "extra_info": {"page_label": "12", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "401f3a6a-41b6-41ee-a977-c004a98eb067": {"doc_ids": ["eb4bcc82-976f-4f4e-914f-2e18368393aa"], "extra_info": {"page_label": "13", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "e89bcb72-c452-4c27-931b-7e91125c62af": {"doc_ids": ["d18c8779-d1d2-4083-990d-46aac9258978"], "extra_info": {"page_label": "14", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "5ab029dc-0056-40a3-9ac6-30a8dc3559e3": {"doc_ids": ["a4b6201c-a8f1-4790-8182-763a0d45bb2a"], "extra_info": {"page_label": "15", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "6d8c8247-18ed-4810-a605-72c5d8f7c0d0": {"doc_ids": ["4d0b6992-3be1-4c12-876d-7a845e7138fc"], "extra_info": {"page_label": "16", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "bb6f9274-613a-4ef8-ad04-564001cb3c4d": {"doc_ids": ["61833f17-15eb-482d-bf8c-c0fd0b6567eb"], "extra_info": {"page_label": "17", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "e2d27779-6d93-45c6-bd21-6b9defba3fa4": {"doc_ids": ["6365e49d-afef-4da3-9342-61e260f74fec"], "extra_info": {"page_label": "18", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "3b1f2ce2-ea57-44a5-9f4e-0b9b9185f73c": {"doc_ids": ["42b23314-3cdf-4993-96e4-187f13154b21"], "extra_info": {"page_label": "19", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "8eb7950e-eff8-4454-816a-99837b171714": {"doc_ids": ["b2fb7ba3-5c27-4fe5-b711-0204e8703256"], "extra_info": {"page_label": "20", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "e0fef81b-2224-400c-a730-16e21c85198b": {"doc_ids": ["a7593103-0bdb-402a-b0f4-abf6c269af73"], "extra_info": {"page_label": "21", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "9e56681c-beb7-4a84-ada5-ffac8d507ee9": {"doc_ids": ["bde15604-7e37-48c8-ab90-2ed521b2f7f9"], "extra_info": {"page_label": "22", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "fe521c7e-e8b4-4cc5-b395-3b0b82c9c569": {"doc_ids": ["07b14f4d-054c-4a84-9f05-17904b7710e3"], "extra_info": {"page_label": "23", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "4d224074-18c2-4016-8010-232b17407065": {"doc_ids": ["be32b610-eee8-4a72-a38b-187468488aee"], "extra_info": {"page_label": "28", "file_name": "HumanaChoice H5216-318 (PPO)  - Summary of Benefits.pdf"}}, "d381e00b-9565-4607-bd96-e12c32174178": {"doc_ids": ["a2bfd2bc-7c3a-436a-a5bd-5b4448eebb22"], "extra_info": {"page_label": "1", "file_name": "MayoDetails.pdf"}}, "d760de93-214b-4af7-b40a-adf7d2d67808": {"doc_ids": ["0cd36c6b-d231-4442-8aea-8ddf91948570", "a0aeb945-9db0-4bfd-9214-f6f0f889df70", "e68a1a5e-0748-4a1c-8d95-148e642f09b8", "11a593a4-999c-43ab-8c28-fb61beaeeab2", "667c4f0a-15e2-4ecd-af2c-b417ec276108"], "extra_info": {"page_label": "1", "file_name": "Pharmacy List.pdf"}}, "86da5c77-71b8-47b9-bae5-57fffbe0a8af": {"doc_ids": ["d3224ec5-4901-4e91-b952-b6b0d073ea07"], "extra_info": {"page_label": "2", "file_name": "Pharmacy List.pdf"}}, "3e5d6b6f-1e0b-4e2c-a720-28ce323585aa": {"doc_ids": ["31943ac9-6514-4b11-9ab4-16ef93e5a8a5"], "extra_info": {"page_label": "1", "file_name": "covered-drugs.pdf"}}, "9b4e637f-2b8d-4ed7-9771-0392df077484": {"doc_ids": ["9de2a99c-2c10-4b37-a263-35c612ac1909"], "extra_info": {"page_label": "2", "file_name": "covered-drugs.pdf"}}, "366ecee9-4ca8-4b22-b8f7-456109e0290b": {"doc_ids": ["ee022ded-f9e0-486d-9ca6-4f4bb618ec8b", "ea1702f5-dc3b-4d0a-9a4d-0d05b3715831"], "extra_info": {"page_label": "3", "file_name": "covered-drugs.pdf"}}, "7fbe6697-faf5-4478-b277-a0bb3168ebb5": {"doc_ids": ["cbb34b17-31fa-46ca-8240-6701e936bb5c"], "extra_info": {"page_label": "4", "file_name": "covered-drugs.pdf"}}, "d64b618a-a2a8-46f9-838e-341c9ab91b2a": {"doc_ids": ["60ee3c0e-fd55-4305-bfa0-7f12a9ba1db3"], "extra_info": {"page_label": "5", "file_name": "covered-drugs.pdf"}}, "997cda37-ca5e-4fe1-ada1-76db62fd55eb": {"doc_ids": ["0d5afc54-41b0-47d4-b93f-d90cf5bf1b9d"], "extra_info": {"page_label": "6", "file_name": "covered-drugs.pdf"}}, "fd51257b-dff5-4081-928f-3230efea4245": {"doc_ids": ["a242925b-5711-452d-bdb7-8ef423133aa4", "2686860a-77d9-42cc-9786-d490cd244a94"], "extra_info": {"page_label": "7", "file_name": "covered-drugs.pdf"}}, "e0c9b6c8-d5cb-4e66-bd49-8a7cdb6d9899": {"doc_ids": ["16de8c9f-3aba-4328-a7dc-1c84c4339618"], "extra_info": {"page_label": "8", "file_name": "covered-drugs.pdf"}}, "46ef5e97-65f4-4374-8a40-20991775651c": {"doc_ids": ["58b89eb8-874d-41a6-bfa2-38ba2dae3742"], "extra_info": {"page_label": "9", "file_name": "covered-drugs.pdf"}}, "ca032878-3313-4906-8fa7-092cb864d91b": {"doc_ids": ["7207c704-40a1-4b59-803a-2fee1f146691"], "extra_info": {"page_label": "10", "file_name": "covered-drugs.pdf"}}, "98f431f6-a2e7-49c3-a058-19f508d4a697": {"doc_ids": ["f03f1576-0741-4693-968f-cf4a2b80dab6", "9863c3a4-6838-42da-94ad-83f2a407a015"], "extra_info": {"page_label": "11", "file_name": "covered-drugs.pdf"}}, "10ba02cc-f43d-45ad-8b0a-627c37976ecd": {"doc_ids": ["85a31859-f378-4f6b-8506-7b862f739090"], "extra_info": {"page_label": "12", "file_name": "covered-drugs.pdf"}}, "ed6f8eaa-232d-4db1-a407-3f2b9204740e": {"doc_ids": ["9078ea14-2971-43c7-a15c-322715ab7c0a"], "extra_info": {"page_label": "13", "file_name": "covered-drugs.pdf"}}, "12566ae1-6c1d-4d53-83dd-9f8a92cd589d": {"doc_ids": ["e55a28d6-15d3-4010-8762-e2b7056e5b83"], "extra_info": {"page_label": "14", "file_name": "covered-drugs.pdf"}}, "105d814a-3ff6-45d5-8666-d0c1b09236c5": {"doc_ids": ["869779ab-6817-41b3-a233-3d14f8c8e7ac"], "extra_info": {"page_label": "15", "file_name": "covered-drugs.pdf"}}, "d43a3d71-79bc-4f19-beb4-9a2279fadce1": {"doc_ids": ["d5fc10e7-53e4-4c48-92e9-732aa15b1040"], "extra_info": {"page_label": "16", "file_name": "covered-drugs.pdf"}}, "30347475-d829-4651-807a-e2af387792ed": {"doc_ids": ["71ce9552-8830-485a-88ca-3c24590fc8a7"], "extra_info": {"page_label": "17", "file_name": "covered-drugs.pdf"}}, "3a741f35-8044-4ff0-9a22-92c91913396b": {"doc_ids": ["d6621d66-2f81-495c-9b2b-65063cdabdb1"], "extra_info": {"page_label": "18", "file_name": "covered-drugs.pdf"}}, "2b7347f4-4104-4ef2-8a91-7615b9fea354": {"doc_ids": ["4f552d33-03d0-483b-ab9c-d9a897b137c7"], "extra_info": {"page_label": "19", "file_name": "covered-drugs.pdf"}}, "0fa826c7-f6ef-460a-bdaf-1c96e5c1c782": {"doc_ids": ["cfac342b-2f49-41a1-99ad-30f47649702d"], "extra_info": {"page_label": "20", "file_name": "covered-drugs.pdf"}}, "9868ff8a-fa79-4f9e-9162-77d73c591944": {"doc_ids": ["3226d0eb-4dc4-40c5-82c6-d8368e4a506e"], "extra_info": {"page_label": "21", "file_name": "covered-drugs.pdf"}}, "2d21a2d9-c14d-4fb0-8ca9-f7da9cc59e86": {"doc_ids": ["2cf09e2e-1eff-4c08-9148-770a16ff27ce", "6ae63a60-700a-44ce-a3ba-ff3d1d220d2e"], "extra_info": {"page_label": "22", "file_name": "covered-drugs.pdf"}}, "9feda2cb-7916-4181-ab8a-e025f5eacb86": {"doc_ids": ["fdb94132-8f7a-4314-a971-8ffb3546b9ab", "a58564b1-972b-4a44-ab5a-af0508dafde8"], "extra_info": {"page_label": "23", "file_name": "covered-drugs.pdf"}}, "ad59ef01-bbcb-43f2-94b7-82a5ec25eb02": {"doc_ids": ["154b239d-a900-4c93-a8ee-49b1e06651b9"], "extra_info": {"page_label": "24", "file_name": "covered-drugs.pdf"}}, "c0678fff-d10f-4018-85e6-49f8081615c1": {"doc_ids": ["6e2153ef-8f10-4da2-963d-513bf96bf2bb"], "extra_info": {"page_label": "25", "file_name": "covered-drugs.pdf"}}, "1f8ae18c-28c1-4a8b-bf4b-9ef2c2d9905f": {"doc_ids": ["53849443-d9b0-4c63-b3e2-fc9b45b720f7"], "extra_info": {"page_label": "26", "file_name": "covered-drugs.pdf"}}, "eba6d0d8-89a7-443a-affd-728f92bc8f29": {"doc_ids": ["f15fdc14-12c1-4928-bc5d-d2b5bfcccb46"], "extra_info": {"page_label": "27", "file_name": "covered-drugs.pdf"}}, "89d7aca4-811b-4064-b93e-11e4293fd880": {"doc_ids": ["d6ef5232-a3ec-4cea-863c-cc6cdfa53ffb"], "extra_info": {"page_label": "28", "file_name": "covered-drugs.pdf"}}, "a37fd933-9557-4cab-8ca8-9831ba6bef7f": {"doc_ids": ["c7d3c1b4-f38d-4769-987f-0c5cc060ee9b"], "extra_info": {"page_label": "29", "file_name": "covered-drugs.pdf"}}, "d85e6c07-f342-459d-9814-360643069e0d": {"doc_ids": ["9ad5e653-6a22-442c-9b4f-55fc842928d9"], "extra_info": {"page_label": "30", "file_name": "covered-drugs.pdf"}}, "c421011f-f926-48d0-806f-65164086660e": {"doc_ids": ["f547f0c1-48d9-4915-a559-b915099768a1"], "extra_info": {"page_label": "31", "file_name": "covered-drugs.pdf"}}, "009fc9e2-66b2-4c46-b9cf-c7cbc02025bf": {"doc_ids": ["c0942f2a-24b1-4f8c-b0fa-9d86c59ed22a"], "extra_info": {"page_label": "32", "file_name": "covered-drugs.pdf"}}, "b3434ad0-6a4b-4f5c-9257-0d207cc9bf8c": {"doc_ids": ["0983cd3c-221c-4e95-9673-8e8178b73cff", "973cb306-f3f4-4f56-ad07-faac69cd9646"], "extra_info": {"page_label": "33", "file_name": "covered-drugs.pdf"}}, "a58c715b-251c-48d9-915e-a5d58ca52a04": {"doc_ids": ["11c24e56-649f-49c9-8089-8514099dc111"], "extra_info": {"page_label": "34", "file_name": "covered-drugs.pdf"}}, "d77102b6-39ba-4fda-89ad-8e805ce31913": {"doc_ids": ["54c8c7f5-b676-4b45-8604-29382816b200"], "extra_info": {"page_label": "35", "file_name": "covered-drugs.pdf"}}, "92bf58ef-8898-4573-915a-40a60f900fb1": {"doc_ids": ["24082785-35a7-46e4-b4d7-28f78524d38a"], "extra_info": {"page_label": "36", "file_name": "covered-drugs.pdf"}}, "f6b2aade-f614-4c20-9645-795dbe8080c8": {"doc_ids": ["11f220c1-1db5-4391-a680-317ad64416c6"], "extra_info": {"page_label": "37", "file_name": "covered-drugs.pdf"}}, "95e171c5-9daf-4f5e-a3c1-ca6506032202": {"doc_ids": ["1b66f01d-2b6d-42e5-b374-0fe3200e705e"], "extra_info": {"page_label": "38", "file_name": "covered-drugs.pdf"}}, "514e0d12-f1a4-437c-8c28-dc7fc34bd1ed": {"doc_ids": ["bd3584a8-8699-4b2f-b8df-d933804cc7f6"], "extra_info": {"page_label": "39", "file_name": "covered-drugs.pdf"}}, "ae0ee819-0056-4fd4-9162-116599ff81ec": {"doc_ids": ["13217e5f-1750-4171-9948-7e1621561e38", "5878cb32-b662-4691-916c-5cc3ed2825f3"], "extra_info": {"page_label": "40", "file_name": "covered-drugs.pdf"}}, "df907850-1548-43ab-823a-bc3c26c3d15e": {"doc_ids": ["fcbd8e4e-fa18-4895-9ddf-a6fb42aa5502"], "extra_info": {"page_label": "41", "file_name": "covered-drugs.pdf"}}, "39ea412b-6dee-455c-8d56-251d6a269237": {"doc_ids": ["af543220-f827-4be3-b884-663b1f721236", "257ce1e2-82e7-40d4-ae7b-13cf733adf76"], "extra_info": {"page_label": "42", "file_name": "covered-drugs.pdf"}}, "d6711024-e820-4845-9eaf-e3e4d24fabd2": {"doc_ids": ["28665762-0c23-41d9-8832-93c980aa3210"], "extra_info": {"page_label": "43", "file_name": "covered-drugs.pdf"}}, "06a88d02-fe43-4815-877d-29a7760b1bba": {"doc_ids": ["ca2f55f4-194a-4efb-9b57-c512f4e30199"], "extra_info": {"page_label": "44", "file_name": "covered-drugs.pdf"}}, "a6703883-5883-4ea4-b0d6-2420402bd717": {"doc_ids": ["c57aa113-b013-4d52-b245-c47032c5fdc0"], "extra_info": {"page_label": "45", "file_name": "covered-drugs.pdf"}}, "4dcb409d-54a1-4424-93b5-30fe5c588db8": {"doc_ids": ["919db0b7-824b-4e73-9a33-b76939d1c8b0"], "extra_info": {"page_label": "46", "file_name": "covered-drugs.pdf"}}, "914ad209-77c3-4a52-843c-b3e2c0f636e0": {"doc_ids": ["791a2a1f-fa4b-4b99-92ce-9dad973f8557"], "extra_info": {"page_label": "47", "file_name": "covered-drugs.pdf"}}, "9329db6a-02f5-4a2d-8a42-d1c98a2ce4ce": {"doc_ids": ["5ab61c14-7c2b-4e11-b7f8-eb286b235f3e"], "extra_info": {"page_label": "48", "file_name": "covered-drugs.pdf"}}, "8fdde9df-aaab-4cbc-93c3-d5b37d6b3f4b": {"doc_ids": ["8a6f8dba-9ace-4bbf-a565-511e18620cab", "9c47187b-c473-4369-900b-5401efb8bec1"], "extra_info": {"page_label": "49", "file_name": "covered-drugs.pdf"}}, "d600d3e3-4d74-4c9a-8755-0d92a9b1a62f": {"doc_ids": ["651db6e2-eb3c-4cfb-b36d-9a107307eea2", "a8074fde-379e-4f43-bbdd-5ff2316881bb"], "extra_info": {"page_label": "50", "file_name": "covered-drugs.pdf"}}, "56b9c672-3cff-4fbe-ba4d-6bbc57a5310d": {"doc_ids": ["6e917c32-4d6e-4aa4-b972-5e74e3146ad2", "2b4b29b2-4be6-48c7-8160-a1b849aa4a12"], "extra_info": {"page_label": "51", "file_name": "covered-drugs.pdf"}}, "44ec8bee-b6a7-4b4e-94fb-3f61e7330623": {"doc_ids": ["a791b139-ee4b-410a-9df8-876575a52b13", "dd475cce-4efa-4e2f-a705-10d20954da0b"], "extra_info": {"page_label": "52", "file_name": "covered-drugs.pdf"}}, "3d93def9-58fe-4564-a3b2-f42dbb29c1ad": {"doc_ids": ["bc89fc15-8557-47b3-9b2d-40c3d287faf2"], "extra_info": {"page_label": "53", "file_name": "covered-drugs.pdf"}}, "eba31375-450f-4e37-8767-4e07a77df9c6": {"doc_ids": ["4619c404-bc29-4bad-87c8-975c4cbd888e"], "extra_info": {"page_label": "54", "file_name": "covered-drugs.pdf"}}, "023c2bfd-d788-44f3-9d99-e0a988c1085e": {"doc_ids": ["40379dff-3627-4a73-818b-d9926a647d15"], "extra_info": {"page_label": "55", "file_name": "covered-drugs.pdf"}}, "3f19b669-8135-4ad4-a451-1b749261056a": {"doc_ids": ["98e9afc0-f51e-49e4-af16-26e6ff202b3d"], "extra_info": {"page_label": "56", "file_name": "covered-drugs.pdf"}}, "260502f2-6abf-4813-ae16-bcf28f6b494f": {"doc_ids": ["2cda68ce-e5f6-419d-aa20-ce007dcca89d"], "extra_info": {"page_label": "57", "file_name": "covered-drugs.pdf"}}, "ab372910-0e5e-4bb0-acbf-8d6e76c93c23": {"doc_ids": ["9c2629dd-53d5-49dc-b73d-f6877853df01"], "extra_info": {"page_label": "58", "file_name": "covered-drugs.pdf"}}, "9542b88a-dc23-459d-831b-a868e566791a": {"doc_ids": ["1dfcaa14-71ad-4309-9cc5-7b1adb968674", "2a388a6e-eb61-4f43-a39b-f3b070326884"], "extra_info": {"page_label": "59", "file_name": "covered-drugs.pdf"}}, "cbeecbcc-69c7-4b12-97a8-bd60cc92ecad": {"doc_ids": ["89ef4e8b-eece-423e-a094-e5839aa63dfa"], "extra_info": {"page_label": "60", "file_name": "covered-drugs.pdf"}}, "643f4e34-4014-414e-9b12-dc862d7c9473": {"doc_ids": ["18f7ec40-2df9-442f-b4f4-85d834c768a1"], "extra_info": {"page_label": "61", "file_name": "covered-drugs.pdf"}}, "24a3e9b9-b1ad-4ee4-9f18-061b8dbe8440": {"doc_ids": ["b98f6cb3-5780-433e-9908-73da6e0ea863"], "extra_info": {"page_label": "62", "file_name": "covered-drugs.pdf"}}, "9722d874-72a7-4490-92bf-a4652f6449ca": {"doc_ids": ["ae460863-8b0c-4bd2-a91c-a6e4a3ba4f9a"], "extra_info": {"page_label": "63", "file_name": "covered-drugs.pdf"}}, "38cc7271-0a7d-4ead-bbf7-3f556753166e": {"doc_ids": ["f0744fe7-df50-429d-941c-f7263318e962"], "extra_info": {"page_label": "64", "file_name": "covered-drugs.pdf"}}, "50ca3d37-7d2b-439c-b773-19398cde035b": {"doc_ids": ["807ca88b-e79e-42c6-b912-f75436a0c99f", "a1fa33f1-5366-4ece-bbb7-8f0941218ff2"], "extra_info": {"page_label": "65", "file_name": "covered-drugs.pdf"}}, "89dc2e45-6571-46a6-9561-f1995ee977ee": {"doc_ids": ["0e26515f-d2fc-4c7b-a103-d8140ce7599c"], "extra_info": {"page_label": "66", "file_name": "covered-drugs.pdf"}}, "9f170c36-3765-4f17-bf08-93eabf3615ec": {"doc_ids": ["a97bed54-5d30-4c9c-8a9d-45d91e3731aa"], "extra_info": {"page_label": "67", "file_name": "covered-drugs.pdf"}}, "1469ce25-7566-49fa-8aba-fbe0ede9d677": {"doc_ids": ["6a924746-c8ec-4a1a-989f-299fe63496a1"], "extra_info": {"page_label": "68", "file_name": "covered-drugs.pdf"}}, "57360270-3d8a-4e22-9fd4-fbc9fb78789f": {"doc_ids": ["7a0db42b-293f-414b-a4ee-d093e896e75e"], "extra_info": {"page_label": "69", "file_name": "covered-drugs.pdf"}}, "7e7c6386-027a-4849-9ead-0ac46c1082c4": {"doc_ids": ["bf70ff21-322b-4115-b60a-8fa480876486"], "extra_info": {"page_label": "70", "file_name": "covered-drugs.pdf"}}, "bf29f4ea-5e23-45e4-a4fb-8308f76e4b04": {"doc_ids": ["d76a66d4-173d-442e-a957-8ff3f85e3c59"], "extra_info": {"page_label": "71", "file_name": "covered-drugs.pdf"}}, "a67a0c69-37d3-4dcf-a851-ba42db79d0ae": {"doc_ids": ["b35aa57a-8fbf-4a98-a804-985e332e159e"], "extra_info": {"page_label": "72", "file_name": "covered-drugs.pdf"}}, "da15542e-e229-4442-b1fc-7688c1e7be6b": {"doc_ids": ["0deeb4d9-44ae-4069-84ec-355af3e9ae4e"], "extra_info": {"page_label": "73", "file_name": "covered-drugs.pdf"}}, "02f0cce7-ae60-4d19-a666-ac5e53c94f05": {"doc_ids": ["32f1c308-54ac-4256-8c7b-17db572c7f90", "e658db25-fb30-4c84-a222-af11f367afd4"], "extra_info": {"page_label": "74", "file_name": "covered-drugs.pdf"}}, "f7dca085-e477-4667-874f-cb5a5d8faeb2": {"doc_ids": ["e95488fe-cdc8-4f3a-9184-c9dba1e556b2", "5b04157e-cb0b-4993-b122-5f09434fc5ff"], "extra_info": {"page_label": "75", "file_name": "covered-drugs.pdf"}}, "a5679258-9c9f-49ec-8269-040a82fe45c0": {"doc_ids": ["2989c3cf-edf6-4f54-847c-9f3294bc8b40", "696e25a9-1801-49c2-b4de-77ca20657b83"], "extra_info": {"page_label": "76", "file_name": "covered-drugs.pdf"}}, "a71483fe-0252-40f4-8065-f69cbe55c3ab": {"doc_ids": ["317ee7fe-3eb3-463e-85b7-5be19faf5582", "0d015a0e-5c1d-4f7c-a7e4-fcf57217c326"], "extra_info": {"page_label": "77", "file_name": "covered-drugs.pdf"}}, "d8528268-6b55-43d7-839c-c66d4f012744": {"doc_ids": ["bd8be6f9-e479-4a92-8a17-87b5e1e434f3"], "extra_info": {"page_label": "78", "file_name": "covered-drugs.pdf"}}, "f0597b1e-6389-4e93-b936-4f433d2728a8": {"doc_ids": ["4701cd83-0d32-4e58-b992-d75ef1ba5ed8", "3147f1ad-9d87-4f84-a019-ca00fbeae987"], "extra_info": {"page_label": "79", "file_name": "covered-drugs.pdf"}}, "982995d7-f964-4e5c-9ea2-a6a296b1168c": {"doc_ids": ["68564dd4-60d4-4be3-b647-9bedd2724a81", "e60d16a9-af1a-4305-8705-99d2e716bf6b"], "extra_info": {"page_label": "80", "file_name": "covered-drugs.pdf"}}, "01d7e509-ce7c-4bfc-b523-13e70dd4e55c": {"doc_ids": ["8d31b1b1-39a2-4ace-baf9-dce0100c425e", "b749a7e6-ab93-4284-997e-d9c906a05fc3"], "extra_info": {"page_label": "81", "file_name": "covered-drugs.pdf"}}, "3d1284ba-742f-4f00-99ba-ba391d2dc05d": {"doc_ids": ["472e3e50-ece6-423f-a941-04f1be0ca11f"], "extra_info": {"page_label": "82", "file_name": "covered-drugs.pdf"}}, "5689055c-d65e-4c1c-850e-6988767ce179": {"doc_ids": ["52d692d4-a8b0-480e-858c-8e64fbb79acc", "dd401094-5e8b-46d5-88b2-0ce9857c54b4"], "extra_info": {"page_label": "83", "file_name": "covered-drugs.pdf"}}, "4e5848ff-1a60-4cce-873f-9661a990882a": {"doc_ids": ["0889fa44-16e9-4800-b2cf-c432fb2744f9", "68699bd1-6840-4d04-b460-926d83735e7d"], "extra_info": {"page_label": "84", "file_name": "covered-drugs.pdf"}}, "27d969ee-3116-4ed1-929e-01b46afeaa85": {"doc_ids": ["f9cc017b-dfdc-4f47-8c03-deff3d646b29", "34829c26-0c6d-4cb2-b035-14c27c0f3d96"], "extra_info": {"page_label": "85", "file_name": "covered-drugs.pdf"}}, "06a7289a-cc72-43db-8e99-34aba1bbddbf": {"doc_ids": ["26e931b5-4ec7-4900-86fc-931eff0dbdf4", "0b24766e-aa5c-477a-a3a3-3df909b5867f"], "extra_info": {"page_label": "86", "file_name": "covered-drugs.pdf"}}, "75383dc2-f1d7-4da0-a723-cbf4ffac5fc3": {"doc_ids": ["f331b363-fcef-4443-9871-81e664147dcf"], "extra_info": {"page_label": "87", "file_name": "covered-drugs.pdf"}}, "dcde70ac-d580-4a37-baec-34e5c68ad0a2": {"doc_ids": ["2a06301b-9034-43fe-bba6-0cddf5ef7659", "f7af74ad-d187-4e4f-b244-590bf30cf669"], "extra_info": {"page_label": "88", "file_name": "covered-drugs.pdf"}}, "fbcc267c-32d4-4041-abfb-14e9a2325b76": {"doc_ids": ["1a94900d-3e19-426e-96bf-9848d9b22f90", "ee1286dd-fb20-4dd6-a51e-d693604d4ea6"], "extra_info": {"page_label": "89", "file_name": "covered-drugs.pdf"}}, "f0630758-a52e-4b37-bff3-8022ebc61c20": {"doc_ids": ["6f00b9d0-2613-4d7b-85f0-ba1bda3c561c", "af822332-d017-4192-b151-4220227d348d"], "extra_info": {"page_label": "90", "file_name": "covered-drugs.pdf"}}, "34f5f364-de68-412e-956c-54db598213bb": {"doc_ids": ["4da48a85-a147-4e03-8ef5-030f1a64760f", "bdcc64ad-2a26-410f-920f-69ee30fe3d63"], "extra_info": {"page_label": "91", "file_name": "covered-drugs.pdf"}}, "feebbea2-1e93-43b9-949f-69b6b6d210f8": {"doc_ids": ["bee95db5-0e83-4aa3-ab01-3f28bb8dccc0", "0a3d38c0-ea0f-4145-9615-3b82d549f6d8"], "extra_info": {"page_label": "92", "file_name": "covered-drugs.pdf"}}, "e0bbe570-7182-45f1-94af-0aa5cd71c9ea": {"doc_ids": ["51f96d84-1330-46b6-b069-3653d9fc708d", "63eff1f2-a97f-4003-958a-cb4f29a2d877"], "extra_info": {"page_label": "93", "file_name": "covered-drugs.pdf"}}, "bfd9a388-f0b2-4ee5-a53a-344444954295": {"doc_ids": ["1d871056-f983-4c8b-93b8-e43c1a334410", "2cf6efad-df50-465f-8d82-c491f955a233"], "extra_info": {"page_label": "94", "file_name": "covered-drugs.pdf"}}, "8804de4d-927f-42cf-8886-5e678eb52072": {"doc_ids": ["2cf246df-ce82-4ccb-81db-3c1cbf29f64a", "e3ecc5eb-6da5-48dc-ad96-10412191e3b6"], "extra_info": {"page_label": "95", "file_name": "covered-drugs.pdf"}}, "3ea0f5cd-f5d8-4a53-a1b7-c251792bc30a": {"doc_ids": ["801b2a31-eafa-4271-852a-5cebbd3af022", "8b47db3b-e8ef-4889-a9ea-8da27020524f"], "extra_info": {"page_label": "96", "file_name": "covered-drugs.pdf"}}, "9ebaf473-8dd2-4c77-acb3-efde7aacea92": {"doc_ids": ["2317efbd-e9a3-422d-b664-9d92ed5ed9af", "9bb90168-2063-4620-9e9a-55c3fea55e28"], "extra_info": {"page_label": "97", "file_name": "covered-drugs.pdf"}}, "b38b8103-9ad4-4a8a-bb82-aa128a7386e8": {"doc_ids": ["ef4c1c90-64d0-47d3-9a32-26a8e7ed95c0", "0ab7c261-fb8d-40ae-9048-e3efe1b044c3"], "extra_info": {"page_label": "98", "file_name": "covered-drugs.pdf"}}, "74bd25f0-59c3-4442-8315-10ffd2c17113": {"doc_ids": ["9b4f2a56-e040-4aee-a9df-ab91e4361aa8"], "extra_info": {"page_label": "99", "file_name": "covered-drugs.pdf"}}, "f2992f20-4a85-4ea9-b87f-d73c3abe30f6": {"doc_ids": ["04ff110a-e221-4369-bfd0-5b62217dd734"], "extra_info": {"page_label": "100", "file_name": "covered-drugs.pdf"}}, "6171c80e-32c4-4cfa-9d9d-21c6008eebee": {"doc_ids": ["80c740ed-1697-42f9-ad11-6c30c4b06b77"], "extra_info": {"page_label": "101", "file_name": "covered-drugs.pdf"}}, "0c983c27-a24e-428e-8b01-7ee379b826e4": {"doc_ids": ["74851931-da80-4837-8177-f594448a38e5", "40e53e01-2cb4-4d99-8ab8-75b331c01e14"], "extra_info": {"page_label": "102", "file_name": "covered-drugs.pdf"}}, "6bf221cb-5621-4db3-a60c-c365a5f117ab": {"doc_ids": ["f645b972-019d-4ca5-9b92-96df346a9d79", "ace4100e-f1f5-4775-8de9-11c8a33d857b"], "extra_info": {"page_label": "103", "file_name": "covered-drugs.pdf"}}, "e619bff8-4340-48dc-b342-850f2ad65828": {"doc_ids": ["055708d8-7f94-477d-bae1-f5fd3ff7f397", "e0d330c3-c7a2-451c-b207-e0cf59e0569c"], "extra_info": {"page_label": "104", "file_name": "covered-drugs.pdf"}}, "e5df9d7c-adbf-4f14-a3cb-0900f21db8e1": {"doc_ids": ["6e8dd6d2-da80-477d-8854-47a10378b4f0"], "extra_info": {"page_label": "105", "file_name": "covered-drugs.pdf"}}, "127f760f-e743-47ef-9aa9-8d1623aa0b1c": {"doc_ids": ["a339e548-1962-4b3e-ad80-47d72f1b85b5"], "extra_info": {"page_label": "106", "file_name": "covered-drugs.pdf"}}, "b7fa1cd8-08cc-443a-b536-3d004397a1ef": {"doc_ids": ["295ab6af-6dc3-4f28-ac96-6a3d2b013fef"], "extra_info": {"page_label": "107", "file_name": "covered-drugs.pdf"}}, "e5dc3e5e-b274-4c5c-8390-ac6c9645e0bd": {"doc_ids": ["10c47816-8de9-4aa1-9c26-4dd07e7b144b"], "extra_info": {"page_label": "108", "file_name": "covered-drugs.pdf"}}, "3a532330-5add-4d57-8822-8eaa8566d70c": {"doc_ids": ["0982f878-f68f-4a5b-87fd-b365e2ed36b5"], "extra_info": {"page_label": "109", "file_name": "covered-drugs.pdf"}}, "8d790f7b-da26-438b-9610-cedebbe3167c": {"doc_ids": ["813bb6e6-a453-40a3-8250-5a86af88b2f2"], "extra_info": {"page_label": "110", "file_name": "covered-drugs.pdf"}}, "93c62739-724d-4b84-a894-4d1829915335": {"doc_ids": ["6d89c1d0-2fa8-4201-be3a-dfcf45ad37d8"], "extra_info": {"page_label": "111", "file_name": "covered-drugs.pdf"}}, "b8c07ae1-7531-4f59-a33a-7aecc604952c": {"doc_ids": ["234b3a34-b16b-415a-8461-517de762eede"], "extra_info": {"page_label": "112", "file_name": "covered-drugs.pdf"}}, "4edd867b-07ef-4a38-87a3-ecbd0fc17685": {"doc_ids": ["604655b7-0d62-4221-b227-0de177954e6d"], "extra_info": {"page_label": "113", "file_name": "covered-drugs.pdf"}}, "c2bc3153-203f-42a6-8202-fca086edafa1": {"doc_ids": ["06e46a1a-005a-48aa-a3dd-4d26f27bb302"], "extra_info": {"page_label": "114", "file_name": "covered-drugs.pdf"}}, "dbe65b41-b652-42a1-b66f-80d2f8df2bea": {"doc_ids": ["5b11a152-14b4-4c01-a345-bfd97e311ad3"], "extra_info": {"page_label": "115", "file_name": "covered-drugs.pdf"}}, "03dcbde7-5230-4348-b9cc-d12d81a2c869": {"doc_ids": ["1d0bfbda-8793-46af-89ed-49365740d75c"], "extra_info": {"page_label": "116", "file_name": "covered-drugs.pdf"}}, "a9c12691-0f49-4d17-b40f-a8efcdbb586c": {"doc_ids": ["c6fe0850-3b74-4552-9f9a-7de5d4825168"], "extra_info": {"page_label": "117", "file_name": "covered-drugs.pdf"}}, "b3760952-ea5a-4bb5-be63-bdd7ade742ec": {"doc_ids": ["c50edbac-8c36-4ea9-8a81-dd288b1d4422"], "extra_info": {"page_label": "118", "file_name": "covered-drugs.pdf"}}, "7370cdec-6d94-46a0-85f0-fc81472b53f2": {"doc_ids": ["5e2a3730-bd5f-4011-a5d9-32fc82184426"], "extra_info": {"page_label": "119", "file_name": "covered-drugs.pdf"}}, "1f20a2be-1257-4db8-939c-e0438e0a8452": {"doc_ids": ["3ee580ab-4408-4249-8840-4b9dedc31146"], "extra_info": {"page_label": "120", "file_name": "covered-drugs.pdf"}}, "086aee2b-5764-459f-86c5-ca72ef3a6dc5": {"doc_ids": ["349027d5-7bf3-4277-a3e4-d7b66eaeebb2"], "extra_info": {"page_label": "121", "file_name": "covered-drugs.pdf"}}, "5738874c-275f-4dc2-b1bf-29b05a8e6e86": {"doc_ids": ["1ac83e14-53c6-41c4-81da-2b5b86053aa9"], "extra_info": {"page_label": "122", "file_name": "covered-drugs.pdf"}}, "035495cf-4948-4143-b4b6-d03afb4f6144": {"doc_ids": ["e2185805-90e5-41d5-937c-67aa9bdc48b1"], "extra_info": {"page_label": "123", "file_name": "covered-drugs.pdf"}}, "ae47c3c5-bc95-4cac-b1dc-7a8bf0ff9fce": {"doc_ids": ["1ce7acb2-9e33-4740-9ae0-67558380cd12"], "extra_info": {"page_label": "124", "file_name": "covered-drugs.pdf"}}, "f832ec61-b897-4745-b835-5158abc4b7c7": {"doc_ids": ["79a3745e-1d78-4ded-996d-b09971c14d6b"], "extra_info": {"page_label": "125", "file_name": "covered-drugs.pdf"}}, "e3cc393d-f9c3-4d3c-9f6b-1f118edcd88b": {"doc_ids": ["e1c8753d-fee9-4101-ae7e-8c251770d409"], "extra_info": {"page_label": "126", "file_name": "covered-drugs.pdf"}}, "088db272-8b0d-4e3d-a324-7d4bf233517e": {"doc_ids": ["85610445-3361-4556-921c-50e92adf755f"], "extra_info": {"page_label": "127", "file_name": "covered-drugs.pdf"}}, "8faf3c04-6f49-4e02-aa35-14919129f4cd": {"doc_ids": ["c509f7d7-14d5-4f06-9bc2-0689e259509f"], "extra_info": {"page_label": "128", "file_name": "covered-drugs.pdf"}}, "129ef60f-c486-4c05-beb1-5130b9e7be24": {"doc_ids": ["25ce4d90-ff5e-4074-8da6-bd1bf136b636"], "extra_info": {"page_label": "129", "file_name": "covered-drugs.pdf"}}, "de73d03d-7c87-41f1-a992-b4fa980f8cfe": {"doc_ids": ["b28404ab-736e-485c-ba80-479395cdb79b"], "extra_info": {"page_label": "130", "file_name": "covered-drugs.pdf"}}, "d18df3cb-bef8-4889-a804-415e03ab7086": {"doc_ids": ["8bd3fddc-19b3-4748-a1ee-231454b0d538"], "extra_info": {"page_label": "133", "file_name": "covered-drugs.pdf"}}, "81a22fd6-5773-4146-bc1e-c0cac30d8514": {"doc_ids": ["efd7971e-40b7-4dff-915b-f94f40e27c0f"], "extra_info": {"page_label": "134", "file_name": "covered-drugs.pdf"}}, "b5910d2b-ac7c-48bd-a526-aabff5029769": {"doc_ids": ["5ad08e7e-53df-4765-8201-0b580a04f964"], "extra_info": {"page_label": "135", "file_name": "covered-drugs.pdf"}}, "877cd254-b969-4020-818f-1d78ca2c953b": {"doc_ids": ["e9fa399d-4add-4ef2-8fb9-31153ac4cae6"], "extra_info": {"page_label": "136", "file_name": "covered-drugs.pdf"}}, "a847fb2f-95d6-4c67-8699-a2df88305780": {"doc_ids": ["356c1e4a-1a5c-4f8c-bfd0-39369d18619f"], "extra_info": {"page_label": "1", "file_name": "pre-authorization required.pdf"}}, "07808233-38ae-4ea0-97f4-ed949647387f": {"doc_ids": ["7777690d-cb9c-4f4f-ae04-62c5f2aaf994"], "extra_info": {"page_label": "2", "file_name": "pre-authorization required.pdf"}}, "c8dcdac5-e757-4371-b2b1-45f4f2092cac": {"doc_ids": ["2e5e0bf6-f699-4bee-b90c-8f3784f9f104"], "extra_info": {"page_label": "3", "file_name": "pre-authorization required.pdf"}}, "708561cb-b946-468a-8062-011d26bd70ab": {"doc_ids": ["81da3871-0a12-4cca-974f-28b014f3c001"], "extra_info": {"page_label": "4", "file_name": "pre-authorization required.pdf"}}, "81aa97fb-da37-4c36-ba3a-15058dd657ca": {"doc_ids": ["8f925daa-77e9-4e49-9354-decd2e4043ef"], "extra_info": {"page_label": "5", "file_name": "pre-authorization required.pdf"}}, "fcb0bb9b-e43a-46b3-bfdd-64b1fd009dce": {"doc_ids": ["e93b2350-d67c-4721-92e7-0f9a07393779"], "extra_info": {"page_label": "6", "file_name": "pre-authorization required.pdf"}}, "34c077aa-02f6-488b-8c08-e64a26a7b253": {"doc_ids": ["49ccbc19-8c14-4113-9366-f6e10390bf82"], "extra_info": {"page_label": "7", "file_name": "pre-authorization required.pdf"}}, "b77112c0-c576-49dd-b52a-1f5646326e8d": {"doc_ids": ["16eb342f-da23-4729-b10e-54893821a438"], "extra_info": {"page_label": "8", "file_name": "pre-authorization required.pdf"}}, "1f9ddaa1-3f03-4773-9443-27bb153195b8": {"doc_ids": ["f29d0ab4-df7b-45fe-ad39-a726f18b3a30"], "extra_info": {"page_label": "9", "file_name": "pre-authorization required.pdf"}}, "a7ab9171-09f1-4033-ab67-c42d6c0522b2": {"doc_ids": ["2b72a8db-8d7e-419f-bbf4-43b072cbef30"], "extra_info": {"page_label": "10", "file_name": "pre-authorization required.pdf"}}, "aa36d483-733c-4b70-8f29-cd0dc0064d2e": {"doc_ids": ["36674254-95ee-4613-8471-541055e283aa"], "extra_info": {"page_label": "11", "file_name": "pre-authorization required.pdf"}}, "ddfe4c8f-3803-494a-98fc-9d391355d06e": {"doc_ids": ["4b55be42-c577-4a54-acc7-5cb026667660"], "extra_info": {"page_label": "12", "file_name": "pre-authorization required.pdf"}}, "f021f8ac-a087-45b2-a6dc-5d220082d90d": {"doc_ids": ["e2555100-60b2-45a9-bc13-3dc8042638a4"], "extra_info": {"page_label": "13", "file_name": "pre-authorization required.pdf"}}, "5b6581eb-2f5b-4061-b17b-e1956bba6754": {"doc_ids": ["aa25a05a-cc3d-4bcb-ad66-ef3c7b68d46d"], "extra_info": {"page_label": "14", "file_name": "pre-authorization required.pdf"}}, "24975b92-7a26-4eb5-a145-c17d069fb815": {"doc_ids": ["1108eab3-c0eb-4d6e-b2a2-b394f2c51cec"], "extra_info": {"page_label": "15", "file_name": "pre-authorization required.pdf"}}, "31c0b408-3b8a-4d91-9664-6162d180fa9f": {"doc_ids": ["6525a768-43c3-4936-9b7e-0756cb4ecc69"], "extra_info": {"page_label": "16", "file_name": "pre-authorization required.pdf"}}, "d404ec4c-c113-42e7-a270-6da65b31ea8e": {"doc_ids": ["25b69f63-b54e-4faa-89de-708574a74935"], "extra_info": {"page_label": "17", "file_name": "pre-authorization required.pdf"}}, "a6a18a04-116e-44da-93bd-067b695befb9": {"doc_ids": ["a29262a0-0c93-457f-9f78-e2b792f87d79"], "extra_info": {"page_label": "18", "file_name": "pre-authorization required.pdf"}}, "e07ff4ae-9985-4891-ac52-9b3d5ea0997f": {"doc_ids": ["1e1263b7-4f81-414a-a712-033484814215"], "extra_info": {"page_label": "19", "file_name": "pre-authorization required.pdf"}}, "9481fc18-7bec-4141-9ed2-9115c5ff6f90": {"doc_ids": ["81e1fe4e-e413-4662-b18a-3f3ccb03aa1b"], "extra_info": {"page_label": "20", "file_name": "pre-authorization required.pdf"}}, "9baf27eb-4f98-480a-a62a-30bbd33b2c36": {"doc_ids": ["e0522904-5bf0-4d20-a40a-59f674d3c525"], "extra_info": {"page_label": "21", "file_name": "pre-authorization required.pdf"}}, "f3646be8-5fe8-4bdb-acb0-f4f35e7cf6df": {"doc_ids": ["8424883b-7390-4784-bfd3-6b9f1630ebb5"], "extra_info": {"page_label": "22", "file_name": "pre-authorization required.pdf"}}, "9dffd154-6c4c-473d-a8f0-f8f7a6ea7ec1": {"doc_ids": ["d6237a1d-5ad5-4c21-a054-614b89d98b6f"], "extra_info": {"page_label": "23", "file_name": "pre-authorization required.pdf"}}, "94fdbb72-5d7e-4c6a-8341-74f3eaa9e40f": {"doc_ids": ["81501a0e-addd-4a42-bb9f-d1749de4aeb2"], "extra_info": {"page_label": "24", "file_name": "pre-authorization required.pdf"}}, "1eea301e-a3d6-4853-b491-e21b2f9ec598": {"doc_ids": ["5105b182-ea99-400d-a52f-68d568ee2f0a"], "extra_info": {"page_label": "25", "file_name": "pre-authorization required.pdf"}}, "218eb4d2-cb26-49a7-91f4-1eb905f6d371": {"doc_ids": ["b10aa813-49d0-4a2e-9194-1a0430c7e8cc"], "extra_info": {"page_label": "26", "file_name": "pre-authorization required.pdf"}}, "98885822-5de3-4fd4-8504-ff15ac4f1c59": {"doc_ids": ["ac624d69-7811-41bf-b881-f4e2ed01d9cf"], "extra_info": {"page_label": "27", "file_name": "pre-authorization required.pdf"}}, "c0d6aae9-1a7b-49f7-be52-feb6710ae610": {"doc_ids": ["cc17dc9b-0355-449e-8ed7-2572286979d6"], "extra_info": {"page_label": "28", "file_name": "pre-authorization required.pdf"}}, "c23944e8-5179-416d-a8a7-8fd8827379dc": {"doc_ids": ["42dcd03c-fcd1-42a5-812b-0265ab79c43c"], "extra_info": {"page_label": "29", "file_name": "pre-authorization required.pdf"}}, "aa35d115-5cd2-450a-a03d-f40f487655dc": {"doc_ids": ["1d5d79c5-ad65-4b56-a432-f8b7b103baaf"], "extra_info": {"page_label": "30", "file_name": "pre-authorization required.pdf"}}, "9053d7a5-bbc9-4ee5-b436-1c52ca084d85": {"doc_ids": ["45eda351-709d-43c8-b8ee-9c01a4cc1828"], "extra_info": {"page_label": "31", "file_name": "pre-authorization required.pdf"}}, "667caa6c-a289-40bd-9c0a-8c8612232c24": {"doc_ids": ["f9917544-b17e-4dad-93f1-5f30d226d5fe"], "extra_info": {"page_label": "32", "file_name": "pre-authorization required.pdf"}}, "be48bce9-d730-42cc-82c5-2c4aa2696055": {"doc_ids": ["3025f9eb-0959-4e8a-9ed1-038827e44300"], "extra_info": {"page_label": "33", "file_name": "pre-authorization required.pdf"}}, "a7792b4f-5209-475c-b165-803325c2bc5a": {"doc_ids": ["243a18c1-dd8a-4cc5-8df1-8d95dbaf951d"], "extra_info": {"page_label": "34", "file_name": "pre-authorization required.pdf"}}, "cd064d91-ac45-4600-a902-cd0bb1b5b3e2": {"doc_ids": ["a133ecfd-c511-4137-8298-79897353e39b"], "extra_info": {"page_label": "35", "file_name": "pre-authorization required.pdf"}}, "114a59ab-728c-49b2-853a-cbba213b6ff8": {"doc_ids": ["f9a45f8d-66b3-4b24-960e-e9239f9b1b9c"], "extra_info": {"page_label": "36", "file_name": "pre-authorization required.pdf"}}, "5db0336f-7694-408d-b1d3-eea1107c8799": {"doc_ids": ["d48e1d12-27b2-4812-8815-666c63648495"], "extra_info": {"page_label": "37", "file_name": "pre-authorization required.pdf"}}, "23251ee2-03d8-40da-b2a5-925018444725": {"doc_ids": ["b8bd003b-61e9-4713-b19a-4a1bdea38ac9"], "extra_info": {"page_label": "38", "file_name": "pre-authorization required.pdf"}}, "e06c63fe-2a3a-4c7c-830e-b6b3bbd855fb": {"doc_ids": ["0b0dbdaa-e8ca-4866-91e7-c7adced2904b"], "extra_info": {"page_label": "39", "file_name": "pre-authorization required.pdf"}}, "6f29e41a-f812-4162-ad45-37ac3cab1afd": {"doc_ids": ["b38cdebe-b5a9-48d0-b99f-deeae0cbcfdc"], "extra_info": {"page_label": "40", "file_name": "pre-authorization required.pdf"}}, "51e07d18-ef1a-4228-a1b3-6fe7aa7ac4d5": {"doc_ids": ["261d514a-785e-4fbd-811e-059580094b87"], "extra_info": {"page_label": "41", "file_name": "pre-authorization required.pdf"}}, "3ae4e3a1-2dfe-4ab0-93f2-ea1c34c6f108": {"doc_ids": ["36e450af-fd4d-426f-8443-9d19151ec92e"], "extra_info": {"page_label": "42", "file_name": "pre-authorization required.pdf"}}, "e974b134-6145-4383-bd70-dc312ac48902": {"doc_ids": ["d7e162e0-54ba-4234-94a1-5d053ddfaeab"], "extra_info": {"page_label": "43", "file_name": "pre-authorization required.pdf"}}, "65cf492d-d45d-4d2f-bd7c-47b5daa06f00": {"doc_ids": ["1f55c7b5-30df-41fa-bdea-c7893b9c181b"], "extra_info": {"page_label": "44", "file_name": "pre-authorization required.pdf"}}, "cc9c178a-c197-4331-8fa4-4fda3d5dad89": {"doc_ids": ["bd072fe1-c636-407d-b2b8-3629cd723a77"], "extra_info": {"page_label": "45", "file_name": "pre-authorization required.pdf"}}, "3e99586e-a37c-46c0-900d-d26fbae4bec0": {"doc_ids": ["0cd01362-f17a-4f91-8608-4943028c4e08"], "extra_info": {"page_label": "46", "file_name": "pre-authorization required.pdf"}}, "1d140eaf-ccd8-41c0-be6d-4eb279622c7b": {"doc_ids": ["3a1ba42b-8b87-48e2-9f86-d7b3a478a6cd"], "extra_info": {"page_label": "47", "file_name": "pre-authorization required.pdf"}}, "10ca498d-155d-4986-8436-798a86a0e22e": {"doc_ids": ["feed908e-f583-4be7-b350-f9204d833002"], "extra_info": {"page_label": "48", "file_name": "pre-authorization required.pdf"}}, "00129353-93d9-4192-8c8e-57f16ed22367": {"doc_ids": ["dbdb9e72-01c9-4912-a90a-976a13858cd8"], "extra_info": {"page_label": "49", "file_name": "pre-authorization required.pdf"}}, "7323d7d5-95ec-4636-af5a-2bfa7f54d943": {"doc_ids": ["c854a73b-ade2-4c22-a68d-fb62d116b52e"], "extra_info": {"page_label": "50", "file_name": "pre-authorization required.pdf"}}, "cd8f94f6-d520-411f-8640-9b9da389ad01": {"doc_ids": ["1fc3fb3f-693c-48b6-91f6-db679d5f0bf5"], "extra_info": {"page_label": "51", "file_name": "pre-authorization required.pdf"}}, "104302c0-1d43-4ae0-a1ce-0a98ce6b9a54": {"doc_ids": ["bc47bc62-bdbb-4bc6-82da-57f7bb750019"], "extra_info": {"page_label": "52", "file_name": "pre-authorization required.pdf"}}, "41c723a6-31b3-47ec-80c7-e805195c82e4": {"doc_ids": ["6c53b6c1-8c40-491d-85d3-b8f5d3d86de9"], "extra_info": {"page_label": "53", "file_name": "pre-authorization required.pdf"}}, "d9b00aeb-bbda-4a5c-87b6-4dea7d13fc5b": {"doc_ids": ["e5c104f2-8850-428e-9e0e-53e0cce18c24"], "extra_info": {"page_label": "54", "file_name": "pre-authorization required.pdf"}}, "9a1538c1-2492-44a5-81aa-c63c94caa618": {"doc_ids": ["37a6620b-4114-47c8-b597-1ebab602c11e"], "extra_info": {"page_label": "55", "file_name": "pre-authorization required.pdf"}}, "9c19605c-cd7f-4416-8ce1-2b44d0ae735e": {"doc_ids": ["5197d6ae-05b2-44cb-84a6-0930e4d7a673"], "extra_info": {"page_label": "56", "file_name": "pre-authorization required.pdf"}}, "7b9aaa04-641b-489a-9445-d3af27f4c1df": {"doc_ids": ["58a1df65-3a98-452e-9047-6790b58aad76"], "extra_info": {"page_label": "57", "file_name": "pre-authorization required.pdf"}}, "df1fa265-80be-4603-9628-88c9597d0ad0": {"doc_ids": ["51f336cd-2feb-4b27-8151-e715ebbb5949"], "extra_info": {"page_label": "58", "file_name": "pre-authorization required.pdf"}}, "7c61def2-3c1c-4c01-b76e-ce02f91404e1": {"doc_ids": ["1feb12bc-6744-4ce1-9b04-0676fd2a9b4a"], "extra_info": {"page_label": "59", "file_name": "pre-authorization required.pdf"}}, "aec0f15b-e05e-46b6-99ce-375434716ff2": {"doc_ids": ["4ce04832-7d92-4d98-b75c-b0362623ff41"], "extra_info": {"page_label": "60", "file_name": "pre-authorization required.pdf"}}, "2a909028-dc81-4412-8241-d944dbb5d3d8": {"doc_ids": ["ec91d208-9eb3-4ef5-943f-3d220a402eea"], "extra_info": {"page_label": "61", "file_name": "pre-authorization required.pdf"}}, "327b3dfa-5bfe-455d-af15-bca96e695756": {"doc_ids": ["989fcb88-a4cf-4fb9-aab9-8f3ec29981a3"], "extra_info": {"page_label": "62", "file_name": "pre-authorization required.pdf"}}, "3e363369-24d7-49f8-8a28-fa580b125227": {"doc_ids": ["03144f58-a22b-44ae-8fef-f6cb3fda2d81"], "extra_info": {"page_label": "63", "file_name": "pre-authorization required.pdf"}}, "be853f4f-973a-4ce9-8a3d-06c3ae902409": {"doc_ids": ["59dd00c0-ab06-4060-87a6-4843e83a07ea"], "extra_info": {"page_label": "64", "file_name": "pre-authorization required.pdf"}}, "e6418e2f-e5e8-4474-ab55-88b33fc95a88": {"doc_ids": ["ed9d357b-eef7-40cf-b1b8-9cc9fb8e5772"], "extra_info": {"page_label": "65", "file_name": "pre-authorization required.pdf"}}, "0dee2c1b-aba4-489f-8ffa-0167f405ec19": {"doc_ids": ["0cb4bfd2-811d-4591-83f6-c03f4068615c"], "extra_info": {"page_label": "66", "file_name": "pre-authorization required.pdf"}}, "cce2af5b-4ebd-406c-b08f-8815a64e8ea9": {"doc_ids": ["be8c18a5-785e-46d0-88bc-e7567f899220"], "extra_info": {"page_label": "67", "file_name": "pre-authorization required.pdf"}}, "c778080a-e532-40ac-ab93-8ef6ff0b3547": {"doc_ids": ["4bd75d11-54a9-459c-bb61-f0bb033fa1fd"], "extra_info": {"page_label": "68", "file_name": "pre-authorization required.pdf"}}, "fa329130-0130-4069-b191-9558e903c569": {"doc_ids": ["9df86eb3-6b77-428c-a518-da2e357e9826"], "extra_info": {"page_label": "69", "file_name": "pre-authorization required.pdf"}}, "3c20feac-bd91-4960-bd4b-34988cf58921": {"doc_ids": ["d614dc29-5315-4670-9714-84cf74769c5b"], "extra_info": {"page_label": "70", "file_name": "pre-authorization required.pdf"}}, "e21afb07-9822-445a-833e-013f46bc321f": {"doc_ids": ["5ce62330-7800-43a3-ae5d-e60b62bb43b0"], "extra_info": {"page_label": "71", "file_name": "pre-authorization required.pdf"}}, "415b75ea-3f7d-483c-8a8a-f25984f59781": {"doc_ids": ["b6c5ed46-d393-4eb1-a875-022e4e7e7b81"], "extra_info": {"page_label": "72", "file_name": "pre-authorization required.pdf"}}, "181f480d-f1b4-49df-a446-5acf992efdb0": {"doc_ids": ["ce90e5c3-d282-440b-ba95-2a7d678b071a"], "extra_info": {"page_label": "73", "file_name": "pre-authorization required.pdf"}}, "69307d73-8208-4075-aa9e-60c12357ba3f": {"doc_ids": ["62dbd8e3-0420-45f2-be5b-49c9bf68e4fa"], "extra_info": {"page_label": "74", "file_name": "pre-authorization required.pdf"}}, "b86bf61a-9c54-41e3-b493-710dcbec0ed8": {"doc_ids": ["799d9c18-626c-4e20-b34a-a53b9658b9ae"], "extra_info": {"page_label": "75", "file_name": "pre-authorization required.pdf"}}, "5323634e-566c-4b34-859f-9cf4a80e5122": {"doc_ids": ["c4890488-911f-4da0-b7d0-5d5feb8a4649"], "extra_info": {"page_label": "76", "file_name": "pre-authorization required.pdf"}}, "cc51f16f-94bd-424c-90e9-9cee2d881414": {"doc_ids": ["1b9a4a62-2e8a-4759-bec9-119d2c8a0513"], "extra_info": {"page_label": "77", "file_name": "pre-authorization required.pdf"}}, "184dcff1-db72-4450-a6d3-e6eef2544683": {"doc_ids": ["478cd9a0-e867-48d0-b27b-d55fae8db294"], "extra_info": {"page_label": "78", "file_name": "pre-authorization required.pdf"}}, "345062ea-55e7-4e49-9fc5-31a71d6a5f01": {"doc_ids": ["508dc4bd-20b4-4505-8d40-ec48a99ead71"], "extra_info": {"page_label": "79", "file_name": "pre-authorization required.pdf"}}, "6c83953b-d084-4a50-9b87-b10dfef61d4f": {"doc_ids": ["4903a4b6-b6fb-451f-9863-61fab0731588"], "extra_info": {"page_label": "80", "file_name": "pre-authorization required.pdf"}}, "f1c27dbc-867b-4700-b3e0-7f6ecae1af29": {"doc_ids": ["d21efa2b-1ab0-40c2-9603-ac25de701b30"], "extra_info": {"page_label": "81", "file_name": "pre-authorization required.pdf"}}, "860c32f8-1fae-491a-a3be-b76f4d5a2a25": {"doc_ids": ["b8f7c502-99ab-45d2-9887-307685d11f56"], "extra_info": {"page_label": "82", "file_name": "pre-authorization required.pdf"}}, "2331cf5d-be9c-436c-8e36-aefa20d2401c": {"doc_ids": ["d51ac964-a70c-4c43-933b-b4586212aa5b"], "extra_info": {"page_label": "83", "file_name": "pre-authorization required.pdf"}}, "04602e06-6925-4b8f-bfcb-2c9aa163acf8": {"doc_ids": ["46642ad1-f56e-46eb-ba38-152d33eb857c"], "extra_info": {"page_label": "84", "file_name": "pre-authorization required.pdf"}}, "19621c4a-6e17-4cc7-8158-ae43b4172ab6": {"doc_ids": ["7c56c090-44e5-4227-b65f-126130d5709c"], "extra_info": {"page_label": "85", "file_name": "pre-authorization required.pdf"}}, "055b9306-2ad0-4afa-befb-9e7ea22b2270": {"doc_ids": ["b4db25a5-6f7b-4db6-b56d-ba74f312ce6d"], "extra_info": {"page_label": "86", "file_name": "pre-authorization required.pdf"}}, "f81610f1-fcc6-4290-9084-b7b7a2e2c5a6": {"doc_ids": ["2845c38d-1caa-4daf-98b7-1c6fd5ac4cea"], "extra_info": {"page_label": "87", "file_name": "pre-authorization required.pdf"}}, "42a483a4-f04c-4faf-8341-84e58ad68e79": {"doc_ids": ["f1d1c9ac-e182-4e49-88be-d9cec680dcba"], "extra_info": {"page_label": "88", "file_name": "pre-authorization required.pdf"}}, "48f71035-c751-4f8e-b0d4-c3c041aecf6c": {"doc_ids": ["21d74570-c9e9-413b-81be-2c3dc3a864c7"], "extra_info": {"page_label": "89", "file_name": "pre-authorization required.pdf"}}, "a0976932-6ddd-4223-843d-a905386fa3ce": {"doc_ids": ["fa64e6d9-aff4-424f-9b86-8f8918f5f36e"], "extra_info": {"page_label": "90", "file_name": "pre-authorization required.pdf"}}, "412a7fab-c1c1-4b27-8c07-21da1fd9a9e4": {"doc_ids": ["ed1c2ecb-3d7a-48e6-88f8-090d2d84e9f8"], "extra_info": {"page_label": "91", "file_name": "pre-authorization required.pdf"}}, "f178d07d-0e0c-4f1a-9aca-ca2633b50468": {"doc_ids": ["363d7670-73a6-4e25-a6c9-fca1d5f12986"], "extra_info": {"page_label": "92", "file_name": "pre-authorization required.pdf"}}, "eaff1146-4d22-4bd1-9846-6b0eb75ea74a": {"doc_ids": ["7909aab6-3932-4fcb-9a33-84218320352f"], "extra_info": {"page_label": "93", "file_name": "pre-authorization required.pdf"}}, "3c21cbd0-94d2-403c-a8ea-44ca9ff87655": {"doc_ids": ["8ef7b1e5-1e54-4b0d-948c-f8bfafa92767"], "extra_info": {"page_label": "94", "file_name": "pre-authorization required.pdf"}}, "0d230ac9-76b7-4810-9fe1-f23a94e80c69": {"doc_ids": ["137cd0f4-6b7f-4990-9077-ffadc3c67f36"], "extra_info": {"page_label": "95", "file_name": "pre-authorization required.pdf"}}, "42d817af-cc03-4cce-92c3-2a59092f883a": {"doc_ids": ["e410cc59-d085-44cf-8a2b-7908a609685d"], "extra_info": {"page_label": "96", "file_name": "pre-authorization required.pdf"}}, "f4559326-88f3-4138-92e8-01c25fef7abb": {"doc_ids": ["e0b55df1-ec6c-4398-8622-85405068e0b5"], "extra_info": {"page_label": "97", "file_name": "pre-authorization required.pdf"}}, "6b434d38-2ac3-42ea-a541-910fa4b66e78": {"doc_ids": ["dac7318e-6c74-4b88-b04d-c317e11339ff"], "extra_info": {"page_label": "98", "file_name": "pre-authorization required.pdf"}}, "32094063-fa64-4695-8860-22c4e06ddbac": {"doc_ids": ["8ffb72cc-e0f5-473c-9e12-4742cea7dfa1"], "extra_info": {"page_label": "99", "file_name": "pre-authorization required.pdf"}}, "ea2617c4-4154-4dc4-b3f1-4df529abeb33": {"doc_ids": ["1d10d145-a211-4325-964c-6764b0e548b0"], "extra_info": {"page_label": "100", "file_name": "pre-authorization required.pdf"}}, "35b8e87b-8a75-4dd9-ad6c-bee57bf85129": {"doc_ids": ["b0a5720f-37b0-4434-8a5f-8f31b83648f1"], "extra_info": {"page_label": "101", "file_name": "pre-authorization required.pdf"}}, "bf9eb918-bf6e-4d9d-85c0-03c90ccd2576": {"doc_ids": ["b915dfaf-bf10-454a-8093-9ae8c923093d"], "extra_info": {"page_label": "102", "file_name": "pre-authorization required.pdf"}}, "1bd00564-4a13-47ac-a9d6-0d8f5a1ab342": {"doc_ids": ["67bd0b8f-e8d8-461d-b0fb-a6f016623f71"], "extra_info": {"page_label": "103", "file_name": "pre-authorization required.pdf"}}, "9b43ab2a-a287-4469-92dd-715869a0d10e": {"doc_ids": ["af329d5e-0812-45de-804c-a0d6e908cc56"], "extra_info": {"page_label": "104", "file_name": "pre-authorization required.pdf"}}, "076873b3-32ef-42f5-81e4-e07bc1ac8b2e": {"doc_ids": ["e89acdd9-e4ad-41da-aabd-3a9d9cb749bf"], "extra_info": {"page_label": "105", "file_name": "pre-authorization required.pdf"}}, "0871ba97-0496-4be7-9a3e-6dac3e94601a": {"doc_ids": ["c7c00819-2d91-44db-8eaa-12a40c7c256e"], "extra_info": {"page_label": "106", "file_name": "pre-authorization required.pdf"}}, "3eb32836-1f31-462b-8949-43c92a79cbe3": {"doc_ids": ["5a85a3cd-9735-4482-abc5-b3f2006e73ef"], "extra_info": {"page_label": "107", "file_name": "pre-authorization required.pdf"}}, "2e7c1c93-eb61-4a1c-9e34-b85e5f682b3d": {"doc_ids": ["355a5f10-cf03-4583-afaf-29b5cfafc1f5"], "extra_info": {"page_label": "108", "file_name": "pre-authorization required.pdf"}}, "13ff403e-e7c4-409e-92c5-fbe4b9a327bd": {"doc_ids": ["42b85f6a-a640-4a39-adc0-84f622c7bd5a"], "extra_info": {"page_label": "109", "file_name": "pre-authorization required.pdf"}}, "6941a77e-c749-45fc-a48a-1e6c7603c248": {"doc_ids": ["76dc2b01-9372-4245-a0de-7122a91e3d0b"], "extra_info": {"page_label": "110", "file_name": "pre-authorization required.pdf"}}, "da9a64d1-3a3a-4ec5-bfb4-5735e9306135": {"doc_ids": ["aad90a0f-1566-403c-b132-b3ef43ab58ef"], "extra_info": {"page_label": "111", "file_name": "pre-authorization required.pdf"}}, "cde128cc-37fb-42d9-85a5-6858c55e25a7": {"doc_ids": ["8ca083b1-8da3-40d9-ae5a-cb34c38c8e74"], "extra_info": {"page_label": "112", "file_name": "pre-authorization required.pdf"}}, "ceccd252-2c95-4e7b-8ccc-c0c37aaf5f42": {"doc_ids": ["f18d6853-6c5c-4b8a-afde-55071a58e330"], "extra_info": {"page_label": "113", "file_name": "pre-authorization required.pdf"}}, "d0edce96-0ce0-4724-a409-d3ebb40ea251": {"doc_ids": ["de86728a-6452-4376-beff-146d1e5ba894"], "extra_info": {"page_label": "114", "file_name": "pre-authorization required.pdf"}}, "9ea13dc3-7521-4584-8ce4-91f17b7710ba": {"doc_ids": ["ac22adbf-d1c6-4ef0-b892-8eb512eedaca"], "extra_info": {"page_label": "115", "file_name": "pre-authorization required.pdf"}}, "03bbc9de-ab91-43cf-a178-14655580c71b": {"doc_ids": ["2ab5c10d-481d-4aa6-91ef-aaf4d1cfd026"], "extra_info": {"page_label": "116", "file_name": "pre-authorization required.pdf"}}, "6b534828-5cac-4f90-a41e-7c1b4c24a204": {"doc_ids": ["9499f986-aa6a-4b21-a6ba-8972afbf4399"], "extra_info": {"page_label": "117", "file_name": "pre-authorization required.pdf"}}, "4d7b994c-6b85-4629-b3a5-2f0114c69a69": {"doc_ids": ["43e555ef-a8c3-44ab-8d5c-dba3f2e83198"], "extra_info": {"page_label": "118", "file_name": "pre-authorization required.pdf"}}, "25770570-e267-42bf-b3ea-ee3edfea91b1": {"doc_ids": ["498f781f-9405-4ee9-8471-2d43e1e45555"], "extra_info": {"page_label": "119", "file_name": "pre-authorization required.pdf"}}, "d2100424-b14e-47d4-8d4e-67e51a9c4a4b": {"doc_ids": ["1279f856-82ec-46f6-a447-ad7a599a6085"], "extra_info": {"page_label": "120", "file_name": "pre-authorization required.pdf"}}, "e6e86a33-ba56-4249-88ec-c5945511b860": {"doc_ids": ["4dad07c8-5c29-4af4-9a63-925c5af7d24c"], "extra_info": {"page_label": "121", "file_name": "pre-authorization required.pdf"}}, "636abaa5-e064-4d9d-9e2c-271cfead0645": {"doc_ids": ["549b43eb-2f8f-4455-b247-de913cd3e17d"], "extra_info": {"page_label": "122", "file_name": "pre-authorization required.pdf"}}, "63db8505-21a4-4789-a851-56803e0da499": {"doc_ids": ["114f6e63-f2b7-4302-b6cd-2f099778efbe"], "extra_info": {"page_label": "123", "file_name": "pre-authorization required.pdf"}}, "60790017-88a6-4d03-a352-fb605a70f76a": {"doc_ids": ["ecbc2516-8222-4b57-aff0-242125d1cec4"], "extra_info": {"page_label": "124", "file_name": "pre-authorization required.pdf"}}, "1469e8e2-7d22-4d4e-9e63-4fa4fde57421": {"doc_ids": ["301418c3-a7af-4f39-a698-c85bee52e037"], "extra_info": {"page_label": "125", "file_name": "pre-authorization required.pdf"}}, "693c30aa-af1e-48a6-8973-b7eac99f46ee": {"doc_ids": ["c7c06382-63b5-4e85-b65a-55b840a5b1b9"], "extra_info": {"page_label": "126", "file_name": "pre-authorization required.pdf"}}, "824ff52c-4e38-4750-a20f-bea9b33ef43b": {"doc_ids": ["00eecb98-85ba-4fb8-8cf5-6756e405b9a5"], "extra_info": {"page_label": "127", "file_name": "pre-authorization required.pdf"}}, "f57a5fbd-f3ca-4057-b090-ba2a8f8bb314": {"doc_ids": ["912b3fc7-a3a3-4136-9bb0-f78d47a6ac12"], "extra_info": {"page_label": "128", "file_name": "pre-authorization required.pdf"}}, "e35e838b-48f0-4d5a-9d60-e526ade9a27f": {"doc_ids": ["f45b9ea0-2ff6-4081-986e-00c2d40fba4b"], "extra_info": {"page_label": "129", "file_name": "pre-authorization required.pdf"}}, "99c39dc7-a000-4839-8ddc-8fa6dfb26214": {"doc_ids": ["7ed72470-ec09-495e-84a9-a1d7eeb90ba9"], "extra_info": {"page_label": "130", "file_name": "pre-authorization required.pdf"}}, "9bd4cdcc-bdfc-4335-8088-5082f7addb1e": {"doc_ids": ["36189eaa-0809-4f77-a9a6-8c0310ee3d48"], "extra_info": {"page_label": "131", "file_name": "pre-authorization required.pdf"}}, "4efcc1d4-cabd-4dac-8bc7-a030573f2dc0": {"doc_ids": ["7f9a3cf2-b823-41b8-8e93-709afc490b0e"], "extra_info": {"page_label": "132", "file_name": "pre-authorization required.pdf"}}, "4dff1f51-2f7d-44e9-b59d-0f6d4e410fac": {"doc_ids": ["e8f3d5eb-9804-41e3-a09b-866af40bb43b"], "extra_info": {"page_label": "133", "file_name": "pre-authorization required.pdf"}}, "ec87f510-8800-4cfd-9307-b8ed35a58b1a": {"doc_ids": ["a0e9e368-78a1-4d62-9d17-6c8ebd462943"], "extra_info": {"page_label": "134", "file_name": "pre-authorization required.pdf"}}, "945b7eb3-a377-4bb5-a85a-196e4c8974f5": {"doc_ids": ["bc3286cd-2a1e-4cc4-8f33-23d351e9ee5d"], "extra_info": {"page_label": "135", "file_name": "pre-authorization required.pdf"}}, "434675b7-8f34-42ed-a031-e7721f8a63e3": {"doc_ids": ["15b3d481-01a3-4315-a917-73eab8018c92"], "extra_info": {"page_label": "136", "file_name": "pre-authorization required.pdf"}}, "5a367987-1ac2-4066-b913-4be442ff7277": {"doc_ids": ["cf489f58-1df0-41b4-a125-3f5d36223964"], "extra_info": {"page_label": "137", "file_name": "pre-authorization required.pdf"}}, "c99fa275-3e9e-4027-9c9a-8fc93ba1ba08": {"doc_ids": ["0e72d7ce-69ae-42d6-9664-aeaea91cfe47"], "extra_info": {"page_label": "138", "file_name": "pre-authorization required.pdf"}}, "a726362b-9703-43e5-b715-3daa2496daae": {"doc_ids": ["e8569ca7-3931-4eb6-89b9-8a42301f5777"], "extra_info": {"page_label": "139", "file_name": "pre-authorization required.pdf"}}, "78fa39f7-fb98-4698-9bdb-8c9aeec7f76b": {"doc_ids": ["18c7d6b2-32a4-46bd-882c-e4aedc7ba081"], "extra_info": {"page_label": "140", "file_name": "pre-authorization required.pdf"}}, "24bf670b-55f4-49d0-b465-1d2dcf564b18": {"doc_ids": ["b0daf8e6-d5f0-423a-80a1-fb99df57c45d"], "extra_info": {"page_label": "141", "file_name": "pre-authorization required.pdf"}}, "03a751cd-12ff-42da-aca7-4c995e8e7273": {"doc_ids": ["2abe43eb-d385-42f0-9e6d-308bef91b460"], "extra_info": {"page_label": "142", "file_name": "pre-authorization required.pdf"}}, "a2134412-3d8e-4f29-bcf7-26e226ca9503": {"doc_ids": ["c421ae8e-4e55-4c52-b7c8-44f746aad846"], "extra_info": {"page_label": "143", "file_name": "pre-authorization required.pdf"}}, "2b696b53-b50b-4f4d-97d8-6ee5c0d2a4eb": {"doc_ids": ["5e61c914-e60d-41ca-b980-3b330eacb402"], "extra_info": {"page_label": "144", "file_name": "pre-authorization required.pdf"}}, "f53b7745-7f92-47d5-a611-ecfe0d6de377": {"doc_ids": ["a80e5fb1-c2c1-469a-91a3-ffa14b038b22"], "extra_info": {"page_label": "145", "file_name": "pre-authorization required.pdf"}}, "3b744cf3-158e-4ddd-90c2-c2f6f3b8864d": {"doc_ids": ["d39c2688-4f24-4049-bb96-3115fc30d07b"], "extra_info": {"page_label": "146", "file_name": "pre-authorization required.pdf"}}, "83325c20-279a-45b0-87c7-1e9fa8b8f004": {"doc_ids": ["63998638-a523-41c9-9e09-d9ff08c5a2e9"], "extra_info": {"page_label": "147", "file_name": "pre-authorization required.pdf"}}, "da1c62ec-2636-4424-9800-b7f0cb1c92ad": {"doc_ids": ["a1b6a349-57ec-45a2-985a-8a6c61c2181e"], "extra_info": {"page_label": "148", "file_name": "pre-authorization required.pdf"}}, "23ceedd7-57e1-42be-8905-7d96b813f318": {"doc_ids": ["e66cb4aa-e780-4769-b248-bd5821fc0fcd"], "extra_info": {"page_label": "149", "file_name": "pre-authorization required.pdf"}}, "7f48cc91-9c3e-46f5-85c8-567291df5f20": {"doc_ids": ["cc1de9fc-57b3-4593-9c1a-a2a656c25258"], "extra_info": {"page_label": "150", "file_name": "pre-authorization required.pdf"}}, "e871de30-8532-491e-a792-180d7ee77014": {"doc_ids": ["c5e41230-db5d-4cfc-8bdf-239f58f55839"], "extra_info": {"page_label": "151", "file_name": "pre-authorization required.pdf"}}, "23d2c467-48f7-4a22-84a0-fe72036924a2": {"doc_ids": ["9d0c893b-33d8-472a-927f-63490f0a3b02"], "extra_info": {"page_label": "152", "file_name": "pre-authorization required.pdf"}}, "138865f7-77b0-4e77-a646-e9945b79649b": {"doc_ids": ["b59aa77e-9613-44f0-b431-f70f52d718d3"], "extra_info": {"page_label": "153", "file_name": "pre-authorization required.pdf"}}, "a0c02117-9c30-4611-9a04-2789d85a6782": {"doc_ids": ["698946bf-c232-405f-a056-231e6a7941b9"], "extra_info": {"page_label": "154", "file_name": "pre-authorization required.pdf"}}, "2ac6849b-d9a1-42e7-8fff-2859fa9c34d1": {"doc_ids": ["ff2264ee-dc44-42f5-b3f0-352e0bde6cec"], "extra_info": {"page_label": "155", "file_name": "pre-authorization required.pdf"}}, "275a1c0d-d39d-4fc0-989f-8fc8fd430d9b": {"doc_ids": ["8c4266d6-8538-488a-a396-305464f8b1ac"], "extra_info": {"page_label": "156", "file_name": "pre-authorization required.pdf"}}, "a47ec575-ab3c-418b-b63f-5d2a8f738cac": {"doc_ids": ["ef1064c8-00a1-43e0-a4dc-f08f656ec9ac"], "extra_info": {"page_label": "157", "file_name": "pre-authorization required.pdf"}}, "78fab72b-a332-4216-9842-4dbf17e3c871": {"doc_ids": ["dd33c794-f724-4f91-b027-a0a3d30846ba"], "extra_info": {"page_label": "158", "file_name": "pre-authorization required.pdf"}}, "8fdb09d9-4a84-4d9f-ad21-56bb090c6f0f": {"doc_ids": ["ac950014-551a-4a18-ad18-8517ece31e9b"], "extra_info": {"page_label": "159", "file_name": "pre-authorization required.pdf"}}, "de6326c3-8f5d-402a-84f0-1d3b8cd968c8": {"doc_ids": ["28fc359d-c4b7-4381-9d73-ec1739438393"], "extra_info": {"page_label": "160", "file_name": "pre-authorization required.pdf"}}, "32d2ff3c-083b-4707-b558-9d7e94cda8c9": {"doc_ids": ["0e3274c6-18a8-4e9f-970f-d8f249d17e74"], "extra_info": {"page_label": "161", "file_name": "pre-authorization required.pdf"}}, "1393c641-8e24-47ac-a333-28fb99f2fce2": {"doc_ids": ["5daafa88-9c03-4038-86a9-1fe80786afcc"], "extra_info": {"page_label": "162", "file_name": "pre-authorization required.pdf"}}, "80080954-fc66-4edb-bdfc-35982c5c93cd": {"doc_ids": ["5e6a013b-07f3-4535-acfe-58b2d788f510"], "extra_info": {"page_label": "163", "file_name": "pre-authorization required.pdf"}}, "2b3bdc96-a2de-4efa-9967-a01a58900e50": {"doc_ids": ["9f1b0313-2218-45ad-b5e9-18781765919c"], "extra_info": {"page_label": "164", "file_name": "pre-authorization required.pdf"}}, "25925ec5-0707-4f25-874d-11816a34f621": {"doc_ids": ["6e73d11b-b0ca-4575-9d22-5cd1b3743326"], "extra_info": {"page_label": "165", "file_name": "pre-authorization required.pdf"}}, "d4547b89-f042-4a34-9e7e-9526ea72964f": {"doc_ids": ["1936b253-6bb0-476d-9767-6fdf5c2c8096"], "extra_info": {"page_label": "166", "file_name": "pre-authorization required.pdf"}}, "d488199d-a5a5-4915-8320-ee2e8072addb": {"doc_ids": ["0909c775-3215-476c-a519-2095af621a55"], "extra_info": {"page_label": "167", "file_name": "pre-authorization required.pdf"}}, "5f1cb4c2-ecbf-4d79-8994-902ffcce0731": {"doc_ids": ["5c1e9478-004d-45eb-b533-019abd4fffd3"], "extra_info": {"page_label": "168", "file_name": "pre-authorization required.pdf"}}, "68d71651-8483-47de-b2df-196156f4ba87": {"doc_ids": ["8edded74-e740-4262-a311-93789f1ab6c4"], "extra_info": {"page_label": "169", "file_name": "pre-authorization required.pdf"}}, "a2c6720d-624d-437d-b303-a798899684b9": {"doc_ids": ["fe0ef0b1-77bd-49c3-8750-f309bbf82e92"], "extra_info": {"page_label": "170", "file_name": "pre-authorization required.pdf"}}, "a63ff3c3-fa23-4c8a-9b12-0c9b76ff128a": {"doc_ids": ["dc8f0491-16f2-4149-8d92-4e4324ddbb4f"], "extra_info": {"page_label": "171", "file_name": "pre-authorization required.pdf"}}, "b7018b8d-a764-4dcb-b8e2-17c5ee384e9d": {"doc_ids": ["f3e8d359-4f61-4c4d-bc12-3487e43f8b4e"], "extra_info": {"page_label": "172", "file_name": "pre-authorization required.pdf"}}, "a059e43d-b131-4725-81af-1599493cf769": {"doc_ids": ["c928124f-cda7-46ab-9435-0ceac7997798"], "extra_info": {"page_label": "173", "file_name": "pre-authorization required.pdf"}}, "8707fba8-509d-41de-9f7d-f8c1006e27de": {"doc_ids": ["d4bc3108-9569-45d0-89e7-9fcd314a5a5c"], "extra_info": {"page_label": "174", "file_name": "pre-authorization required.pdf"}}, "cd22d62b-0d90-40fa-8ab0-26511e5675e8": {"doc_ids": ["e0104e43-de56-472c-9450-b731fa80e4c4"], "extra_info": {"page_label": "175", "file_name": "pre-authorization required.pdf"}}, "b896a6e8-3eb5-4336-ae98-cb78e86b357f": {"doc_ids": ["2aa89f8a-55cf-4430-974d-fe8556c11031"], "extra_info": {"page_label": "176", "file_name": "pre-authorization required.pdf"}}, "7f5d26a1-0c64-45b0-94d3-0c2e9aed4898": {"doc_ids": ["a3a76478-420e-4e7b-b530-e47c9538a1d2"], "extra_info": {"page_label": "177", "file_name": "pre-authorization required.pdf"}}, "c8fca6bd-03d3-4bf3-a23a-5a93ef07c027": {"doc_ids": ["5a1402c5-7458-4e64-8c4e-2540e2a6a8d1"], "extra_info": {"page_label": "178", "file_name": "pre-authorization required.pdf"}}, "46097bfd-96ab-421d-b6a3-de00c4b9694b": {"doc_ids": ["9551cf04-fec4-4910-a89a-aed5427eb987"], "extra_info": {"page_label": "179", "file_name": "pre-authorization required.pdf"}}, "6e4100ab-734f-4c5a-8386-b61029b126c9": {"doc_ids": ["0369a904-39f2-457c-a4dd-074cc1eab899"], "extra_info": {"page_label": "180", "file_name": "pre-authorization required.pdf"}}, "8bebe3e5-0529-413b-b243-b3d499a873c5": {"doc_ids": ["1f791435-7faf-46c3-8bc4-9978134fbde9"], "extra_info": {"page_label": "181", "file_name": "pre-authorization required.pdf"}}, "6a4cfe11-fc27-4b83-bcad-342a38c3f039": {"doc_ids": ["8f2edc7e-4440-48b6-af9c-9bcd938548a4"], "extra_info": {"page_label": "182", "file_name": "pre-authorization required.pdf"}}, "62ea4c80-a0ca-4665-a4d5-c4b0cc2cb7f0": {"doc_ids": ["5208a8ba-07f2-47d1-9abc-85e1b1c6167b"], "extra_info": {"page_label": "183", "file_name": "pre-authorization required.pdf"}}, "6080e8ff-e7be-4981-aed6-01c683f169ac": {"doc_ids": ["97ce3b47-1d3b-422d-af18-6b2d09342048"], "extra_info": {"page_label": "184", "file_name": "pre-authorization required.pdf"}}, "87d7aa3c-80fb-4c2c-8e92-eb6c67428315": {"doc_ids": ["2382fb7c-33d2-4539-ae03-e13f1de8a54a"], "extra_info": {"page_label": "185", "file_name": "pre-authorization required.pdf"}}, "3c310313-3c33-45ee-ad42-17dff9eae989": {"doc_ids": ["29dcfd9a-f700-4f8b-b1ba-261e3b15a12d"], "extra_info": {"page_label": "186", "file_name": "pre-authorization required.pdf"}}, "21e86423-e88a-4b97-b736-b0b0d7ab8efe": {"doc_ids": ["9ab19c9b-62df-4c36-8180-8d5092d6a246"], "extra_info": {"page_label": "187", "file_name": "pre-authorization required.pdf"}}, "bdd4f762-f7b8-4fbb-add2-ffa79a22ca37": {"doc_ids": ["b946b8c4-9ff3-470b-a231-cde95a3dfcb5"], "extra_info": {"page_label": "188", "file_name": "pre-authorization required.pdf"}}, "dfa3cfcf-269f-43a7-a294-dbf998169be5": {"doc_ids": ["8b148c6d-a5cb-4b0c-95b9-f4ad38276193"], "extra_info": {"page_label": "189", "file_name": "pre-authorization required.pdf"}}, "508dc100-0972-4dc6-ae44-d57084fced3a": {"doc_ids": ["6eaf47b1-8994-4b8d-8327-94c5f6fcc5a2"], "extra_info": {"page_label": "190", "file_name": "pre-authorization required.pdf"}}, "507849b8-ed25-4346-99f5-7d108fc54753": {"doc_ids": ["bf8eda26-dd22-4642-be2b-708f66631e52"], "extra_info": {"page_label": "191", "file_name": "pre-authorization required.pdf"}}, "004efd65-2443-48ea-9d2c-c73983289e0d": {"doc_ids": ["08643010-bf07-45f6-94ba-f27742e767ea"], "extra_info": {"page_label": "192", "file_name": "pre-authorization required.pdf"}}, "f2c25fbb-ed9b-4816-b720-5ee7cf8c2221": {"doc_ids": ["382991f7-fb0d-44f1-9c18-2870fefec121"], "extra_info": {"page_label": "193", "file_name": "pre-authorization required.pdf"}}, "086565fa-f127-4e47-8260-022216a8a6c1": {"doc_ids": ["e81b8a8b-418c-4703-ac45-f2d7f40766c8"], "extra_info": {"page_label": "194", "file_name": "pre-authorization required.pdf"}}, "114b8ce6-75da-4212-9013-bef3907dd520": {"doc_ids": ["1ab588e2-d47b-4882-9da1-d5ac28693eda"], "extra_info": {"page_label": "195", "file_name": "pre-authorization required.pdf"}}, "8c8fcb7f-2b9a-48b0-a7ff-8e843b2f74f5": {"doc_ids": ["34dee817-57e0-46b4-8a11-584a8bef5444"], "extra_info": {"page_label": "196", "file_name": "pre-authorization required.pdf"}}, "633af932-0c41-4c87-8252-32bb7894481d": {"doc_ids": ["e6f7f79a-de3f-4fe0-a123-bb76e0ab69db"], "extra_info": {"page_label": "197", "file_name": "pre-authorization required.pdf"}}, "dcca2fee-d258-4bcf-abbf-276e9244e1b4": {"doc_ids": ["322a4344-3a7b-4cdf-8ffb-dc679e967ef2"], "extra_info": {"page_label": "198", "file_name": "pre-authorization required.pdf"}}, "6631ce49-9c9c-45ed-b570-66b6950ec48a": {"doc_ids": ["9d15791c-7d16-4f1d-b961-a7f05d0ac272"], "extra_info": {"page_label": "199", "file_name": "pre-authorization required.pdf"}}, "9ac6e846-2e0d-49bd-a299-f608b265b393": {"doc_ids": ["c3945cc4-1d98-4b71-b97f-205d4b56a744"], "extra_info": {"page_label": "200", "file_name": "pre-authorization required.pdf"}}, "ad7e60da-c33f-4f92-80e4-0d25dde15446": {"doc_ids": ["9f2bf40c-90c9-45fb-a375-63017cc36302"], "extra_info": {"page_label": "201", "file_name": "pre-authorization required.pdf"}}, "e1e146aa-baac-4e5e-b32f-eaccc391aad3": {"doc_ids": ["c39e743b-b20e-4949-b697-5984952ac433"], "extra_info": {"page_label": "202", "file_name": "pre-authorization required.pdf"}}, "1499f467-6304-481b-a63a-cfa688140176": {"doc_ids": ["fca1d3f2-4034-441b-ad32-bae654b0d2ac"], "extra_info": {"page_label": "203", "file_name": "pre-authorization required.pdf"}}, "ce7887fa-11d6-47ed-8b51-9eac3f4d80df": {"doc_ids": ["75c23303-1371-416a-a3e0-935de045b55f"], "extra_info": {"page_label": "204", "file_name": "pre-authorization required.pdf"}}, "758dbe39-d01c-43ff-9823-6cf8e62879f9": {"doc_ids": ["f4e12164-6f7a-4055-8a7c-e4a9c9f46052"], "extra_info": {"page_label": "205", "file_name": "pre-authorization required.pdf"}}, "d50d8d90-7c9a-4f96-9cb6-2302cd20fcf3": {"doc_ids": ["15ce4fc7-8c50-47d9-8105-7a9526fddaa5"], "extra_info": {"page_label": "206", "file_name": "pre-authorization required.pdf"}}, "0247e755-31c2-449b-85b3-33650727f053": {"doc_ids": ["56e7ccb7-6298-49bf-aea3-77442de968cd"], "extra_info": {"page_label": "207", "file_name": "pre-authorization required.pdf"}}, "0fbbf768-8dce-44f6-9522-ee8750bac54d": {"doc_ids": ["d8ce423b-15f1-4b3a-9fc0-8132db0130b3"], "extra_info": {"page_label": "208", "file_name": "pre-authorization required.pdf"}}, "80da111d-306d-43b4-9811-3bd1f9a93c24": {"doc_ids": ["1358ae23-f358-4669-ba8d-e5392cfd733c"], "extra_info": {"page_label": "209", "file_name": "pre-authorization required.pdf"}}, "d6eb2dd0-1c37-4e68-8932-6eaaf36fd94c": {"doc_ids": ["6a8b72ae-8c38-498a-9d1f-706ee147745d"], "extra_info": {"page_label": "210", "file_name": "pre-authorization required.pdf"}}, "78ade4ee-520d-4f5c-81e8-0c6f9bd532bd": {"doc_ids": ["a151bbba-d08f-4d98-b064-ffe798529f73"], "extra_info": {"page_label": "211", "file_name": "pre-authorization required.pdf"}}, "15f1f5c2-f546-416a-ab51-b72076e93bdf": {"doc_ids": ["2e83f2cd-2261-44f3-81db-a879c9df1b8c"], "extra_info": {"page_label": "212", "file_name": "pre-authorization required.pdf"}}, "ef49c2e6-b8a7-4354-a499-2cba224dd3c6": {"doc_ids": ["7e8e88a7-1cfc-4cde-92f7-5ff9d027cdef"], "extra_info": {"page_label": "213", "file_name": "pre-authorization required.pdf"}}, "121f9361-40a1-4d85-9f3e-21dd1e81f272": {"doc_ids": ["ffbbac72-413c-4de9-9d88-ddee9d1c4be3"], "extra_info": {"page_label": "214", "file_name": "pre-authorization required.pdf"}}, "07d0943b-9d24-460f-a58b-f2d5ff609048": {"doc_ids": ["6bcd7c42-c58a-4c15-b063-b271a24faa3c"], "extra_info": {"page_label": "215", "file_name": "pre-authorization required.pdf"}}, "df1c1dc0-89aa-421a-93a7-f05576c40e0d": {"doc_ids": ["927e27d1-dcff-4052-9766-055fe1e97283"], "extra_info": {"page_label": "216", "file_name": "pre-authorization required.pdf"}}, "de9b9807-c0ef-41b4-a497-862040ccc0a7": {"doc_ids": ["ad8525aa-308f-49c1-9b33-a6d7def983ef"], "extra_info": {"page_label": "217", "file_name": "pre-authorization required.pdf"}}, "0276bb85-a36a-40c3-9d81-ae61429ccef6": {"doc_ids": ["c819d81d-d153-4f02-ad38-a22196b46829"], "extra_info": {"page_label": "218", "file_name": "pre-authorization required.pdf"}}, "a4635b4b-7196-4b9c-a071-2bb83fc59786": {"doc_ids": ["90fbb569-1fb7-4cd3-b2bb-d172e9bcd9b4"], "extra_info": {"page_label": "219", "file_name": "pre-authorization required.pdf"}}, "dadde287-8b1e-4bb8-b813-b0a4f176316b": {"doc_ids": ["2953ac72-eb20-4d77-b539-e45ffa4dd9ea"], "extra_info": {"page_label": "220", "file_name": "pre-authorization required.pdf"}}, "46840c2c-9db3-48e3-8526-ed50c89481e1": {"doc_ids": ["d6379e70-3ee9-4c0c-b530-8edbe76cfe3f"], "extra_info": {"page_label": "221", "file_name": "pre-authorization required.pdf"}}, "1add03c0-848a-4cb8-8bad-3265c8d61752": {"doc_ids": ["dfd217cc-57d5-4110-8a4c-dfe7c580ad9f"], "extra_info": {"page_label": "222", "file_name": "pre-authorization required.pdf"}}, "e21d9c6d-8438-49bd-a5ab-90f5560a2ce7": {"doc_ids": ["b6a15f9f-0bbf-4a2c-b50e-4e12228ed010"], "extra_info": {"page_label": "223", "file_name": "pre-authorization required.pdf"}}, "8ea60a77-e6c6-42bc-b230-596bd0eb64ed": {"doc_ids": ["07a84d7c-7fc1-4a18-a1cc-147c02f5f819"], "extra_info": {"page_label": "224", "file_name": "pre-authorization required.pdf"}}, "558ad263-ffde-42c6-b7b5-913533920fa2": {"doc_ids": ["7a51fad4-2cb5-4ce1-80a6-a387fa11e76b"], "extra_info": {"page_label": "225", "file_name": "pre-authorization required.pdf"}}, "3557d504-42cb-468f-9d55-834cf519c63a": {"doc_ids": ["1edceb96-1176-4f7e-bc71-60294ae22cd4"], "extra_info": {"page_label": "226", "file_name": "pre-authorization required.pdf"}}, "cd67c46f-a9d4-488d-9e00-99038ddd1b57": {"doc_ids": ["a3f77112-987d-4ea8-a45d-29c10de4833f"], "extra_info": {"page_label": "227", "file_name": "pre-authorization required.pdf"}}, "c8327f63-39fc-4b79-b811-8ca9067e337e": {"doc_ids": ["aa7b5a31-6b96-4bd9-9a72-a33f6c414a96"], "extra_info": {"page_label": "228", "file_name": "pre-authorization required.pdf"}}, "bc8292de-1df3-4da7-becb-8b614abad96a": {"doc_ids": ["ffa3cb6c-2251-4b0b-a72d-60043472bcba"], "extra_info": {"page_label": "229", "file_name": "pre-authorization required.pdf"}}, "c72bef93-2767-43ae-a693-ae4e47eff9ac": {"doc_ids": ["bcaa6cfd-7c75-4880-890b-f10a2b6b07b0"], "extra_info": {"page_label": "230", "file_name": "pre-authorization required.pdf"}}, "78f3dcf2-29bb-4b88-a975-a6429119e755": {"doc_ids": ["29158ac0-f1ff-49c6-9c60-e41a54a15b3e"], "extra_info": {"page_label": "231", "file_name": "pre-authorization required.pdf"}}, "0d78ed61-4e05-4750-9e20-c7caad359760": {"doc_ids": ["f2137c9e-41d9-4791-be45-cc75b4a0d843"], "extra_info": {"page_label": "232", "file_name": "pre-authorization required.pdf"}}, "e08a4edd-af60-4719-b1d2-e3c070c07a82": {"doc_ids": ["8a51eee4-4faa-4984-8ba5-bd269564d700"], "extra_info": {"page_label": "233", "file_name": "pre-authorization required.pdf"}}, "247d984a-3c79-4e3e-be60-6b7050b69a65": {"doc_ids": ["354e0415-cf38-41c7-8fc3-ba2ebc3eb896"], "extra_info": {"page_label": "234", "file_name": "pre-authorization required.pdf"}}, "ffeb173c-1a18-4e34-9cf7-ed5081d5c7d5": {"doc_ids": ["f0e09827-31fb-40cc-ab3d-dc20bd175f01"], "extra_info": {"page_label": "235", "file_name": "pre-authorization required.pdf"}}, "87d61007-2221-4876-a1ac-60dd7acf8240": {"doc_ids": ["7ae7478f-1f22-442b-b640-a8a527039da4"], "extra_info": {"page_label": "236", "file_name": "pre-authorization required.pdf"}}, "4e73fb27-a794-451b-8b84-ab0ff5410d36": {"doc_ids": ["94895fba-960d-45ea-8b45-2e8e7def4a0a"], "extra_info": {"page_label": "237", "file_name": "pre-authorization required.pdf"}}, "77faf3d9-1103-4f77-9a61-498e5aafa985": {"doc_ids": ["a9195cca-1f1f-4cd0-acee-c8c14bd2d101"], "extra_info": {"page_label": "238", "file_name": "pre-authorization required.pdf"}}, "7951d1a5-4df4-4973-b4ea-935c3c12c081": {"doc_ids": ["bd078d28-ffd8-4672-ae70-958598be15d1"], "extra_info": {"page_label": "239", "file_name": "pre-authorization required.pdf"}}, "51d7c345-f023-4f57-9f51-b04fc2432cc2": {"doc_ids": ["fa3b70d8-8c5b-4185-9f7b-711c67b7ca10"], "extra_info": {"page_label": "240", "file_name": "pre-authorization required.pdf"}}, "94bb0a44-3fef-4c51-99f4-550737ce40d2": {"doc_ids": ["8203a1a4-3767-4635-aaa1-d4a57d5a0f92"], "extra_info": {"page_label": "241", "file_name": "pre-authorization required.pdf"}}, "a9682377-c0ee-49ef-a23d-4d7e182419ef": {"doc_ids": ["61ee8ba5-d018-431e-9872-ddbf292d7fee"], "extra_info": {"page_label": "242", "file_name": "pre-authorization required.pdf"}}, "6abc409f-37cf-4a53-8400-7ff57472ee2f": {"doc_ids": ["787d20d6-7df4-49b1-ad16-fc483d7e54a8"], "extra_info": {"page_label": "243", "file_name": "pre-authorization required.pdf"}}, "94ac2ab4-47c6-4d10-8110-0d238cb078cf": {"doc_ids": ["44e87891-92f3-48ff-8053-3031cd806cef"], "extra_info": {"page_label": "244", "file_name": "pre-authorization required.pdf"}}, "95a005ad-f0b5-4a3a-a0f1-16c992eb5d74": {"doc_ids": ["f6d91ea9-4812-4c4b-b44b-d8939a797599"], "extra_info": {"page_label": "245", "file_name": "pre-authorization required.pdf"}}, "a02bcb24-35ff-4e4c-aafd-0c6b9b5957de": {"doc_ids": ["eea281bb-fa93-40df-aa47-2e5e25749def"], "extra_info": {"page_label": "246", "file_name": "pre-authorization required.pdf"}}, "ab72c98b-4577-4160-9502-097e7e780f15": {"doc_ids": ["d307392c-3912-46bd-b72f-0da258fccee8"], "extra_info": {"page_label": "247", "file_name": "pre-authorization required.pdf"}}, "f7f7af08-1552-482d-b735-e1a3ce67bf28": {"doc_ids": ["0401efeb-ca89-42de-959d-8a0ef7fe0424"], "extra_info": {"page_label": "248", "file_name": "pre-authorization required.pdf"}}, "69a32055-d30f-4946-a47f-14a264f19eee": {"doc_ids": ["9513b161-e964-4cb4-82f5-2a0580d998ce"], "extra_info": {"page_label": "249", "file_name": "pre-authorization required.pdf"}}, "acf7146f-75e4-47fa-acf2-3fe31fd6fe4d": {"doc_ids": ["e9cf8cba-9068-4103-a120-29dae73227d5"], "extra_info": {"page_label": "250", "file_name": "pre-authorization required.pdf"}}, "5cdb6e55-b772-44b5-9f33-ba9307e9583d": {"doc_ids": ["8c6b3641-ecc3-4e6b-bd1c-39d0a9cf6812"], "extra_info": {"page_label": "251", "file_name": "pre-authorization required.pdf"}}, "4725e493-7f03-4188-9bcb-5e3ca2762b24": {"doc_ids": ["850f9238-d920-4d5c-babb-b9fdf722674d"], "extra_info": {"page_label": "252", "file_name": "pre-authorization required.pdf"}}, "ab2c3c79-d20e-4657-b26d-e36edc75c654": {"doc_ids": ["780cf419-b5ce-4175-b2e6-3aa435bc5d3c"], "extra_info": {"page_label": "253", "file_name": "pre-authorization required.pdf"}}, "e7043aa8-4ada-463f-aea8-364ad491fcac": {"doc_ids": ["6bfaac1d-955a-4e06-aec4-f69b457ee3aa"], "extra_info": {"page_label": "254", "file_name": "pre-authorization required.pdf"}}, "ba4d27fb-10a6-49ef-8b51-6b27c61b80fe": {"doc_ids": ["4ae3188c-374f-4252-9fcb-fd3280a1749e"], "extra_info": {"page_label": "255", "file_name": "pre-authorization required.pdf"}}, "e55f865f-8e11-4f7e-b4db-59f0aa92da85": {"doc_ids": ["7d7c0d3d-4a72-4566-8d7a-77908c94092e"], "extra_info": {"page_label": "256", "file_name": "pre-authorization required.pdf"}}, "5ede3ff9-e7f4-4745-ad15-3ee087bfbdc1": {"doc_ids": ["3d49904c-dd3c-4ecb-abc0-28fa7920627a"], "extra_info": {"page_label": "257", "file_name": "pre-authorization required.pdf"}}, "5a22b1aa-b859-485d-bdb5-6bc47d2804fa": {"doc_ids": ["9e95ffa3-48b7-4d7d-bbad-a587064b7a8f"], "extra_info": {"page_label": "258", "file_name": "pre-authorization required.pdf"}}, "24dab8f4-7064-41ee-80c1-6bd7cc23c3fd": {"doc_ids": ["17bb1153-5581-45f5-9c0d-a3bcf3987a8e"], "extra_info": {"page_label": "259", "file_name": "pre-authorization required.pdf"}}, "0c73d0f3-876a-4b87-a42e-9c8d1b560bee": {"doc_ids": ["ed4c92b1-2ed6-4356-be3d-7770969f728c"], "extra_info": {"page_label": "260", "file_name": "pre-authorization required.pdf"}}, "3583205d-5450-4b31-8a49-4c0b5cb65b14": {"doc_ids": ["068874b1-4336-4741-a970-f55f0c5be626"], "extra_info": {"page_label": "261", "file_name": "pre-authorization required.pdf"}}, "39b31029-8c1c-4ada-a102-2d7631aa8471": {"doc_ids": ["4cd2d5c1-8abe-4989-b475-362d9f7fa550"], "extra_info": {"page_label": "262", "file_name": "pre-authorization required.pdf"}}, "5cb561e4-ec01-4b82-a21b-9dcec146fa1d": {"doc_ids": ["8e905a21-69fe-49da-8dd3-d81a3724dc1c"], "extra_info": {"page_label": "263", "file_name": "pre-authorization required.pdf"}}, "07286f3f-8e8b-4733-ae7d-b70ea7f4d0e4": {"doc_ids": ["d6f9a5cb-6c10-4ba0-b48b-8ba49f7f9b94"], "extra_info": {"page_label": "264", "file_name": "pre-authorization required.pdf"}}, "94a1ea6c-87e6-49d5-ae67-3e19b07ce9fa": {"doc_ids": ["ea0b4c78-3082-480c-af75-9d8e49bb26b0"], "extra_info": {"page_label": "265", "file_name": "pre-authorization required.pdf"}}, "2609894b-b9b0-4655-8497-aa10c4708dd8": {"doc_ids": ["78acd7bd-575c-49a9-9f74-73428925ec4a"], "extra_info": {"page_label": "266", "file_name": "pre-authorization required.pdf"}}, "3b0b1a52-c981-4627-9a14-15d7cadbbcd2": {"doc_ids": ["201e6356-0f8b-4d36-b64d-26d18f295f45"], "extra_info": {"page_label": "267", "file_name": "pre-authorization required.pdf"}}, "60eb08b1-d2ac-4cb7-a94c-d177c8c958c5": {"doc_ids": ["f49d2f07-6985-4185-a032-4d31f7cb6801"], "extra_info": {"page_label": "268", "file_name": "pre-authorization required.pdf"}}, "df3c0f07-6a28-4edc-8094-cd7814cbb23c": {"doc_ids": ["abe04782-6de9-457d-8211-0a0a2209e5d6"], "extra_info": {"page_label": "269", "file_name": "pre-authorization required.pdf"}}, "26f4e3b4-6fa4-4365-9e8b-a0ea729102a3": {"doc_ids": ["0b60e6b8-801e-4b79-970b-38d804d7c7ae"], "extra_info": {"page_label": "270", "file_name": "pre-authorization required.pdf"}}, "df2a3492-1771-460d-9f63-fa6cf8014eec": {"doc_ids": ["d034c4fe-4a0e-4a02-a954-e9490577c00c"], "extra_info": {"page_label": "271", "file_name": "pre-authorization required.pdf"}}, "0b452979-6d92-483c-9c4a-e658f7f7c57e": {"doc_ids": ["9855127c-d5a1-4d20-8905-7293d3ab727b"], "extra_info": {"page_label": "272", "file_name": "pre-authorization required.pdf"}}, "81308c8a-2f9d-435a-8e09-775896c8e395": {"doc_ids": ["a6dacf3f-50a3-449d-b9db-eb3b69390aea"], "extra_info": {"page_label": "273", "file_name": "pre-authorization required.pdf"}}, "1a5972b4-cd29-429f-a8ec-6b2ab6beb073": {"doc_ids": ["3cac6de3-595c-4cc6-8b18-56a969b78536"], "extra_info": {"page_label": "274", "file_name": "pre-authorization required.pdf"}}, "66e468b7-4c21-40d2-a900-0ee735401d7b": {"doc_ids": ["97193ef7-ac5d-4541-bd90-b235fc1dc844"], "extra_info": {"page_label": "275", "file_name": "pre-authorization required.pdf"}}, "0e0cb180-f887-4458-bed6-35464a266f7d": {"doc_ids": ["c90eb876-9688-4547-84ae-72b5ceedfa78"], "extra_info": {"page_label": "276", "file_name": "pre-authorization required.pdf"}}, "6cef2fb0-b427-4e6f-a6e6-14933765b29c": {"doc_ids": ["f39c49e5-a9e2-42a4-a561-1846d3d5a97b"], "extra_info": {"page_label": "277", "file_name": "pre-authorization required.pdf"}}, "01cb1b4c-cc47-4f16-bf45-7b5a6447f76f": {"doc_ids": ["4b9759b5-0d72-46aa-ae7e-60aa904a0a0e"], "extra_info": {"page_label": "278", "file_name": "pre-authorization required.pdf"}}, "3c430dd1-ed89-4dc1-8514-f8865fbbecb4": {"doc_ids": ["c73a8c23-3ed7-4084-945b-940d3b56ebfc"], "extra_info": {"page_label": "279", "file_name": "pre-authorization required.pdf"}}, "cff80025-df10-49be-9301-6b2836922236": {"doc_ids": ["955fecd9-cc4d-4682-8aa5-6513c8bfcc84"], "extra_info": {"page_label": "280", "file_name": "pre-authorization required.pdf"}}, "749cd542-5c14-4707-b708-2d5f5ae288ab": {"doc_ids": ["0038f1f2-7755-454e-be67-97aa6fc46bd0"], "extra_info": {"page_label": "281", "file_name": "pre-authorization required.pdf"}}, "bdde8bcf-c9c4-42a0-936a-d8cc8ec932e8": {"doc_ids": ["e730bf65-1ec8-490e-b04a-ab55149a2c0c"], "extra_info": {"page_label": "282", "file_name": "pre-authorization required.pdf"}}, "336abce8-ec2c-4360-a948-5e01dd0d7783": {"doc_ids": ["6515052e-4dc8-49e7-a11d-15dfae7deb7a"], "extra_info": {"page_label": "283", "file_name": "pre-authorization required.pdf"}}, "384768ff-e2aa-40ca-912f-5b6416124c3a": {"doc_ids": ["ec29bb5c-6b44-4086-a389-d20f6ac21da4"], "extra_info": {"page_label": "284", "file_name": "pre-authorization required.pdf"}}, "776d0b00-5b8a-4b45-b458-ef32f5193812": {"doc_ids": ["4fae2431-af9b-4060-8a32-32cddc5e4291"], "extra_info": {"page_label": "285", "file_name": "pre-authorization required.pdf"}}, "b4c149af-53d6-4255-9210-7d4d7357e3c2": {"doc_ids": ["d1363008-a323-44bf-b2aa-1da950980fcc"], "extra_info": {"page_label": "286", "file_name": "pre-authorization required.pdf"}}, "462d23ff-7436-4a2c-ade2-41f55927ca03": {"doc_ids": ["f727b4fb-6d3b-430b-a0c3-bcb7f59f7046"], "extra_info": {"page_label": "287", "file_name": "pre-authorization required.pdf"}}, "414ecf77-57d4-413a-94ae-750508e5ed94": {"doc_ids": ["f6f2655c-1288-4b4f-9929-3ba335aefab2"], "extra_info": {"page_label": "288", "file_name": "pre-authorization required.pdf"}}, "4171b3ff-2964-4db9-8628-002c92bce3b9": {"doc_ids": ["a38bb385-df45-4fd4-b059-8b0dea2bbb6d"], "extra_info": {"page_label": "289", "file_name": "pre-authorization required.pdf"}}, "af5f1c45-7c22-4c70-99a6-98d8cb2721bd": {"doc_ids": ["2f907a19-b6d3-4e7f-9fec-a8d6d7547a9f"], "extra_info": {"page_label": "290", "file_name": "pre-authorization required.pdf"}}, "2a48de98-0286-414d-a6db-3aee15c99be6": {"doc_ids": ["9865f2ad-f6a1-467e-8ff7-85b77c5ee8c6"], "extra_info": {"page_label": "291", "file_name": "pre-authorization required.pdf"}}, "3a8df7df-0ae3-4bfd-ac1d-42ba092c7d6b": {"doc_ids": ["dcd7e421-86ff-4257-b1c6-a572af7a1084"], "extra_info": {"page_label": "292", "file_name": "pre-authorization required.pdf"}}, "ec850558-5fe6-48b8-b194-602252973974": {"doc_ids": ["43ada732-52bc-4fb6-9c15-b2638262c489"], "extra_info": {"page_label": "293", "file_name": "pre-authorization required.pdf"}}, "24a41545-a3fc-4622-a3bb-c00df3d5db67": {"doc_ids": ["7c254f65-67de-43a8-bf9c-453305b0913c"], "extra_info": {"page_label": "294", "file_name": "pre-authorization required.pdf"}}, "37d01a7f-8a52-4362-8b82-9c0def403bb2": {"doc_ids": ["0ed4d19c-a44b-46a4-a741-c9fa1b3ee5f4"], "extra_info": {"page_label": "295", "file_name": "pre-authorization required.pdf"}}, "9ecb09c7-a8ae-4ede-bd71-ba6c1bed02a2": {"doc_ids": ["03a16896-b01b-4385-9277-0490c71ea03f"], "extra_info": {"page_label": "296", "file_name": "pre-authorization required.pdf"}}, "5dfdd7d6-b8aa-40f0-9540-53005d5051f8": {"doc_ids": ["4f89973b-478e-46f3-bc78-4cf742266554"], "extra_info": {"page_label": "297", "file_name": "pre-authorization required.pdf"}}, "ca0cbef1-2f62-4bd2-b5cd-e1c8567310c1": {"doc_ids": ["8f8f06a8-f407-478d-b35a-43fd7aeed25f"], "extra_info": {"page_label": "298", "file_name": "pre-authorization required.pdf"}}, "ecede01a-446b-4293-b61c-d048af2c319f": {"doc_ids": ["e27fe8dd-f326-4ee9-bfd2-4b1ee0dee945"], "extra_info": {"page_label": "299", "file_name": "pre-authorization required.pdf"}}, "f3d745c2-a69c-4c86-b0fa-d7b548f01c3e": {"doc_ids": ["2529215b-cf3b-41f9-98a7-e65d906a44ce"], "extra_info": {"page_label": "300", "file_name": "pre-authorization required.pdf"}}, "60bc563b-5de0-4d8f-9706-3cd073d7e0b2": {"doc_ids": ["81dca8f8-2d17-4589-bd11-e97503a4cc52"], "extra_info": {"page_label": "301", "file_name": "pre-authorization required.pdf"}}, "ce8a2086-3000-4a51-bb7b-29520c7f2ba4": {"doc_ids": ["387d8976-73a1-4622-ae5a-5f2b4ee107a1"], "extra_info": {"page_label": "302", "file_name": "pre-authorization required.pdf"}}, "40876388-91ee-4964-a5bf-131db01c4e0f": {"doc_ids": ["55967287-7588-4a47-ba8d-d401fb7b476f"], "extra_info": {"page_label": "303", "file_name": "pre-authorization required.pdf"}}, "fe42144d-77fe-4521-b31e-f0823544694b": {"doc_ids": ["d4dde60a-ed31-4d33-82b9-9a30a7bb5214"], "extra_info": {"page_label": "304", "file_name": "pre-authorization required.pdf"}}, "4f2454e1-59fb-4793-8932-fb2a993618a6": {"doc_ids": ["c324b847-384d-467f-961e-c16ae97d54f2"], "extra_info": {"page_label": "305", "file_name": "pre-authorization required.pdf"}}, "b0974ac5-8ae1-4b2f-8a9c-69f0b6eac6e6": {"doc_ids": ["88243c49-1427-4a22-bf7c-249b6432eadd"], "extra_info": {"page_label": "306", "file_name": "pre-authorization required.pdf"}}, "226b529d-4b0b-49fa-a8b2-7064d3b5cbea": {"doc_ids": ["44cbde19-d1c0-4f53-ab2a-5286ef34e289"], "extra_info": {"page_label": "307", "file_name": "pre-authorization required.pdf"}}, "e6e5ddac-d620-4627-93ec-5337445784c2": {"doc_ids": ["0175dfc5-757e-4ae4-9db0-740cf8dc1d90"], "extra_info": {"page_label": "308", "file_name": "pre-authorization required.pdf"}}, "232f29bc-c4a0-42ff-96a1-a90352605f5d": {"doc_ids": ["98d4c05e-08f3-4328-9da6-8f91d50122b0"], "extra_info": {"page_label": "309", "file_name": "pre-authorization required.pdf"}}, "b51c56fc-0a71-49e6-a1b7-10a32cebd706": {"doc_ids": ["006990df-7627-4faf-a24b-62ff39751d36"], "extra_info": {"page_label": "310", "file_name": "pre-authorization required.pdf"}}, "98ff0b8f-129c-47e3-b55c-809f905860e4": {"doc_ids": ["96a84b8f-7a50-4f93-8fdd-43cbffbb3d87"], "extra_info": {"page_label": "311", "file_name": "pre-authorization required.pdf"}}, "b5f65755-5547-45ee-b105-565be28f523f": {"doc_ids": ["b2e5479c-9bfe-4b19-9887-942dd000daf1"], "extra_info": {"page_label": "312", "file_name": "pre-authorization required.pdf"}}, "42ea1e25-cf2f-43a3-9337-11dc472a014e": {"doc_ids": ["af3be54d-6663-44ef-8f12-b87bd7945823"], "extra_info": {"page_label": "313", "file_name": "pre-authorization required.pdf"}}, "18d36f4d-ca74-4901-9067-94bbd0efe45d": {"doc_ids": ["38cda45c-009a-4bdc-a434-ba23aa7503b1"], "extra_info": {"page_label": "314", "file_name": "pre-authorization required.pdf"}}, "d6e934d2-8c37-42a4-8778-736efd10fde4": {"doc_ids": ["4710042e-9a78-447f-b4fa-8f4078a8a1df"], "extra_info": {"page_label": "315", "file_name": "pre-authorization required.pdf"}}, "96dff55e-3917-43d3-b8ab-99863b131ce6": {"doc_ids": ["4ceb835b-878a-4611-b0a6-4a6d4c7ab15a"], "extra_info": {"page_label": "316", "file_name": "pre-authorization required.pdf"}}, "257468ea-ae7d-4161-ae66-83ce63718261": {"doc_ids": ["ea866d2d-4a9a-4190-aa49-06b057298ef3"], "extra_info": {"page_label": "317", "file_name": "pre-authorization required.pdf"}}, "44fe6449-503d-400a-8f3d-3f275a100420": {"doc_ids": ["e998a342-b8f8-4c30-aa32-3b5859069d7d"], "extra_info": {"page_label": "318", "file_name": "pre-authorization required.pdf"}}, "e2333efd-72b0-4095-8c0e-3b3fbe4692f7": {"doc_ids": ["5bb4148a-6227-4ae9-a44b-5ca5fca286c6"], "extra_info": {"page_label": "319", "file_name": "pre-authorization required.pdf"}}, "f3eabe6d-d169-4594-aef9-7f543d5556cd": {"doc_ids": ["451e9d7f-0538-42cb-97a8-dacd4e1710cc"], "extra_info": {"page_label": "320", "file_name": "pre-authorization required.pdf"}}, "8c102189-e2eb-49dc-8454-45d03575fe84": {"doc_ids": ["5358de7c-6e7b-470c-8c3a-e0faf226bc0b"], "extra_info": {"page_label": "321", "file_name": "pre-authorization required.pdf"}}, "4bf88be7-80ae-40c3-a395-bda7db450141": {"doc_ids": ["8f7d053c-a2d5-42fc-bbf2-1582da38ec76"], "extra_info": {"page_label": "322", "file_name": "pre-authorization required.pdf"}}, "3ff72645-dcc6-4428-9488-3871755a0762": {"doc_ids": ["7368dc06-7900-430f-bcb9-9b37abff02a3"], "extra_info": {"page_label": "323", "file_name": "pre-authorization required.pdf"}}, "48a6d3cc-7119-4a71-96db-5735901c03c8": {"doc_ids": ["ac01f906-5f8e-4e96-8413-e02cd1b58068"], "extra_info": {"page_label": "324", "file_name": "pre-authorization required.pdf"}}, "4f5d46cb-c9d7-4864-a33c-6727843ac3bc": {"doc_ids": ["3febb6a9-c76b-4c6c-a4b6-27518a474a1a"], "extra_info": {"page_label": "325", "file_name": "pre-authorization required.pdf"}}, "69063419-5029-4d09-8ddf-9562e50ffc45": {"doc_ids": ["020e5f41-e689-4c14-a650-2858abd353f2"], "extra_info": {"page_label": "326", "file_name": "pre-authorization required.pdf"}}, "6dc4e23e-5da1-48c8-83b1-bd800489482c": {"doc_ids": ["5f66589c-7f61-43e4-8248-ee2ff7a82b82"], "extra_info": {"page_label": "327", "file_name": "pre-authorization required.pdf"}}, "a2d448fd-f3cc-4816-88fd-5053e26d4105": {"doc_ids": ["4f478de9-e57b-4d8a-af10-fbc9b7a24160"], "extra_info": {"page_label": "328", "file_name": "pre-authorization required.pdf"}}, "12c79bfb-e559-47f6-9f99-2cf62da9e53a": {"doc_ids": ["488f957d-ef56-46a8-b33a-eaa62fa7df08"], "extra_info": {"page_label": "329", "file_name": "pre-authorization required.pdf"}}, "e126ca03-2a60-4321-b541-e649a37ccd4f": {"doc_ids": ["ca485d5c-9cb2-4e0c-ae03-71bc5b759623"], "extra_info": {"page_label": "330", "file_name": "pre-authorization required.pdf"}}, "b0cfcc2b-ec77-4807-a009-1c1173cbab3e": {"doc_ids": ["7a657c28-4321-4a88-8e8c-99f05dc847ea"], "extra_info": {"page_label": "331", "file_name": "pre-authorization required.pdf"}}, "45009599-a8bc-43fb-9a55-6d5aa5c7c19f": {"doc_ids": ["492c8765-cdbe-447d-b7b2-1d8ac4daefe9"], "extra_info": {"page_label": "332", "file_name": "pre-authorization required.pdf"}}, "a39e3f8e-443e-44f1-a80b-3aed7b618597": {"doc_ids": ["7cfff30f-ab6d-483a-8b4d-8a08d0ac27ea"], "extra_info": {"page_label": "333", "file_name": "pre-authorization required.pdf"}}, "e4572bba-8711-43b1-9198-cd474de46866": {"doc_ids": ["b42059f1-be3d-4cd2-98f0-b2908a83b1a8"], "extra_info": {"page_label": "334", "file_name": "pre-authorization required.pdf"}}, "65dfb233-3dcf-4356-a908-41ef6a66f5d0": {"doc_ids": ["3ff821f4-6d06-441a-ae6e-132645bffc43"], "extra_info": {"page_label": "335", "file_name": "pre-authorization required.pdf"}}, "e1164e5b-3b62-4f61-b926-a034caa7dfea": {"doc_ids": ["334a6160-c908-44bd-a54b-2211479f8fde"], "extra_info": {"page_label": "336", "file_name": "pre-authorization required.pdf"}}, "35c0bffb-7b02-40b7-bfad-f8b7d9bea40c": {"doc_ids": ["3dbd59c1-579d-41ca-a5c4-fa74c8ef22d7"], "extra_info": {"page_label": "337", "file_name": "pre-authorization required.pdf"}}, "22ffd56f-6035-44b6-9570-e26b64f2ce7b": {"doc_ids": ["74de8415-af9b-4b8a-8618-8e1d185a71dd"], "extra_info": {"page_label": "338", "file_name": "pre-authorization required.pdf"}}, "a1d7a51a-d6c8-4a1c-ad13-c1ca3d0f03de": {"doc_ids": ["703883af-8bf9-4060-99dd-5bb356c95309"], "extra_info": {"page_label": "339", "file_name": "pre-authorization required.pdf"}}, "fc8d5073-29ee-477a-b1f4-7e30307ba454": {"doc_ids": ["b64ea6cc-5b23-4db3-a747-fa039e24db57"], "extra_info": {"page_label": "340", "file_name": "pre-authorization required.pdf"}}, "a8ef26c0-cde7-48ba-ab31-90be94e7cdd9": {"doc_ids": ["a631dafc-b283-451d-959c-3c709095d9b2"], "extra_info": {"page_label": "341", "file_name": "pre-authorization required.pdf"}}, "9b5c4d08-b6e0-4ac2-87e7-29e2923c2a2d": {"doc_ids": ["ca3f54b9-5472-4cd8-bf7d-8ff8915cebe2"], "extra_info": {"page_label": "342", "file_name": "pre-authorization required.pdf"}}, "e11fd00a-4766-4334-9313-c1f86c914a00": {"doc_ids": ["8b705786-0bfd-496f-a02c-23776027cf4c"], "extra_info": {"page_label": "343", "file_name": "pre-authorization required.pdf"}}, "7862bc3b-0436-4254-912e-5673e6133f39": {"doc_ids": ["5dad3e21-e2c5-4ddf-b3f2-f78f8f83af57"], "extra_info": {"page_label": "344", "file_name": "pre-authorization required.pdf"}}, "90e68fd0-c37f-401a-835b-c203f5995f0e": {"doc_ids": ["bda38b47-08e2-4e79-b7cd-f1a595030b7c"], "extra_info": {"page_label": "345", "file_name": "pre-authorization required.pdf"}}, "21899607-b365-48d9-a6e7-931bda1a421e": {"doc_ids": ["d28555d7-798d-43e7-8d34-6d01a498ca05"], "extra_info": {"page_label": "346", "file_name": "pre-authorization required.pdf"}}, "cda036b4-0f2a-4fdc-836b-152edc0f19b7": {"doc_ids": ["002314dd-fc6b-494a-8faa-ada13e991af1"], "extra_info": {"page_label": "347", "file_name": "pre-authorization required.pdf"}}, "1e830ae7-5d66-4a7a-a47e-997f5ec4b79b": {"doc_ids": ["1c9091c8-21ce-46cf-b7f0-2fe48a5a6594"], "extra_info": {"page_label": "348", "file_name": "pre-authorization required.pdf"}}, "34624f91-2ffa-4889-bdad-8284ef515811": {"doc_ids": ["99e42df5-e612-4f52-aae7-91c158cd0ac9"], "extra_info": {"page_label": "349", "file_name": "pre-authorization required.pdf"}}, "9e697894-019c-4e06-9ff9-0e80c4b9d417": {"doc_ids": ["4d63ebd8-77ff-49d7-b25f-9efa93afc02d"], "extra_info": {"page_label": "350", "file_name": "pre-authorization required.pdf"}}, "7b75a06d-207d-472e-a794-2d40ee948c06": {"doc_ids": ["cbebd2eb-4eda-4859-8136-8253dffd49e8"], "extra_info": {"page_label": "351", "file_name": "pre-authorization required.pdf"}}, "3065eb16-5ab7-4da7-a614-33579b5501fe": {"doc_ids": ["1cda8364-b707-4155-82f0-e39516bb6b94"], "extra_info": {"page_label": "352", "file_name": "pre-authorization required.pdf"}}, "b6519bd7-7c9e-4148-91d7-af69cf468b3d": {"doc_ids": ["fc49c44b-f106-48ce-998d-8a863b34dc22"], "extra_info": {"page_label": "353", "file_name": "pre-authorization required.pdf"}}, "c5b244f0-5ec1-4f82-9772-fe331a5e41f9": {"doc_ids": ["71546001-f484-429a-b5e8-912a20b60e0d"], "extra_info": {"page_label": "354", "file_name": "pre-authorization required.pdf"}}, "677d206f-470b-4c7e-9c04-a9c0584bf4bf": {"doc_ids": ["1dd0b841-be46-4692-a6e5-b5b1df298323"], "extra_info": {"page_label": "355", "file_name": "pre-authorization required.pdf"}}, "1e0cabdf-3fdc-473c-b71f-ea6800595025": {"doc_ids": ["7eeb39da-7c98-47cd-af23-4c1018ec8264"], "extra_info": {"page_label": "356", "file_name": "pre-authorization required.pdf"}}, "b1997818-dff9-4017-acf7-faf2bbc1a2d7": {"doc_ids": ["28bbeee3-7a83-43bc-917a-be874b607714"], "extra_info": {"page_label": "357", "file_name": "pre-authorization required.pdf"}}, "ee2a612c-1ae1-4b1d-b2c0-593ba514712a": {"doc_ids": ["9b36f7e8-f78b-4fd7-9b97-3ca7bc28113d"], "extra_info": {"page_label": "358", "file_name": "pre-authorization required.pdf"}}, "b6831d47-f333-4b52-b989-8fc3ae399f32": {"doc_ids": ["3318a725-4fbd-4ee1-a2be-78a2d99b02e3"], "extra_info": {"page_label": "359", "file_name": "pre-authorization required.pdf"}}, "1531f16e-236c-4df4-975c-cb4a1f276cae": {"doc_ids": ["da28393a-c79e-498e-b579-5b62592b619f"], "extra_info": {"page_label": "360", "file_name": "pre-authorization required.pdf"}}, "993d37fa-eda9-45fb-94c8-3ee57f9751b6": {"doc_ids": ["cfda2ff8-f456-4133-b96a-9b4fc955aaf4"], "extra_info": {"page_label": "361", "file_name": "pre-authorization required.pdf"}}, "2cbb2d3f-68c3-49b4-8d01-f9855a055f46": {"doc_ids": ["1a9cc8ee-38cd-4c7a-b9b2-622fda2d189c"], "extra_info": {"page_label": "362", "file_name": "pre-authorization required.pdf"}}, "dfc67de1-e93d-4d04-9d1e-0d48266d789e": {"doc_ids": ["80e74c01-f6de-40bc-8ffd-c26187bd1212"], "extra_info": {"page_label": "363", "file_name": "pre-authorization required.pdf"}}, "ee1b9385-b668-4dcd-9855-43babf162488": {"doc_ids": ["56f7a74a-ba53-4239-9362-bb28d5865ea3"], "extra_info": {"page_label": "364", "file_name": "pre-authorization required.pdf"}}, "a21c61ba-76cd-4646-83af-d52ec3cdc4af": {"doc_ids": ["487223e0-55e5-4a06-9535-a8870f47f6e4"], "extra_info": {"page_label": "365", "file_name": "pre-authorization required.pdf"}}, "d0caeda5-7dc1-4f76-a910-0734bd5ca345": {"doc_ids": ["0eb95164-f8df-4b01-b127-d006c3241f7e"], "extra_info": {"page_label": "366", "file_name": "pre-authorization required.pdf"}}, "09a4c596-e330-4b3e-87db-31583e9b1ff3": {"doc_ids": ["e482013e-5db1-48b7-b405-273d5ab147f9"], "extra_info": {"page_label": "367", "file_name": "pre-authorization required.pdf"}}, "9596f487-e87b-4e2a-ac93-31e50ea1b7c8": {"doc_ids": ["27757c46-2adb-4959-a3dd-cfd2f3a0eff3"], "extra_info": {"page_label": "368", "file_name": "pre-authorization required.pdf"}}, "9be01ad9-3ff4-44be-aef2-dd4c7ce9f8da": {"doc_ids": ["a2f6ddf8-0d76-4747-ac09-b83f6d0c107b"], "extra_info": {"page_label": "369", "file_name": "pre-authorization required.pdf"}}, "15795960-3957-4a62-b842-d68025b9b0f7": {"doc_ids": ["1bf3ef12-1591-4b6f-8609-d9cdd7638adc"], "extra_info": {"page_label": "370", "file_name": "pre-authorization required.pdf"}}, "a483d805-ae51-4d4f-851e-f43b7694a986": {"doc_ids": ["30857626-dbc4-478c-b0de-a01b28c47be4"], "extra_info": {"page_label": "371", "file_name": "pre-authorization required.pdf"}}, "2f301f63-42ba-48ff-b518-3a4b0331239f": {"doc_ids": ["8a0ce770-30f1-45ac-a23f-e878cc9978a7"], "extra_info": {"page_label": "372", "file_name": "pre-authorization required.pdf"}}, "a9f2669b-e1f0-4ed1-82ab-fc2ddc3176a3": {"doc_ids": ["2a4ff576-904c-45eb-a94e-25a711b69f9d"], "extra_info": {"page_label": "373", "file_name": "pre-authorization required.pdf"}}, "72071ce9-8943-44ef-b0f4-173473900109": {"doc_ids": ["881b16ed-cefc-4bd6-953f-38434587ab35"], "extra_info": {"page_label": "374", "file_name": "pre-authorization required.pdf"}}, "c2d0fa78-51a7-4f25-a286-f37e24004221": {"doc_ids": ["c0fbdc59-6e0b-4569-8c89-ef7957e81792"], "extra_info": {"page_label": "375", "file_name": "pre-authorization required.pdf"}}, "463ebedf-6f3a-4a66-9c98-9167ba3904c0": {"doc_ids": ["96fdd029-27d6-4b02-8c5b-90a3e5a6d49e"], "extra_info": {"page_label": "376", "file_name": "pre-authorization required.pdf"}}, "37809a6f-b2f5-45db-b29c-9a55ef6e2489": {"doc_ids": ["6a9c7d86-11b6-42fc-b776-b9ce293a55bc"], "extra_info": {"page_label": "377", "file_name": "pre-authorization required.pdf"}}, "693eaf89-71c1-4f60-95aa-352de08cc3ad": {"doc_ids": ["c9f24c44-b718-43ae-a1d0-f1bb724680f2"], "extra_info": {"page_label": "378", "file_name": "pre-authorization required.pdf"}}, "a635a522-9234-4c38-91b4-01eedb898e5a": {"doc_ids": ["c555d382-0caf-4bfe-915b-222822e41f44"], "extra_info": {"page_label": "379", "file_name": "pre-authorization required.pdf"}}, "fb0dcbb5-8062-4d93-96e1-513967316679": {"doc_ids": ["efaab952-db8d-483a-95c7-8c21d919ce22"], "extra_info": {"page_label": "380", "file_name": "pre-authorization required.pdf"}}, "daad47a3-2fbe-4a84-8a66-fd8f30d37b22": {"doc_ids": ["78ecccb7-7853-44db-a72c-bdfad171f9a7"], "extra_info": {"page_label": "381", "file_name": "pre-authorization required.pdf"}}, "382dc190-350c-471a-bf5e-29f3d21b4183": {"doc_ids": ["b9f55d22-dfec-4fe5-860b-e50b4f405698"], "extra_info": {"page_label": "382", "file_name": "pre-authorization required.pdf"}}, "b19860d0-a8b2-4fd8-a497-08317d6b458e": {"doc_ids": ["54276fe0-90bb-4c71-9727-6a0b66d964f5"], "extra_info": {"page_label": "383", "file_name": "pre-authorization required.pdf"}}, "76b417b2-e951-4961-bb01-f9a807cb1fdb": {"doc_ids": ["a594843e-1ae9-453f-b28b-35307515e532"], "extra_info": {"page_label": "384", "file_name": "pre-authorization required.pdf"}}, "4603de5a-4ed7-4aca-bff8-efbad600648b": {"doc_ids": ["e08f3971-3b5c-4d66-a61e-4e8694313af5"], "extra_info": {"page_label": "385", "file_name": "pre-authorization required.pdf"}}, "460b2792-0635-425e-a325-1cfbaabea87c": {"doc_ids": ["37f2a501-e4a8-4408-818c-8b45783e333d"], "extra_info": {"page_label": "386", "file_name": "pre-authorization required.pdf"}}, "230b0a18-d3d4-4add-ad16-c7d1796f37e1": {"doc_ids": ["f367f092-50a9-4277-885d-ce111fa10f75"], "extra_info": {"page_label": "387", "file_name": "pre-authorization required.pdf"}}, "41859b7c-0fe0-4414-881e-5e1e5dee2e25": {"doc_ids": ["f1c430d6-b694-42fb-bc25-fc7ce19b9094"], "extra_info": {"page_label": "388", "file_name": "pre-authorization required.pdf"}}, "1c6a9a9d-ffd2-42c1-88cb-6576f7270649": {"doc_ids": ["1f079a5c-f225-4f2b-a1e7-0d60ad4d866f"], "extra_info": {"page_label": "389", "file_name": "pre-authorization required.pdf"}}, "31c2981a-30ed-4cf1-8620-e284f5c1a9f7": {"doc_ids": ["22715473-75d4-4d1b-8f7b-fb1bf3830f48"], "extra_info": {"page_label": "390", "file_name": "pre-authorization required.pdf"}}, "c725e63d-eb03-45ef-b8dd-2ac5513d0869": {"doc_ids": ["fcb29b46-7831-47e2-a56a-4daa0336ec26"], "extra_info": {"page_label": "391", "file_name": "pre-authorization required.pdf"}}, "d16ab139-677f-446d-bd7d-c91cb4b4ea09": {"doc_ids": ["62a8be04-fb96-45de-93c1-be8276e889ac"], "extra_info": {"page_label": "392", "file_name": "pre-authorization required.pdf"}}, "cc4733cf-c374-4ab9-ac86-2c2d349f460b": {"doc_ids": ["19265670-4059-4ee1-88d9-65deeb407c8e"], "extra_info": {"page_label": "393", "file_name": "pre-authorization required.pdf"}}, "3215ecd1-ac16-4bdc-b6ab-67c0522f8f39": {"doc_ids": ["fae6e2a5-e636-4989-9a4f-f5e11563f325"], "extra_info": {"page_label": "394", "file_name": "pre-authorization required.pdf"}}, "d141ff33-267c-419e-be58-effb86936228": {"doc_ids": ["aae2a2e3-fec3-4e1f-b490-ba46e5160abe"], "extra_info": {"page_label": "395", "file_name": "pre-authorization required.pdf"}}, "5efcbdbe-63d7-474c-933a-f574e37660ee": {"doc_ids": ["6c6bf142-58e3-4cd0-85c7-42a0ac4358e6"], "extra_info": {"page_label": "396", "file_name": "pre-authorization required.pdf"}}, "4ed5e69b-0198-4c78-8bf1-9259f274f6e9": {"doc_ids": ["0518bd10-110d-4fff-8c52-805f5ea01252"], "extra_info": {"page_label": "397", "file_name": "pre-authorization required.pdf"}}, "8fc317ad-54a4-4fb2-81de-b2c218683806": {"doc_ids": ["5673735d-95d3-4166-a509-f118055eb917"], "extra_info": {"page_label": "398", "file_name": "pre-authorization required.pdf"}}, "a0f7551e-0226-47d3-8902-27475db55773": {"doc_ids": ["3ba2197a-e29a-4d18-a103-dbcecaf8c455"], "extra_info": {"page_label": "399", "file_name": "pre-authorization required.pdf"}}, "816dfe9f-d71a-404f-acb2-2e62cc31c9fc": {"doc_ids": ["8f95cfe2-7bb8-4540-80f2-ef20818bfcf9"], "extra_info": {"page_label": "400", "file_name": "pre-authorization required.pdf"}}, "47c5846a-8764-4cea-8c73-fe7222394144": {"doc_ids": ["b3c9a1dc-ac0f-4bcc-85fe-d762b488cc3d"], "extra_info": {"page_label": "401", "file_name": "pre-authorization required.pdf"}}, "1c075cc5-b177-466d-9fa4-08b5459bde7d": {"doc_ids": ["5e0654b1-7304-4898-945d-b4f359a0aadc"], "extra_info": {"page_label": "402", "file_name": "pre-authorization required.pdf"}}, "543d46f6-df78-4208-a7e2-19eac4abe0a1": {"doc_ids": ["d176515d-5618-4171-a7eb-fa4c019ba968"], "extra_info": {"page_label": "403", "file_name": "pre-authorization required.pdf"}}, "c5f27eb3-1472-4f01-b1b7-a9f2c59a6e14": {"doc_ids": ["7d8534db-dc8c-4e21-b99d-9227f8b41b38"], "extra_info": {"page_label": "404", "file_name": "pre-authorization required.pdf"}}, "63f6f599-08d0-41f1-aa0b-7853d37680de": {"doc_ids": ["2af7ceca-3bf3-4ed4-b501-80c0b08aee25"], "extra_info": {"page_label": "405", "file_name": "pre-authorization required.pdf"}}, "0f2f3811-f208-48a3-a8bd-ee2235511082": {"doc_ids": ["225deadd-845e-475b-b26f-64101ab30e28"], "extra_info": {"page_label": "406", "file_name": "pre-authorization required.pdf"}}, "f903908a-bc35-4bec-abc6-893a7361d491": {"doc_ids": ["f3afb49e-5381-4446-ae5d-d514e63015b3"], "extra_info": {"page_label": "407", "file_name": "pre-authorization required.pdf"}}, "0559c94e-060e-4999-951e-d90b6b4ec9a2": {"doc_ids": ["82cc373f-7ec2-477d-aefb-736e26e2c7b3"], "extra_info": {"page_label": "408", "file_name": "pre-authorization required.pdf"}}, "a9a5525c-0cd9-44d3-b2f4-91409f2af742": {"doc_ids": ["c5604f4d-a6e1-476c-a478-cba1fe857d95"], "extra_info": {"page_label": "409", "file_name": "pre-authorization required.pdf"}}, "1e2056f2-499e-45b5-8779-8eabe6734ecf": {"doc_ids": ["ffc7d5ec-e5a8-4808-b499-5a6f8e9b4bfd"], "extra_info": {"page_label": "410", "file_name": "pre-authorization required.pdf"}}, "e878de0e-a3d9-4d63-a971-4cd1b5803615": {"doc_ids": ["5fbbe4c8-77da-449e-8ca6-2ec2cebbf472"], "extra_info": {"page_label": "411", "file_name": "pre-authorization required.pdf"}}, "81669650-a9ba-4971-abe1-0ccebe3dd724": {"doc_ids": ["2e43c1b1-154a-47dd-ac7e-f2639b14bee8"], "extra_info": {"page_label": "412", "file_name": "pre-authorization required.pdf"}}, "377c898d-7e9f-4bf1-826e-85fda05e57a2": {"doc_ids": ["18af92ce-f91e-4fa7-9588-caad85a9c511"], "extra_info": {"page_label": "413", "file_name": "pre-authorization required.pdf"}}, "c55afdb3-1a01-4b96-b04c-f20047f90e8c": {"doc_ids": ["bda4f18b-a7df-42a5-8f91-3e8a58055249"], "extra_info": {"page_label": "414", "file_name": "pre-authorization required.pdf"}}, "ba6f5e33-35c8-496a-b13a-1cb45e6e9d26": {"doc_ids": ["f0b15c18-fba5-427e-b526-d96bcc8e830e"], "extra_info": {"page_label": "415", "file_name": "pre-authorization required.pdf"}}, "d5ff17a3-c856-4373-a805-fe3005eb7a71": {"doc_ids": ["61e05fd5-4415-4e25-bcb5-fcede87483f6"], "extra_info": {"page_label": "416", "file_name": "pre-authorization required.pdf"}}, "dcff5e19-8243-48c8-8fdb-a69f22bce720": {"doc_ids": ["5452d07a-d1b4-4975-a7b8-8dcb99b1c843"], "extra_info": {"page_label": "417", "file_name": "pre-authorization required.pdf"}}, "cba15e6b-ac48-4d01-92bd-11198429ce24": {"doc_ids": ["974615f5-007a-4a88-8f0f-ccaa7e5ddc5b"], "extra_info": {"page_label": "418", "file_name": "pre-authorization required.pdf"}}, "47ed7d38-b865-4b68-b694-6fef2ad83a7f": {"doc_ids": ["42cebb9f-6bb7-46ca-b9de-e8b76fc88686"], "extra_info": {"page_label": "419", "file_name": "pre-authorization required.pdf"}}, "063b52cb-0999-4696-a03e-954fc0cc234a": {"doc_ids": ["c861fb02-29ed-4342-b10a-fecb03df7c32"], "extra_info": {"page_label": "420", "file_name": "pre-authorization required.pdf"}}, "cbaa77d4-c12e-49f0-98ed-265aa167838e": {"doc_ids": ["5a7ff84d-f018-42f6-ba40-4c35572a5f39"], "extra_info": {"page_label": "421", "file_name": "pre-authorization required.pdf"}}, "cb151eb1-aa1a-41c0-b412-c0412a1a4ed9": {"doc_ids": ["b30e144f-2952-4298-93c7-ed980670eb36"], "extra_info": {"page_label": "422", "file_name": "pre-authorization required.pdf"}}, "79b48b04-8ebd-4436-8714-a18e48155ba4": {"doc_ids": ["8b152745-7bfe-4763-9578-0f269bc292fe"], "extra_info": {"page_label": "423", "file_name": "pre-authorization required.pdf"}}, "9d4d3440-2785-4647-9312-c96b2ef9036a": {"doc_ids": ["38fd24f9-55f8-4eda-a85e-bf3017577b42"], "extra_info": {"page_label": "424", "file_name": "pre-authorization required.pdf"}}, "9b9c3b6d-cfaa-40d0-8560-a57ba65fc468": {"doc_ids": ["4cea0fdd-a19c-4ff5-9d1a-aee8f847968d"], "extra_info": {"page_label": "425", "file_name": "pre-authorization required.pdf"}}, "a54a31d8-ad0e-43a0-ad86-2d27768cb95c": {"doc_ids": ["63a8a489-8aba-4af8-a6e8-726df0cc8e66"], "extra_info": {"page_label": "426", "file_name": "pre-authorization required.pdf"}}, "31298161-4dc4-450a-9497-ba577031a9f0": {"doc_ids": ["e9f6e980-d6c0-4c03-9bd8-a5ab037702e4"], "extra_info": {"page_label": "427", "file_name": "pre-authorization required.pdf"}}, "be33ca8e-f443-4cff-8917-48d588d3090b": {"doc_ids": ["f3a6e4e9-66f3-4a01-9d11-85c7b2883922"], "extra_info": {"page_label": "428", "file_name": "pre-authorization required.pdf"}}, "ebc0fad6-6550-44d4-b789-a9231f27064c": {"doc_ids": ["bf506543-6cdb-43f2-b736-0218e509d707"], "extra_info": {"page_label": "429", "file_name": "pre-authorization required.pdf"}}, "7084a685-83d8-4166-aa96-392f356434a5": {"doc_ids": ["449b48b7-a228-4736-8d23-d3aba6abaf5d"], "extra_info": {"page_label": "430", "file_name": "pre-authorization required.pdf"}}, "f1bcfd1c-0e47-46b8-a3f2-c8e297c38e95": {"doc_ids": ["259c8441-f1c3-4684-84bb-3b0a4a69db07"], "extra_info": {"page_label": "431", "file_name": "pre-authorization required.pdf"}}, "57fb5e34-7f4e-492a-ba50-00850d2825ed": {"doc_ids": ["970a332d-aa27-4f81-a75f-7a923e2514cc"], "extra_info": {"page_label": "432", "file_name": "pre-authorization required.pdf"}}, "fa9bea77-18b4-4d86-885e-66739e3ab9f8": {"doc_ids": ["31642533-dc57-4b59-a4d9-4c453ddff48f"], "extra_info": {"page_label": "433", "file_name": "pre-authorization required.pdf"}}, "f1afef2e-28ea-4a5c-bf4d-34fa7874eed8": {"doc_ids": ["9ae50e80-72eb-4fd0-8908-9b8a9652c5f4"], "extra_info": {"page_label": "434", "file_name": "pre-authorization required.pdf"}}, "95e7d944-bb77-4e58-a666-6474b8bcf00b": {"doc_ids": ["c4007f61-fe21-4224-a719-377f57f96ca0"], "extra_info": {"page_label": "435", "file_name": "pre-authorization required.pdf"}}, "2f63ee3e-f938-4ea3-bf53-8d3b11cde4a6": {"doc_ids": ["339a7d48-f745-4580-824a-3af9545ef028"], "extra_info": {"page_label": "436", "file_name": "pre-authorization required.pdf"}}, "ecefb3dc-9971-446d-ac1b-859dc79a46c8": {"doc_ids": ["2cf83360-c4d3-48da-8429-3714b050dcfa"], "extra_info": {"page_label": "437", "file_name": "pre-authorization required.pdf"}}, "3ed2688a-a340-48f7-b8e0-290364f4523e": {"doc_ids": ["7bb82104-ad72-4dd1-93cd-402d3754fde8"], "extra_info": {"page_label": "438", "file_name": "pre-authorization required.pdf"}}, "038bf8e0-7cef-4b5c-9eb8-27e6892cd040": {"doc_ids": ["d51871a8-6afd-481f-91a9-376f60cf94fc"], "extra_info": {"page_label": "439", "file_name": "pre-authorization required.pdf"}}, "a59ea249-c96c-4e51-a549-78207b5a38bf": {"doc_ids": ["7ab6a887-19e9-4bba-ba4f-555b8530cce8"], "extra_info": {"page_label": "440", "file_name": "pre-authorization required.pdf"}}, "66c60223-5c98-4811-8c80-751e492bee12": {"doc_ids": ["0b9a3017-6fdc-46ad-a3fa-a66975f3fbc2"], "extra_info": {"page_label": "441", "file_name": "pre-authorization required.pdf"}}, "5fbaf4a9-bb83-4705-b764-7fa18079d8cb": {"doc_ids": ["edf4db94-a109-43bd-9197-622efcbf2954"], "extra_info": {"page_label": "442", "file_name": "pre-authorization required.pdf"}}, "70af5338-1745-4bca-aa86-7844d2eec1d4": {"doc_ids": ["b652e2a0-225b-4105-affc-3405a5ceda4d"], "extra_info": {"page_label": "443", "file_name": "pre-authorization required.pdf"}}, "7c3ead24-69b6-4d90-8d03-758c13653368": {"doc_ids": ["2e9f3c74-6543-4ea6-a98c-66fde8ca147e"], "extra_info": {"page_label": "444", "file_name": "pre-authorization required.pdf"}}, "5e2cbb88-6965-4df3-8963-b213aa51d63c": {"doc_ids": ["ef1df2ab-a61a-42ee-9a3a-6fa244902196"], "extra_info": {"page_label": "445", "file_name": "pre-authorization required.pdf"}}, "9505e518-cc79-4165-8303-86dd9d256127": {"doc_ids": ["a8cd47ee-eb41-401b-8bb1-b388b31b6204"], "extra_info": {"page_label": "446", "file_name": "pre-authorization required.pdf"}}, "92e4c537-733c-4e23-adca-4c8103d9d2e4": {"doc_ids": ["b989716e-ed9a-4cd0-91a1-b8feab4c4d48"], "extra_info": {"page_label": "447", "file_name": "pre-authorization required.pdf"}}, "c50d516c-91dd-42be-b02f-5891c960b1be": {"doc_ids": ["e0637e71-58db-4ab2-b31a-c2896a334e8b"], "extra_info": {"page_label": "448", "file_name": "pre-authorization required.pdf"}}, "cfb83702-5ed4-4e1a-a30b-70165a53212d": {"doc_ids": ["61eab87a-bbba-4713-a9b7-10dd4ce722f1"], "extra_info": {"page_label": "449", "file_name": "pre-authorization required.pdf"}}, "4bfc9a7e-5144-47c7-9fc0-e3fe8c05c137": {"doc_ids": ["ba555a6d-062d-477e-8774-463328a5d449"], "extra_info": {"page_label": "450", "file_name": "pre-authorization required.pdf"}}, "8f1e0af0-532f-410f-a28c-1954f6c7e031": {"doc_ids": ["e4e68299-2544-414e-a336-cde553ffea37"], "extra_info": {"page_label": "451", "file_name": "pre-authorization required.pdf"}}, "7407440f-62eb-48b3-9d34-8a6ba12532cb": {"doc_ids": ["0e5b7bb7-e9fa-4643-8944-b646baf33dcd"], "extra_info": {"page_label": "452", "file_name": "pre-authorization required.pdf"}}, "c6c39b15-a458-4fe8-8a59-d3b7b79641ef": {"doc_ids": ["c18aab26-a58f-4b28-b1cd-ce6f44b10ee6"], "extra_info": {"page_label": "453", "file_name": "pre-authorization required.pdf"}}, "1745d44f-99d0-4d3e-b055-92b27e5ecb7d": {"doc_ids": ["e7fadaa2-1098-4632-be64-1ed38a44ff18"], "extra_info": {"page_label": "454", "file_name": "pre-authorization required.pdf"}}, "7c8017f2-b028-4e02-83de-fd7ad7e10925": {"doc_ids": ["8cb2ac7b-4fab-4994-b543-9fb80e3fc16c"], "extra_info": {"page_label": "455", "file_name": "pre-authorization required.pdf"}}, "5db5bced-031e-4adc-bc4d-17634d2ccec5": {"doc_ids": ["2989b029-076c-4d3d-920a-78cc08f4c2b7"], "extra_info": {"page_label": "456", "file_name": "pre-authorization required.pdf"}}, "4bfdd0b3-18b8-405d-84fb-ccfc5f48490b": {"doc_ids": ["65881e5f-a03c-4ae2-9e39-f1bd6430fe9f"], "extra_info": {"page_label": "457", "file_name": "pre-authorization required.pdf"}}, "5e0f0676-70ca-4f35-bf2a-7471428972f1": {"doc_ids": ["e2da1f4f-b365-4b3d-bf0f-94085b7d8767"], "extra_info": {"page_label": "458", "file_name": "pre-authorization required.pdf"}}, "02c3045e-942e-4fed-9d9a-205bf3708177": {"doc_ids": ["b2e98b18-e002-4330-aca8-85decb6f077f"], "extra_info": {"page_label": "459", "file_name": "pre-authorization required.pdf"}}, "ac22a433-f284-4c89-8527-9c97f81dcabe": {"doc_ids": ["e726f119-fc84-4a3e-ba05-9356c690e380"], "extra_info": {"page_label": "460", "file_name": "pre-authorization required.pdf"}}, "776c361f-2d56-4134-92d6-721b1a74b7bb": {"doc_ids": ["66ad97a3-e34b-4a06-bbde-238dbe33c11c"], "extra_info": {"page_label": "461", "file_name": "pre-authorization required.pdf"}}, "bcc9205d-6149-40b2-b74e-ef50462d9f59": {"doc_ids": ["01e86f14-1724-4843-a94c-f9a43cc9ae80"], "extra_info": {"page_label": "462", "file_name": "pre-authorization required.pdf"}}, "0565530d-301c-45ac-aaa0-44b1d8cdb36a": {"doc_ids": ["a0f064ca-c352-405c-9383-98183dd38259"], "extra_info": {"page_label": "463", "file_name": "pre-authorization required.pdf"}}, "90473aca-452d-468f-92dd-bb27d3d4191b": {"doc_ids": ["e7943ad1-c579-410f-b708-90ac4b982722"], "extra_info": {"page_label": "464", "file_name": "pre-authorization required.pdf"}}, "4d91befa-f6ff-4a94-8f35-8d9d70194f8e": {"doc_ids": ["07e8fd14-7ba1-458a-a807-83894f081c06"], "extra_info": {"page_label": "465", "file_name": "pre-authorization required.pdf"}}, "40811b3b-4b90-44cd-8288-a0e58a632068": {"doc_ids": ["cfc5e652-a898-4df8-9021-d17b21bf39fa"], "extra_info": {"page_label": "466", "file_name": "pre-authorization required.pdf"}}, "f18533ec-40f7-4f2e-bb74-f837928f1582": {"doc_ids": ["1beb2649-3411-480f-b14d-faf250b75df1"], "extra_info": {"page_label": "467", "file_name": "pre-authorization required.pdf"}}, "93bf7c7a-d3c9-4d3f-89dc-36e0225a6131": {"doc_ids": ["faeaf271-1f84-416c-874e-72cfe9d8a296"], "extra_info": {"page_label": "468", "file_name": "pre-authorization required.pdf"}}, "da28e9b1-4c67-4b7d-a3b7-02c716f15884": {"doc_ids": ["f4eee52f-55e1-41cb-8e3f-a664c9fa9b86"], "extra_info": {"page_label": "469", "file_name": "pre-authorization required.pdf"}}, "ae4a396c-fd92-497c-b2ce-50ceba4cd2ca": {"doc_ids": ["40a3aa91-c52a-4960-b069-43f68ad04b9e"], "extra_info": {"page_label": "470", "file_name": "pre-authorization required.pdf"}}, "f0175172-52d1-4e1f-b9ce-3653697804d2": {"doc_ids": ["4909a2d9-84a2-45d3-a887-acba255a5c34"], "extra_info": {"page_label": "471", "file_name": "pre-authorization required.pdf"}}, "6fc42ca3-9179-403d-adc1-34d1a2cac95d": {"doc_ids": ["8cd09970-fb68-48cf-ab76-b3e6adbe9f0d"], "extra_info": {"page_label": "472", "file_name": "pre-authorization required.pdf"}}, "a28ba738-07a6-4228-a914-c5333d4b10d1": {"doc_ids": ["ebee5cca-c5a3-43e4-99ac-63a889a9bdd7"], "extra_info": {"page_label": "473", "file_name": "pre-authorization required.pdf"}}, "a465c11b-032f-4d8a-84e6-475f5e026c12": {"doc_ids": ["29c2bbb5-c96e-4856-aeae-2b3df7b557b8"], "extra_info": {"page_label": "474", "file_name": "pre-authorization required.pdf"}}, "66bfe2ad-b7c3-4a94-b565-31f95ccda9ae": {"doc_ids": ["3b1a94cf-f216-4965-9590-5ad7855752ca"], "extra_info": {"page_label": "475", "file_name": "pre-authorization required.pdf"}}, "4f410207-d907-4f28-b2b3-10f9973edbae": {"doc_ids": ["91bf2d06-bad1-4f73-b81f-9dd024642cb0"], "extra_info": {"page_label": "476", "file_name": "pre-authorization required.pdf"}}, "970fdd93-4f95-465e-b78f-23f9a42f749f": {"doc_ids": ["85a3bdf8-8eca-4217-adad-fd8b5246d572"], "extra_info": {"page_label": "477", "file_name": "pre-authorization required.pdf"}}, "e373ec7a-cf77-4dbe-8ac0-87e1def9cb7e": {"doc_ids": ["c906778d-79fe-4013-ad07-5e1cba35663d"], "extra_info": {"page_label": "478", "file_name": "pre-authorization required.pdf"}}, "7463f9c0-325e-47b9-a5de-fc6dd92946bd": {"doc_ids": ["0e5d033b-e77c-46eb-8259-31c939356e34"], "extra_info": {"page_label": "479", "file_name": "pre-authorization required.pdf"}}, "0c863ddf-b040-489b-907e-1b3cabea62e7": {"doc_ids": ["94b380e6-4e5b-407b-ad79-b0349e20b077"], "extra_info": {"page_label": "480", "file_name": "pre-authorization required.pdf"}}, "134da570-79fa-4e90-8ac6-1fc22abbd5bb": {"doc_ids": ["aacd5263-fd60-4e6b-b43d-533c753928af"], "extra_info": {"page_label": "481", "file_name": "pre-authorization required.pdf"}}, "5daeb425-4a9f-4bd8-9174-758c37177f13": {"doc_ids": ["aca4d2be-d4a3-4450-8641-6bc7353ce19a"], "extra_info": {"page_label": "482", "file_name": "pre-authorization required.pdf"}}, "47277464-fb86-42b1-a160-a0cf8235ec95": {"doc_ids": ["2b0d3255-0492-41f9-8ecf-7691a3294b87"], "extra_info": {"page_label": "483", "file_name": "pre-authorization required.pdf"}}, "9fef27f8-1a57-4fa2-bd44-289942713981": {"doc_ids": ["8321c303-5b62-4904-891e-8c8c1deffedd"], "extra_info": {"page_label": "484", "file_name": "pre-authorization required.pdf"}}, "95cf5097-407a-4607-96d5-e471e34174fb": {"doc_ids": ["c6a41617-96ed-4094-ad7e-5d3a6e9aa71a"], "extra_info": {"page_label": "485", "file_name": "pre-authorization required.pdf"}}, "fb4b34d3-279e-4b6a-916e-e2c1ae1676c9": {"doc_ids": ["4c2aaba9-6fe7-4ead-9fd8-ace3849c66ba"], "extra_info": {"page_label": "486", "file_name": "pre-authorization required.pdf"}}, "a61514eb-9daf-49b6-90fb-58e4585e5e36": {"doc_ids": ["1581619a-81ea-4812-9521-8c2cc3bd3a73"], "extra_info": {"page_label": "487", "file_name": "pre-authorization required.pdf"}}, "75f9b52e-83bb-4c03-a327-a65faf58304b": {"doc_ids": ["3343a8b4-0b58-4781-a514-278fdee4890a"], "extra_info": {"page_label": "488", "file_name": "pre-authorization required.pdf"}}, "4335e411-a543-41c2-bf42-364a8c482cf8": {"doc_ids": ["c8057314-74ba-4c0c-8007-8412e5aaef37"], "extra_info": {"page_label": "489", "file_name": "pre-authorization required.pdf"}}, "d815c595-b5d1-4918-94da-e8f92bf2d95b": {"doc_ids": ["9ad23b6a-90ed-485f-b1d9-a9c0a1857919"], "extra_info": {"page_label": "490", "file_name": "pre-authorization required.pdf"}}, "31ba72e0-0cb9-45fb-bdf8-37d3661d7afe": {"doc_ids": ["01cf9e2a-9851-4eb6-bc8c-21ad39d03540"], "extra_info": {"page_label": "491", "file_name": "pre-authorization required.pdf"}}, "9e1c853b-10c6-4a43-892a-404777e6f766": {"doc_ids": ["128330ab-6690-4d66-a373-a8d07ff72d5e"], "extra_info": {"page_label": "492", "file_name": "pre-authorization required.pdf"}}, "6654c66c-1993-47ff-9a43-d03f063dd893": {"doc_ids": ["edaf5f55-2173-4996-9c3f-63554ea61be5"], "extra_info": {"page_label": "493", "file_name": "pre-authorization required.pdf"}}, "85d680ec-46d5-4908-bee2-5b642800c54a": {"doc_ids": ["7aa8349e-2408-4801-a065-aa726eac7eb1"], "extra_info": {"page_label": "494", "file_name": "pre-authorization required.pdf"}}, "01591232-3e55-487b-819e-5433b570998f": {"doc_ids": ["59bacfc6-e309-4f69-b0bc-339d51a689c7"], "extra_info": {"page_label": "495", "file_name": "pre-authorization required.pdf"}}, "7c461718-0a2c-4d28-a6c2-54cddbbe36fa": {"doc_ids": ["1b532328-bf14-4e7b-a869-c88f54e20daa"], "extra_info": {"page_label": "496", "file_name": "pre-authorization required.pdf"}}, "a6176669-729e-43df-9c4d-3e9938a9d8b2": {"doc_ids": ["1eb7c451-a607-427b-bc2c-235b4364d433"], "extra_info": {"page_label": "497", "file_name": "pre-authorization required.pdf"}}, "0766d2d3-fc00-416f-bd84-d51be4430048": {"doc_ids": ["a2ebfc14-7106-4532-9788-60e121b83c4c"], "extra_info": {"page_label": "498", "file_name": "pre-authorization required.pdf"}}, "66cd6f43-e0e2-4e31-91a3-6af0685ad24e": {"doc_ids": ["1c956516-bf64-49e7-98ea-20ab4dd87258", "5ccac1c4-d6f1-4c65-9d4a-bc837cd8a778"], "extra_info": {"page_label": "499", "file_name": "pre-authorization required.pdf"}}, "febd6f07-4102-4322-a244-85c462a8074e": {"doc_ids": ["52ef6ef9-8905-4547-a1e1-30e04b8a36d1", "06735e6a-5bf2-4f45-b83e-a374fdff67ca"], "extra_info": {"page_label": "500", "file_name": "pre-authorization required.pdf"}}}}