psg stringlengths 98 550 |
|---|
These are the summary of benefits for the plan named Humana Community HMO H1036-236. This plan is available in the county of Jefferson in Kentucky. This plan applies to the year 2023.
The Pre-Enrollment Checklist includes Understanding the Benefits.
Before making an enrollment decision, it is important that you fully ... |
Understanding the Benefits. The Evidence of Coverage (EOC) provides a complete list of all coverage and services. It is important to review plan coverage, costs and benefits before you enroll. Visit Humana.com/medicare or call 1-800-833-2364 (TTY: 711) to view a copy of the Evidence of Coverage EOC.
Review the provider... |
Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.
Review the formulary to make sure your drugs are covered.
Here are important Rules. You must continue t... |
Benefits, premiums and/or copayments/co-insurance may change on January 1, 2024.
Except in emergency or urgent situations, we do not cover services by out-of-network providers. Out-of-network providers are doctors who are not listed in the provider directory.
To find out more about the Humana Community HMO plan, inclu... |
To be eligible to join the Humana Community HMO plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and live in our service area.
If you are a member of this plan, call toll-free 1-800-457-4708. If you are not a member of this plan, call toll free 1-800-833-2364. From October 1 to March 31, ca... |
Here is more information about the Humana Community (HMO).
Do you have Medicare and Medicaid? If you are a dual-eligible beneficiary enrolled in both Medicare and the state's program, you may not have to pay the medical costs displayed in this booklet and your prescription drug costs will be lower, too. |
If you have Medicaid, be sure to show your Medicaid ID card in addition to your Humana membership card to make your provider aware that you may have additional coverage. Your services are paid first by Humana and then by Medicaid.
As a member you must select an in-network doctor to act as your Primary Care Provider (PC... |
Humana Community (HMO) has a network of doctors, hospitals, pharmacies and other providers. If you use providers who aren't in our network, the plan may not pay for these services.
Here is information about the Monthly Plan Premium, Deductible and Limits.
The Monthly Plan Premium is $0 . You must keep paying your Me... |
The maximum out-of-pocket responsibility is $3,900 for in-network costs. The most you pay for copays, coinsurance and other costs for covered medical services for the year.
Here are the Covered Medical and Hospital Benefits.
Acute inpatient hospital care has a $250 copay per day for days 1 through 7 and a $0 copay ... |
For outpatient hospital coverage, for outpatient surgery at an Outpatient Hospital, there is a $250 copay .
For outpatient surgery at an Ambulatory Surgical Center, there is a $200 copay .
For primary care Doctor visits , the copay is $0.
For Specialists the copay is $15. |
You do not need a referral to receive covered services from plan providers. Certain procedures, services and drugs may need advance approval from your plan. This is called a "prior authorization" or "preauthorization." Please contact your PCP or refer to the Evidence of Coverage (EOC) for services that require a prior ... |
For preventive care, our plan covers many preventive services at no cost when you see an in-network provider.
Abdominal aortic aneurysm screening is a preventative service.
Alcohol misuse counseling is a preventative service.
Bone mass measurement is a preventative service.
Breast cancer screening (mammogram) is a ... |
Cervical and vaginal cancer screening is a preventative service.
Colorectal cancer screenings (colonoscopy, fecal occult blood test, flexible sigmoidoscopy) is a preventative service.
Depression screening is a preventative service.
Diabetes screenings is a preventative service.
HIV screening is a preventative serv... |
Prostate cancer screenings (PSA) is a preventative service.
Sexually transmitted infections screening and counseling is a preventative service.
Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) is a preventative service.
Vaccines, including flu shots, hepatitis B shots,... |
Lung cancer screening is a preventative service.
Routine physical exam is a preventative service.
Medicare diabetes prevention program is a preventative service.
Any additional preventive services approved by Medicare during the contract year will be covered.
Here is information about emergency care .
The Emergenc... |
Urgently needed services $20 copay at an urgent care center
Urgently needed services are provided to treat a non-emergency,
unforeseen medical illness, injury or condition that requires immediate
medical attention.
Here is information about OUTPATIENT CARE AND SERVICES .
For diagnostic services, labs and imaging , ... |
For Diagnostic radiology, there is a $180 to $300 copay .
For Lab services, there is a $0 to $20 copay .
For Diagnostic tests and procedures there is a $0 to $100 copay .
For Outpatient X-rays there is a $0 to $75 copay .
For Radiation therapy, there is a $15 copay or 20% of the cost .
Here is information about outpa... |
Routine hearing that is In-Network, called HER963, there is a $0 copay for routine hearing exams up to 1 per year.
There is a $0 copay for each Advanced level hearing aid up to 1 per ear every 3 years.
There is a $299 copay for each Premium level hearing aid up to 1 per ear every 3 years. |
A hearing aid purchase includes unlimited follow-up provider visits during first year following a TruHearing hearing aid purchase . The hearing aid purchase has a 60-day trial period and a 3-year extended warranty and 80 batteries per aid for non-rechargeable models . You must see a TruHearing provider to use this b... |
For a routine dental service, the cost-share indicated below is what you pay for the covered service.
For In-Network, DEN046 , there is a $0 copay for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
There is a $0 copay for comprehensive oral evaluation or periodontal exam, occlusal adjust... |
There is a $0 copay for bridges, complete dentures, crown recementation, denture recementation, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years.
There is a $0 copay for crown, root canal, root canal retreatment up to 1 per tooth per lifetime.
There is a $0 copay for bitewing x-rays, intrao... |
conditioning up to 1 per year.
There is a $0 copay for emergency treatment for pain, fluoride treatment, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
There is a $0 copay for periodontal maintenance up to 4 per year.
There is a $0 copay for amalgam and/or composite filling, necessary ane... |
There is a $3000 maximum benefit coverage amount per year for preventive and comprehensive benefits.
Dental services are subject to our standard claims review procedures which could include dental history to approve coverage. Dental benefits under this plan may not cover all American Dental Association procedure codes... |
Network dentists have agreed to provide services at contracted fees (the in-network fee schedules, of INFS). If a member visits a participating network dentist, the member will not receive a bill for charges more than the negotiated fee schedule on covered services (coinsurance payment still applies).
Use the HumanaDe... |
Humana.com > Find a Doctor > from the Search Type drop down select Dental > under Coverage Type select All Dental Networks > enter zip code > from the network drop down select HumanaDental Medicare.
Medicare-covered vision services have a $15 copay.
A Medicare-covered diabetic eye exam has a $0 copay .
A Medicare-co... |
Routine vision that is In-Network with the code VIS733 , has a $0 copay for routine exam up to 1 per year.
There is a $300 maximum benefit coverage amount per year for contact lenses or eyeglasses-lenses and frames, fitting for eyeglasses-lenses and frames.
Eyeglass lens options may be available with the maximum be... |
The provider locator for routine vision can be found online at Humana.com > Find a Doctor > select Vision care icon > Vision coverage through Medicare Advantage plans.
For Mental health services that are Inpatient, there is a $250 copay per day for days 1 through 6. And there is a $0 copay per day for days 7 through... |
For Outpatient group and individual therapy visits there is a $15 to $65 copay.
Cost share may vary depending on where service is provided.
For a Skilled nursing facility (SNF) there is a $0 copay per day for days 1 through 20 . And there is a $196 copay per day for days 21-100 . Your plan covers up to 100 days in... |
For the Transportation benefit, there is a $0 copay for a plan approved location with up to 48 one-way trips per year.
This benefit is not to exceed 25 miles per trip.
The member must contact transportation vendor to arrange transportation and should contact Customer Care to be directed to
their plan's specific tran... |
This plan has Prescription Drug Benefits .
Here is information about what You Pay for Vaccines .
Our plan covers most Part D vaccines at no cost to you, no matter what cost-sharing tier it’s on .
Here is information about What You Pay for Insulin .
You won’t pay more than $35 for a one-month (up to 30-day) supply of e... |
including the Select Insulins covered under the Insulin Savings Program as described below.
What you pay for prescription drugs depends on whether you receive "Extra Help" or not.
If you receive "Extra Help", you will still pay no more than $35 for a one-month supply for each Part D covered insulin.
Please see your ... |
If you don't receive Extra Help for your drugs, you'll pay a different amount based on the type of cost-sharing option you use. |
For the Initial coverage, you are responsible to pay for a 30-day supply or a 90-day supply the amount based on the tier of the prescription drug. A prescription drug can be either in tier 1 preferred generic, tier 2 generic, tier 3 preferred brand, tier 4 non-preferred drug, or tier 5 specialty tier. You are responsib... |
There are two different kinds of cost-sharing for prescription drugs, including Mail Order Cost-Sharing and Retail Cost-Sharing. There are two different kinds of Mail Order pharmacy options, Standard and Preferred. The Mail order pharmacy option called Standard includes Walmart Mail, PillPack and other pharmacies that ... |
For the Standard Mail order pharmacy option, for Tier 1 Preferred Generic drugs, the 30-day supply costs $10 and the 90-day supply costs $30.
For the Standard Mail order pharmacy option, for Tier 2 Generic drugs, the 30-day supply costs $20 and the 90-day supply costs $60.
For the Standard Mail order pharmacy option, f... |
For the Standard Mail order pharmacy option, for Tier 4 Non-Preferred drugs, the 30-day supply costs $100 and the 90-day supply costs $300.
For the Standard Mail order pharmacy option, for Tier 5 Specialty Tier drugs, the 30-day supply costs 33% and the 90-day supply is not available.
For the Preferred CenterWell Pharm... |
For the Preferred CenterWell Pharmacy Mail order pharmacy option, for Tier 2 Generic drugs, the 30-day supply costs $0 and the 90-day supply costs $0.
For the Preferred CenterWell Pharmacy Mail order pharmacy option, for Tier 3 Preferred Brand drugs, the 30-day supply costs $42 and the 90-day supply costs $116.
For the... |
For the Preferred CenterWell Pharmacy Mail order pharmacy option, for Tier 5 Specialty Tier drugs, the 30-day supply costs 33% and the 90-day supply is not available.
The other kind of prescription drug cost sharing is called Retail Cost-Sharing, which means that you can physically go to the pharmacy. You can go to any... |
For the retail pharmacy option, for Tier 1 Preferred Generic drugs, the 30-day supply costs $0 and the 90-day supply costs $0.
For the retail pharmacy option, for Tier 2 Generic drugs, the 30-day supply costs $0 and the 90-day supply costs $0.
For the retail pharmacy option, for Tier 3 Preferred Brand drugs, the 30-day... |
For the retail pharmacy option, for Tier 5 Specialty Tier drugs, the 30-day supply costs 33% and the 90-day supply is not available.
Your plan participates in the Insulin Savings Program. You will pay no more than $35 for a one-month (up to a 30-day) supply for Select Insulins, no matter what cost-sharing tier it’s on... |
Drug Guide. You are not eligible for this program if you receive "Extra Help".
Your plan also provides enhanced insulin coverage which means you will pay no more than $35 for a one-month (up to 30-day) supply for all Part D insulins covered by our plan, including Select Insulins, no matter what cost-sharing tier it’s ... |
Your share of the cost for Select Insulins depends on whether you choose the Mail Order Cost-Sharing option for Select Insulins or the Retail Cost-Sharing options for Select Insulins.
There are two mail order cost-sharing pharmacy options, including the Standard option which includes Walmart Mail, PillPack and any oth... |
The second cost-sharing pharmacy option is the Preferred CenterWell Pharmacy.
For the Standard mail order cost-sharing pharmacy option for select insulins, for tier 3 preferred brand insulin drugs the 30-day supply costs $35 and the 90-day supply costs $105.
For the preferred CenterWell mail order cost-sharing pharmac... |
For the retail cost-sharing option for buying select insulin drugs, you can got to any in network retailer pharmacies.
For the retail cost-sharing option for buying select insuling drugs, for the tier 3 preferred brand option the 30-day supply costs $35 and the 90-day supply costs $105. |
If you receive Extra Help for your drugs, you'll pay the following copay depending on whether you choose generic drugs and depending on whether you choose a 30-day supply or a 90-day supply. This plan does not have a deductible.
For generic drugs, for a 30-day supply, you pay a $0 copay and for a 90-day supply you ... |
For brand name drugs that happen to be treated as generic drugs, you pay a $1.45 copay for a 30-day supply and for a 90-day supply you pay a $1.45 copay or you can also just pay 15% of the cost.
Note that some drugs are only limited to a 30-day supply.
In addition, Erectile dysfunction (ED) drugs are covered at the Ti... |
Cost sharing may change depending on the pharmacy you choose, when you enter another phase of the Part D benefit and if you qualify for "Extra Help." To find out if you qualify for "Extra Help," please contact the Social Security Office at 1-800-772-1213 Monday — Friday, 7 a.m. — 7 p.m. TTY users should call 1-800-325-... |
If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
After you enter the coverage gap, you pay 25 percent of the plan's cost for covered brand name drugs and 25 percent of the p... |
Under this plan, you may pay even less for the following, all Tier 1 (Preferred Generic) Drugs , all Tier 2 (Generic) drugs and for select insulin tier 3 preferred brand drugs. For more information on cost sharing in the coverage gap, please call us or access your Evidence of Coverage online. |
For Catastrophic Coverage , after your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,4 00 you pay the greater of 5% of the cost, or $4.15 copay for generic (including brand drugs treated as generic) and a $10.35 copay for all other drugs .
Me... |
Medical equipment/ supplies cost share may vary depending on the service and where service is provided .
Forf Durable medical equipment (like wheelchairs or oxygen) you pay 16% of the cost .
For Medical supplies you pay 20% of the cost .
For Prosthetics (such as artificial limbs or braces) you pay 20% of the cost .... |
For Rehabilitation services such as Cardiac rehabilitation there is a $10 copay .
For Rehabilitation services such as Pulmonary rehabilitation there is a $10 copay .
For Telehealth services (in addition to Original Medicare) for the Primary care provider (PCP) there is a $0 copay .
For Telehealth services (in additi... |
For Telehealth services (in addition to Original Medicare) for Substance abuse and behavioral health services there is a $0 copay .
This summary of benefits is only a summary of the full set of benefits that are listed in the Evidence of Coverage (EOC), which is a document that provides a complete list of coverage and... |
For the Humana Flex Allowance , there is a $1000 annual allowance on a prepaid card to use toward out of pocket costs for the plan's preventive and comprehensive dental, vision, or hearing services including copays. Members can use this benefit at participating providers where the primary business is Dental Care, Visi... |
Allowance amounts cannot be combined with other benefit allowances. Limitations and restrictions may apply.
There is a Over-the-Counter (OTC) Allowance of $50 maximum benefit coverage amount per month for over-the-counter (OTC) prepaid card to purchase eligible OTC health and wellness products at participating reta... |
The Allowance amounts cannot be combined with other benefit allowances. Limitations and restrictions may apply. |
For the Humana Spending Account Card , the allowances listed below will be loaded onto this prepaid card. Each allowance is separate from any other allowance listed. Allowances shown are accessed by using this card. Allowance amounts cannot be combined with other benefit allowances. Limitations and restrictions may app... |
Flexible Care Assistance is available to members with chronic health conditions, who are participating in care management services, and meet program criteria. Eligible members may receive medical expense assistance and other additional benefits, either primarily health related or non-primarily health related, to addres... |
For routine Chiropractic services , there is a $0 copay per visit for unlimited visits.
For Routine foot care there is a $0 copay per visit for up to 12 visits .
The Humana Well Dine Meal Program is Humana's home delivered meal program for members following an inpatient stay in the hospital or nursing facility.
Go... |
The SilverSneakers fitness program is a Basic fitness center membership including fitness classes. |
No dataset card yet
- Downloads last month
- 5