Page 56 - Cover Letter and Evaluation for Bob Workman

10/25/2017 Your Medicare Health Plan Details

Your Plan Details

Zip Code: 99206
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs Drug List ID: 7744939488
and more coverage and star ratings.
Password Date: 10/23/2017
Important Coverage Information

Symbols
A process through which the physician or other health care provider is required to obtain advance approval from the plan that payment
will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect to a particular item or service, the
enrollee is not responsible for obtaining (prior) authorization.
Some Dental Coverage Some Vision Coverage Some Hearing Coverage
* Estimated

HumanaChoice H5216- 500 West Main Street Overall Star Rating: [?] Enroll
Louisville, KY 40202
046 (PPO)
(H5216-046-0) Members: 4 out of 5 stars
1-800-457-4708
Organization: Humana Insurance 711 (TTY/TDD)
Company
Non Members:
Plan Type: Local Preferred 1-800-833-2364
Provider Organization 711 (TTY/TDD)

Benefits Highlights

Monthly health plan premium $0.00

Health plan deductible $0

Other health plan deductibles?
In-Network: No

Maximum out-of-pocket enrollee $4,500 In and Out-of-network
responsibility (does not include $3,600 In-network
prescription drugs)
Optional supplemental benefits [?] Yes
Inpatient hospital coverage
In-Network: $275 for days 1 through 5
$0 for days 6 through 90
$0 for days 91 and beyond
Out-of-Network: 50% per stay

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5216&plnid=046&sgmntid=0#plan_benefits 1/2