Page 54 - Evaluation for 2018

1/3/2018 Your Medicare Health Plan Details

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Your Plan Details

Zip Code: 99005
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: 1321108544
and more coverage and star ratings.
Password Date: 12/23/2017
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.
A process through which the enrollee’s primary care physician or other network physician (depending on the plan policy) permits or
instructs the enrollee to obtain an item or service from another physician or other provider type.
Some Dental Coverage Some Vision Coverage Some Hearing Coverage
* Estimated

Humana Gold Plus H5619- 500 West Main Street Overall Star Rating: [?] Enroll
Louisville, KY 40202
060 (HMO)
(H5619-060-0) Members: 4 out of 5 stars
1-800-457-4708
Organization: Arcadian Health Plan, 711 (TTY/TDD)
Inc.
Non Members:
Plan Type: 1-800-833-2364
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 $5,900 In-network
responsibility (does not include
prescription drugs)
Optional supplemental benefits [?] Yes

Inpatient hospital coverage $360 for days 1 through 5
$0 for days 6 through 90
$0 for days 91 and beyond

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