Page 52 - Cover Letter and Evaluation for Amy Prack

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Your Plan Details

Zip Code: 43221
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: 3233662560
and more coverage and star ratings.
Password Date: 05/12/2019
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

Humana Gold Plus H6622- 500 West Main Street Overall Star Rating: Enroll
013 (HMO) Louisville, KY 40202 Members: [?]
1-800-457-4708 711 (TTY/TDD)
(H6622-013-0) Non Members: 1-800-833-2364 4 out of 5 stars
711 (TTY/TDD)
Organization: Humana
Plan Type: HMO

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-network
responsibility (does not include
prescription drugs)
Optional supplemental benefits [?] Yes
Additional benefits and/or reduced cost-
sharing for enrollees with certain health In-Network: No
conditions?
Inpatient hospital coverage $395 per day for days 1 through 4
$0 per day for days 5 through 90
$0 per day for days 91 and beyond
Outpatient hospital coverage $350 per visit