Page 76 - Cover Letter & Evaluation for Isaac Kapon

10/5/2017 Your Medicare Health Plan Details

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Your Plan Details
Zip Code: 89014
Current Coverage: Original Medicare
Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits,
drug costs and more coverage and star ratings. Drug List ID: 1485169984
Password Date: 10/05/2017
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: [?] Enrollment begins
Louisville, KY 40202 Coming Soon October 15, 2017
141 (PPO)
(H5216-141-0) 1 Members:
1-800-457-4708
Organization: Humana Insurance 711 (TTY/TDD)
Company
Non Members:
Plan Type: 1-800-833-2364
711 (TTY/TDD)

Additional Plan Information

Overall Star Rating [?] Coming Soon

Health Plan Star Ratings [?] Coming Soon

Drug Plan Star Ratings [?] Coming Soon

Plan Type: Local Preferred Provider Organization
Plan Status: Approved by Medicare
Area: Clark and Nye (partial) counties

View plan website 
Important Note:
This plan does not charge an annual deductible for all drugs. The $365.00 annual deductible only applies to drugs on certain tiers.
This plan's deductible only applies to out-of-network services.

Provider Network: 3001-3500 physicians and providers.
View provider and physician network website 

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H5216&plnid=141&sgmntid=0 1/2