Page 78 - 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) Members:
1-800-457-4708
Organization: Humana Insurance 711 (TTY/TDD)
Company
Non Members:
Plan Type: 1-800-833-2364
711 (TTY/TDD)

Benefits Highlights

Monthly health plan premium $0.00

Health plan deductible $1,500 annual deductible
Other health plan deductibles?
In-Network: No
Maximum out-of-pocket enrollee $10,000 In and Out-of-network
responsibility (does not include $6,700 In-network
prescription drugs)
Optional supplemental benefits [?] Yes

Inpatient hospital coverage
In-Network: $450 for days 1 through 4
$0 for days 5 through 90
$0 for days 91 and beyond
Out-of-Network: 40% per stay

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