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Documents and forms for Humana Healthy Horizons in Ohio members

Find the documents and forms you need to get the most from your health plan.

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Key plan documents

Welcome Kit

All new members get a Quick Start Guide in the mail. You also can view it below. Your Quick Start Guide includes the information you need at the start of your enrollment in Humana Healthy Horizons® in Ohio.

Quick Start Guide – English, PDF

Quick Start Guide – Spanish, PDF

Welcome letter from Gainwell, PDF

Adobe Reader is needed to view PDFs. If you do not have Adobe Reader, download it today.

Health Risk Assessment (HRA)

The HRA is a set of health questions for you to answer. Your answers will help us make sure you get the care you need. Your Quick Start Guide includes an HRA and a postage-paid envelope in which to return it. You also can download an HRA below.

Health Risk Assessment – English, PDF

Health Risk Assessment – Spanish, PDF

Earn $25 in rewards through Go365 for Humana Healthy Horizons® if you complete your HRA during the first 90 days of enrollment in Humana Healthy Horizons in Ohio. This reward is available to all members.

Learn more about Go365 for Humana Healthy Horizons

Member Handbook

Have questions about your plan, benefits, and covered services? Check out your Member Handbook. Your handbook also has information about our medical necessity criteria. To request we send you a handbook or a copy of this criteria, call 877-856-5702 (TTY: 711), Monday – Friday, from 7 a.m. – 8 p.m., Eastern time.

Member Handbook – English, PDF

Member Handbook – Spanish, PDF

Healthcare power of attorney and living will (advance directive), PDF

If you need to change your address

To make sure you don’t lose your Medicaid coverage, be sure to keep your information current with the Ohio Department of Medicaid (ODM). If you need to change your address:

  • Call the Ohio Medicaid Consumer Hotline at 800-324-8680, Monday – Friday, 7 a.m. – 8 p.m., and Saturday, 8 a.m. – 5 p.m.
  • Contact a case worker through your local department of job and family services
  • Use your Ohio Benefits Self-Service account, if you have one, to report the change through the online portal

Learn more about updating your information when needed

Get a free phone

Through the federal Safelink program, you can get a free phone and talk time to use every month.

Learn about the federal Safelink program, PDF

Provider directories

Refer to the provider directory in the region where you live to find information about in-network providers, specialists, healthcare facilities, and more. You also can use our Find a Doctor service.

Region 1 – West

Ohio Counties

Adams, Brown, Clermont, Clinton, and Highland

Allen and Crawford

Auglaize, Fulton, Henry, Mercer, Ottowa, Paulding, Sandusky, Van Wert, and Williams

Butler and Warren

Champaign, Darke, Logan, Miami, Preble, and Shelby


Defiance, Seneca, and Wood



Hancock, Hardin, Marion, Putnam, and Wyandot



Indiana, Kentucky, and Michigan border counties

IN counties: Delaware, Fayette, Henry, Randolph, Union, and Wayne

IN counties: Adams, Allen, Blackford, De Kalb, Jay, Lagrange, Noble, Steuben, Wells and Whitley. MI counties: Hillsdale, Jackson, Lenawee, Monroe, Washtenaw, and Wayne

IN counties: Dearborn, Franklin, and Ohio. KY counties: Boone, Bracken, Campbell, Kenton, Lewis, Mason, and Pendleton

Region 2 – Northeast

Ohio Counties

Ashland, Coshocton, Erie, Holmes, Huron, Knox, Richland, and Wayne

Ashtabula, Columbiana, Harrison, and Jefferson

Carrol and Trumbull


Geauga and Lorain



Medina and Portage

Stark and Tuscarawas


Pennsylvania and W. Virginia border counties

PA county: Allegheny. WV counties: Brooke and Hancock

PA counties: Beaver, Butler, Crawford, Erie, Lawrence, Mercer, Venango, and Washington

Region 3 – Central/Southeast

Ohio Counties

Athens, Belmont, Guernsey, Meigs, Monroe, Morgan, Muskingum, Noble, and Washington

Delaware, Fairfield, and Union

Fayette, Hocking, Licking, Madison, Morrow, Perry, and Pickaway


Gallia, Pike, Scioto, and Vinton

Jackson, Lawrence, and Ross

Kentucky and W. Virginia border counties

KY counties: Boyd, Carter, Greenup, Lewis. WV counties: Cabell, Jackson, Lincoln, Marshall, Mason, Ohio, Pleasants, Putnam, Ritchie, Tyler, Wayne, Wetzel, Wirt, Wood

ODM online provider directory

Pharmacy information

View the Gainwell member handbook, PDF

Get answers to frequently asked questions about Gainwell and your pharmacy coverage, PDF

Preferred Drug List

The Ohio Department of Medicaid (ODM) Unified Preferred Drug List (PDL) is a list of drugs and medicines covered for Ohio residents who receive Medicaid benefits. Gainwell Technologies administers pharmacy benefits for all Ohio Medicaid recipients. Your provider can prescribe you drugs and medicines on this list if needed. If your provider wants to prescribe you medicine that requires prior authorization, he or she will send Gainwell Technologies a prior authorization request.

Review the ODM Unified PDL

Grievances and appeals forms

We want you to be happy with the care you get. We hope you get the best care possible.

If you are not happy with any part of your healthcare plan, Member Services, your provider, or a facility, you can send in a grievance.

You also can appeal a claim or a denied service using the grievances and appeals forms.

If you are sending an appeal or grievance for another covered member, be sure to fill out an Appointment of Representative Form, PDF.

ODM Appeals Form, PDF

Learn more about grievances and appeals

Change PCP form

Your doctor can use the Change PCP form to let us know that they will be your primary care physician (PCP).

Change PCP form, PDF

Legal and privacy notices

Detecting, preventing, and reporting healthcare fraud

As part of our efforts to improve the healthcare system, we are committed to:

  • Detecting, correcting, and preventing healthcare fraud
  • Educating our members about how to detect and/or prevent fraud

Learn more about detecting, preventing, and reporting healthcare fraud and how you can help, PDF

Performance measurement

Refer to the below information to see how we’re measured as a health plan and also how we’re doing.

Guide to Healthcare Effectiveness Data and Information Set (HEDIS®) measurements

State of Health Care Quality Report (NCQA)

Expanded Benefits Reimbursement Form

We hope you don’t have to pay out of pocket for the benefits you get as a Humana Healthy Horizons in Ohio member. If you do, let us know by filling out an Expanded Benefits Reimbursement claim form, and you may get a refund.

Fill out the form below to send a reimbursement claim.

Expanded Benefits Reimbursement Form – English, PDF

Expanded Benefits Reimbursement Form – Spanish, PDF

Member Reimbursement Form

We hope you don’t have to pay out of pocket services you get as a Humana Healthy Horizons in Ohio member. If you do, let us know by filling out a Member Reimbursement claim form, and you may get a refund.

Fill out the form below to send a reimbursement claim.

Member Reimbursement Form – Bilingual (English and Spanish), PDF

Looking for help?

Find a doctor

Find a doctor, hospital, or pharmacy.

Value-added benefits

Learn about the extra benefits and services available to Humana Healthy Horizons in Ohio members.

Documents & forms

Find the documents and forms you need, including your Member Handbook.