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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

Change of Address (County) Form, PDF

Change of Primary Care Provider Form, PDF

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

Adams, Allen, Auglaize, Brown, Butler, Champaign, Clark, Clermont, Clinton, Crawford, Darke, Defiance, Fulton, Greene, Hamilton, Hancock, Hardin, Henry, Highland, Logan, Lucas, Marion, Mercer, Miami, Montgomery, Ottawa, Paulding, Preble, Putnam, Sandusky, Seneca, Shelby, Van Wert, Warren, Williams, Wood, Wyandot

Region 2 – Northeast

Ashland, Ashtabula, Carroll, Columbiana, Coshocton, Cuyahoga, Erie, Holmes, Geauga, Harrison, Huron, Jefferson, Knox, Lake, Lorain, Mahoning, Medina, Portage, Richland, Stark, Summit, Trumbull, Tuscarawas, Wayne

Region 3 – Central/Southeast

Athens, Belmont, Delaware, Fairfield, Fayette, Franklin, Gallia, Guernsey, Hocking, Jackson, Lawrence, Licking, Madison, Meigs, Monroe, Morgan, Morrow, Muskingum, Noble, Perry, Pickaway, Pike, Ross, Scioto, Union, Vinton, Washington

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

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)

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.