Humana Fully Integrated D-SNP

Documents and forms

Find the documents and forms you need to get the most out of your Humana Fully Integrated D-SNP enrollment.

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Evidence of coverage

Your 2025 Evidence of Coverage - Humana Dual Fully Integrated H2875-001 (HMO-POS D-SNP)
Su Evidencia de Cobertura 2025 - Humana Dual Fully Integrated H2875-001 (HMO-POS D-SNP)

Your 2025 Evidence of Coverage - Humana Dual Fully Integrated H2875-003 (HMO D-SNP)
Su Evidencia de Cobertura 2025 - Humana Dual Fully Integrated H2875-003 (HMO D-SNP)

Your 2025 Evidence of Coverage - Humana Gold Plus SNP-DE H2875-002 (HMO D-SNP)
Su Evidencia de Cobertura 2025 - Humana Gold Plus SNP-DE H2875-002 (HMO D-SNP)

Your 2025 Evidence of Coverage - Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP)
Su Evidencia de Cobertura 2025 - Humana Gold Plus SNP-DE H2875-004 (HMO D-SNP)

Pharmacy documents

Over-the-Counter Order Form – English
Over-the-Counter Order Form - Spanish

Pharmacy Direct Member Reimbursement Form

2025 Prescription Drug Guide (HMO D-SNP) - English
2025 Prescription Drug Guide (HMO D-SNP) - Spanish

2025 Prescription Drug Guide (HMO-POS D-SNP) - English
2025 Prescription Drug Guide (HMO-POS D-SNP) - Spanish

2025 Prior Authorization Criteria

2025 Strep Therapy Criteria

DSNP Transition Policy

Prior authorization forms

Medical and pharmacy authorizations

Provider directory

You can search for a provider near you using our Find Care tool

View a printable PDF of your provider directory

Humana Healthy Horizons in Virginia

Humana Inc. and its subsidiaries comply with applicable Federal civil rights laws and do not discriminate or exclude people because of their race, color, religion, gender, gender identity, sex, sexual orientation, age, disability, national origin, military status, veteran status, genetic information, ancestry, ethnicity, marital status, language, health status, or need for health services. We also provide free language interpreter services. See our full accessibility rights information, non-discrimination disclosure, and language options.

If you are requesting membership in a Dual Eligible Special Needs Plan (D-SNP), the following statement applies: I understand this plan is for individuals with both Medicaid and Medicare. My ability to enroll is based on verification that I am entitled to both Medicare and medical assistance under Medicaid.

Medicare beneficiaries may also enroll in Humana Medicare plans through the CMS Medicare Online Enrollment Center located at https://www.medicare.gov.

Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: diabetes mellitus, cardiovascular disorders, chronic and disabling mental health conditions, chronic lung disorders, chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.

For certain plans, the Healthy Options Allowance may be subject to additional eligibility requirements. Allowance amounts cannot be combined with other benefit allowances. Limitations and restrictions may apply.

Our health benefit plans have exclusions and limitations and terms under which the coverage may be continued in force or discontinued. For costs and complete details of the coverage, refer to the plan document or call or write your Humana insurance agent or the company. In the event of any disagreement between this communication and the plan document, the plan document will control.

Other pharmacies may be available in our network. You can locate network pharmacies by visiting Humana.com/finder/pharmacy. CenterWell Pharmacy is the preferred cost-sharing mail-order pharmacy under many Humana MAPD and PDP plans. There are other pharmacies, including preferred cost-sharing retail pharmacies, are available in our network. Members can choose any network pharmacy for their prescriptions.

Humana is a Dual Eligible Special Needs plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in any Humana plan depends on contract renewal.

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Last Updated: 7/21/2025