Translated forms and documents

The 2023 and 2024 Enrollment Application and other plan documents are available in Chinese, Korean and Spanish for certain plans.

Applications

Full application – Chinese – 2024, PDF

Full application – Chinese – 2023, PDF

D-SNP application – Chinese – 2024, PDF

D-SNP application – Chinese – 2023, PDF

Plan documents

2024 Medicare Transition Policy – Chinese , PDF

2023 Medicare Transition Policy – Chinese , PDF

Low Income Premium Subsidy, PDF

Humana Gold Plus^® H3533-033 (HMO) 

Summary of benefits – Chinese Brooklyn and Queens, NY – 2024, Humana Gold Plus HMO H3533-033 (HMO), PDF 

Summary of benefits – Chinese – 2023, Humana Gold Plus HMO H3533-033 (HMO), PDF 

Evidence of coverage – Chinese – Brooklyn & Queens, NY Chinese – 2024, Humana Gold Plus HMO H3533-033 (HMO), PDF

Evidence of coverage – Chinese – 2023, Humana Gold Plus HMO H3533-033 (HMO), PDF

Annual Notice of Change – H3533-033 – Chinese – Brooklyn & Queens, NY – 2024, Humana Gold Plus HMO H3533-033 (HMO), PDF 

Annual Notice of Change – Chinese – 2023, Humana Gold Plus HMO H3533-033 (HMO), PDF 

CMS 3533 Plan Star Ratings – 2024, Humana Gold Plus HMO H3533-033 (HMO), PDF

CMS 3533 Plan Star Ratings – 2023, Humana Gold Plus HMO H3533-033 (HMO), PDF

Prescription Drug Guides 20240076PDGCH2449224 – 2024, PDF

Prescription Drug Guides 20230013PDGCH2349223 – 2023, PDF

Prescription Drug Guides 20240076PDGCH2449224C – 2024, PDF

Prescription Drug Guides 20230013PDGCH2349223C – 2023, PDF

Benefits at a Glance – Chinese – Brooklyn & Queens, NY – 2024, Humana Gold Plus HMO H3533-033 (HMO), PDF

Benefits at a Glance – 2023, Humana Gold Plus HMO H3533-033 (HMO), PDF

Humana Gold Plus H3533-034-001 (D-SNP)

Summary of benefits – Chinese – 2023,Humana Gold Plus H3533-034-001 (D-SNP), PDF

Evidence of coverage – Chinese – 2023,Humana Gold Plus H3533-034-001 (D-SNP), PDF

Annual Notice of Change – Chinese – 2023,Humana Gold Plus H3533-034-001 (D-SNP), PDF

CMS 3533 30533 Plan Star Ratings – 2023, PDF

Prescription Drug Guides 20230016PDGCH2349223 – 2023, PDF

Prescription Drug Guides 20230016PDGCH2349223C – 2023, opens in new window

Benefits at a Glance – 2023,Humana Gold Plus H3533-034-001 (D-SNP), PDF

Humana Gold Plus H3533-034-002 (D-SNP)

Summary of benefits – Chinese – 2023, Humana Gold Plus H3533-034-002 (D-SNP), PDF

Evidence of coverage – Chinese – 2023, Humana Gold Plus H3533-034-002 (D-SNP), PDF

Annual Notice of Change – Chinese – 2023, Humana Gold Plus H3533-034-002 (D-SNP), PDF

CMS 3533 Plan Star Ratings – 2023, Humana Gold Plus H3533-034-002 (D-SNP), PDF

Prescription Drug Guides 20230016PDGCH2349223 – 2023, PDF

Prescription Drug Guides 20230016PDGCH2349223C – 2023, PDF

Benefits at a Glance – 2023, PDF

HumanaChoice^® H5525-055 (PPO)

Summary of benefits – Chinese – San Francisco and Marin County, CA – 2024,H5525-055 (PPO), PDF

Summary of benefits – Chinese – 2023,H5525-055 (PPO), PDF

Evidence of coverage – Chinese – San Francisco & Marin Counties, CA – Chinese – 2024,H5525-055 (PPO), PDF

Evidence of coverage – Chinese – 2023,H5525-055 (PPO), PDF

Annual Notice of Change – Chinese – H5525-055 – San Francisco, Marin Counties, CA – 2024,H5525-055 (PPO), PDF

CMS 5525 Plan Star Ratings – 2024,H5525-055 (PPO), PDF

CMS 5525 Plan Star Ratings – 2023, PDF

Prescription Drug Guides 20240056PDGCH2449624 – 2024, PDF

Prescription Drug Guides 20230081PDGCH2349723 – 2023, PDF

Prescription Drug Guides 20240056PDGCH2449624C – 2023, PDF

Prescription Drug Guides 20230081PDGCH2349723C – 2023, PDF

Benefits at a Glance – Chinese – San Francisco and Marin Counties, CA – 2024,H5525-055 (PPO), PDF

Benefits at a Glance – 2023,H5525-055 (PPO), PDF

Provider and Pharmacy Directories

H3533NYHS01ACCH24 – 2024, PDF 

H3533NYHS01ACCH23 – 2023, PDF 

H3533NYHS01BCCH24 – 2024 , PDF 

H3533NYHS01BCCH23 – 2023 , PDF 

H3533NYHS01CCCH24 – 2024, PDF 

H3533NYHS01CCCH23 – 2023, PDF 

H3533NYHS01DCCH24 – 2024 , PDF

H3533NYHS01DCCH23 – 2023 , PDF

H3533NYHS01EGCH24 – 2024 , PDF

H3533NYHS01FGCH24 – 2024 , PDF

H3533NYHS01GCCH24 – 2024 , PDF

H3533NYHS01HGCH24 – 2024 , PDF

H5525CALP01CH24 – 2024 , PDF

H5525CALP01CH23 – 2023 , PDF

Applications

Full application – Korean – 2024, PDF

Full application – Korean – 2023, PDF

D-SNP application – Korean – 2024, PDF

D-SNP application – Korean – 2023, PDF

Plan documents

2024 Medicare Transition Policy – Korean , PDF

HumanaChoice^® H5619 (HMO)

CMS 5619 Plan Star Ratings – 2024 , PDF

Annual Notice of Changes – Korean – Clark County, WA – 2024 , PDF

Annual Notice of Changes – Korean – Snohomish County, WA – 2024 , PDF

Annual Notice of Changes – Korean – Whatcom & Skagit Counties, WA – 2024 , PDF

Annual Notice of Changes – Korean – Washington state – 2024 , PDF

Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)

Evidence of coverage – Korean – Clark County, WA – 2024 , PDF

Evidence of coverage – Korean – Snohomish County, WA – 2024 , PDF

Evidence of coverage – Korean – Whatcom & Skagit Counties, WA – 2024, PDF

Evidence of coverage – Korean – Washington state – 2024 , PDF

Summary of benefits – Korean – Clark County, WA – 2024 , PDF

Summary of benefits – Korean – Snohomish County, WA – 2024 , PDF

Summary of benefits – Korean – Whatcom and Skagit Counties, WA – 2024 , PDF

Summary of benefits – Korean – Washington state – 2024 , PDF

Summary of benefits – Korean – Whatcom and Skagit Counties, WA – 2024, PDF

Benefits at a glance – Korean – Clark County, WA – 2024 , PDF

Benefits at a glance – Korean – Snohomish County, WA – 2024 , PDF

Benefits at a glance – Korean – Whatcom and Skagit Counties, WA – 2024 , PDF

Benefits at a glance – Korean – Washington state – 2024 , PDF

Humana Gold Plus SNP-DE H5619-155 (HMO D-SNP)

Evidence of coverage – Korean – King & Snohomish Counties, WA – 2024, PDF

Summary of benefits – Korean – King and Snohomish Counties, WA – 2024, PDF

Benefits at a glance – Korean – King and Snohomish Counties, WA – 2024, PDF

Provider and Pharmacy Directories

H5619WAHS01AGKO24 – 2024 , PDF

H5619WAHS01BGKO24 – 2024 , PDF

H5619WAHS01CGKO24 – 2024 , PDF

H5619WAHS01DGKO24 – 2024 , PDF

H5619WAHS01EGKO24 – 2024 , PDF

H5619WAHS03AGKO24 – 2024 , PDF

H5619WAHS03BGKO24 – 2024 , PDF

Applications

Full application – Spanish – 2024, PDF

Full application – Spanish – 2023, PDF

D-SNP application – Spanish – 2024, PDF

D-SNP application – Spanish – 2023, PDF