Humana Gold Choice H8145-032 (PFFS)
Humana Gold Choice H8145-032 (PFFS) H8145-032 Plan Details
Humana Gold Choice H8145-032 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-032.
$83.00
Monthly Premium
Humana Gold Choice H8145-032 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-032.
Humana Gold Choice H8145-032 (PFFS) H8145-032 Plan Details
Humana Gold Choice H8145-032 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-032.
$83.00
Monthly Premium
Indiana Counties Served
Adams
Allen
Blackford
Boone
Brown
Clark
Clay
Clinton
Crawford
Dearborn
Decatur
Dubois
Fayette
Floyd
Fountain
Franklin
Fulton
Gibson
Hamilton
Hancock
Harrison
Hendricks
Henry
Howard
Huntington
Jackson
Jay
Jefferson
Jennings
Johnson
Knox
Kosciusko
Lawrence
Madison
Marion
Marshall
Martin
Miami
Montgomery
Morgan
Newton
Noble
Ohio
Orange
Owen
Parke
Perry
Pike
Posey
Pulaski
Putnam
Randolph
Ripley
Rush
Scott
Spencer
St. Joseph
Starke
Steuben
Switzerland
Tipton
Union
Vanderburgh
Vigo
Warren
Warrick
Wells
Whitley
Ohio Counties Served
Ashland
Athens
Auglaize
Butler
Champaign
Clark
Clermont
Columbiana
Coshocton
Crawford
Delaware
Fairfield
Fayette
Franklin
Greene
Hamilton
Hancock
Holmes
Knox
Licking
Logan
Mahoning
Marion
Mercer
Miami
Montgomery
Muskingum
Pickaway
Preble
Richland
Ross
Shelby
Stark
Trumbull
Tuscarawas
Union
Warren
Wayne
Wyandot
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $225 |
| Out of Pocket Max |
In-Network: $-1 Out-of-Network: N/A |
| Initial Coverage Limit | $4430 |
| Catastrophic Coverage Limit | $7,050 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $20.00 Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $20.00 to $50.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $50.00 Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $50.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $390.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Out-of-Network: Coinsurance for Acute Hospital Services per Stay 30% |
| Urgent Care | Copayment for Urgent Care $20.00 to $50.00 Cost share amount will apply based on the setting where the service is received: In-Network $20.00 PCP $50.00 Specialist $35.00 Urgent Care Center Out-Of-Network $20.00 PCP $50.00 Specialist $35.00 Urgent Care Center Worldwide Coverage: Copayment for Worldwide Urgent Coverage $90.00 |
| Emergency Room Visit | Copayment for Emergency Care $90.00 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $90.00 Copayment for Worldwide Emergency Transportation $90.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $270.00 Air Ambulance: Copayment for Air Ambulance Services $270.00 Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $270.00 Copayment for Medicare Covered Ambulance Services - Air $270.00 |
Health Care Services and Medical Supplies
Humana Gold Choice H8145-032 (PFFS) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $20.00 Out-of-Network: Copayment for Medicare Covered Chiropractic Services $20.00 to $50.00 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Coinsurance for Medicare-covered Diabetic Supplies 10% to 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10.00 Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Out-of-Network: Coinsurance for Medicare Covered Diabetic Supplies and Services 10% to 20% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 20% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $110.00 Copayment for Medicare-covered Lab Services $0.00 to $35.00 Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $350.00 Copayment for Medicare-covered Therapeutic Radiological Services $50.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $20.00 to $110.00 Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00 to $180.00 Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30% Copayment for Medicare Covered Lab Services $0.00 to $180.00 Coinsurance for Medicare Covered Lab Services 30% Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $180.00 Coinsurance for Medicare Covered Diagnostic Radiological Services 30% Copayment for Medicare Covered Therapeutic Radiological Services $50.00 Coinsurance for Medicare Covered Therapeutic Radiological Services 30% Copayment for Medicare Covered Outpatient X-Ray Services $20.00 to $50.00 Coinsurance for Medicare Covered Outpatient X-Ray Services 30% |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Out-of-Network: Copayment for Medicare Covered Home Health $0.00 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $390.00 per day for days 1 to 4 $0.00 per day for days 5 to 90 Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 30% |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 Out-of-Network: Copayment for Medicare Covered Individual Sessions $40.00 Copayment for Medicare Covered Group Sessions $40.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $365.00 Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $0.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $315.00 Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $365.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $365.00 |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 to $95.00 Copayment for Medicare-covered Group Sessions $40.00 to $95.00 Out-of-Network: Copayment for Medicare Covered Individual or Group Sessions $40.00 to $95.00 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $50.00 Out-of-Network: Copayment for Medicare Covered Podiatry Services $50.00 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $178.00 per day for days 21 to 100 Out-of-Network: $0.00 per day for days 1 to 20 $178.00 per day for days 21 to 100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $50.00 Coinsurance for Restorative Services 50%
Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $50.00 Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 50% Coinsurance for Non-Medicare Covered Comprehensive Dental 55% |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $50.00 Eyewear: Copayment for Medicare-Covered Benefits $0.00 Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $0.00 to $365.00 Copayment for Medicare Covered Eyewear $0.00 |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $50.00 Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $50.00 |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
Prescription Drug Costs and Coverage
The Humana Gold Choice H8145-032 (PFFS) plan offers the following prescription drug coverage, with an annual drug deductible of $225 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $225 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $225 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $225 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
