Humana Gold Choice H8145-042 (PFFS)
Humana Gold Choice H8145-042 (PFFS) H8145-042 Plan Details
Humana Gold Choice H8145-042 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-042.
$28.00
Monthly Premium
Humana Gold Choice H8145-042 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-042.
Humana Gold Choice H8145-042 (PFFS) H8145-042 Plan Details
Humana Gold Choice H8145-042 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-042.
$28.00
Monthly Premium
Virginia Counties Served
Bland
Botetourt
Chesterfield
Hampton City
Isle Of Wight
Bedford
Brunswick
Buckingham
Carroll
Chesapeake City
Craig
Emporia City
Essex
Floyd
Galax City
Giles
Gloucester
Goochland
Greensville
Hanover
Henrico
Lancaster
Middlesex
Newport News City
Norfolk City
Northumberland
Nottoway
Orange
Patrick
Petersburg City
Portsmouth City
Powhatan
Prince Edward
Radford
Richmond
Richmond City
Roanoke
Roanoke City
Salem
Southampton
Suffolk City
Virginia Beach City
Williamsburg City
York
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $-1 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $0.00 |
| 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: $345.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Out-of-Network: $345.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 |
| Urgent Care | Copayment for Urgent Care $40.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $95.00 |
| Emergency Room Visit | Copayment for Emergency Care $95.00 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $95.00 Copayment for Worldwide Emergency Transportation $95.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $290.00 Air Ambulance: Copayment for Air Ambulance Services $290.00 Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $290.00 Copayment for Medicare Covered Ambulance Services - Air $290.00 |
Health Care Services and Medical Supplies
Humana Gold Choice H8145-042 (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 |
| 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: Copayment for Medicare Covered Diabetic Supplies and Services $10.00 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 $100.00 Copayment for Medicare-covered Lab Services $0.00 to $50.00 Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $50.00 to $275.00 Copayment for Medicare-covered Therapeutic Radiological Services $50.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0.00 to $110.00 Out-of-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 $110.00 Copayment for Medicare Covered Diagnostic Radiological Services $50.00 to $345.00 Copayment for Medicare Covered Therapeutic Radiological Services $50.00 Coinsurance for Medicare Covered Therapeutic Radiological Services 20% Copayment for Medicare Covered Outpatient X-Ray Services $0.00 to $110.00 |
| 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: $345.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Out-of-Network: $345.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 |
| 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 to $100.00 Copayment for Medicare Covered Group Sessions $40.00 to $100.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $50.00 to $345.00 Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $0.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $295.00 Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $50.00 to $345.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $295.00 |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 to $100.00 Copayment for Medicare-covered Group Sessions $40.00 to $100.00 Out-of-Network: Copayment for Medicare Covered Individual or Group Sessions $40.00 to $100.00 |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $75.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit Out-of-Network: Over-The-Counter (OTC) Items: Coinsurance for Non-Medicare Covered Over-The-Counter (OTC) Items 50% Maximum Plan Benefit of $75.00 |
| 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 $188.00 per day for days 21 to 61 $0.00 per day for days 62 to 100 Out-of-Network: $0.00 per day for days 1 to 20 $188.00 per day for days 21 to 61 $0.00 per day for days 62 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 Copayment for Non-routine Services $0.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $50.00 Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Copayment for Non-Medicare Covered Comprehensive Dental $0.00 |
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 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 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $99.00 to $399.00
Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $50.00 Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $0.00 Copayment for Non-Medicare Covered Hearing Aids $99.00 to $399.00 |
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 |
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