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
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$0.00
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
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
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
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$0.00
Monthly Premium
Virginia Counties Served
Henrico
Newport News City
Chesterfield
Roanoke City
Portsmouth City
Chesapeake City
Richmond City
Middlesex
Galax City
Lancaster
York
Gloucester
Prince Edward
Goochland
Hampton City
Carroll
Hanover
Norfolk City
Suffolk City
Roanoke
Virginia Beach City
Petersburg City
Powhatan
Botetourt
Salem
Emporia City
Williamsburg City
Floyd
Orange
Patrick
Radford
Southampton
Essex
Buckingham
Bland
Craig
Bedford
Giles
Isle of Wight
Greensville
Richmond
Brunswick
Northumberland
Nottoway
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $-1 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| 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 $50.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00 |
| Emergency Room Visit | Copayment for Emergency Care $100.00 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 Copayment for Worldwide Emergency Transportation $100.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $300.00 Air Ambulance: Copayment for Air Ambulance Services $300.00 Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $300.00 Copayment for Medicare Covered Ambulance Services - Air $300.00 |
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 $15.00 Out-of-Network: Copayment for Medicare Covered Chiropractic Services $15.00 |
| 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 $300.00 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 $125.00 Out-of-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 Copayment for Medicare Covered Diagnostic Radiological Services $50.00 to $300.00 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 $125.00 |
| 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 $45.00 Copayment for Medicare-covered Group Sessions $45.00 Out-of-Network: Copayment for Medicare Covered Individual Sessions $45.00 Copayment for Medicare Covered Group Sessions $45.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $375.00 Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $350.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $325.00 Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $375.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $325.00 |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $45.00 to $100.00 Copayment for Medicare-covered Group Sessions $45.00 to $100.00 Out-of-Network: Copayment for Medicare Covered Individual or Group Sessions $45.00 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 $203.00 per day for days 21 to 100 Out-of-Network: $0.00 per day for days 1 to 20 $203.00 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: $0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years. $0 copayment for complete dentures, crown recementation, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years. $0 copayment for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. $0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. $0 copayment for adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, tissue conditioning up to 1 per year. $0 copayment for emergency treatment for pain, fluoride treatment, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year. $2,000 combined maximum benefit coverage amount per year for all preventive and comprehensive benefits. Out of Network: $0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years. $0 copayment for complete dentures, crown recementation, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years. $0 copayment for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. $0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. $0 copayment for adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, tissue conditioning up to 1 per year. $0 copayment for emergency treatment for pain, fluoride treatment, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year. $2,000 combined maximum benefit coverage amount per year for all preventive and comprehensive benefits. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. |
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 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00
Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $0.00 to $50.00 Copayment for Medicare Covered Eyewear $0.00 Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $0.00 Copayment for Non-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: Coinsurance for Non-Medicare Covered Hearing Exams 50% Coinsurance for Non-Medicare Covered Hearing Aids 50% |
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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