Humana Gold Choice H8145-089 (PFFS)

Humana Inc.
Humana Gold Choice H8145-089 (PFFS) H8145-089 Plan Details
3.5 out of 5 stars

Humana Gold Choice H8145-089 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-089.

$96.00
Monthly Premium

Humana Gold Choice H8145-089 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-089.

Humana Inc.
Humana Gold Choice H8145-089 (PFFS) H8145-089 Plan Details
3.5 out of 5 stars

Humana Gold Choice H8145-089 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-089.

$96.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $445
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:
Coinsurance for Medicare Covered Primary Care Office Visit 30%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $50.00
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 30%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$454.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 30%
Urgent Care
Copayment for Urgent Care $20.00 to $50.00
Coinsurance for Urgent Care 30%

Cost share amount will apply based on the setting where the service is received: In-Network $20.00 PCP $50.00 Specialist $25.00 Urgent Care Center Out-Of-Network 30% PCP 30% Specialist 30% 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 $290.00

Air Ambulance:
Coinsurance for Air Ambulance Services 20%
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $290.00
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

Humana Gold Choice H8145-089 (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:
Coinsurance for Medicare Covered Chiropractic Services 30%
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 $0.00
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 20% to 30%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 9%
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 $40.00

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $40.00 to $250.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $20.00 to $100.00
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30%
Coinsurance for Medicare Covered Lab Services 30%
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 30%
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:
Coinsurance for Medicare Covered Home Health 30%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$405.00 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:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $50.00 to $250.00

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $0.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $200.00
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 30%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%
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:
Coinsurance for Medicare Covered Individual or Group Sessions 30%
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 $225.00 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 $225.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $50.00
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 30%
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 55
$0.00 per day for days 56 to 100
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 30%

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Comprehensive Dental:
Copayment for Medicare-covered Benefits $50.00
Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 30%

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:
Coinsurance for Medicare Covered Eye Exams 30%
Coinsurance for Medicare Covered Eyewear 30%

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:
Coinsurance for Medicare Covered Hearing Exams 30%

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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    Out-of-Network:

    Medicare-covered Zero Dollar Preventive Services:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0.00
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 30%