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Humana Gold Choice H8145-120 (PFFS)

Humana Inc.
Humana Gold Choice H8145-120 (PFFS) H8145-120 Plan Details
4 out of 5 stars

Humana Gold Choice H8145-120 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-120.

$31.00
Monthly Premium

Humana Gold Choice H8145-120 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-120.

Humana Inc.
Humana Gold Choice H8145-120 (PFFS) H8145-120 Plan Details
4 out of 5 stars

Humana Gold Choice H8145-120 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-120.

$31.00
Monthly Premium

Arkansas Counties Served

Arkansas Ashley Benton Baxter Carroll Cleburne Conway Craighead Crawford Crittenden Cross Dallas Faulkner Franklin Fulton Garland Greene Hot Spring Independence Jackson Jefferson Johnson Lawrence Lee Logan Mccurtain Montgomery Pope Prairie Pulaski Randolph Saline Scott Sebastian Stone Union Van Buren Washington

Kansas Counties Served

Anderson Chase Bourbon Butler Chautauqua Cherokee Coffey Crawford Doniphan Elk Geary Greenwood Harper Harvey Jackson Jewell Johnson Labette Leavenworth Lyon Mitchell Neosho Norton Phillips Republic Riley Sedgwick Smith Washington Wilson Woodson Wyandotte

Missouri Counties Served

Atchison Barry Barton Benton Boone Butler Callaway Camden Carroll Carter Cass Cedar Chariton Christian Clay Cole Crawford Dade Dallas Dekalb Dent Douglas Gasconade Gentry Greene Grundy Henry Hickory Holt Iron Jackson Jasper Jefferson Laclede Lawrence Macon Madison Mcdonald Mercer Miller Mississippi Montgomery New Madrid Newton Nodaway Ozark Pemiscot Perry Phelps Pike Platte Polk Pulaski Reynolds Ripley Saint Charles Saint Clair Saint Louis Saint Louis City Stoddard Stone Taney Vernon Washington Worth Wright

Oklahoma Counties Served

Adair Atoka Canadian Bryan Caddo Choctaw Cleveland Craig Delaware Garvin Grady Haskell Kingfisher Latimer Logan Love Marshall Mayes Mcclain Mccurtain Mcintosh Murray Muskogee Oklahoma Okmulgee Ottawa Pottawatomie Seminole Sequoyah Tulsa Wagoner Washita Woodward

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 $10.00
Out-of-Network:

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 40%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40.00
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 40%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$360.00 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 40%
Urgent Care
Copayment for Urgent Care $30.00

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 $265.00

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

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $265.00
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

Humana Gold Choice H8145-120 (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 $10.00
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 40%
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 20% to 40%
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 $40.00
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
Copayment for Medicare-covered Lab Services $0.00 to $30.00
Coinsurance for Medicare-covered Lab Services 25%

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $360.00
Copayment for Medicare-covered Therapeutic Radiological Services $40.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $10.00 to $40.00
Coinsurance for Medicare-covered X-Ray Services 20%
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40%
Coinsurance for Medicare Covered Lab Services 40%
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Coinsurance for Medicare Covered Outpatient X-Ray Services 40%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Out-of-Network:
Coinsurance for Medicare Covered Home Health 40%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$318.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 40%
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 40%
Coinsurance for Medicare Covered Group Sessions 40%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $40.00
Coinsurance for Medicare Covered Outpatient Hospital Services 20%

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
Coinsurance for Ambulatory Surgical Center Services 20%
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 40%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Coinsurance for Medicare-covered Individual Sessions 20%
Copayment for Medicare-covered Group Sessions $40.00
Coinsurance for Medicare-covered Group Sessions 20%
Out-of-Network:
Coinsurance for Medicare Covered Individual or Group Sessions 40%
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $40.00
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 40%
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:
Coinsurance for Skilled Nursing Facility Services per Stay 40%

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
  • Maximum 3 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 3 visits (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $40.00
Copayment for Non-routine Services $0.00
  • Maximum 2 visits every year
Copayment for Diagnostic Services $0.00
  • Maximum 1 visit every three years
Copayment for Restorative Services $0.00
  • Maximum 3 visits (Please see Evidence of Coverage for details)
Copayment for Endodontics $0.00
  • Maximum 2 visits (Please see Evidence of Coverage for details)
Copayment for Periodontics $0.00
  • Maximum 2 visits every three years
Copayment for Extractions $0.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
  • Maximum 4 visits (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 40%
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 $40.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Maximum Plan Benefit of $75.00 every year for in and out of network services combined

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
  • Maximum 1 Pair every year
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every year
Maximum Plan Benefit of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 40%
Coinsurance for Medicare Covered Eyewear 40%
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 $40.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $399.00 to $699.00
  • Maximum 2 Hearing Aids every year
$399 copayment per ear per year for advanced level hearing aid purchase or $699 copayment per ear per year for premium level hearing aid purchase.
Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 40%
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $0.00
Copayment for Non-Medicare Covered Hearing Aids $399.00 to $699.00

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:
  • 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 40%
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