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Humana Gold Choice H8145-122 (PFFS)

Humana Inc.
Humana Gold Choice H8145-122 (PFFS) H8145-122 Plan Details
4 out of 5 stars

Humana Gold Choice H8145-122 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-122.

$131.00
Monthly Premium

Humana Gold Choice H8145-122 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-122.

Humana Inc.
Humana Gold Choice H8145-122 (PFFS) H8145-122 Plan Details
4 out of 5 stars

Humana Gold Choice H8145-122 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-122.

$131.00
Monthly Premium

Arkansas Counties Served

Arkansas Ashley Benton Bradley Baxter Boone Calhoun Carroll Clark Clay Cleburne Cleveland Columbia Conway Craighead Crawford Crittenden Cross Dallas Drew Faulkner Franklin Fulton Garland Grant Greene Hempstead Hot Spring Howard Independence Izard Jackson Jefferson Johnson Lafayette Lawrence Le Flore Lee Little River Logan Lonoke Madison Mccurtain Miller Mississippi Montgomery Nevada Newton Ouachita Perry Phillips Pike Poinsett Polk Pope Prairie Pulaski Randolph Saint Francis Saline Scott Searcy Sebastian Sevier Sharp Stone Union Van Buren Washington Yell

Illinois Counties Served

Calhoun Jersey Macoupin Monroe

Kansas Counties Served

Allen Anderson Chase Atchison Barton Bourbon Brown Butler Chautauqua Cherokee Coffey Cowley Crawford Dickinson Doniphan Douglas Elk Ellsworth Franklin Geary Greenwood Harper Harvey Jackson Jefferson Jewell Johnson Kingman Labette Leavenworth Linn Lyon Marion Marshall Mcpherson Miami Mitchell Montgomery Morris Nemaha Neosho Norton Osage Ottawa Pawnee Phillips Pottawatomie Pratt Reno Republic Rice Riley Russell Sedgwick Shawnee Smith Sumner Thayer Wabaunsee Washington Wilson Woodson Wyandotte

Missouri Counties Served

Adair Audrain Andrew Bates Butler Caldwell Cass Chariton Clark Clay Clinton Cooper Daviess Dunklin Howard Howell Jackson Johnson Knox Lafayette Lincoln Linn Macon Maries Moniteau Monroe Morgan Oregon Osage Pettis Platte Putnam Randolph Ray Ripley Sainte Genevieve Saline Schuyler Scotland Shannon Shelby Sullivan Texas Warren Webster

Oklahoma Counties Served

Adair Atoka Canadian Carter Le Flore Alfalfa Blaine Bryan Caddo Cherokee Choctaw Cleveland Coal Cotton Craig Creek Custer Delaware Dewey Garfield Garvin Grady Grant Greer Haskell Hughes Jefferson Johnston Kay Kingfisher Kiowa Latimer Lincoln Logan Love Major Marshall Mayes Mcclain Mccurtain Mcintosh Murray Muskogee Noble Nowata Okfuskee Oklahoma Okmulgee Osage Ottawa Pawnee Payne Pittsburg Pontotoc Pottawatomie Pushmataha Sebastian Seminole Sequoyah Stephens Tillman Tulsa Wagoner Washita Woods Woodward

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $195
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 $0.00
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $0.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0.00
Your plan covers an unlimited number of days for an inpatient stay.
Out-of-Network:
Copayment for Acute Hospital Services per Stay $0.00
Urgent Care
Copayment for Urgent Care $0.00

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 $0.00

Air Ambulance:
Copayment for Air Ambulance Services $0.00
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $0.00
Copayment for Medicare Covered Ambulance Services - Air $0.00

Health Care Services and Medical Supplies

Humana Gold Choice H8145-122 (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 $0.00
Out-of-Network:
Copayment for Medicare Covered Chiropractic Services $0.00
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 $0.00
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 $0.00
Coinsurance for Medicare Covered Diabetic Supplies and Services 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 $20.00
Copayment for Medicare-covered Lab Services $0.00 to $20.00

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00
Coinsurance for Medicare-covered Diagnostic Radiological Services 20%
Copayment for Medicare-covered Therapeutic Radiological Services $0.00
Copayment for Medicare-covered X-Ray Services $0.00 to $20.00
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00 to $20.00
Copayment for Medicare Covered Lab Services $0.00 to $20.00
Copayment for Medicare Covered Diagnostic Radiological Services $0.00
Coinsurance for Medicare Covered Diagnostic Radiological Services 20%
Copayment for Medicare Covered Therapeutic Radiological Services $0.00
Copayment for Medicare Covered Outpatient X-Ray Services $0.00 to $20.00
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:
Copayment for Psychiatric Hospital Services per Stay $0.00
Out-of-Network:
Copayment for Psychiatric Hospital Services per Stay $0.00
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Out-of-Network:
Copayment for Medicare Covered Individual Sessions $0.00
Copayment for Medicare Covered Group Sessions $0.00
Outpatient Services / Surgery
In-Network:

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

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
Out-of-Network:

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $40.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00 to $40.00
Copayment for Medicare-covered Group Sessions $0.00 to $40.00
Out-of-Network:
Copayment for Medicare Covered Individual or Group Sessions $0.00 to $40.00
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 $0.00
Out-of-Network:
Copayment for Medicare Covered Podiatry Services $0.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$196.00 per day for days 21 to 100
Out-of-Network:
$0.00 per day for days 1 to 20
$196.00 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:
Maximum Plan Allowance of $2000.00 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 $0.00
Maximum Plan Allowance of $2000.00 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:
Copayment for Medicare Covered Comprehensive Dental $0.00
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
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 $100.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $0.00
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 $0.00
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:
Copayment for Medicare Covered Hearing Exams $0.00
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

    Prescription Drug Costs and Coverage

    The Humana Gold Choice H8145-122 (PFFS) plan offers the following prescription drug coverage, with an annual drug deductible of $195 (excludes Tiers 1, 2 and 3) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $195 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $10.00
    Generic
    • Standard retail $5.00
    • Preferred cost-share mail order $5.00
    • Standard mail order $20.00
    Preferred Brand
    • Standard retail $47.00
    • Preferred cost-share mail order $47.00
    • Standard mail order $47.00
    Annual Drug Deductible $195 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Generic
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Preferred Brand
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    • Standard mail order N/A
    Annual Drug Deductible $195 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $30.00
    Generic
    • Standard retail $15.00
    • Preferred cost-share mail order $0.00
    • Standard mail order $60.00
    Preferred Brand
    • Standard retail $141.00
    • Preferred cost-share mail order $131.00
    • Standard mail order $141.00
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