Humana Gold Choice H8145-122 (PFFS)
Humana Gold Choice H8145-122 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-122.
Humana Gold Choice H8145-122 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-122.
Arkansas Counties Served
Kansas Counties Served
Missouri Counties Served
Oklahoma Counties Served
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
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 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
Hearing Aids: Copayment for Hearing Aids $399.00 to $699.00
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:
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 |
|
Generic |
|
Preferred Brand |
|
Annual Drug Deductible | $195 (excludes Tiers 1, 2 and 3) |
Preferred Generic |
|
Generic |
|
Preferred Brand |
|
Annual Drug Deductible | $195 (excludes Tiers 1, 2 and 3) |
Preferred Generic |
|
Generic |
|
Preferred Brand |
|