Humana Gold Choice H8145-126 (PFFS)

Humana Inc.
Humana Gold Choice H8145-126 (PFFS) H8145-126 Plan Details
3.5 out of 5 stars

Humana Gold Choice H8145-126 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-126.

$30.00
Monthly Premium

Humana Gold Choice H8145-126 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-126.

Humana Inc.
Humana Gold Choice H8145-126 (PFFS) H8145-126 Plan Details
3.5 out of 5 stars

Humana Gold Choice H8145-126 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc..
Plan ID: H8145-126.

$30.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $-1
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 $10.00
Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $20.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45.00
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $50.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$360.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Out-of-Network:
$360.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Urgent Care
Copayment for Urgent Care $10.00 to $50.00
Coinsurance for Urgent Care 30%

Cost share amount will apply based on the setting where the service is received: In-Network $10.00 PCP $45.00 Specialist $35.00 Urgent Care Center Out-Of-Network $20.00 PCP $50.00 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 $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 H8145-126 (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:
Copayment for Medicare Covered Chiropractic Services $50.00
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:
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 $50.00
Copayment for Medicare-covered Lab Services $0.00 to $50.00

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $45.00 to $250.00
Coinsurance for Medicare-covered Diagnostic Radiological Services 20%
Copayment for Medicare-covered Therapeutic Radiological Services $45.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $10.00 to $50.00
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00 to $50.00
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30%
Copayment for Medicare Covered Lab Services $20.00 to $50.00
Coinsurance for Medicare Covered Lab Services 30%
Copayment for Medicare Covered Diagnostic Radiological Services $50.00
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 30%
Copayment for Medicare Covered Outpatient X-Ray Services $20.00 to $50.00
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:
$360.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Out-of-Network:
$360.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
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:
Copayment for Medicare Covered Individual Sessions $50.00
Copayment for Medicare Covered Group Sessions $50.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $45.00 to $360.00

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

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $225.00
Out-of-Network:

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $50.00
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 $50.00
Copayment for Medicare-covered Group Sessions $40.00 to $50.00
Out-of-Network:
Copayment for Medicare Covered Individual or Group Sessions $50.00
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 $10.00 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 $10.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $45.00
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
$172.00 per day for days 21 to 100
Out-of-Network:
$0.00 per day for days 1 to 20
$172.00 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:

Comprehensive Dental:
Copayment for Medicare-covered Benefits $45.00
Out-of-Network:

Medicare Covered Dental Services:
Copayment for Medicare Covered Comprehensive Dental $50.00

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 $45.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Maximum Plan Benefit of $130.00 every year for in and out of network services combined

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $50.00
Coinsurance for Medicare Covered Eyewear 30%
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $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 $45.00
Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $50.00

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 30%