Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H8145-021-000
Plan Organization Humana
Plan Type PFFS
Plan Name Humana Gold Choice H8145-021 (PFFS)
Plan Organization Type PFFS
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 3.5
Plan Cost Sharing
Premium $8.00
Total Premium (Includes Part B) $143.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $8.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $8.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $2.00
Monthly Part D Premium 50% Assistance $4.00
Monthly Part D Premium 25% Assistance $6.00
Part D Drug Deductible $360.00
Annual Drug Deductible $360.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $0.00
Gap Coverage No

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services No - - - Not covered
Endodontics No - - - Not covered
Extractions No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Restorative services No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network - - 30% coinsurance
Diagnostic tests and procedures - Out-of-Network - - $0 copay or 30% coinsurance
Lab services - Out-of-Network - - 30% coinsurance
Outpatient x-rays - Out-of-Network - - 30% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 30% coinsurance per visit
Specialist - Out-of-Network - - 30% coinsurance per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $15-45 copay or 30% coinsurance per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network - - 30% coinsurance
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $290 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation No - - - Not covered
Hearing aids - inner ear No - - - Not covered
Hearing aids - outer ear No - - - Not covered
Hearing aids - over the ear No - - - Not covered
Hearing exam - Out-of-Network - - 30% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - 30% per stay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,700 In and Out-of-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network - - 30% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network - - 30% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network - - 30% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network - - 20-30% coinsurance
Other Part B drugs - Out-of-Network - - 20-30% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network - - 30% per stay
Outpatient group therapy visit - Out-of-Network - - 30% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network - - 30% coinsurance
Outpatient individual therapy visit - Out-of-Network - - 30% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network - - 30% coinsurance
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Yes
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - 30% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $0 copay or 30% coinsurance
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning No - - - Not covered
Dental x-ray(s) No - - - Not covered
Fluoride treatment No - - - Not covered
Oral exam No - - - Not covered
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network - - 30% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network - - 30% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - 30% per stay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses No - - - Not covered
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) No - - - Not covered
Other No - - - Not covered
Routine eye exam No - - - Not covered
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Covered

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $19.50
Preventive dental Monthly Premium $19.50
Package #2
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $21.50
Eye exams Monthly Premium $21.50
Eyewear Monthly Premium $21.50
Preventive dental Monthly Premium $21.50
Package #3
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $21.60
Preventive dental Monthly Premium $21.60
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Allen County, Kentucky, Anderson County, Kentucky, Barbour County, West Virginia, Bell County, Kentucky, Berkeley County, West Virginia, Boone County, Kentucky, Boone County, West Virginia, Bourbon County, Kentucky, Braxton County, West Virginia, Breathitt County, Kentucky, Breckinridge County, Kentucky, Brooke County, West Virginia, Cabell County, West Virginia, Calhoun County, West Virginia, Calloway County, Kentucky, Campbell County, Kentucky, Carlisle County, Kentucky, Casey County, Kentucky, Christian County, Kentucky, Clark County, Kentucky, Clay County, West Virginia, Doddridge County, West Virginia, Elliott County, Kentucky, Fayette County, Kentucky, Fleming County, Kentucky, Gilmer County, West Virginia, Grant County, West Virginia, Graves County, Kentucky, Grayson County, Kentucky, Greenbrier County, West Virginia, Hancock County, West Virginia, Hardy County, West Virginia, Harrison County, West Virginia, Hart County, Kentucky, Jackson County, West Virginia, Jefferson County, West Virginia, Jessamine County, Kentucky, Kanawha County, West Virginia, Kenton County, Kentucky, Laurel County, Kentucky, Lewis County, West Virginia, Logan County, Kentucky, Logan County, West Virginia, Madison County, Kentucky, Marion County, West Virginia, Marshall County, Kentucky, Marshall County, West Virginia, Mason County, West Virginia, Mcdowell County, West Virginia, Mercer County, West Virginia, Mingo County, West Virginia, Monroe County, West Virginia, Nicholas County, West Virginia, Ohio County, West Virginia, Pendleton County, West Virginia, Pocahontas County, West Virginia, Putnam County, West Virginia, Raleigh County, West Virginia, Randolph County, West Virginia, Ritchie County, West Virginia, Roane County, West Virginia, Rowan County, Kentucky, Russell County, Kentucky, Scott County, Kentucky, Simpson County, Kentucky, Summers County, West Virginia, Taylor County, Kentucky, Taylor County, West Virginia, Tucker County, West Virginia, Tyler County, West Virginia, Upshur County, West Virginia, Wayne County, West Virginia, Webster County, West Virginia, Wetzel County, West Virginia, Whitley County, Kentucky, Woodford County, Kentucky, Wyoming County, West Virginia

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