Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H8145-055-000
Plan Organization Humana
Plan Type PFFS *
Plan Name Humana Gold Choice H8145-055 (PFFS)
Drugs Covered No
Doctors Choice Plan Doctors for Most Services
Overall Star Rating 3.5
Plan Cost Sharing
Premium $7.00
Total Premium (Includes Part B) $142.50
Monthly Part C Premium $7.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $0.00

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 - - $45-390 copay
Diagnostic tests and procedures - Out-of-Network - - $0-105 copay
Lab services - Out-of-Network - - $0-105 copay
Outpatient x-rays - Out-of-Network - - $15-100 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $15 copay per visit
Specialist - Out-of-Network - - $45 copay 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 per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network - - $45 copay
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $270 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 - - $45 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $390 per day for days 1 through 5$0 per day for days 6 through 90
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 - - 10-20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network - - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network - - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network - - 20% coinsurance
Other Part B drugs - Out-of-Network - - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network - - $390 per day for days 1 through 4$0 per day for days 5 through 90
Outpatient group therapy visit - Out-of-Network - - $40-100 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network - - $40-100 copay
Outpatient individual therapy visit - Out-of-Network - - $40-100 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network - - $40-100 copay
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 - - $45-390 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $0 copay
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 - - $20-40 copay
Physical therapy and speech and language therapy visit - Out-of-Network - - $20-40 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $0 per day for days 1 through 20$178 per day for days 21 through 100
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 $18.10
Preventive dental Monthly Premium $18.10
Package #2
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $20.70
Eye exams Monthly Premium $20.70
Eyewear Monthly Premium $20.70
Preventive dental Monthly Premium $20.70
Package #3
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $21.50
Preventive dental Monthly Premium $21.50
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
Adams County, Pennsylvania, Barbour County, West Virginia, Berkeley County, West Virginia, Berks County, Pennsylvania, Boone County, West Virginia, Bradford County, Pennsylvania, Braxton County, West Virginia, Brooke County, West Virginia, Cabell County, West Virginia, Calhoun County, West Virginia, Cameron County, Pennsylvania, Carbon County, Pennsylvania, Centre County, Pennsylvania, Chester County, Pennsylvania, Clay County, West Virginia, Clinton County, Pennsylvania, Crawford County, Pennsylvania, Cumberland County, Pennsylvania, Dauphin County, Pennsylvania, Doddridge County, West Virginia, Erie County, Pennsylvania, Franklin County, Pennsylvania, Gilmer County, West Virginia, Grant County, West Virginia, Greenbrier County, West Virginia, Hancock County, West Virginia, Hardy County, West Virginia, Harrison County, West Virginia, Huntingdon County, Pennsylvania, Jackson County, West Virginia, Jefferson County, Pennsylvania, Jefferson County, West Virginia, Juniata County, Pennsylvania, Kanawha County, West Virginia, Lackawanna County, Pennsylvania, Lancaster County, Pennsylvania, Lebanon County, Pennsylvania, Lewis County, West Virginia, Logan County, West Virginia, Luzerne County, Pennsylvania, Lycoming County, Pennsylvania, Marion County, West Virginia, Marshall County, West Virginia, Mason County, West Virginia, Mcdowell County, West Virginia, Mercer County, West Virginia, Mifflin County, Pennsylvania, Mingo County, West Virginia, Monroe County, West Virginia, Montour County, Pennsylvania, Nicholas County, West Virginia, Ohio County, West Virginia, Pendleton County, West Virginia, Perry County, Pennsylvania, Pocahontas County, West Virginia, Potter County, Pennsylvania, Putnam County, West Virginia, Raleigh County, West Virginia, Randolph County, West Virginia, Ritchie County, West Virginia, Roane County, West Virginia, Snyder County, Pennsylvania, Sullivan County, Pennsylvania, Summers County, West Virginia, Susquehanna County, Pennsylvania, Taylor County, West Virginia, Tioga County, Pennsylvania, Tucker County, West Virginia, Tyler County, West Virginia, Upshur County, West Virginia, Wayne County, Pennsylvania, Wayne County, West Virginia, Webster County, West Virginia, Wetzel County, West Virginia, Wyoming County, Pennsylvania, Wyoming County, West Virginia, York County, Pennsylvania

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