Plan Basics
Contract Year |
2021 |
Medicare Type |
Medicare Advantage Plan (Part C) |
CMS Plan ID |
H8145-069-000 |
Plan Organization |
Humana |
Plan Type |
PFFS |
Plan Name |
Humana Gold Choice H8145-069 (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 |
$53.00 |
Total Premium (Includes Part B) |
$188.50 |
Monthly Part C Premium |
$12.60 |
Monthly Part D Basic Premium |
$40.40 |
Monthly Part D Supplemental Premium |
$0.00 |
Monthly Part D Total Premium |
$40.40 |
Monthly Part D Premium Full Assistance |
$11.80 |
Monthly Part D Premium 75% Assistance |
$18.90 |
Monthly Part D Premium 50% Assistance |
$26.10 |
Monthly Part D Premium 25% Assistance |
$33.20 |
Part D Drug Deductible |
$340.00 |
Annual Drug Deductible |
$340.00 |
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 |
Yes |
Out-of-Network |
- |
- |
55% coinsurance |
Non-routine services |
No |
- |
- |
- |
Not covered |
Periodontics |
No |
- |
- |
- |
Not covered |
Prosthodontics, other oral/maxillofacial surgery, other services |
No |
- |
- |
- |
Not covered |
Restorative services |
Yes |
Out-of-Network |
- |
- |
55% coinsurance |
Diagnostic Procedures/lab Services/imaging
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diagnostic radiology services (e.g., MRI) |
- |
Out-of-Network |
- |
- |
$50-495 copay |
Diagnostic tests and procedures |
- |
Out-of-Network |
- |
- |
$0-100 copay |
Lab services |
- |
Out-of-Network |
- |
- |
$0-100 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 |
- |
- |
$15-50 copay per visit |
Specialist |
- |
Out-of-Network |
- |
- |
$50 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 |
- |
- |
- |
- |
$15-50 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 |
- |
- |
$50 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 |
Yes |
Out-of-Network |
- |
- |
$0 copay |
Hearing aids |
Yes |
Out-of-Network |
- |
- |
$699-999 copay |
Hearing exam |
- |
Out-of-Network |
- |
- |
$50 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 |
- |
- |
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 |
- |
- |
$587 per day for days 1 through 3$0 per day for days 4 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 |
- |
- |
$50-495 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 |
Yes |
Out-of-Network |
- |
- |
$0 copay |
Dental x-ray(s) |
Yes |
Out-of-Network |
- |
- |
$0 copay |
Fluoride treatment |
No |
- |
- |
- |
Not covered |
Oral exam |
Yes |
Out-of-Network |
- |
- |
$0 copay |
Rehabilitation Services
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Occupational therapy visit |
- |
Out-of-Network |
- |
- |
$25-40 copay |
Physical therapy and speech and language therapy visit |
- |
Out-of-Network |
- |
- |
$25-40 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 |
Eye exams |
Monthly Premium |
$15.30 |
Eyewear |
Monthly Premium |
$15.30 |
Package #2
Category |
Cost Sharing Type |
Cost Share |
Comprehensive dental |
Monthly Premium |
$33.00 |
Preventive dental |
Monthly Premium |
$33.00 |
Package #3
Category |
Cost Sharing Type |
Cost Share |
Comprehensive dental |
Monthly Premium |
$37.50 |
Preventive dental |
Monthly Premium |
$37.50 |
Official Medicare Contact
Medicare Phone |
1-800-MEDICARE (1-800-633-4227) |
Medicare TTY User |
1-877-486-2048 |
Plan Available in these Counties
Abbeville County, South Carolina,
Aiken County, South Carolina,
Anderson County, South Carolina,
Atkinson County, Georgia,
Baker County, Georgia,
Bamberg County, South Carolina,
Barrow County, Georgia,
Ben Hill County, Georgia,
Brantley County, Georgia,
Candler County, Georgia,
Chatham County, Georgia,
Chattooga County, Georgia,
Clayton County, Georgia,
Clinch County, Georgia,
Crisp County, Georgia,
Dekalb County, Georgia,
Edgefield County, South Carolina,
Elbert County, Georgia,
Forsyth County, Georgia,
Franklin County, Georgia,
Fulton County, Georgia,
Gilmer County, Georgia,
Glascock County, Georgia,
Greenville County, South Carolina,
Gwinnett County, Georgia,
Habersham County, Georgia,
Hancock County, Georgia,
Hart County, Georgia,
Heard County, Georgia,
Henry County, Georgia,
Irwin County, Georgia,
Jackson County, Georgia,
Jasper County, South Carolina,
Jefferson County, Georgia,
Jenkins County, Georgia,
Lee County, South Carolina,
Lincoln County, Georgia,
Morgan County, Georgia,
Muscogee County, Georgia,
Oconee County, South Carolina,
Polk County, Georgia,
Pulaski County, Georgia,
Quitman County, Georgia,
Richland County, South Carolina,
Rockdale County, Georgia,
Spartanburg County, South Carolina,
Talbot County, Georgia,
Taliaferro County, Georgia,
Terrell County, Georgia,
Tift County, Georgia,
Towns County, Georgia,
Treutlen County, Georgia,
Turner County, Georgia,
Upson County, Georgia,
Walton County, Georgia,
Warren County, Georgia,
Washington County, Georgia,
White County, Georgia,
Wilcox County, Georgia,
Wilkes County, Georgia,
York County, South Carolina
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