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
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
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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