Humana Gold Plus H4141-017 (HMO) - 2021

Humana Gold Plus H4141-017 (HMO) - Humana - Local HMO

Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H4141-017-003
Plan Organization Humana
Plan Type Local HMO
Plan Name Humana Gold Plus H4141-017 (HMO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 4
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $0.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $0.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $0.00
Monthly Part D Premium 50% Assistance $0.00
Monthly Part D Premium 25% Assistance $0.00
Part D Drug Deductible $0.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $7550.00
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 - Yes No 50% coinsurance
Non-routine services Yes - Yes No 50% coinsurance
Periodontics Yes - Yes No 70% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services Yes - Yes No 70% coinsurance
Restorative services Yes - Yes No 50-70% coinsurance
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes No $35-495 copay
Diagnostic tests and procedures - - Yes No $0-100 copay
Lab services - - Yes No $0-45 copay
Outpatient x-rays - - Yes No $0-100 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - Yes No $35 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 - - - - $0-35 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - Yes No $35 copay
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $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 Yes - Yes No $0 copay
Hearing aids Yes - No No $599-899 copay
Hearing exam - - Yes No $35 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $298 per day for days 1 through 7$0 per day for days 8 through 90$0 per day for days 91 and beyond
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $7,550 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - Yes - $0 copay or 10-20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - 20% coinsurance
Other Part B drugs - - Yes - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes No $587 per day for days 1 through 3$0 per day for days 4 through 90
Outpatient group therapy visit - - Yes No $40 copay
Outpatient group therapy visit with a psychiatrist - - Yes No $40 copay
Outpatient individual therapy visit - - Yes No $40 copay
Outpatient individual therapy visit with a psychiatrist - - Yes No $40 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
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
- - Yes No $35-375 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - No No $0 copay
Dental x-ray(s) Yes - No No $0 copay
Fluoride treatment Yes - No No $0 copay
Oral exam Yes - No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - Yes No $25-40 copay
Physical therapy and speech and language therapy visit - - Yes No $25-40 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 per day for days 1 through 20$184 per day for days 21 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - Yes No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - Yes No $0 copay
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) Yes - Yes No $0 copay
Other No - - - Not covered
Routine eye exam Yes - Yes No $0 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
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
Barrow County, Georgia, Bartow County, Georgia, Bryan County, Georgia, Burke County, Georgia, Chatham County, Georgia, Chattahoochee County, Georgia, Cherokee County, Georgia, Clarke County, Georgia, Cobb County, Georgia, Columbia County, Georgia, Coweta County, Georgia, Douglas County, Georgia, Effingham County, Georgia, Elbert County, Georgia, Fayette County, Georgia, Floyd County, Georgia, Forsyth County, Georgia, Greene County, Georgia, Hall County, Georgia, Harris County, Georgia, Jackson County, Georgia, Liberty County, Georgia, Madison County, Georgia, Marion County, Georgia, Mcduffie County, Georgia, Meriwether County, Georgia, Morgan County, Georgia, Muscogee County, Georgia, Newton County, Georgia, Oconee County, Georgia, Oglethorpe County, Georgia, Paulding County, Georgia, Pickens County, Georgia, Putnam County, Georgia, Richmond County, Georgia, Rockdale County, Georgia, Stewart County, Georgia, Talbot County, Georgia, Troup County, Georgia, Walton County, Georgia, Webster County, Georgia

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