Humana Gold Plus SNP-DE H4141-003 (HMO D-SNP) - 2021

Humana Gold Plus SNP-DE H4141-003 (HMO D-SNP) - Humana - Local HMO

Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H4141-003-000
Plan Organization Humana
Plan Type Local HMO
Plan Name Humana Gold Plus SNP-DE H4141-003 (HMO D-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan Yes
Special Needs Plan Type Dual-Eligible
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 $29.70
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $29.70
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $7.40
Monthly Part D Premium 50% Assistance $14.80
Monthly Part D Premium 25% Assistance $22.30
Part D Drug Deductible $445.00
Annual Drug Deductible $445.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00

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 Yes - Yes No $0 copay
Extractions Yes - Yes No $0 copay
Non-routine services Yes - Yes No $0 copay
Periodontics Yes - Yes No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes - Yes No $0 copay
Restorative services Yes - Yes No $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes No $0 copay
Diagnostic tests and procedures - - Yes No $0 copay
Lab services - - Yes No $0 copay
Outpatient x-rays - - Yes No $0 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - Yes No $0 copay
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $0 copay
Urgent care - - - - $0 copay
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - Yes No $0 copay
Routine foot care Yes - Yes No $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0 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 $0 copay
Hearing exam - - Yes No $0 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 copay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $3,450 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - Yes - $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - $0 copay
Prosthetics (e.g., braces, artificial limbs) - - Yes - $0 copay
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - $0 copay
Other Part B drugs - - Yes - $0 copay
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes No $0 copay
Outpatient group therapy visit - - Yes No $0 copay
Outpatient group therapy visit with a psychiatrist - - Yes No $0 copay
Outpatient individual therapy visit - - Yes No $0 copay
Outpatient individual therapy visit with a psychiatrist - - Yes No $0 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 $0 copay
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 No - - - Not covered
Oral exam Yes - No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - Yes No $0 copay
Physical therapy and speech and language therapy visit - - Yes No $0 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 copay
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
- - Yes 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
Baker County, Georgia, Barrow County, Georgia, Bartow County, Georgia, Bibb County, Georgia, Bryan County, Georgia, Burke County, Georgia, Chatham County, Georgia, Chattahoochee County, Georgia, Cherokee County, Georgia, Clarke County, Georgia, Clayton County, Georgia, Cobb County, Georgia, Columbia County, Georgia, Coweta County, Georgia, Crawford County, Georgia, Dekalb County, Georgia, Dougherty County, Georgia, Douglas County, Georgia, Effingham County, Georgia, Elbert County, Georgia, Fayette County, Georgia, Floyd County, Georgia, Forsyth County, Georgia, Fulton County, Georgia, Greene County, Georgia, Gwinnett County, Georgia, Hall County, Georgia, Harris County, Georgia, Henry County, Georgia, Houston County, Georgia, Jackson County, Georgia, Jones County, Georgia, Lee County, Georgia, Liberty County, Georgia, Lincoln County, Georgia, Madison County, Georgia, Marion County, Georgia, Mcduffie County, Georgia, Meriwether County, Georgia, Monroe County, Georgia, Morgan County, Georgia, Muscogee County, Georgia, Newton County, Georgia, Oconee County, Georgia, Oglethorpe County, Georgia, Paulding County, Georgia, Peach County, Georgia, Pickens County, Georgia, Putnam County, Georgia, Richmond County, Georgia, Rockdale County, Georgia, Stewart County, Georgia, Sumter County, Georgia, Talbot County, Georgia, Terrell County, Georgia, Troup County, Georgia, Twiggs County, Georgia, Walton County, Georgia, Webster County, Georgia, Worth County, Georgia

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