Humana Gold Plus SNP-DE H4461-022 (HMO D-SNP) H4461-022-000 is a 2021 Medicare Advantage Dual-Eligible Special Needs Plan provided by Humana.
A Special Needs Plan (SNP) is a type of Medicare Advantage Plan designed for Medicare beneficiaries with specific conditions or characteristics.
Dual Eligible Special Needs Plans are for beneficiaries enrolled in Medicare and Medicaid. This includes all categories of Medicaid. Please only choose this plan if you are eligible for both Medicare and Medicaid.
Special Needs plans provide both health coverage and drug coverage, and each coverage type has different costs to consider.
This plan has a monthly premium of $0.00, which covers both the health and drug portions of the plan.
When it comes to out-of-pocket costs for drugs, this plan has a Part D drug Deductible of $445.00 and an Initial Coverage Limit of $4130. Each drug tier may be subject to different cost-sharing in each coverage phase, so keep that in mind when considering out-of-pocket costs. Check out the drug formulary below for more information, or reach out to a licensed Medicare agent for help using the call number on this page. Alternatively, if you know what plan you want, you can enroll online yourself using our site as well.
Plan Basics
| Contract Year |
2021 |
| Medicare Type |
Medicare Advantage Plan (Part C) |
| CMS Plan ID |
H4461-022-000 |
| Plan Organization |
Humana |
| Plan Type |
Local HMO |
| Plan Name |
Humana Gold Plus SNP-DE H4461-022 (HMO D-SNP) |
| Plan Organization Type |
Local CCP |
| Drugs Covered |
Yes |
| Doctors Choice |
Plan Doctors for Most Services |
| Benefit Type |
Basic Alternative |
| Special Needs Plan |
Yes |
| Special Needs Plan Type |
Dual-Eligible |
| Overall Star Rating |
4.5 |
Plan Cost Sharing
| Premium |
$0.00 |
| Total Premium (Includes Part B) |
$135.50 |
| Monthly Part C Premium |
$0.00 |
| Monthly Part D Basic Premium |
$30.20 |
| Monthly Part D Supplemental Premium |
$0.00 |
| Monthly Part D Total Premium |
$30.20 |
| Monthly Part D Premium Full Assistance |
$0.00 |
| Monthly Part D Premium 75% Assistance |
$7.50 |
| Monthly Part D Premium 50% Assistance |
$15.10 |
| Monthly Part D Premium 25% Assistance |
$22.60 |
| 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 |
- |
- |
No |
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 |
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 |
$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 |
Official Medicare Contact
| Medicare Phone |
1-800-MEDICARE (1-800-633-4227) |
| Medicare TTY User |
1-877-486-2048 |
Plan Available in these Counties
Anderson County, Tennessee,
Bedford County, Tennessee,
Benton County, Tennessee,
Bledsoe County, Tennessee,
Blount County, Tennessee,
Bradley County, Tennessee,
Campbell County, Tennessee,
Cannon County, Tennessee,
Carroll County, Tennessee,
Carter County, Tennessee,
Cheatham County, Tennessee,
Chester County, Tennessee,
Claiborne County, Tennessee,
Clay County, Tennessee,
Cocke County, Tennessee,
Coffee County, Tennessee,
Crockett County, Tennessee,
Cumberland County, Tennessee,
Davidson County, Tennessee,
Decatur County, Tennessee,
Dekalb County, Tennessee,
Dickson County, Tennessee,
Dyer County, Tennessee,
Fayette County, Tennessee,
Fentress County, Tennessee,
Franklin County, Tennessee,
Gibson County, Tennessee,
Giles County, Tennessee,
Grainger County, Tennessee,
Greene County, Tennessee,
Grundy County, Tennessee,
Hamblen County, Tennessee,
Hamilton County, Tennessee,
Hancock County, Tennessee,
Hardeman County, Tennessee,
Hardin County, Tennessee,
Hawkins County, Tennessee,
Haywood County, Tennessee,
Henderson County, Tennessee,
Henry County, Tennessee,
Hickman County, Tennessee,
Houston County, Tennessee,
Humphreys County, Tennessee,
Jackson County, Tennessee,
Jefferson County, Tennessee,
Johnson County, Tennessee,
Knox County, Tennessee,
Lake County, Tennessee,
Lauderdale County, Tennessee,
Lawrence County, Tennessee,
Lewis County, Tennessee,
Lincoln County, Tennessee,
Loudon County, Tennessee,
Macon County, Tennessee,
Madison County, Tennessee,
Marion County, Tennessee,
Marshall County, Tennessee,
Maury County, Tennessee,
Mcminn County, Tennessee,
Mcnairy County, Tennessee,
Meigs County, Tennessee,
Monroe County, Tennessee,
Montgomery County, Tennessee,
Moore County, Tennessee,
Morgan County, Tennessee,
Obion County, Tennessee,
Overton County, Tennessee,
Perry County, Tennessee,
Pickett County, Tennessee,
Polk County, Tennessee,
Putnam County, Tennessee,
Rhea County, Tennessee,
Roane County, Tennessee,
Robertson County, Tennessee,
Rutherford County, Tennessee,
Scott County, Tennessee,
Sequatchie County, Tennessee,
Sevier County, Tennessee,
Shelby County, Tennessee,
Smith County, Tennessee,
Stewart County, Tennessee,
Sullivan County, Tennessee,
Sumner County, Tennessee,
Tipton County, Tennessee,
Trousdale County, Tennessee,
Unicoi County, Tennessee,
Union County, Tennessee,
Van Buren County, Tennessee,
Warren County, Tennessee,
Washington County, Tennessee,
Wayne County, Tennessee,
Weakley County, Tennessee,
White County, Tennessee,
Williamson County, Tennessee,
Wilson County, Tennessee
NOTE: Information on MedicarePolicyHelper.com is for educational purposes only. We are not affiliated with Medicare, or CMS. Medicare has not reviewed or endorsed the information on our site. All plan data on our site comes directly from medicare.gov and is subject to change.