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2011 Humana Gold Choice H8145-051 (PFFS) in Harrison, West Virginia

Medicare Advantage Plan Benefit Details in Plain Text

The following Medicare Advantage plan benefits apply to the Humana Gold Choice H8145-051 (PFFS) (H8145 - 051) in Harrison, West Virginia .

This plan is administered by HUMANA INSURANCE COMPANY. To switch to a different Medicare Advantage plan or to change your location, click here.

Click here to see the Humana Gold Choice H8145-051 (PFFS) health and prescription benefit details in chart format

or email and view benefits chart

Plan Premium

The Humana Gold Choice H8145-051 (PFFS) has a monthly premium of $31.00. That is $372.00 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $31.00 montly premium is in addition to your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a PFFS plan.

Prescription Drug Coverage: Deductible, Cost-sharing, Formulary

This plan does NOT have a deductible for the prescription drug coverage. That means that you have first dollar coverage. Some plans have a deductible that must be paid (in full) prior to the prescription coverage assisting in your prescription costs (see cost-sharing below). The maximum deductible for 2011 is $310. This plan (Humana Gold Choice H8145-051 (PFFS)) has no deductible.

The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Since this plan has no deductible, your coverage (initial coverage phase) will start right away. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The Humana Gold Choice H8145-051 (PFFS)’s formulary is divided into 4 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:

Tier 1 (Preferred Generic Drugs) contains 1,512 drugs and has a co-payment of $6.00.
Tier 2 (Non-Preferred Generic and Preferred Brand Drugs) contains 858 drugs and has a co-payment of $39.00.
Tier 3 (Non-Preferred Brand Drugs) contains 1,331 drugs and has a co-payment of $80.00.
Tier 4 (Specialty Tier Drugs) contains 296 drugs and has a co-insurance of 33% of the drug cost.

Click here to browse the Humana Gold Choice H8145-051 (PFFS) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 7% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 50% and your plan will pay an additional 0% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 50% discount. The 50% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (Humana Gold Choice H8145-051 (PFFS)) offers Coverage for Few Generics and Few Brands during the Coverage Gap phase. This means that a few (less than 10%) of the generic drugs and a few (less than 10%) of the brand-name drugs on the plans formulary (or drug list) will be covered through the coverage gap (or donut hole).

The Humana Gold Choice H8145-051 (PFFS) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** Cost **

Premium and Other Important Information

$31 monthly plan premium in addition to your monthly Medicare Part B premium.

Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

This plan covers all Medicare-covered preventive services with zero cost sharing.

This plan does not allow providers to balance bill (charging more than your cost share amount).

$155 yearly deductible. Contact the plan for services that apply.

$6 700 out-of-pocket limit.

In-Network: This limit includes only Medicare-covered services.

Out-Of-Network: This limit includes only Medicare-covered services.

** Doctor and Hospital Choice **

Doctor and Hospital Choice

You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment.

** Extra Benefits **

Prescription Drugs

0% to 20% of the cost for Part B-covered drugs (not including Part B-covered chemotherapy drugs).

20% of the cost for Part B-covered chemotherapy drugs.

0% to 20% of the cost for Part B drugs out-of-network.

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.humana.com/members/tools/prescription_tools/medicare_drug_list.asp on the web.

Different out-of-pocket costs may apply for people who

have limited incomes
live in long term care facilities or
have access to Indian/Tribal/Urban (Indian Health Service).

The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).

Total yearly drug costs are the total drug costs paid by both you and the plan.

The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.

Some drugs have quantity limits.

Your provider must get prior authorization from Humana Gold Choice H8145-051 (PFFS) for certain drugs.

You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.

If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount.

If you request a formulary exception for a drug and Humana Gold Choice H8145-051 (PFFS) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug.

$0 deductible.

You pay the following until total yearly drug costs reach $2 840:

Tier 1: Preferred Generic Drugs

Tier 2: Non-Preferred Generic and Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Specialty Tier Drugs

$6 copay for a one-month (30-day) supply of drugs in this tier

$39 copay for a one-month (30-day) supply of drugs in this tier

$80 copay for a one-month (30-day) supply of drugs in this tier

33% coinsurance for a one-month (30-day) supply of drugs in this tier

$18 copay for a three-month (90-day) supply of drugs in this tier

$117 copay for a three-month (90-day) supply of drugs in this tier

$240 copay for a three-month (90-day) supply of drugs in this tier

Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

Tier 1: Preferred Generic Drugs

Tier 2: Non-Preferred Generic and Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Specialty Tier Drugs

$6 copay for a one-month (34-day) supply of drugs in this tier

$39 copay for a one-month (34-day) supply of drugs in this tier

$80 copay for a one-month (34-day) supply of drugs in this tier

33% coinsurance for a one-month (34-day) supply of drugs in this tier

Tier 1: Preferred Generic Drugs

Tier 2: Non-Preferred Generic and Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Specialty Tier Drugs

$0 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.

$39 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.

$80 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.

33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.

$0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.

$107 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.

$230 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.

$6 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

$39 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

$80 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

$18 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

$117 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

$240 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

Call plan for details concerning additional Gap Coverage.

You pay the following:

Tier 1: Preferred Generic Drugs

Tier 2: Non-Preferred Generic and Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Specialty Tier Drugs

$6 copay for a one-month (30-day) supply of select drugs covered in this tier

$39 copay for a one-month (30-day) supply of select drugs covered in this tier

$80 copay for a one-month (30-day) supply of select drugs covered in this tier

33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier

$18 copay for a three-month (90-day) supply of select drugs covered in this tier

$117 copay for a three-month (90-day) supply of select drugs covered in this tier

$240 copay for a three-month (90-day) supply of select drugs covered in this tier

Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

Tier 1: Preferred Generic Drugs

Tier 2: Non-Preferred Generic and Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Specialty Tier Drugs

$6 copay for a one-month (34-day) supply of select drugs covered in this tier

$39 copay for a one-month (34-day) supply of select drugs covered in this tier

$80 copay for a one-month (34-day) supply of select drugs covered in this tier

33% coinsurance for a one-month (34-day) supply of select drugs covered in this tier

Tier 1: Preferred Generic Drugs

Tier 2: Non-Preferred Generic and Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Specialty Tier Drugs

$0 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy

$39 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy

$80 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy

33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy

$0 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy

$107 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy

$230 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy

$6 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy

$39 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy

$80 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy

33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy

$18 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy

$117 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy

$240 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy

Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.

After your total yearly drug costs reach $2 840 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 550.

Please contact the plan for a complete list of drugs covered through the gap.

After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of:

A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
5% coinsurance.

Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Humana Gold Choice H8145-051 (PFFS).

You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840:

Tier 1: Preferred Generic Drugs

Tier 2: Non-Preferred Generic and Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Specialty Tier Drugs

$6 copay for a one-month (30-day) supply of drugs in this tier

$39 copay for a one-month (30-day) supply of drugs in this tier

$80 copay for a one-month (30-day) supply of drugs in this tier

33% coinsurance for a one-month (30-day) supply of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

You will be reimbursed for these drugs purchased out-of-network up to the full cost of the drug minus the following:

Tier 1: Preferred Generic Drugs

Tier 2: Non-Preferred Generic and Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Specialty Tier Drugs

$6 copay for a one-month (30-day) supply of select drugs covered in this tier

$39 copay for a one-month (30-day) supply of select drugs covered in this tier

$80 copay for a one-month (30-day) supply of select drugs covered in this tier

33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of:

A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
5% coinsurance.

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

Physical Exams

$0 copay for routine exams.

Limited to 1 exam(s) every year.

$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits.

$0 copay for routine exams.

Vision Services

20% of the cost for one pair of eyeglasses or contact lenses after cataract surgery.

0% to 20% of the cost for exams to diagnose and treat diseases and conditions of the eye.

0% of the cost for up to 1 routine eye exam(s) every year

$0 copay for up to 1 pair(s) of glasses every year

$0 copay for up to 1 pair(s) of contacts every year

$100 plan coverage limit for eye wear every year.

0% to 20% of the cost for eye exams.

$35 copay for eye exams.

20% of the cost for eye wear.

$0 copay for eye wear.

Dental Services

20% of the cost for Medicare-covered dental benefits.

$0 copay for up to 1 oral exam(s) every year

$0 copay for up to 1 cleaning(s) every year

$0 copay for up to 1 dental x-ray(s) every year

Plan offers additional comprehensive dental benefits.

50% of the cost for preventive dental benefits.

20% of the cost for comprehensive dental benefits.

50% of the cost for comprehensive dental benefits.

** Important Information **

Premium and Other Important Information

$31 monthly plan premium in addition to your monthly Medicare Part B premium.

This plan covers all Medicare-covered preventive services with zero cost sharing.

This plan does not allow providers to balance bill (charging more than your cost share amount).

$155 yearly deductible. Contact the plan for services that apply.

$6 700 out-of-pocket limit.

In-Network: This limit includes only Medicare-covered services.

Out-Of-Network: This limit includes only Medicare-covered services.

Doctor and Hospital Choice

You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment.

** Inpatient Care **

Inpatient Hospital Care (Acute)

You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment except in emergencies.

No limit to the number of days covered by the plan each benefit period.

You will not be charged additional cost sharing for professional services.

For additional hospital days:

Days 91 - 150: $550 copay per day

Days 151 and beyond: $0 copay per day

Inpatient Mental Health Care

You get up to 190 days in a Psychiatric Hospital in a lifetime.

Same deductible and copay as inpatient hospital care (see 'Inpatient Hospital Care')

Skilled Nursing Facility (SNF)

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

For SNF stays:

Days 1 - 20: $0 copay per day

Days 21 - 100: $137.50 copay per day

For each SNF stay:

Days 1 - 20: $0 copay per SNF day

Days 21 - 100: $137.50 copay per SNF day

Home Health Care

$0 copay for each Medicare-covered home health visit.

$0 copay for home health visits.

Hospice

You must get care from a Medicare-certified hospice.

** Outpatient Care **

Doctor Office Visits

You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment.

See 'Welcome to Medicare; and Annual Wellness Visit' for more information.

20% of the cost for each primary care doctor visit for Medicare-covered benefits.

20% of the cost for each in-area network urgent care Medicare-covered visit.

20% of the cost for each specialist visit for Medicare-covered benefits.

20% for each primary care doctor visit.

20% for each specialist visit.

Chiropractic Services

20% of the cost for each Medicare-covered visit.

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

20% of the cost for chiropractic benefits.

Podiatry Services

20% of the cost for each Medicare-covered visit.

Medicare-covered podiatry benefits are for medically-necessary foot care.

20% of the cost for podiatry benefits.

Outpatient Mental Health Care

20% of the cost for each Medicare-covered individual or group therapy visit.

20% of the cost for Mental Health benefits.

20% of the cost for Mental Health benefits with a psychiatrist.

Outpatient Substance Abuse Care

20% of the cost for Medicare-covered individual or group visits.

20% of the cost for outpatient substance abuse benefits.

Outpatient Hospital Services

20% of the cost for each Medicare-covered ambulatory surgical center visit.

20% of the cost for each Medicare-covered outpatient hospital facility visit.

20% of the cost for ambulatory surgical center benefits.

20% of the cost for outpatient hospital facility benefits.

Emergency Care

$50 copay for Medicare-covered emergency room visits.

$25 000 plan coverage limit for emergency services outside the U.S. every year.

Outpatient Rehabilitation Services

There may be limits on physical therapy occupational therapy and speech and language pathology services. If so there may be exceptions to these limits.

20% of the cost for Medicare-covered Occupational Therapy visits.

20% of the cost for Medicare-covered Physical and/or Speech and Language Therapy visits.

20% of the cost for Medicare-covered Cardiac Rehab services.

20% of the cost for Occupational Therapy benefits.

20% of the cost for Physical and/or Speech and Language Therapy visits.

20% of the cost for Cardiac Rehab services.

** Outpatient Medical Services and Supplies **

Durable Medical Equipment

20% of the cost for Medicare-covered items.

20% of the cost for durable medical equipment.

Prosthetic Devices

20% of the cost for Medicare-covered items.

20% of the cost for prosthetic devices.

Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies

$0 copay for Diabetes self-monitoring training.

$0 copay for Nutrition Therapy for Diabetes.

$0 to $10 copay [or 20% of the cost] for Diabetes supplies.

$0 copay for Diabetes self-monitoring training.

$0 copay for Nutrition Therapy for Diabetes.

20% of the cost for Diabetes supplies.

** Preventive Services **

Bone Mass Measurement

$0 copay for Medicare-covered bone mass measurement.

Colorectal Screening Exams

$0 copay for Medicare-covered colorectal screenings.

$0 copay for colorectal screenings.

Immunizations

$0 copay for Flu and Pneumonia vaccines.

$0 copay for Hepatitis B vaccine.

$0 copay for immunizations.

Pap Smears and Pelvic Exams

$0 copay for Medicare-covered pap smears and pelvic exams

$0 copay for pap smears and pelvic exams.

Prostate Cancer Screening Exams

$0 copay for Medicare-covered prostate cancer screening.

$0 copay for prostate cancer screening.

** Additional Benefits **

Dialysis

20% of the cost for renal dialysis

$0 copay for Nutrition Therapy for End-Stage Renal Disease.

20% of the cost for renal dialysis.

$0 copay for Nutrition Therapy for End-Stage Renal Disease.

Prescription Drugs

0% to 20% of the cost for Part B-covered drugs (not including Part B-covered chemotherapy drugs).

20% of the cost for Part B-covered chemotherapy drugs.

0% to 20% of the cost for Part B drugs out-of-network.

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.humana.com/members/tools/prescription_tools/medicare_drug_list.asp on the web.

Different out-of-pocket costs may apply for people who

have limited incomes
live in long term care facilities or
have access to Indian/Tribal/Urban (Indian Health Service).