2012 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Humana Gold Choice H2944-204 (PFFS) | ||||
Location: | Carter, Missouri Click to see other locations | ||||
Plan ID: | H2944 - 204 - 0 Click to see other plans | ||||
Member Services: | 1-800-457-4708 TTY users 711 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Humana Gold Choice H2944-204 (PFFS) benefit details
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— Medicare Plan Features — | |||||
Monthly Premium: | $49.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $320 | ||||
Annual Initial Coverage Limit (ICL): | $2,930 | ||||
Health Plan Type: | PFFS | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Additional Gap Coverage? | Few Generics, Few Brands | ||||
Total Number of Formulary Drugs: | 3,277 drugs | Browse the Humana Gold Choice H2944-204 (PFFS) Formulary | |||
This plan has 4 drug tiers. See cost-sharing highlights below. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $1.00 | $5.00 | 20% | 30% | |
• Number of Drugs per Tier: | 260 | 1060 | 945 | 1012 | |
Plan's Pharmacy Search: | http://www.humana.com/Medicare/medicare_prescription_drugs | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in (H2944 - 204): | 635 members | ||||
Plan’s Summary Star Rating: | 3 out of 5 Stars. | ||||
• Customer Service Rating: | 3 out of 5 Stars. | ||||
• Member Experience Rating: | 3 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 3 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
$49 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 does not allow providers to balance bill (charging more than your cost share amount). | |||||
Unless otherwise noted out-of-network services not covered. | |||||
$6 700 out-of-pocket limit for 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 ** | |||||
Over-the-Counter Items | |||||
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$49 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 does not allow providers to balance bill (charging more than your cost share amount). | |||||
Unless otherwise noted out-of-network services not covered. | |||||
$6 700 out-of-pocket limit for 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 | |||||
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 hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 7: $250 copay per day | |||||
Days 8 - 90: $0 copay per day | |||||
$0 copay for each additional hospital day. | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 7: $200 copay per day | |||||
Days 8 - 90: $0 copay per day | |||||
Skilled Nursing Facility (SNF) | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
For SNF stays: | |||||
Days 1 - 14: $0 copay per day | |||||
Days 15 - 21: $50 copay per day | |||||
Days 22 - 100: $125 copay per day | |||||
Home Health Care | |||||
$0 copay for Medicare-covered home health visits | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select 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. | |||||
$20 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$40 copay for each specialist visit for Medicare-covered benefits. | |||||
Chiropractic Services | |||||
$20 copay 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. | |||||
Podiatry Services | |||||
$40 copay for each Medicare-covered visit | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
$40 copay for each Medicare-covered individual therapy visit | |||||
$40 copay for each Medicare-covered group therapy visit | |||||
$40 copay for each Medicare-covered individual therapy visit with a psychiatrist | |||||
$40 copay for each Medicare-covered group therapy visit with a psychiatrist | |||||
20% of the cost for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
25% of the cost for Medicare-covered individual visits | |||||
25% of the cost for Medicare-covered group visits | |||||
Outpatient Services/Surgery | |||||
20% of the cost for each Medicare-covered ambulatory surgical center visit | |||||
20% to 25% of the cost for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
20% of the cost for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
$65 copay for Medicare-covered emergency room visits | |||||
$25 000 plan coverage limit for emergency services outside the U.S. every year. | |||||
Urgently Needed Care | |||||
Cost sharing is the same as Doctor Office Visit cost sharing. | |||||
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. | |||||
$40 copay [or 25% of the cost] for Medicare-covered Occupational Therapy visits | |||||
$40 copay [or 25% of the cost] for Medicare-covered Physical and/or Speech and Language Therapy visits | |||||
** 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 | |||||
Diabetes Programs and Supplies | |||||
$0 copay for Diabetes self-management training | |||||
0% to 20% of the cost for Diabetes monitoring supplies | |||||
$10 copay for Therapeutic shoes or inserts | |||||
20% of the cost for Diabetes monitoring supplies | |||||
20% of the cost for Therapeutic shoes or inserts | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
$0 to $40 copay [or 25% of the cost] for Medicare-covered lab services | |||||
$0 to $40 copay [or 0% to 25% of the cost] for Medicare-covered diagnostic procedures and tests | |||||
$20 to $40 copay [or 20% to 25% of the cost] for Medicare-covered X-rays | |||||
$20 to $40 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
$40 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services | |||||
0% to 25% of the cost for diagnostic procedures tests and lab services | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
$40 copay [or 25% of the cost] for Medicare-covered Cardiac Rehabilitation Services | |||||
$40 copay [or 25% of the cost] for Medicare-covered Intensive Cardiac Rehabilitation Services | |||||
$40 copay [or 20% to 25% of the cost] for Medicare-covered Pulmonary Rehabilitation Services | |||||
Preventive Services and Wellness/Education Programs | |||||
$0 copay for all preventive services covered under Original Medicare at zero cost sharing: | |||||
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Please contact plan for details. | |||||
The plan covers the following supplemental education/wellness programs: | |||||
Kidney Disease and Conditions | |||||
20% of the cost for renal dialysis | |||||
$0 copay for kidney disease education services | |||||
Outpatient 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. | |||||
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 | |||||
The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). 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 a Part D 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 H2944-204 (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 H2944-204 (PFFS) approves the exception you will pay Tier 4: Non-Preferred Brand Drugs cost sharing for that drug. | |||||
$320 deductible on all drugs except Tier 1: Preferred Generic Drugs Tier 2: Non-Preferred Generic Drugs. | |||||
After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 930: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
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 Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
The plan covers few formulary generics (less than 10% of formulary generic drugs) few formulary brands (less than 10% of formulary brand drugs) through the coverage gap. | |||||
You pay the following: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
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 Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
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 $2 930 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 86% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 700. | |||||
Please contact the plan for a complete list of drugs covered through the gap. | |||||
After your yearly out-of-pocket drug costs reach $4 700 you pay the greater of: | |||||
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 H2944-204 (PFFS). | |||||
After you pay your yearly deductible you will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until your total yearly drug costs reach $2 930: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
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 plan's cost of the drug minus the following: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Non-Preferred Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Brand Drugs | |||||
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 $4 700 you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share which is the greater of: | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
Dental Services | |||||
In general preventive dental benefits (such as cleaning) not covered. However this plan covers preventive dental benefits for an extra cost (see 'Optional Benefits.') | |||||
$40 copay for Medicare-covered dental benefits | |||||
Hearing Services | |||||
In general supplemental routine hearing exams and hearing aids not covered. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
In general supplemental routine eye exams and eye wear not covered. However this plan covers some vision benefits for an extra cost (see 'Optional Benefits'). | |||||
Over-the-Counter Items | |||||
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
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 hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 7: $250 copay per day | |||||
Days 8 - 90: $0 copay per day | |||||
$0 copay for each additional hospital day. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. | |||||
$20 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$40 copay for each specialist visit for Medicare-covered benefits. | |||||
Outpatient Services/Surgery | |||||
20% of the cost for each Medicare-covered ambulatory surgical center visit | |||||
20% to 25% of the cost for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
20% of the cost for Medicare-covered ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
20% of the cost for Medicare-covered items | |||||
20% of the cost for durable medical equipment | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
$0 to $40 copay [or 25% of the cost] for Medicare-covered lab services | |||||
$0 to $40 copay [or 0% to 25% of the cost] for Medicare-covered diagnostic procedures and tests | |||||
$20 to $40 copay [or 20% to 25% of the cost] for Medicare-covered X-rays | |||||
$20 to $40 copay [or 20% to 25% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
$40 copay [or 20% of the cost] for Medicare-covered therapeutic radiology services | |||||
0% to 25% of the cost for diagnostic procedures tests and lab services | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 1 - MyOption Dental High PPO: | |||||
$27 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$1 500 plan coverage limit every year for these benefits. | |||||
** Important Information ** | |||||
Package: 1 - MyOption Dental High PPO: | |||||
$27 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$1 500 plan coverage limit every year for these benefits. | |||||
** Preventive Services ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
30% of the cost for preventive dental services | |||||
55% to 75% of the cost for comprehensive dental services | |||||
$1 500 plan coverage limit for comprehensive dental benefits every year. This limit applies to both in-network and out-of-network benefits. | |||||
$1 500 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits. | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 2 - MyOption Dental Low PPO: | |||||
$17 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$1 000 plan coverage limit every year for these benefits. | |||||
** Important Information ** | |||||
Package: 2 - MyOption Dental Low PPO: | |||||
$17 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$1 000 plan coverage limit every year for these benefits. | |||||
** Preventive Services ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
30% of the cost for preventive dental services | |||||
55% of the cost for comprehensive dental services | |||||
$1 000 plan coverage limit for comprehensive dental benefits every year. This limit applies to both in-network and out-of-network benefits. | |||||
$1 000 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits. | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 3 - MyOption Vision: | |||||
$15 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$290 plan coverage limit every year for these benefits. | |||||
** Important Information ** | |||||
Package: 3 - MyOption Vision: | |||||
$15 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$290 plan coverage limit every year for these benefits. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 4 - MyOption Plus: | |||||
$28 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
** Important Information ** | |||||
Package: 4 - MyOption Plus: | |||||
$28 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
** Preventive Services ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
30% of the cost for preventive dental services | |||||
55% of the cost for comprehensive dental services | |||||
$1 000 plan coverage limit for comprehensive dental benefits every year. This limit applies to both in-network and out-of-network benefits. | |||||
$1 000 plan coverage limit for preventive dental benefits every year. This limit applies to both in-network and out-of-network benefits. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 5 - MyOption Fitness Well Being: | |||||
$30 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
** Important Information ** | |||||
Package: 5 - MyOption Fitness Well Being: | |||||
$30 monthly premium in addition to your $49 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: |