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2014 Medicare Advantage Plan Benefit Details for the Humana Gold Plus SNP-I H1036-185 (HMO SNP)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2014 Medicare Advantage Plan Details
Medicare Plan Name:Humana Gold Plus SNP-I H1036-185 (HMO SNP)
Location:Broward, Florida     Click to see other locations
Plan ID:H1036 - 185 - 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
Email a copy of the Humana Gold Plus SNP-I H1036-185 (HMO SNP) benefit details
— Medicare Plan Features —
Monthly Premium:$7.70 (see Plan Premium Details below)
Annual Deductible:$310
Annual Initial Coverage Limit (ICL):$2,850
Health Plan Type:Local HMO
Special Needs Plan (SNP)
Eligibility Requirement:		Institutional
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,835 drugsBrowse the Humana Gold Plus SNP-I H1036-185 (HMO SNP) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. 
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$0.00$0.00$45.00$95.0025%
• Number of Drugs per
  Tier:		3928968751271401
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 (H1036 - 185):less than 10 members
Plan’s Summary Star Rating: 4.5 out of 5 Stars.
• Customer Service Rating: 4 out of 5 Stars.
• Member Experience Rating: 4 out of 5 Stars.
• Drug Cost Accuracy Rating: 4 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
$7.7 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.
$3 400 out-of-pocket limit for Medicare-covered services.
** Doctor and Hospital Choice **
Doctor and Hospital Choice
You must go to network doctors specialists and hospitals.
Referral required for network specialists (for certain benefits).
** Extra Benefits **
Wellness/Education and Other Supplemental Benefits & Services
The plan covers the following supplemental education/wellness programs:
  • Health Education
  • Nutritional Benefit
  • Additional Smoking and Tobacco Use Cessation Visits
  • Nursing Hotline
    • $25 copay for Personal Emergency Response System. Contact plan for details.
    Acupuncture
    This plan does not cover Acupuncture and other alternative therapies.
    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.
    ** Important Information **
    Premium and Other Important Information
    $7.7 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.
    $3 400 out-of-pocket limit for Medicare-covered services.
    Doctor and Hospital Choice
    You must go to network doctors specialists and hospitals.
    Referral required for network specialists (for certain benefits).
    ** Inpatient Care **
    Inpatient Hospital Care
    No limit to the number of days covered by the plan each hospital stay.
    $0 copay
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    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.
    $0 copay
    Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    Skilled Nursing Facility (SNF)
    Authorization rules may apply.
    Plan covers up to 100 days each benefit period
    No prior hospital stay is required.
    For SNF stays:
    • Days 1 - 10: $0 copay per day
  • Days 11 - 100: $50 copay per day
    • Home Health Care
    Authorization rules may apply.
    $0 copay for each Medicare-covered home health visit
    Hospice
    You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.
    ** Outpatient Care **
    Doctor Office Visits
    Authorization rules may apply.
    $0 copay for each Medicare-covered primary care doctor visit.
    $0 copay for each Medicare-covered specialist visit.
    Chiropractic Services
    Authorization rules may apply.
    $0 copay for each Medicare-covered chiropractic 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).
    Podiatry Services
    $0 copay for each Medicare-covered podiatry visit
    $0 copay for each supplemental routine podiatry visit
    Medicare-covered podiatry visits are for medically necessary foot care.
    Outpatient Mental Health Care
    Authorization rules may apply.
    $0 copay for each Medicare-covered individual therapy visit
    $0 copay for each Medicare-covered group therapy visit
    $0 copay for each Medicare-covered individual therapy visit with a psychiatrist
    $0 copay for each Medicare-covered group therapy visit with a psychiatrist
    $0 copay for Medicare-covered partial hospitalization program services
    Outpatient Substance Abuse Care
    Authorization rules may apply.
    $25 copay for Medicare-covered individual substance abuse outpatient treatment visits
    $25 copay for Medicare-covered group substance abuse outpatient treatment visits
    Outpatient Services
    Authorization rules may apply.
    $0 copay for each Medicare-covered ambulatory surgical center visit
    $0 to $125 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit
    Ambulance Services
    Authorization rules may apply.
    $50 copay for Medicare-covered ambulance benefits.
    Emergency Care
    $50 copay for Medicare-covered emergency room visits
    Worldwide coverage.
    If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit.
    Urgently Needed Care
    $0 copay for Medicare-covered urgently-needed-care visits
    Outpatient Rehabilitation Services
    Authorization rules may apply.
    Medically necessary physical therapy occupational therapy and speech and language pathology services are covered.
    $25 copay for Medicare-covered Occupational Therapy visits
    $25 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    Authorization rules may apply.
    0% to 20% of the cost for Medicare-covered durable medical equipment
    You may pay less if you purchase these items from the plan's preferred manufacturers/vendors. Contact the plan for a list of non-preferred and preferred manufacturers/vendors.
    Prosthetic Devices
    Authorization rules may apply.
    $0 copay for Medicare-covered prosthetic devices
    $0 copay for Medicare-covered medical supplies related to prosthetics splints and other devices
    Diabetes Programs and Supplies
    Authorization rules may apply.
    $0 copay for Medicare-covered Diabetes self-management training
    $0 copay for Medicare-covered Diabetes monitoring supplies
    $0 copay for Medicare-covered Therapeutic shoes or inserts
    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    Authorization rules may apply.
    $0 copay for Medicare-covered lab services
    $0 to $25 copay for Medicare-covered diagnostic procedures and tests
    $0 copay for Medicare-covered X-rays
    $0 to $125 copay for Medicare-covered diagnostic radiology services (not including X-rays)
    $0 to $25 copay for Medicare-covered therapeutic radiology services
    ** Preventive Services **
    Cardiac and Pulmonary Rehabilitation Services
    Authorization rules may apply.
    $0 to $25 copay for Medicare-covered Cardiac Rehabilitation Services
    $0 to $25 copay for Medicare-covered Intensive Cardiac Rehabilitation Services
    $0 to $25 copay for Medicare-covered Pulmonary Rehabilitation Services
    Preventive Services
    $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.
    Plan covers a physical exam annually.
    Kidney Disease and Conditions
    Authorization rules may apply.
    0% to 20% of the cost for Medicare-covered renal dialysis
    $0 copay for Medicare-covered kidney disease education services
    Outpatient Prescription Drugs
    0% to 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.
    This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.humana.com/medicare/medicare_prescription_drugs/medicare_drug_tools/medicare_drug_list/ 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) providers.
    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 Plus SNP-I H1036-185 (HMO SNP) 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.
    The plan charges a minimum cost sharing amount for certain low-cost drugs.
    If you request a formulary exception for a drug and Humana Gold Plus SNP-I H1036-185 (HMO SNP) approves the exception you will pay Tier 4: Non-Preferred Brand cost sharing for that drug.
    $310 deductible on all drugs except Tier 1: Preferred Generic Tier 2: Non-Preferred Generic drugs.
    After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 850:
    Tier 1: Preferred Generic
    Tier 2: Non-Preferred Generic
    Tier 3: Preferred Brand
    Tier 4: Non-Preferred Brand
    Tier 5: Specialty Tier
    Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.
    You can get drugs the following way(s):
    • $0 copay for a one-month (30-day) supply of drugs in this tier
  • $0 copay for a one-month (30-day) supply of drugs in this tier
  • $45 copay for a one-month (30-day) supply of drugs in this tier
  • $95 copay for a one-month (30-day) supply of drugs in this tier
  • 25% coinsurance for a one-month (30-day) supply of drugs in this tier
  • $0 copay for a three-month (90-day) supply of drugs in this tier
  • $0 copay for a three-month (90-day) supply of drugs in this tier
  • $135 copay for a three-month (90-day) supply of drugs in this tier
  • $285 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.
    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
    Tier 2: Non-Preferred Generic
    Tier 3: Preferred Brand
    Tier 4: Non-Preferred Brand
    Tier 5: Specialty Tier
    Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.
    You can get drugs the following way(s):
    • $0 copay for a one-month (31-day) supply of drugs in this tier
  • $0 copay for a one-month (31-day) supply of drugs in this tier
  • $45 copay for a one-month (31-day) supply of drugs in this tier
  • $95 copay for a one-month (31-day) supply of drugs in this tier
  • 25% coinsurance for a one-month (31-day) supply of drugs in this tier
    • Tier 1: Preferred Generic
    Tier 2: Non-Preferred Generic
    Tier 3: Preferred Brand
    Tier 4: Non-Preferred Brand
    Tier 5: Specialty Tier
    Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.
    You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s):
    • $0 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $0 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $45 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $95 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 25% 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.
  • $0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $125 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $275 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $0 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $0 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $45 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $95 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 25% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $0 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $0 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $285 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.
    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 $2 850 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 47.5% for the plan's costs for brand drugs and 72% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 550.
    After your yearly out-of-pocket drug costs reach $4 550 you pay the greater of:
    • 5% coinsurance or
    • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.
    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 Plus SNP-I H1036-185 (HMO SNP).
    You can get out-of-network drugs the following way:
    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 $2 850:
    Tier 1: Preferred Generic
    Tier 2: Non-Preferred Generic
    Tier 3: Preferred Brand
    Tier 4: Non-Preferred Brand
    Tier 5: Specialty Tier
    • $0 copay for a one-month (30-day) supply of drugs in this tier
  • $0 copay for a one-month (30-day) supply of drugs in this tier
  • $45 copay for a one-month (30-day) supply of drugs in this tier
  • $95 copay for a one-month (30-day) supply of drugs in this tier
  • 25% 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 up to 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s).
    After your yearly out-of-pocket drug costs reach $4 550 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:
    • 5% coinsurance or
    • $2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.
    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
    $0 copay for Medicare-covered dental benefits
    $0 copay for up to 1 supplemental oral exam(s) every year
    $0 copay for up to 1 supplemental cleaning(s) every year
    $0 copay for up to 2 supplemental dental x-ray(s) every year
    Plan offers additional supplemental comprehensive dental benefits.
    Hearing Services
    $0 copay for Medicare-covered diagnostic hearing exams
    $0 copay for up to 1 supplemental routine hearing exam(s) every year
    $0 copay for up to 1 supplemental hearing aid fitting-evaluation(s) every year
    $0 copay each for up to 2 supplemental hearing aid(s) every year
    $1 000 plan coverage limit for supplemental hearing aids every year.
    ** Additional Benefits **
    Vision Services
    $0 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye including an annual glaucoma screening for people at risk
    $0 copay for up to 1 supplemental routine eye exam(s) every year
    $0 copay for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery.
    $0 copay for up to 1 pair(s) of eyeglasses (lenses and frames) every year
    $0 copay for up to 1 pair(s) of contact lenses every year
    $115 plan coverage limit for supplemental eyewear every year
    Wellness/Education and Other Supplemental Benefits & Services
    The plan covers the following supplemental education/wellness programs:
    • Health Education
  • Nutritional Benefit
  • Additional Smoking and Tobacco Use Cessation Visits
  • Nursing Hotline
    • $25 copay for Personal Emergency Response System. Contact plan for details.
    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
    Authorization rules may apply.
    $0 copay for each one-way trip to Plan-approved location.
    Acupuncture
    This plan does not cover Acupuncture and other alternative therapies.
    ** Inpatient Care **
    Inpatient Hospital Care
    No limit to the number of days covered by the plan each hospital stay.
    $0 copay
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    ** Outpatient Care **
    Doctor Office Visits
    Authorization rules may apply.
    $0 copay for each Medicare-covered primary care doctor visit.
    $0 copay for each Medicare-covered specialist visit.
    Outpatient Services
    Authorization rules may apply.
    $0 copay for each Medicare-covered ambulatory surgical center visit
    $0 to $125 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit
    Ambulance Services
    Authorization rules may apply.
    $50 copay for Medicare-covered ambulance benefits.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    Authorization rules may apply.
    0% to 20% of the cost for Medicare-covered durable medical equipment
    You may pay less if you purchase these items from the plan's preferred manufacturers/vendors. Contact the plan for a list of non-preferred and preferred manufacturers/vendors.
    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    Authorization rules may apply.
    $0 copay for Medicare-covered lab services
    $0 to $25 copay for Medicare-covered diagnostic procedures and tests
    $0 copay for Medicare-covered X-rays
    $0 to $125 copay for Medicare-covered diagnostic radiology services (not including X-rays)
    $0 to $25 copay for Medicare-covered therapeutic radiology services
    ** Additional Benefits **
    Wellness/Education and Other Supplemental Benefits & Services
    The plan covers the following supplemental education/wellness programs:
    • Health Education
  • Nutritional Benefit
  • Additional Smoking and Tobacco Use Cessation Visits
  • Nursing Hotline
    • $25 copay for Personal Emergency Response System. Contact plan for details.
    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.




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    • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
    • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
    • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
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    • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
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    • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
    • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
    • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
    • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
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