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2014 Medicare Advantage Plan Benefit Details for the Humana Gold Choice H8145-126 (PFFS) - H8145-126-0
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 Choice H8145-126 (PFFS)
Location:Caldwell, Texas     Click to see other locations
Plan ID:H8145 - 126 - 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 Choice H8145-126 (PFFS) benefit details
— Medicare Plan Features —
Monthly Premium:$15.00 (see Plan Premium Details below)
Annual Deductible:no drug coverage
Health Plan Type:PFFS *
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$0
Number of Members enrolled in this plan in (H8145 - 126):22,121 members
Plan’s Summary Star Rating: Insufficient data to rate this plan.
• 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
$15.00 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 a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B 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).
$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 **
Wellness/Education and Other Supplemental Benefits & Services
The plan covers the following supplemental education/wellness programs:
  • Health Education
  • Additional Smoking and Tobacco Use Cessation Visits
  • Nursing Hotline
    • $0 copay for supplemental education/wellness programs
    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
    $15.00 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 a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B 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).
    $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 or hospital that accepts the plan's terms and conditions of payment. In emergencies you may go to any doctor or hospital even those that do not participate with the plan.
    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 non-Medicare-covered hospital day.
    For Medicare-covered hospital stays:
    • Days 1 - 7: $250 copay per day
  • Days 8 - 90: $0 copay per 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: $210 copay per day
  • Days 8 - 90: $0 copay per day
    • Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.
    For Medicare-covered hospital stays:
    • Days 1 - 7: $210 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: $25 copay per day
  • Days 22 - 100: $150 copay per day
    • For each Medicare-covered SNF stay:
    • Days 1 - 14: $0 copay per SNF day
  • Days 15 - 21: $25 copay per SNF day
  • Days 22 - 100: $150 copay per SNF day
    • Home Health Care
    $0 copay for each Medicare-covered home health visit
    20% of the cost for Medicare-covered home health visits
    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
    You may go to any doctor that accepts the plan's terms and conditions of payment.
    $10 copay for each Medicare-covered primary care doctor visit.
    $45 copay for each Medicare-covered specialist visit.
    $10 copay for each Medicare-covered primary care doctor visit
    $45 copay for each Medicare-covered specialist visit
    Chiropractic Services
    $20 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).
    $20 copay for Medicare-covered chiropractic visits.
    Podiatry Services
    $45 copay for each Medicare-covered podiatry visit
    Medicare-covered podiatry visits are for medically necessary foot care.
    $45 copay for Medicare-covered podiatry visits
    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
    $45 copay for Medicare-covered partial hospitalization program services
    $40 copay for Medicare-covered Mental Health visits with a psychiatrist
    $40 copay for Medicare-covered Mental Health visits
    $45 copay for Medicare-covered partial hospitalization program services
    Outpatient Substance Abuse Care
    $50 copay for Medicare-covered individual substance abuse outpatient treatment visits
    $50 copay for Medicare-covered group substance abuse outpatient treatment visits
    $50 copay for Medicare-covered substance abuse outpatient treatment visits
    Outpatient Services
    $200 copay for each Medicare-covered ambulatory surgical center visit
    $50 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit
    20% of the cost for Medicare-covered outpatient hospital facility visits
    $200 copay for Medicare-covered ambulatory surgical center visits
    Ambulance Services
    $250 copay for Medicare-covered ambulance benefits.
    $250 copay for Medicare-covered ambulance benefits.
    Emergency Care
    $65 copay for Medicare-covered emergency room visits
    $25 000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year.
    Urgently Needed Care
    $10 to $45 copay for Medicare-covered urgently-needed-care visits
    Outpatient Rehabilitation Services
    Medically necessary physical therapy occupational therapy and speech and language pathology services are covered.
    $50 copay for Medicare-covered Occupational Therapy visits
    $50 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits
    $45 to $50 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits
    $45 to $50 copay for Medicare-covered Occupational Therapy visits.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    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.
    20% of the cost for Medicare-covered durable medical equipment
    Prosthetic Devices
    20% of the cost for Medicare-covered prosthetic devices
    20% of the cost for Medicare-covered medical supplies related to prosthetics splints and other devices
    20% of the cost for Medicare-covered prosthetic devices.
    Diabetes Programs and Supplies
    $0 copay for Medicare-covered Diabetes self-management training
    0% to 20% of the cost for Medicare-covered Diabetes monitoring supplies
    $10 copay for Medicare-covered Therapeutic shoes or inserts
    $0 copay for Medicare-covered Diabetes self-management training
    20% of the cost for Medicare-covered Diabetes monitoring supplies
    20% of the cost for Medicare-covered Therapeutic shoes or inserts
    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    $0 to $50 copay for Medicare-covered lab services
    $0 to $50 copay for Medicare-covered diagnostic procedures and tests
    $10 to $50 copay for Medicare-covered X-rays
    $200 copay [or 20% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays)
    $45 to $50 copay for Medicare-covered therapeutic radiology services
    $45 to $50 copay for Medicare-covered therapeutic radiology services
    $10 to $50 copay for Medicare-covered outpatient X-rays
    $200 copay [or 20% of the cost] for Medicare-covered diagnostic radiology services
    $0 to $50 copay [or 20% of the cost] for Medicare-covered diagnostic procedures and tests
    $0 to $50 copay for Medicare-covered lab services
    ** Preventive Services **
    Cardiac and Pulmonary Rehabilitation Services
    $45 to $50 copay for Medicare-covered Cardiac Rehabilitation Services
    $45 to $50 copay for Medicare-covered Intensive Cardiac Rehabilitation Services
    $45 to $50 copay for Medicare-covered Pulmonary Rehabilitation Services
    $45 to $50 copay for Medicare-covered Cardiac Rehabilitation Services
    $45 to $50 copay for Medicare-covered Intensive Cardiac Rehabilitation Services
    $45 to $50 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.
    $0 copay for a supplemental annual physical exam
    $0 copay for Medicare-covered preventive services
    $0 copay for a supplemental annual physical exam
    Kidney Disease and Conditions
    0% to 20% of the cost for Medicare-covered renal dialysis
    $0 copay for Medicare-covered kidney disease education services
    $0 copay for Medicare-covered kidney disease education services
    0% to 20% of the cost for Medicare-covered renal dialysis
    Outpatient Prescription Drugs
    Most drugs not covered.
    20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.
    20% of the cost for Medicare Part B drugs out-of-network.
    This plan does not offer prescription drug coverage.
    Dental Services
    This plan covers some preventive dental benefits for an extra cost (see "Optional Supplemental Benefits.")
    $45 copay for Medicare-covered dental benefits
    $45 copay for Medicare-covered comprehensive dental benefits
    Hearing Services
    In general supplemental routine hearing exams and hearing aids not covered.
    $45 copay for Medicare-covered diagnostic hearing exams
    $45 copay for Medicare-covered diagnostic hearing exams.
    ** Additional Benefits **
    Vision Services
    $0 to $45 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.
    $45 copay for Medicare-covered eye exams
    $0 copay for supplemental routine eye exams
    $0 copay for Medicare-covered eyewear
    $130 plan coverage limit for supplemental eye exams every year. This limit applies to both in-network and out-of-network benefits.
    Wellness/Education and Other Supplemental Benefits & Services
    The plan covers the following supplemental education/wellness programs:
    • Health Education
  • Additional Smoking and Tobacco Use Cessation Visits
  • Nursing Hotline
    • $0 copay for supplemental education/wellness programs
    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 and other alternative therapies.
    ** Inpatient Care **
    Inpatient Hospital Care
    You may go to any doctor or hospital that accepts the plan's terms and conditions of payment. In emergencies you may go to any doctor or hospital even those that do not participate with the plan.
    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 non-Medicare-covered hospital day.
    For Medicare-covered hospital stays:
    • Days 1 - 7: $250 copay per day
  • Days 8 - 90: $0 copay per day
    • ** Outpatient Care **
    Doctor Office Visits
    You may go to any doctor that accepts the plan's terms and conditions of payment.
    $10 copay for each Medicare-covered primary care doctor visit.
    $45 copay for each Medicare-covered specialist visit.
    $10 copay for each Medicare-covered primary care doctor visit
    $45 copay for each Medicare-covered specialist visit
    Outpatient Services
    $200 copay for each Medicare-covered ambulatory surgical center visit
    $50 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit
    20% of the cost for Medicare-covered outpatient hospital facility visits
    $200 copay for Medicare-covered ambulatory surgical center visits
    Ambulance Services
    $250 copay for Medicare-covered ambulance benefits.
    $250 copay for Medicare-covered ambulance benefits.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    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.
    20% of the cost for Medicare-covered durable medical equipment
    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    $0 to $50 copay for Medicare-covered lab services
    $0 to $50 copay for Medicare-covered diagnostic procedures and tests
    $10 to $50 copay for Medicare-covered X-rays
    $200 copay [or 20% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays)
    $45 to $50 copay for Medicare-covered therapeutic radiology services
    $45 to $50 copay for Medicare-covered therapeutic radiology services
    $10 to $50 copay for Medicare-covered outpatient X-rays
    $200 copay [or 20% of the cost] for Medicare-covered diagnostic radiology services
    $0 to $50 copay [or 20% of the cost] for Medicare-covered diagnostic procedures and tests
    $0 to $50 copay for Medicare-covered lab services
    ** Additional Benefits **
    Wellness/Education and Other Supplemental Benefits & Services
    The plan covers the following supplemental education/wellness programs:
    • Health Education
  • Additional Smoking and Tobacco Use Cessation Visits
  • Nursing Hotline
    • $0 copay for supplemental education/wellness programs
    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.
    ** Cost **
    Premium and Other Important Information
    Package: 1 - MyOption Dental - High PPO:
    $15.20 monthly premium in addition to your $15 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    $1 500 plan coverage limit every year for these benefits.
    $50 deductible for these benefits.
    ** Important Information **
    Package: 1 - MyOption Dental - High PPO:
    $15.20 monthly premium in addition to your $15 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    $1 500 plan coverage limit every year for these benefits.
    $50 deductible for these benefits.
    ** Preventive Services **
    Dental Services
    Plan offers additional supplemental comprehensive dental benefits.
    0% of the cost for up to 2 supplemental oral exam(s) every year
    0% of the cost for up to 2 supplemental cleaning(s) every year
    0% of the cost for up to 1 supplemental dental x-ray(s) every year
    30% of the cost for supplemental preventive dental services
    55% to 75% of the cost for supplemental comprehensive dental services
    $1 500 plan coverage limit for supplemental 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 Fitness:
    $13 monthly premium in addition to your $15 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Supplemental Education/Health Management Programs
    ** Important Information **
    Package: 2 - MyOption Fitness:
    $13 monthly premium in addition to your $15 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Supplemental Education/Health Management Programs




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