2016 Medicare Advantage Plan Details | |||||||||||||||
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Medicare Plan Name: | Humana Gold Plus Integrated H3480-001 (Medicare-Medicaid Plan) | ||||||||||||||
Location: | Isle of Wight, Virginia Click to see other locations | ||||||||||||||
Plan ID: | H3480 - 001 - 0 Click to see other plans | ||||||||||||||
Member Services: | 1-855-280-4002 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 Plus Integrated H3480-001 (Medicare-Medicaid Plan) benefit details | |||||||||||||||
— Medicare Plan Features — | |||||||||||||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||||||||||||
Annual Rx Deductible: | $0 | ||||||||||||||
Health Plan Type: | MMP | ||||||||||||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $0 | ||||||||||||||
Additional Rx Gap Coverage? | Yes, some additional gap coverage. | ||||||||||||||
Total Number of Formulary Drugs: | 3,350 drugs | Browse the Humana Gold Plus Integrated H3480-001 (Medicare-Medicaid Plan) Formulary | |||||||||||||
This plan has 4 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||||||||||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 | ||||||||||
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||||
• Number of Drugs per Tier: | 2163 | 1187 | |||||||||||||
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 Isle of Wight, Virginia: | 55 members | ||||||||||||||
Number of Members enrolled in this plan in Virginia: | 10,041 members | ||||||||||||||
Number of Members enrolled in this plan in (H3480 - 001): | 10,321 members | ||||||||||||||
Plan’s Summary Star Rating: | New plan - No summary rating as of yet. | ||||||||||||||
• Customer Service Rating: | New plan - not yet rated. | ||||||||||||||
• Member Experience Rating: | New plan - not yet rated. | ||||||||||||||
• Drug Cost Accuracy Rating: | New plan - not yet rated. | ||||||||||||||
— 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 ** | |||||||||||||||
Monthly premium, deductible, and limits on how much you pay for covered services | |||||||||||||||
Some services may require a monthly payment amount. | |||||||||||||||
You pay nothing | |||||||||||||||
In this plan you will pay nothing for services from any provider. | |||||||||||||||
Please note that you will still need to pay your cost-sharing for your Part D prescription drugs. | |||||||||||||||
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. | |||||||||||||||
** Doctor and Hospital Choice ** | |||||||||||||||
Acupuncture | |||||||||||||||
Not covered | |||||||||||||||
** Extra Benefits ** | |||||||||||||||
Inpatient mental health care | |||||||||||||||
For inpatient mental health care see the "Mental Health Care" section. | |||||||||||||||
Outpatient prescription drugs | |||||||||||||||
For Part B drugs such as chemotherapy drugs: You pay nothing | |||||||||||||||
Other Part B drugs: You pay nothing | |||||||||||||||
You may get your drugs at network retail pharmacies and mail order pharmacies. | |||||||||||||||
You pay the following: | |||||||||||||||
Standard Retail Cost-Sharing
| |||||||||||||||
Standard Mail Order Cost-Sharing
| |||||||||||||||
If you reside in a long-term care facility you pay the same as at a retail pharmacy. | |||||||||||||||
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. | |||||||||||||||
You pay nothing | |||||||||||||||
Institutional care | |||||||||||||||
Case management (long term care): You pay nothing | |||||||||||||||
Nursing home services: You pay nothing | |||||||||||||||
** Important Information ** | |||||||||||||||
Monthly premium, deductible, and limits on how much you pay for covered services | |||||||||||||||
Some services may require a monthly payment amount. | |||||||||||||||
You pay nothing | |||||||||||||||
In this plan you will pay nothing for services from any provider. | |||||||||||||||
Please note that you will still need to pay your cost-sharing for your Part D prescription drugs. | |||||||||||||||
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. | |||||||||||||||
** Outpatient Care and Services ** | |||||||||||||||
Acupuncture | |||||||||||||||
Not covered | |||||||||||||||
Additional home care services | |||||||||||||||
Personal care services: You pay nothing | |||||||||||||||
Self-directed personal assistance services: You pay nothing | |||||||||||||||
Additional services | |||||||||||||||
Case management: You pay nothing | |||||||||||||||
Respite Care Services (for up to 480 hours every year): You pay nothing | |||||||||||||||
Adult Day Health Care: You pay nothing | |||||||||||||||
Personal Emergency Response System/Medication Monitoring System: You pay nothing | |||||||||||||||
Transition Services: You pay nothing (there is a limit to how much our plan will pay) | |||||||||||||||
Additional Skilled Nursing Facility Days: You pay nothing | |||||||||||||||
Community Mental Health Rehabilitative Services: You pay nothing | |||||||||||||||
Additional Outpatient Mental Health Services: You pay nothing | |||||||||||||||
Telemedicine Services: You pay nothing | |||||||||||||||
HIV Testing and Treatment Counseling (Prenatal): You pay nothing | |||||||||||||||
High Risk Prenatal Services: You pay nothing | |||||||||||||||
Additional Outpatient Substance Abuse Treatment Services: You pay nothing | |||||||||||||||
Nutrition Education for Pregnant Women (for up to 3 sessions every pregnancy): You pay nothing | |||||||||||||||
Health Education for Pregnant Women (for up to 12 sessions every pregnancy): You pay nothing | |||||||||||||||
Day & Residential Treatment for Pregnant Women: You pay nothing | |||||||||||||||
Federally Qualified health Center Services/Rural Health Clinic Services: You pay nothing | |||||||||||||||
Emergency Custody Orders/Temporary Detention Orders (TDOs): You pay nothing | |||||||||||||||
Court Ordered Services: You pay nothing | |||||||||||||||
Service Facilitation: You pay nothing | |||||||||||||||
Ambulance | |||||||||||||||
You pay nothing | |||||||||||||||
Chiropractic care | |||||||||||||||
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay nothing | |||||||||||||||
Dental services | |||||||||||||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): You pay nothing | |||||||||||||||
Preventive dental services: | |||||||||||||||
Diabetes supplies and services | |||||||||||||||
Diabetes monitoring supplies: You pay nothing | |||||||||||||||
Diabetes self-management training: You pay nothing | |||||||||||||||
Therapeutic shoes or inserts: You pay nothing | |||||||||||||||
Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting) | |||||||||||||||
Diagnostic radiology services (such as MRIs CT scans): You pay nothing | |||||||||||||||
Diagnostic tests and procedures: You pay nothing | |||||||||||||||
Lab services: You pay nothing | |||||||||||||||
Outpatient x-rays: You pay nothing | |||||||||||||||
Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing | |||||||||||||||
Doctor's office visits | |||||||||||||||
Primary care physician visit: You pay nothing | |||||||||||||||
Specialist visit: You pay nothing | |||||||||||||||
Durable medical equipment (wheelchairs, oxygen, etc.) | |||||||||||||||
You pay nothing | |||||||||||||||
Other Durable Medical Equipment (non-specific e.g. outside home): You pay nothing | |||||||||||||||
Medical Supplies: You pay nothing | |||||||||||||||
Emergency care | |||||||||||||||
You pay nothing | |||||||||||||||
Foot care (podiatry services) | |||||||||||||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing | |||||||||||||||
Routine foot care (for up to 12 visit(s) every year): You pay nothing | |||||||||||||||
Hearing services | |||||||||||||||
Exam to diagnose and treat hearing and balance issues: You pay nothing | |||||||||||||||
Routine hearing exam (for up to 1 every year): You pay nothing | |||||||||||||||
Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing | |||||||||||||||
Hearing aid: You pay nothing | |||||||||||||||
Our plan pays up to $1 000 every three years for hearing aids. | |||||||||||||||
Home health care | |||||||||||||||
You pay nothing | |||||||||||||||
Additional hours of care: You pay nothing | |||||||||||||||
Home Health Aide (for up to 32 visits every year): You pay nothing. | |||||||||||||||
Mental health care | |||||||||||||||
Inpatient visit: | |||||||||||||||
Our plan covers an unlimited number of days for an inpatient hospital stay. | |||||||||||||||
You pay nothing | |||||||||||||||
Outpatient group therapy visit: You pay nothing | |||||||||||||||
Outpatient individual therapy visit: You pay nothing | |||||||||||||||
Outpatient rehabilitation | |||||||||||||||
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing. Additional visits are covered but your cost may be more. | |||||||||||||||
Respiratory care services: You pay nothing | |||||||||||||||
Occupational therapy visit: You pay nothing | |||||||||||||||
Additional Acute and Non-Acute Occupational Therapy: You pay nothing | |||||||||||||||
Physical therapy and speech and language therapy visit: You pay nothing | |||||||||||||||
Additional Acute and Non-Acute Physical Therapy: You pay nothing | |||||||||||||||
Additional Acute and Non-Acute Speech Therapy: You pay nothing | |||||||||||||||
Outpatient substance abuse | |||||||||||||||
Group therapy visit: You pay nothing | |||||||||||||||
Individual therapy visit: You pay nothing | |||||||||||||||
Outpatient surgery | |||||||||||||||
Ambulatory surgical center: You pay nothing | |||||||||||||||
Outpatient hospital: You pay nothing | |||||||||||||||
Over-the-counter items | |||||||||||||||
Please visit our website to see our list of covered over-the-counter items. | |||||||||||||||
Prosthetic devices (braces, artificial limbs, etc.) | |||||||||||||||
Prosthetic devices: You pay nothing | |||||||||||||||
Related medical supplies: You pay nothing | |||||||||||||||
Prosthetics/Orthotics: You pay nothing | |||||||||||||||
Renal dialysis | |||||||||||||||
You pay nothing | |||||||||||||||
Transportation | |||||||||||||||
You pay nothing | |||||||||||||||
Urgently needed services | |||||||||||||||
You pay nothing | |||||||||||||||
Vision services | |||||||||||||||
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing | |||||||||||||||
Routine eye exam (for up to 1 every year): You pay nothing | |||||||||||||||
Contact lenses (for up to 1 every year): You pay nothing | |||||||||||||||
Eyeglasses (frames and lenses) (for up to 1 every year): You pay nothing | |||||||||||||||
Eyeglasses or contact lenses after cataract surgery: You pay nothing | |||||||||||||||
Our plan pays up to $100 every year for contact lenses and eyeglasses (frames and lenses). | |||||||||||||||
** Hospice ** | |||||||||||||||
Hospice | |||||||||||||||
You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. | |||||||||||||||
** Preventive Care ** | |||||||||||||||
Preventive care | |||||||||||||||
You pay nothing | |||||||||||||||
Our plan covers many preventive services including:
| |||||||||||||||
Family planning services: You pay nothing | |||||||||||||||
Tobacco cessation counseling for pregnant women: You pay nothing | |||||||||||||||
** Inpatient Care ** | |||||||||||||||
Inpatient hospital care | |||||||||||||||
Our plan covers an unlimited number of days for an inpatient hospital stay. | |||||||||||||||
You pay nothing | |||||||||||||||
Inpatient mental health care | |||||||||||||||
For inpatient mental health care see the "Mental Health Care" section. | |||||||||||||||
Institutional care | |||||||||||||||
Case management (long term care): You pay nothing | |||||||||||||||
Nursing home services: You pay nothing | |||||||||||||||
Skilled Nursing Facility (SNF) | |||||||||||||||
Our plan covers an unlimited number of days in a SNF. | |||||||||||||||
You pay nothing | |||||||||||||||
Outpatient prescription drugs | |||||||||||||||
For Part B drugs such as chemotherapy drugs: You pay nothing | |||||||||||||||
Other Part B drugs: You pay nothing | |||||||||||||||
You may get your drugs at network retail pharmacies and mail order pharmacies. | |||||||||||||||
You pay the following: | |||||||||||||||
Standard Retail Cost-Sharing
| |||||||||||||||
Standard Mail Order Cost-Sharing
| |||||||||||||||
If you reside in a long-term care facility you pay the same as at a retail pharmacy. | |||||||||||||||
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. | |||||||||||||||
You pay nothing | |||||||||||||||
Additional home care services | |||||||||||||||
Personal care services: You pay nothing | |||||||||||||||
Self-directed personal assistance services: You pay nothing | |||||||||||||||
** Outpatient Care ** | |||||||||||||||
Diabetes supplies and services | |||||||||||||||
Diabetes monitoring supplies: You pay nothing | |||||||||||||||
Diabetes self-management training: You pay nothing | |||||||||||||||
Therapeutic shoes or inserts: You pay nothing | |||||||||||||||
Foot care (podiatry services) | |||||||||||||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing | |||||||||||||||
Routine foot care (for up to 12 visit(s) every year): You pay nothing | |||||||||||||||
Hearing services | |||||||||||||||
Exam to diagnose and treat hearing and balance issues: You pay nothing | |||||||||||||||
Routine hearing exam (for up to 1 every year): You pay nothing | |||||||||||||||
Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing | |||||||||||||||
Hearing aid: You pay nothing | |||||||||||||||
Our plan pays up to $1 000 every three years for hearing aids. | |||||||||||||||
** Outpatient Medical Services and Supplies ** | |||||||||||||||
Outpatient substance abuse | |||||||||||||||
Group therapy visit: You pay nothing | |||||||||||||||
Individual therapy visit: You pay nothing | |||||||||||||||
Prosthetic devices (braces, artificial limbs, etc.) | |||||||||||||||
Prosthetic devices: You pay nothing | |||||||||||||||
Related medical supplies: You pay nothing | |||||||||||||||
Prosthetics/Orthotics: You pay nothing | |||||||||||||||
** Additional Benefits ** | |||||||||||||||
Inpatient mental health care | |||||||||||||||
For inpatient mental health care see the "Mental Health Care" section. | |||||||||||||||
Institutional care | |||||||||||||||
Case management (long term care): You pay nothing | |||||||||||||||
Nursing home services: You pay nothing |