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2019 Medicare Advantage Plan Benefit Details for the Humana Gold Choice H8145-123 (PFFS) - H8145-123-0

2019 Medicare Advantage Plan Details
Medicare Plan Name:Humana Gold Choice H8145-123 (PFFS)
Location:Grand, Colorado
Plan ID:H8145 - 123 - 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:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
Email a copy of the Humana Gold Choice H8145-123 (PFFS) benefit details
— Medicare Plan Features —
Monthly Premium:$103.00 (see Plan Premium Details below)
Annual Deductible:$300 (Tier 1 and 2 excluded from the Deductible.)
Annual Initial Coverage Limit (ICL):$3,820
Health Plan Type:PFFS
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$0
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,519 drugsBrowse the Humana Gold Choice H8145-123 (PFFS) 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:
Number of Drugs per
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 Grand, Colorado:25 members
Number of Members enrolled in this plan in Colorado:1,974 members
Number of Members enrolled in this plan in (H8145 - 123):2,609 members
Plan’s Summary Star Rating: 3.5 out of 5 Stars.
Customer Service Rating: 5 out of 5 Stars.
Member Experience Rating: 4 out of 5 Stars.
Drug Cost Accuracy Rating: 4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows:
Part C
Part D Base
Part D Supplemental
Monthly Premium with Extra Help Low-Income Subsidy (LIS):100%
Monthly Part D Premium with LIS:$8.60$14.70$20.80$27.00
Total Monthly Premium with LIS (Parts C & D):$78.50$84.60$90.70$96.90
— Plan Health Benefits —
** Benefit Highlights **
Health plan deductible $0
Other health plan deductibles? In-Network:  No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) $6,700 In and Out-of-network
Optional supplemental benefits Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? In-Network:  No
Inpatient hospital coverage In-Network:  $325 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 91 and beyond
  Out-of-Network:  $325 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient hospital coverage In-Network:  $325 per visit
  Out-of-Network:  $15-325 per visit
Doctor visits Primary:  In-Network:  $15 per visit
  Primary:  Out-of-Network:  $15-325 per visit
  Specialist:  In-Network:  $50 per visit
  Specialist:  Out-of-Network:  $50-325 or 25% per visit
Preventive care In-Network:  $0 copay
  Out-of-Network:  $0-100
Emergency care/Urgent care Emergency:  $90 per visit (always covered)
  Urgent care:  $15-50 per visit (always covered)
Vision Routine eye exam:  In-Network:  $0 copay
  Routine eye exam:  Out-of-Network:  $0-100
  Other:  Not covered
  Contact lenses:  Not covered
  Eyeglasses (frames and lenses):  Not covered
  Eyeglass frames:  Not covered
  Eyeglass lenses:  Not covered
  Upgrades:  Not covered
Mental health services Inpatient hospital - psychiatric:  In-Network:  $325 per day for days 1 through 4
$0 per day for days 5 through 90
  Inpatient hospital - psychiatric:  Out-of-Network:  $325 per day for days 1 through 4
$0 per day for days 5 through 90
  Outpatient group therapy visit with a psychiatrist:  In-Network:  $20
  Outpatient group therapy visit with a psychiatrist:  Out-of-Network:  $20-25
  Outpatient individual therapy visit with a psychiatrist:  In-Network:  $20
  Outpatient individual therapy visit with a psychiatrist:  Out-of-Network:  $20-25
  Outpatient group therapy visit:  In-Network:  $20
  Outpatient group therapy visit:  Out-of-Network:  $20-25
  Outpatient individual therapy visit:  In-Network:  $20
  Outpatient individual therapy visit:  Out-of-Network:  $20-25
Skilled Nursing Facility In-Network:  $0 per day for days 1 through 20
$172 per day for days 21 through 60
$0 per day for days 61 through 100
  Out-of-Network:  $0 per day for days 1 through 20
$172 per day for days 21 through 60
$0 per day for days 61 through 100
Rehabilitation services Occupational therapy visit:  In-Network:  $30
  Occupational therapy visit:  Out-of-Network:  $30
  Physical therapy and speech and language therapy visit:  In-Network:  $30
  Physical therapy and speech and language therapy visit:  Out-of-Network:  $30
Ground ambulance In-Network:  $265
  Out-of-Network:  $265
Transportation Not covered
Foot care (podiatry services) Foot exams and treatment:  In-Network:  $50
  Foot exams and treatment:  Out-of-Network:  $50-325 or 25%
  Routine foot care:  Not covered
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen):  In-Network:  20% per item
  Durable medical equipment (e.g., wheelchairs, oxygen):  Out-of-Network:  25% per item
  Prosthetics (e.g., braces, artificial limbs):  In-Network:  20% per item
  Prosthetics (e.g., braces, artificial limbs):  Out-of-Network:  25% per item
  Diabetes supplies:  In-Network:  $0 or 10-20% per item
  Diabetes supplies:  Out-of-Network:  25% per item
Wellness programs (e.g., fitness, nursing hotline) Covered
Medicare Part B drugs Chemotherapy:  In-Network:  20%
  Chemotherapy:  Out-of-Network:  25%
  Other Part B drugs:  In-Network:  20%
  Other Part B drugs:  Out-of-Network:  25%
** Benefits Services **
Diagnostic procedures/lab services/imaging Diagnostic tests and procedures:  In-Network:  $0-100
  Diagnostic tests and procedures:  Out-of-Network:  $0-100
  Lab services:  In-Network:  $0-45
  Lab services:  Out-of-Network:  $0-100
  Diagnostic radiology services (e.g., MRI):  In-Network:  $50-325
  Diagnostic radiology services (e.g., MRI):  Out-of-Network:  $50-325 or 25%
  Outpatient x-rays:  In-Network:  $15-100
  Outpatient x-rays:  Out-of-Network:  $15-325
Hearing Hearing exam:  In-Network:  $50
  Hearing exam:  Out-of-Network:  $50-325 or 25%
  Fitting/evaluation:  In-Network:  $0 copay
  Fitting/evaluation:  Out-of-Network:  $0-100
  Hearing aids:  In-Network:  $699-999
  Hearing aids:  Out-of-Network:  $699-999
Preventive dental Oral exam:  In-Network:  $0 copay
  Oral exam:  Out-of-Network:  50%
  Cleaning:  In-Network:  $0 copay
  Cleaning:  Out-of-Network:  50%
  Fluoride treatment:  Not covered
  Dental x-ray(s):  In-Network:  $0 copay
  Dental x-ray(s):  Out-of-Network:  50%
Comprehensive dental Non-routine services:  Not covered
  Diagnostic services:  Not covered
  Restorative services:  In-Network:  50%
  Restorative services:  Out-of-Network:  50-55%
  Endodontics:  Not covered
  Periodontics:  Not covered
  Extractions:  Not covered
  Prosthodontics, other oral/maxillofacial surgery, other services:  Not covered
** Optional Supplemental Benefits **
Package #1 Comprehensive dental, Preventive dental
  Monthly Premium:  $25.10
  Deductible:  N/A
Package #2 Wellness programs (e.g., fitness, nursing hotline)
  Monthly Premium:  $15.00
  Deductible:  N/A

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