2024 Humana Gold Plus H5619-001 (HMO) in Sagadahoc, Maine

Medicare Advantage Plan Benefit Details in Plain Text

The following Medicare Advantage plan benefits apply to the Humana Gold Plus H5619-001 (HMO) (H5619 - 001) in Sagadahoc, Maine .

This plan is administered by ARCADIAN HEALTH PLAN, INC.. To switch to a different Medicare Advantage plan or to change your location, click here.

Click here to see the Humana Gold Plus H5619-001 (HMO) health and prescription benefit details in chart format

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Plan Premium

This plan has a $0.00 monthly premium. Although you pay no additional monthly premium, you must continue to pay your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a Local HMO plan.

Plan Membership and Plan Ratings

The Humana Gold Plus H5619-001 (HMO) (H5619 - 001) currently has 663 members. , and 433 members in Maine.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 4 stars. The detail CMS plan carrier ratings are as follows:

Customer Service Rating of 5 out of 5 stars
Member Experience Rating of 5 out of 5 stars
Drug Cost Information Accuracy Rating of 3 out of 5 stars

Prescription Drug Coverage: Deductible, Cost-sharing, Formulary

This plan has a $450 deductible. However, formulary drugs on Tier 1 and 2 are excluded from the $450 deductible and have first dollar coverage (or a $0 deductible). So, you are 100% responsible for the first $450 in medication costs for drugs not on the excluded tiers. After you have met the deductible, the Humana Gold Plus H5619-001 (HMO) will share the costs of your medications with you (see cost-sharing below). The maximum deductible for 2024 is $545, but this plan (Humana Gold Plus H5619-001 (HMO)) has a $450. There are other plans with a lower deductible or even a $0 deductible for all formulary drugs. Click here to review plans with a $0 deductible.

The following information is about the Humana Gold Plus H5619-001 (HMO) formulary (or drug list). There are 3448 drugs on the Humana Gold Plus H5619-001 (HMO) formulary. Click here to browse the Humana Gold Plus H5619-001 (HMO) Formulary.

The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Once you have spent $450, your initial coverage phase will start. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The Humana Gold Plus H5619-001 (HMO)’s formulary is divided into 5 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:

Tier 1 (Preferred Generic) contains 396 drugs and has a co-payment of $0.00.
Tier 2 (Generic) contains 574 drugs and has a co-payment of $5.00.
Tier 3 (Preferred Brand) contains 804 drugs and has a co-payment of $47.00.
Tier 4 (Non-Preferred Drug) contains 1,029 drugs and has a co-payment of $100.00.
Tier 5 (Specialty Tier) contains 671 drugs and has a co-insurance of 26% of the drug cost.

All forms of insulin covered by this Medicare Part D plan will have a copay of $35 or less through all phases of coverage. Please contact the drug plan for more details.

Click here to browse the Humana Gold Plus H5619-001 (HMO) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 75% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 70% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 75% discount. The 70% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (Humana Gold Plus H5619-001 (HMO)) offers Coverage in the gap, however Medicare has not specified the details of the gap coverage.

The Humana Gold Plus H5619-001 (HMO) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

Base Plan
Premium
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: $450.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $7,350 In-network
Optional supplemental benefits
• Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: Yes, contact plan for further details
Doctor visits
• Primary: $0 copay
• Specialist: $45 copay per visit (authorization required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $0-100 copay (authorization required)
• Lab services: $0-55 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): $45-390 copay (authorization required)
• Outpatient x-rays: $0-125 copay (authorization required)
Emergency care/Urgent care
• Emergency: $100 copay per visit (always covered)
• Urgent care: $55 copay per visit (always covered)
Inpatient hospital coverage
• $390 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 90 and beyond (authorization required)
Outpatient hospital coverage
• $50-390 copay per visit (authorization required)
Skilled Nursing Facility
• $0 per day for days 1 through 20 $203 per day for days 21 through 100 (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $300 copay
Rehabilitation services
• Occupational therapy visit: $40 copay (authorization required)
• Physical therapy and speech and language therapy visit: $40 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric: $350 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist: $40 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist: $40 copay (authorization required)
• Outpatient group therapy visit: $40 copay (authorization required)
• Outpatient individual therapy visit: $40 copay (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)
• Diabetes supplies: $0 copay or 10-20% coinsurance per item (authorization required)
Hearing
• Hearing exam: $45 copay (authorization required)
• Fitting/evaluation: $0 copay (authorization required)
• Hearing aids: $699-999 copay (limits apply)
Preventive dental
• Oral exam: $0 copay (limits apply)
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: $0 copay (limits apply)
• Dental x-ray(s): $0 copay (limits apply)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services: $0 copay (limits apply, authorization required)
• Restorative services: Not covered
• Endodontics: Not covered
• Periodontics: Not covered
• Extractions: Not covered
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision
• Routine eye exam: $0 copay (limits apply, authorization required)
• Other: Not covered
• Contact lenses: $0 copay (limits apply, authorization required)
• Eyeglasses (frames and lenses): $0 copay (limits apply, authorization required)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: Not covered
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Some coverage
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Some coverage
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Not covered
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Not covered
• Counseling Services: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment: $45 copay (authorization required)
• Routine foot care: $45 copay (limits apply, authorization required)
Medicare Part B drugs
• Part B Insulin drugs: 0-20% coinsurance (up to $35) (authorization required)
• Chemotherapy: 0-20% coinsurance (authorization required)
• Other Part B drugs: 0-20% coinsurance (authorization required)
Package #1
• Monthly Premium: $42.20
• Deductible: N/A
Package #2
• Monthly Premium: $58.60
• Deductible: N/A
Package #3
• Monthly Premium: $72.80
• Deductible: N/A

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