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2018 Medicare Advantage Plan Benefit Details for the Northeast Community Care - Plus (HMO)

2018 Medicare Advantage Plan Details
Medicare Plan Name:Humana Gold Plus H5619-001 (HMO)
Location:Androscoggin, Maine
Plan ID:H5619 - 001 - 0     Click to see other plans
Member Services:1-800-457-4708 TTY users 711
— Enrollment Options —
Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
Speak to a licensed sales agent to learn more and enroll.
Call Medicare Solutions at 855-373-9484 / TTY 711

Mon-Thu: 8:30am-8pm, Fri: 8:30am-7pm, Sat: 9am-3pm
Email a copy of the Humana Gold Plus H5619-001 (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Deductible:$300 (Tier 1 and 2 excluded from the Deductible.)
Annual Initial Coverage Limit (ICL):$3,750
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$6,700
Gap Coverage:No Gap Coverage
Total Number of Formulary Drugs:3,666 drugsBrowse the Humana Gold Plus H5619-001 (HMO) 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 Androscoggin, Maine:726 members
Number of Members enrolled in this plan in Maine:857 members
Plan’s Summary Star Rating: 4 out of 5 Stars.
Customer Service Rating: 5 out of 5 Stars.
Member Experience Rating: Insufficient data to rate this plan.
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:$0.00$0.00$0.00$0.00
Total Monthly Premium with LIS (Parts C & D):$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Benefit Highlights **
Important Note This plan does not charge an annual deductible for all drugs. The $300.00 annual deductible only applies to drugs on certain tiers.
Monthly health plan premium $0.00
Monthly drug plan premium $0.00
Total monthly premium $0.00
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-network
Optional Supplemental Benefits? Yes
Inpatient hospital coverage $360 for days 1 through 5 $0 for days 6 through 90 $0 for days 91 and beyond
Outpatient hospital coverage $360 per visit
Doctor visits Primary: $5 per visit Specialist: $45 per visit
Preventive care $0 copay
Emergency care/Urgent care Emergency: $80 per visit (always covered) Urgent care: $5-45 per visit (always covered)
Diagnostic procedures/lab services/imaging Diagnostic tests and procedures: $0-95 Lab services: $0-40 Diagnostic radiology services (e.g., MRI): $5-360 Outpatient x-rays: $5-95
Mental health services $324 for days 1 through 5 $0 for days 6 through 90 Outpatient group therapy visit with a psychiatrist: $40 Outpatient individual therapy visit with a psychiatrist: $40 Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40
Skilled Nursing Facility $0 for days 1 through 20 $167.50 for days 21 through 100
Rehabilitation services Occupational therapy visit: $40 Physical therapy and speech and language therapy visit: $40
Ambulance $265 or 20%
Transportation $0 copay
Foot care (podiatry services) Foot exams and treatment: $45 Routine foot care: Not covered
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen): 20% per item Prosthetics (e.g., braces, artificial limbs): 20% per item Diabetes supplies: $0 or 10-20% per item
Wellness programs (e.g., fitness, nursing hotline) Covered
Medicare Part B drugs Chemotherapy: 20% Other Part B drugs: 20%
Dental Services Preventive dental -
Cleaning $0 copay
There may be limits on how much the plan will provide.
Dental x-ray(s) $0 copay
There may be limits on how much the plan will provide.
Fluoride treatment Not covered
Oral exam $0 copay
There may be limits on how much the plan will provide.
Comprehensive dental -
Diagnostic services Not covered
Endodontics Not covered
Extractions Not covered
Non-routine services Not covered
Periodontics Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Not covered
Restorative services Not covered
Vision Services Contact lenses $0 copay
There may be limits on how much the plan will provide.
Eyeglass frames Not covered

Eyeglass lenses Not covered

Eyeglasses (frames and lenses) $0 copay
There may be limits on how much the plan will provide.
Other Not covered

Routine eye exam $0 copay
There may be limits on how much the plan will provide.
Upgrades Not covered
Hearing Services Fitting/evaluation $0 copay
There may be limits on how much the plan will provide.
Hearing aids $0 copay
There may be limits on how much the plan will provide.
Hearing exam $45

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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.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • 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.