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2018 Medicare Advantage Plan Benefit Details for the Humana Gold Choice H8145-087 (PFFS)


2018 Medicare Advantage Plan Details
Medicare Plan Name:Humana Gold Choice H8145-087 (PFFS)
Location:Madison, Mississippi
Plan ID:H8145 - 087 - 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
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Call Medicare Solutions at 855-373-9484 / TTY 711

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Email a copy of the Humana Gold Choice H8145-087 (PFFS) benefit details
— Medicare Plan Features —
Monthly Premium:$95.00 (see Plan Premium Details below)
Annual Deductible:$315 (Tier 1 and 2 excluded from the Deductible.)
Annual Initial Coverage Limit (ICL):$3,750
Health Plan Type:PFFS
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$0
Gap Coverage:No Gap Coverage
Total Number of Formulary Drugs:3,666 drugsBrowse the Humana Gold Choice H8145-087 (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:
$5.00$15.00$47.00$100.0026%
Number of Drugs per
  Tier:
3095937121470582
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 Mississippi:501 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:
Total
Premium
Part C
Premium
Part D Base
Premium
Part D Supplemental
Premium
$95.00$66.20$28.80$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS):100%
Subsidy
75%
Subsidy
50%
Subsidy
25%
Subsidy
Monthly Part D Premium with LIS:$3.00$9.40$15.90$22.30
Total Monthly Premium with LIS (Parts C & D):$69.20$75.60$82.10$88.50
— Plan Health Benefits —
** Benefit Highlights **
Important Note This plan does not charge an annual deductible for all drugs. The $315.00 annual deductible only applies to drugs on certain tiers.
Monthly health plan premium $66.20
Monthly drug plan premium $28.80
Total monthly premium $95.00
Health plan deductible $750 Out-of-network
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? No
Inpatient hospital coverage In-Network: $225 for days 1 through 5 $0 for days 6 through 90 $0 for days 91 and beyond Out-of-Network: 30% per stay
Outpatient hospital coverage In-Network: 25% per visit Out-of-Network: 30% per visit
Doctor visits Primary: In-Network: $15 per visit Out-of-Network: 30% per visit Specialist: In-Network: $45 per visit Out-of-Network: 30% per visit
Preventive care In-Network: $0 copay Out-of-Network: $0 or 30%
Emergency care/Urgent care Emergency: $80 per visit (always covered) Urgent care: $15-45 or 30% per visit (always covered)
Diagnostic procedures/lab services/imaging Diagnostic tests and procedures: In-Network: $0-45 or 25% Out-of-Network: 30% Lab services: In-Network: $0-35 or 25% Out-of-Network: 30% Diagnostic radiology services (e.g., MRI): In-Network: $45-225 or 20-25% Out-of-Network: 30% Outpatient x-rays: In-Network: $15-45 or 20-25% Out-of-Network: 30%
Mental health services In-Network: $225 for days 1 through 5 $0 for days 6 through 90 Out-of-Network: 30% per stay Outpatient group therapy visit with a psychiatrist: In-Network: $40 Out-of-Network: 30% Outpatient individual therapy visit with a psychiatrist: In-Network: $40 Out-of-Network: 30% Outpatient group therapy visit: In-Network: $40 Out-of-Network: 30% Outpatient individual therapy visit: In-Network: $40 Out-of-Network: 30%
Skilled Nursing Facility In-Network: $0 for days 1 through 20 $164.50 for days 21 through 100 Out-of-Network: 30% per stay
Rehabilitation services Occupational therapy visit: In-Network: $15 Out-of-Network: 30% Physical therapy and speech and language therapy visit: In-Network: $15 Out-of-Network: 30%
Ambulance In-Network: $265 or 20% Out-of-Network: $265 or 20%
Transportation Not covered
Foot care (podiatry services) Foot exams and treatment: In-Network: $45 Out-of-Network: 30% Routine foot care: Not covered
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen): In-Network: 20% per item Out-of-Network: 20% per item Prosthetics (e.g., braces, artificial limbs): In-Network: 20% per item Out-of-Network: 20% per item Diabetes supplies: In-Network: $0 or 10-20% per item Out-of-Network: 20% per item
Wellness programs (e.g., fitness, nursing hotline) Covered
Medicare Part B drugs Chemotherapy: In-Network: 20% Out-of-Network: 20% Other Part B drugs: In-Network: 20% Out-of-Network: 20%
Dental Services Preventive dental -
Cleaning In-Network: $0 copay
Out-of-Network: 50%
There may be limits on how much the plan will provide.
Dental x-ray(s) In-Network: $0 copay
Out-of-Network: 50%
There may be limits on how much the plan will provide.
Fluoride treatment Not covered
Oral exam In-Network: $0 copay
Out-of-Network: 50%
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 Not covered

Eyeglass frames Not covered

Eyeglass lenses Not covered

Eyeglasses (frames and lenses) Not covered

Other Not covered

Routine eye exam In-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
Upgrades Not covered
Hearing Services Fitting/evaluation Not covered

Hearing aids - inner ear Not covered

Hearing aids - outer ear Not covered

Hearing aids - over the ear Not covered

Hearing exam In-Network: $45
Out-of-Network: 30%


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