Humana Gold Plus H1036-025 (HMO)

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Medicare Advantage Plans (Part C)

  • Humana Gold Plus H1036-025 (HMO)
  • 2012 Plan

  • Overall plan rating Star Star Star Star (4 out of 5 stars)
    Provided by CMS Oct 2012
Summary
Plan Type HMO
Office Visit for Primary Doctor $0 copay
Office Visit for Specialist $25 Copay
Doctor Choice Plan Doctor Only
Annual Deductible $0
Out-of-Pocket Maximum $3,400
Prescription Drug Coverage Yes
Physical Exams $0 copay
Hospital Services Coverage
Emergency Room $65 copay.
Worldwide coverage.
If you are admitted to the hospital within 24-hour(s) for the same condition, then $0 copay.
Ambulance Services $150 copay
Outpatient Lab/X-Ray $0 to $75 copay for lab services, diagnostic procedures and tests, X-rays.
Outpatient Surgery $50 copay for each ambulatory surgical center visit.
$75 copay [or 20% of the cost] for each outpatient hospital facility visit.
Urgent Care $0 to $25 copay
Hospitalization Days 1 - 5: $75 copay per day.
Days 6 - 90: $0 copay per day.
$0 copay for each additional hospital day.
No limit to the number of days covered by the plan each benefit period.
Outpatient Rehabilitation Services $75 copay for Occupational Therapy visits, Physical and/or Speech and Language Therapy visits.
Skilled Nursing Facility Days 1 - 7: $0 copay per day.
Days 8 - 100: $50 copay per day.
Plan covers up to 100 days each benefit period.
No prior hospital stay is required.
Home Health Care $0 copay
Hospice You must get care from a Medicare-certified hospice.
Your plan will pay for a consultative visit before you select hospice.
Prescription Drug Coverage
Prescription Drug Deductible $0
Retail Pharmacy for Prescription Drugs
$0 copay for a one-month (30-day) supply.
$0 copay for a three-month (90-day) supply.
$0 copay for a one-month (30-day) supply.
$0 copay for a three-month (90-day) supply.
$0 copay for a one-month (30-day) supply.
$0 copay for a three-month (90-day) supply.
$55 copay for a one-month (30-day) supply.
$165 copay for a three-month (90-day) supply.
Not all drugs are available at this extended day supply.
33% coinsurance for a one-month (30-day) supply
Mail Order Pharmacy for Prescription Drugs
$0 copay for a one-month (30-day) supply.
$0 copay for a three-month (90-day) supply.
$0 copay for a one-month (30-day) supply.
$0 copay for a three-month (90-day) supply.
$0 copay for a one-month (30-day) supply.
$0 copay for a three-month (90-day) supply.
$55 copay for a one-month (30-day) supply.
$155 copay for a three-month (90-day) supply.
Not all drugs are available at this extended day supply.
33% coinsurance for a one-month (30-day) supply
Additional Coverage
Dental Services $25 copay for dental benefits.
$0 copay for up to 2 oral exam(s) every year;
$0 copay for up to 2 cleaning(s) every year;
$0 copay for up to 2 dental x-ray(s).
Hearing Services $0 copay for up to 2 hearing aid(s) every year.
- $25 copay for diagnostic hearing exams.
$0 copay for up to 1 supplemental routine hearing test(s) every year.
$0 copay for up to 1 hearing aid fitting evaluation(s) every year.
$1,000 plan coverage limit for hearing aids every year.
Vision Services $0 copay for- one pair of eyeglasses or contact lenses after cataract surgery.
$0 copay for up to 1 pair(s) of glasses every year.
$0 copay for up to 1 pair(s) of contacts every year.
$0 to $25 copay for exams to diagnose and treat diseases and conditions of the eye.
$0 copay for up to 1 supplemental routine eye exam(s) every year.
$150 plan coverage limit for eye wear every year.
Chiropractic Coverage $20 Copay
Outpatient Mental Health Coverage $25 copay.
$25 copay for partial hospitalization program services.
Additional Information
  See more benefit details:
Summary of Benefits
  Medicare & You
  • You can always call our licensed agents at 1 -877-543-9375 (TTY User: 711) Mon - Fri 8AM - 8PM ET, Sat 9AM - 6PM ET if you have questions, need help comparing plans, or to complete your enrollment.
  • You may contact the Humana Medicare Enrollment and Information Center at 1-877-207-0150; TTY Users: 711. Sept. 11, 2011 - Feb. 14, 2012 - 8 a.m. - 8 p.m., seven days a week; Feb. 15 - Sept. 7, 2012, Monday - Friday, 8:00 a.m. to 8:00 p.m., Local time. Humana is a Medicare Advantage organization with a Medicare contract.
  • Limitations, copayments, and restrictions may apply.
  • Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. This is not a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE or consult www.medicare.gov (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • You must continue to pay your Medicare Part B premium.
  • You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week; 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 Medicaid Office.
  • Medicare beneficiaries may also enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Plan Ratings are assessed each year by Center for Medicare & Medicaid Services (CMS) and may change from one year to the next.
  • Not every plan is available statewide or in all service areas.
Last Updated: 3/8/2013
Y0040_MULTIPLAN_GHHH66GHH_F Approved
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