Humana Gold Plus H1036-171 (HMO)

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Medicare Advantage Plans (Part C)

  • Humana Gold Plus H1036-171 (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 $10 copay for each primary care doctor visit for Medicare-covered benefits.
Office Visit for Specialist $10 to $35 copay for each specialist visit for Medicare-covered benefits.
Doctor Choice Plan Doctor Only
Annual Deductible $0
Out-of-Pocket Maximum $3,400
Prescription Drug Coverage Yes
Physical Exams $0 copay for all preventive services covered under Original Medicare at zero cost sharing.
Hospital Services Coverage
Emergency Room $65 copay for Medicare-covered emergency room visits.
Worldwide coverage.
If you are admitted to the hospital within 24-hour(s) for the same condition, you pay $0 for the emergency room visit.
Ambulance Services $200 copay for Medicare-covered ambulance benefits.
Outpatient Lab/X-Ray $0 to $35 copay for Medicare-covered lab services.
$0 to $50 copay for Medicare-covered diagnostic procedures and tests.
$0 to $35 copay for Medicare-covered X-rays.
Outpatient Surgery $175 copay for each Medicare-covered ambulatory surgical center visit.
$10 to $175 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit.
Urgent Care $10 to $35 copay for Medicare-covered urgently needed care visits.
Hospitalization No limit to the number of days covered by the plan each hospital stay.
For Medicare-covered hospital stays: Days 1 - 5: $150 copay per day;
Days 6 - 90: $0 copay per day;
$0 copay for each additional hospital day.
Outpatient Rehabilitation Services $10 copay for Medicare-covered Occupational Therapy visits.
$10 copay for Medicare-covered Physical and/or Speech and Language Therapy visits.
Skilled Nursing Facility Plan covers up to 100 days each benefit period;
No prior hospital stay is required.
For SNF stays: Days 1 - 7: $0 copay per day;
Days 8 - 100: $84 copay per day.
Home Health Care $0 copay for each Medicare-covered home health visit.
Hospice You must get care from a Medicare-certified hospice.
Prescription Drug Coverage
Prescription Drug Deductible $0
Retail Pharmacy for Prescription Drugs
You pay the following until total yearly drug costs reach $2,930: - $6 copay for a one-month (30-day) supply of drugs in this tier;
- $18 copay for a three-month (90-day) supply of drugs in this tier.
You pay the following until total yearly drug costs reach $2,930: - $40 copay for a one-month (30-day) supply of drugs in this tier;
- $120 copay for a three-month (90-day) supply of drugs in this tier.
You pay the following until total yearly drug costs reach $2,930: - $40 copay for a one-month (30-day) supply of drugs in this tier;
- $120 copay for a three-month (90-day) supply of drugs in this tier.
You pay the following until total yearly drug costs reach $2,930: - $80 copay for a one-month (30-day) supply of drugs in this tier;
- $240 copay for a three-month (90-day) supply of drugs in this tier.
Not all drugs on this tier are available at this extended day supply.
33% coinsurance for a one-month (30-day) supply of drugs in this tier.
Mail Order Pharmacy for Prescription Drugs
You pay the following until total yearly drug costs reach $2,930: - $0 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
- $0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
You pay the following until total yearly drug costs reach $2,930: - $40 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
- $110 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
You pay the following until total yearly drug costs reach $2,930: - $40 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
- $110 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
You pay the following until total yearly drug costs reach $2,930: - $80 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
- $230 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
Additional Coverage
Dental Services In general, preventive dental benefits (such as cleaning) not covered.
$35 copay for Medicare-covered dental benefits.
Hearing Services In general, routine hearing exams and hearing aids not covered.
- $35 copay for Medicare-covered diagnostic hearing exams.
Vision Services $0 copay for one pair of eyeglasses or contact lenses after cataract surgery.
- $0 to $35 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.
Chiropractic Coverage $20 copay for each Medicare-covered visit.
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.
Outpatient Mental Health Coverage $35 copay for each Medicare-covered individual therapy visit, $35 copay for each Medicare-covered group therapy visit, $35 copay for each Medicare-covered individual therapy visit with a psychiatrist, $35 copay for each Medicare-covered group therapy visit with a psychiatrist, $35 copay for Medicare-covered 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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