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2016 Medicare Advantage Plan Benefit Details for the Humana Gold Choice H8145-121 (PFFS)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2016 Medicare Advantage Plan Details
Medicare Plan Name:Humana Gold Choice H8145-121 (PFFS)
Location:Schuyler, Illinois     Click to see other locations
Plan ID:H8145 - 121 - 0     Click to see other plans
Member Services:1-800-457-4708 TTY users 711
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the Humana Gold Choice H8145-121 (PFFS) benefit details
— Medicare Plan Features —
Monthly Premium:$39.00 (see Plan Premium Details below)
Annual Deductible:no drug coverage
Health Plan Type:PFFS *
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$0
Number of Members enrolled in this plan in Schuyler, Illinois:12 members
Number of Members enrolled in this plan in Illinois:2,340 members
Number of Members enrolled in this plan in (H8145 - 121):3,502 members
Plan’s Summary Star Rating: 4 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 —
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Cost **
Monthly premium, deductible, and limits on how much you pay for covered services
$39.00 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical services.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $6 700 for services you receive from any provider.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums.
Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply.
** Doctor and Hospital Choice **
Acupuncture
Not covered
** Extra Benefits **
Inpatient mental health care
For inpatient mental health care see the "Mental Health Care" section.
Outpatient prescription drugs
For Part B drugs such as chemotherapy drugs:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
Other Part B drugs:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
Our plan does not cover Part D prescription drug.
** Important Information **
Monthly premium, deductible, and limits on how much you pay for covered services
$39.00 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical services.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $6 700 for services you receive from any provider.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums.
Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply.
** Outpatient Care and Services **
Acupuncture
Not covered
Ambulance
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
Chiropractic care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
Dental services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
Preventive dental services:
  • Cleaning:
    • In-network:  You pay nothing. You are covered for up to 1 every year.
    • Out-of-network:  50% of the cost
  • Dental x-ray(s):
    • In-network:  You pay nothing. You are covered for up to 1 every year.
    • Out-of-network:  50% of the cost
  • Oral exam:
    • In-network:  You pay nothing. You are covered for up to 1 every year.
    • Out-of-network:  50% of the cost
    Diabetes supplies and services
    Diabetes monitoring supplies:
    • In-network:  0-20% of the cost depending on the supply
    • Out-of-network:  20% of the cost
    Diabetes self-management training:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
    Therapeutic shoes or inserts:
    • In-network:  You pay nothing
    • Out-of-network:  20% of the cost
    Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting)
    Diagnostic radiology services (such as MRIs CT scans):
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Diagnostic tests and procedures:
    • In-network:  0-20% of the cost depending on the service
    • Out-of-network:  0-20% of the cost depending on the service
    Lab services:
    • In-network:  0-20% of the cost depending on the service
    • Out-of-network:  0-20% of the cost depending on the service
    Outpatient x-rays:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Therapeutic radiology services (such as radiation treatment for cancer):
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Doctor's office visits
    Primary care physician visit:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Specialist visit:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Durable medical equipment (wheelchairs, oxygen, etc.)
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    If you go to a preferred vendor your cost may be less. Contact us for a list of preferred vendors.
    Emergency care
    $75 copay
    Foot care (podiatry services)
    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Hearing services
    Exam to diagnose and treat hearing and balance issues:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Home health care
    • In-network:  You pay nothing
    • Out-of-network:  20% of the cost
    Mental health care
    Inpatient visit:
    Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
    The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
    Our plan covers 90 days for an inpatient hospital stay.
    Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
    Outpatient group therapy visit:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Outpatient individual therapy visit:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Outpatient rehabilitation
    Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Occupational therapy visit:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Physical therapy and speech and language therapy visit:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Outpatient substance abuse
    Group therapy visit:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Individual therapy visit:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Outpatient surgery
    Ambulatory surgical center:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Outpatient hospital:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Over-the-counter items
    Please visit our website to see our list of covered over-the-counter items.
    Prosthetic devices (braces, artificial limbs, etc.)
    Prosthetic devices:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Related medical supplies:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Renal dialysis
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Transportation
    Not covered
    Urgently needed services
    20% of the cost (up to $65)
    Vision services
    Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
    • In-network:  0-20% of the cost depending on the service
    • Out-of-network:  0-20% of the cost depending on the service
    Routine eye exam:
    • In-network:  You pay nothing. You are covered for up to 1 every year.
    • Out-of-network:  You pay nothing.  There may be a limit to how often these services are covered.
    Our plan pays up to $130 every year for routine eye exams from any provider.
    Eyeglasses or contact lenses after cataract surgery:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    ** Hospice **
    Hospice
    You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.
    ** Preventive Care **
    Preventive care
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
    Our plan covers many preventive services including:
    • Abdominal aortic aneurysm screening
    • Alcohol misuse counseling
    • Bone mass measurement
    • Breast cancer screening (mammogram)
    • Cardiovascular disease (behavioral therapy)
    • Cardiovascular screenings
    • Cervical and vaginal cancer screening
    • Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
    • Depression screening
    • Diabetes screenings
    • HIV screening
    • Medical nutrition therapy services
    • Obesity screening and counseling
    • Prostate cancer screenings (PSA)
    • Sexually transmitted infections screening and counseling
    • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
    • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
    • "Welcome to Medicare" preventive visit (one-time)
    • Yearly "Wellness" visit
    Any additional preventive services approved by Medicare during the contract year will be covered.
    ** Inpatient Care **
    Inpatient hospital care
    The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
    Our plan covers an unlimited number of days for an inpatient hospital stay.
    • $630 copay per day for days 91 through 150
    • You pay nothing per day for days 151 and beyond
      • Inpatient mental health care
      For inpatient mental health care see the "Mental Health Care" section.
      Skilled Nursing Facility (SNF)
      Our plan covers up to 100 days in a SNF.
      • In-network:  
        • You pay nothing per day for days 1 through 20
        • $156 copay per day for days 21 through 100
          • Out-of-network:  
            • You pay nothing per day for days 1 through 20
            • $156 copay per day for days 21 through 100
              • Outpatient prescription drugs
              For Part B drugs such as chemotherapy drugs:
              • In-network:  20% of the cost
              • Out-of-network:  20% of the cost
              Other Part B drugs:
              • In-network:  20% of the cost
              • Out-of-network:  20% of the cost
              Our plan does not cover Part D prescription drug.
              ** Outpatient Care **
              Diabetes supplies and services
              Diabetes monitoring supplies:
              • In-network:  0-20% of the cost depending on the supply
              • Out-of-network:  20% of the cost
              Diabetes self-management training:
              • In-network:  You pay nothing
              • Out-of-network:  You pay nothing
              Therapeutic shoes or inserts:
              • In-network:  You pay nothing
              • Out-of-network:  20% of the cost
              Foot care (podiatry services)
              Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
              • In-network:  20% of the cost
              • Out-of-network:  20% of the cost
              Hearing services
              Exam to diagnose and treat hearing and balance issues:
              • In-network:  20% of the cost
              • Out-of-network:  20% of the cost
              ** Outpatient Medical Services and Supplies **
              Outpatient substance abuse
              Group therapy visit:
              • In-network:  20% of the cost
              • Out-of-network:  20% of the cost
              Individual therapy visit:
              • In-network:  20% of the cost
              • Out-of-network:  20% of the cost
              Prosthetic devices (braces, artificial limbs, etc.)
              Prosthetic devices:
              • In-network:  20% of the cost
              • Out-of-network:  20% of the cost
              Related medical supplies:
              • In-network:  20% of the cost
              • Out-of-network:  20% of the cost
              ** Additional Benefits **
              Inpatient mental health care
              For inpatient mental health care see the "Mental Health Care" section.
              ** Cost **
              Monthly premium, deductible, and limits on how much you pay for covered services
              Package 1: MyOption Vision
              Benefits include:
                • Eye Exams
                • Eyewear
              Additional $15.30 per month. You must keep paying your Medicare Part B premium and your $39 monthly plan premium.
              This package does not have a deductible.
              Our plan has a coverage limit for certain benefits.
              ** Important Information **
              Package 1: MyOption Vision
              Benefits include:
                • Eye Exams
                • Eyewear
              Additional $15.30 per month. You must keep paying your Medicare Part B premium and your $39 monthly plan premium.
              This package does not have a deductible.
              Our plan has a coverage limit for certain benefits.
              ** Cost **
              Package 2: MyOption Enhanced Dental PPO
              Benefits include:
                • Preventive Dental
                • Comprehensive Dental
              Additional $26.20 per month. You must keep paying your Medicare Part B premium and your $39 monthly plan premium.
              This package does not have a deductible.
              Our plan pays up to $1 500 every year. Our plan has additional coverage limits for certain benefits.
              ** Important Information **
              Package 2: MyOption Enhanced Dental PPO
              Benefits include:
                • Preventive Dental
                • Comprehensive Dental
              Additional $26.20 per month. You must keep paying your Medicare Part B premium and your $39 monthly plan premium.
              This package does not have a deductible.
              Our plan pays up to $1 500 every year. Our plan has additional coverage limits for certain benefits.




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