Humana Gold Choice H8145-163 (PFFS)

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

• • In-Network: No

Comprehensive Dental

• Adjunctive General Services
  • In-Network: No Coins – 0.00 Copay (Limits Apply)
  • Out-of-Network: No Coins – 0.00 Copay (Limits Apply)

Diagnostic and Preventive Dental

• Dental X-Rays
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: No Coins – 0.00 Copay
• Oral Exams
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: No Coins – 0.00 Copay
• Other Diagnostic Dental Services
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: No Coins – 0.00 Copay
• Other Preventive Dental Services
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: No Coins – 0.00 Copay
• Prophylaxis (cleaning)
  • In-Network: No Coins – 0.00 Copay
  • Out-of-Network: No Coins – 0.00 Copay

Diagnostic procedures/lab services/imaging

• Diagnostic radiology services (e.g., MRI)
  • In-Network: $0-300 copay
• Diagnostic tests and procedures
  • Out-of-Network: $0-105 copay
• Lab services
  • Out-of-Network: $0-20 copay
• Diagnostic tests and procedures
  • In-Network: $0-105 copay
• Lab services
  • In-Network: $0-20 copay
• Outpatient x-rays
  • Out-of-Network: $0-100 copay
• Diagnostic radiology services (e.g., MRI)
  • Out-of-Network: $0-300 copay
• Outpatient x-rays
  • In-Network: $0-100 copay

Doctor visits

• Primary
  • Out-of-Network: $0 copay
• Specialist
  • In-Network: $0 copay
  • Out-of-Network: $0 copay
• Primary
  • In-Network: $0 copay

Emergency care/Urgent care

• Emergency
  • $140 copay per visit (always covered)
• Urgent care
  • $0 copay

Foot care (podiatry services)

• Foot exams and treatment
  • Out-of-Network: $0 copay
• Routine foot care
  • Not covered
• Foot exams and treatment
  • In-Network: $0 copay

Ground ambulance

• • In-Network: $315 copay
  • Out-of-Network: $315 copay

Health plan deductible

• • $0

Hearing

• Fitting/evaluation
  • Out-of-Network: $0 copay
• Hearing aids
  • In-Network: $699-999 copay (Limits Apply)
• Hearing aids OTC
  • Not covered
• Medicare-Covered Hearing Exam
  • Out-of-Network: $0 copay
• Hearing aids
  • Out-of-Network: $699-999 copay (Limits Apply)
• Fitting/evaluation
  • In-Network: $0 copay
• Medicare-Covered Hearing Exam
  • In-Network: $0 copay

Inpatient hospital coverage

• • In-Network: $0 copay per stay
  • Out-of-Network: $0 copay per stay

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

• • $1,500 In and Out-of-network

Medical equipment/supplies

• Diabetes supplies
  • In-Network: $0 copay or 10% coinsurance per item
  • Out-of-Network: 10% coinsurance per item
• Durable medical equipment (e.g., wheelchairs, oxygen)
  • In-Network: 20% coinsurance per item
  • Out-of-Network: 20% coinsurance per item
• Prosthetics (e.g., braces, artificial limbs)
  • In-Network: 20% coinsurance per item
  • Out-of-Network: 20% coinsurance per item

Medicare Part B drugs

• Other Part B drugs
  • In-Network: 0-20% coinsurance
• Chemotherapy
  • In-Network: 0-20% coinsurance
  • Out-of-Network: 20% coinsurance
• Other Part B drugs
  • Out-of-Network: 20% coinsurance

Mental health services

• Outpatient group therapy visit with a psychiatrist
  • In-Network: $40 copay
  • Out-of-Network: $40 copay
• Outpatient group therapy visit
  • In-Network: $40 copay
  • Out-of-Network: $40 copay
• Outpatient individual therapy visit
  • In-Network: $40 copay
  • Out-of-Network: $40 copay
• Outpatient individual therapy visit with a psychiatrist
  • In-Network: $40 copay
  • Out-of-Network: $40 copay
• Inpatient hospital – psychiatric
  • In-Network: $0 copay per stay
  • Out-of-Network: $0 copay per stay

Optional supplemental benefits

• • No

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • In-Network: $0-390 copay per visit
  • Out-of-Network: $0-390 copay per visit

Preventive care

• • Out-of-Network: $0 copay
  • In-Network: $0 copay

Rehabilitation services

• Occupational therapy visit
  • Out-of-Network: $20-40 copay
• Physical therapy and speech and language therapy visit
  • In-Network: $20-40 copay
• Occupational therapy visit
  • In-Network: $20-40 copay
• Physical therapy and speech and language therapy visit
  • Out-of-Network: $20-40 copay

Skilled Nursing Facility

• • Out-of-Network: $20 per day for days 1 through 20
    $214 per day for days 21 through 100
  • In-Network: $20 per day for days 1 through 20
    $214 per day for days 21 through 100

Transportation

• • Not covered

Vision

• Contact lenses
  • In-Network: $0 copay (Limits Apply)
• Eyeglass lenses
  • Not covered
• Routine eye exam
  • In-Network: $0 copay (Limits Apply)
• Upgrades
  • Not covered
• Eyeglass frames
  • Not covered
• Contact lenses
  • Out-of-Network: $0 copay (Limits Apply)
• Eyeglasses (frames and lenses)
  • In-Network: $0 copay (Limits Apply)
  • Out-of-Network: $0 copay (Limits Apply)
• Routine eye exam
  • Out-of-Network: $0 copay (Limits Apply)
• Other
  • Not covered

Wellness programs (e.g., fitness, nursing hotline)

• • Covered