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Humana Gold Plus Giveback H0028-066 (HMO-POS)

Humana Inc.
Humana Gold Plus Giveback H0028-066 (HMO-POS) H0028-066 Plan Details
3.5 out of 5 stars

Humana Gold Plus Giveback H0028-066 (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H0028-066

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Humana Gold Plus Giveback H0028-066 (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H0028-066

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Humana Inc.
Humana Gold Plus Giveback H0028-066 (HMO-POS) H0028-066 Plan Details
3.5 out of 5 stars

Humana Gold Plus Giveback H0028-066 (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H0028-066

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Missouri Counties Served

Jackson Platte Clay Ray Lafayette

Kansas Counties Served

Jefferson Leavenworth Franklin Wyandotte Miami Johnson Shawnee

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $250
Out of Pocket Max In-Network: $4150
Out-of-Network: N/A
Initial Coverage Limit $2000
Catastrophic Coverage Limit $2,000
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $35
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$395 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $65

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $140
Emergency Room Visit
Copayment for Emergency Care $140
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $140
Copayment for Worldwide Emergency Transportation $140
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $315

Air Ambulance:
Coinsurance for Air Ambulance Services 20%
Prior Authorization Required for Air Ambulance
Prior authorization required

Health Care Services and Medical Supplies

Humana Gold Plus Giveback H0028-066 (HMO-POS) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $0
Prior Authorization Required for Chiropractic Services
Prior authorization required
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0
Coinsurance for Medicare-covered Diabetic Supplies 10% to 20%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $65
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
$45 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$35 OP Diag Proc & Tests - SPC$65 OP Diag Proc & Tests - UCC$45 Sleep Study (Fac Based) - OPH$35 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $395
Copayment for Medicare-covered Therapeutic Radiological Services $20 to $30
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $150
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$395 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $35
Copayment for Medicare-covered Group Sessions $35
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $300
Prior Authorization Required for Outpatient Hospital Services
$0 Diag Colonoscopy - OPH$40 Mental Health - OPH$300 Surgery Svcs - OPH$35 Wound Care - OPH_

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $395
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $250
Prior Authorization Required for Ambulatory Surgical Center Services
$0 Diag Colonoscopy - ASC$250 Surgery Svcs - ASC_
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $35 to $40
Copayment for Medicare-covered Group Sessions $35 to $40
Prior Authorization Required for Outpatient Substance Abuse Services
$40 OP Substance Abuse Care - OPH$35 OP Substance Abuse Care - SPC_
Prior authorization required
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $50 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $50 every three months
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $35
Prior Authorization Required for Podiatry Services
Prior authorization required
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$203 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years.
$0 copayment for bridge recementation, crown recementation, panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime.
$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
$0 copayment for adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, tissue conditioning up to 1 per year.
$0 copayment for emergency treatment for pain, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year.
30% coinsurance for bridges-pontic, complete dentures, partial dentures up to 1 every 5 years.
30% coinsurance for bridges-crown up to 2 every 5 years.
$2,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.
Out of Network
$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years.
$0 copayment for bridge recementation, crown recementation, panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime.
$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
$0 copayment for adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, tissue conditioning up to 1 per year.
$0 copayment for emergency treatment for pain, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year.
30% coinsurance for bridges-pontic, complete dentures, partial dentures up to 1 every 5 years.
30% coinsurance for bridges-crown up to 2 every 5 years.
$2,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $35
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
  • Maximum 1 Pair every year
Copayment for Eyeglasses (lenses and frames) $0
  • Maximum 1 Pair every year
Maximum Plan Benefit of $150 every year
Members must use Humana's Medicare Insight Network, a national network of providers, which includes standard or PLUS providers. The allowance for the standard network is $50 less than the PLUS network.

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $35
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $499 to $799
  • Maximum 2 Hearing Aids every year

Prior authorization required

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
    • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The Humana Gold Plus Giveback H0028-066 (HMO-POS) plan offers the following prescription drug coverage, with an annual drug deductible of $250 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $250 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard mail order $10.00
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    Generic
    • Standard mail order $20.00
    • Standard retail $5.00
    • Preferred cost-share mail order $5.00
    Annual Drug Deductible $250 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard mail order N/A
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    Generic
    • Standard mail order N/A
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    Annual Drug Deductible $250 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard mail order $30.00
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    Generic
    • Standard mail order $60.00
    • Standard retail $15.00
    • Preferred cost-share mail order $0.00
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