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Humana Gold Choice H8145-069 (PFFS) - H8145-069-000

4 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

Humana Gold Choice H8145-069 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H8145-069-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

Georgia and South Carolina Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Georgia and South Carolina Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$340.00
Out-of-pocket maximum-$1.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $0
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Medicare Covered Physician Specialist Office Visit $20
Inpatient hospital careIn-Network:

Acute Hospital Services:
$390 per day for days 1 to 5
$0 per day for days 6 to 90
Urgent care
Urgent Care:
Copayment for Urgent Care $55

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $100
Emergency room visit
Emergency Care:
Copayment for Emergency Care $100

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100
Copayment for Worldwide Emergency Transportation $100
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $300
Copayment for Medicare Covered Ambulance Services - Air $300

Health Care Services and Medical Supplies

Humana Gold Choice H8145-069 (PFFS) covers a range of additional benefits. Learn more about Humana Gold Choice H8145-069 (PFFS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $20
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Medicare Covered Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 10%
Copayment for Medicare Covered Diabetic Therapeutic Shoes or Inserts $10
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Diagnostic tests, lab and radiology services, and X-rays
Out-of-Network:

Medicare Covered Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests
$0 to $120
Copayment for Medicare Covered Lab Services
$0 to $55
Copayment for Medicare Covered Diagnostic Radiological Services $0 to $495
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Copayment for Medicare Covered Outpatient X-Ray Services $0 to $130
$15 Coumadin Clinic Svcs - OPH$120 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$20 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC$100 Sleep Study (Fac Based) - OPH$20 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_
Home health care
Out-of-Network:

Medicare Covered Home Health Services:
Copayment for Medicare Covered Home Health $0
Mental health inpatient care
Out-of-Network:

Psychiatric Hospital Services:
$587 per day for days 1 to 3
$0 per day for days 4 to 90
Mental health outpatient care
Out-of-Network:

Medicare Covered Mental Health Services:
Copayment for Medicare Covered Individual Sessions $60
Copayment for Medicare Covered Group Sessions $60
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $415
$0 Diag Colonoscopy - OPH$100 Mental Health - OPH$415 Surgery Svcs - OPH$35 Wound Care - OPH_

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $390

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $415
$0 Diag Colonoscopy - ASC$415 Surgery Svcs - ASC_
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $60 to $100
Copayment for Medicare-covered Group Sessions $60 to $100
$100 OP Substance Abuse Care - OPH$60 OP Substance Abuse Care - SPC_
Over-the-counter items
Out-of-Network:

Non-Medicare Covered Over-The-Counter (OTC) Items Services:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0
  • Maximum 250 visits every three months
Maximum Plan Benefit of $250
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $20
Copayment for Routine Foot Care $20
  • Maximum 6 visits every year
Skilled Nursing Facility (SNF) care
Out-of-Network:

Skilled Nursing Facility Services:
$10 per day for days 1 to 20
$214 per day for days 21 to 100

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
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, bridges-pontic, complete dentures, crown recementation, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 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.
$2,500 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, bridges-pontic, complete dentures, crown recementation, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 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.
$2,500 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, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $20
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year
Maximum Plan Benefit of $40 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 $450 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, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing care
Out-of-Network:

Medicare Covered Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $20

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programsIn-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 Choice H8145-069 (PFFS) offers prescription drug coverage, with an annual drug deductible of $340.00 (excludes Tiers 1 and 2)

    Coverage & Cost
    Coverage
    Cost
    Annual drug deductible$340.00 (excludes Tiers 1 and 2)
    Tier 1
    • Standard retail $7.00
    • Preferred mail order $7.00
    • Standard mail order $10.00
    Tier 2
    • Standard retail $17.00
    • Preferred mail order $17.00
    • Standard mail order $20.00
    Annual drug deductible$340.00 (excludes Tiers 1 and 2)
    Tier 1
    • Standard retail N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    Tier 2
    • Standard retail N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    Annual drug deductible$340.00 (excludes Tiers 1 and 2)
    Tier 1
    • Standard retail $21.00
    • Preferred mail order $0.00
    • Standard mail order $30.00
    Tier 2
    • Standard retail $51.00
    • Preferred mail order $0.00
    • Standard mail order $60.00

    When reviewing Georgia and South Carolina Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

    You may be able to find plans in your part of Georgia and South Carolina that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

    Plan Documents

    Links to plan documents

    Georgia Counties Served

    South Carolina Counties Served

    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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