Humana Gold Choice H8145-091 (PFFS)

4 out of 5 stars* for plan year 2024
$10.00 Monthly Premium

Humana Gold Choice H8145-091 (PFFS) is a PFFS Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H8145-091-000

$10.00 Monthly Premium

Virginia 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 Virginia 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

Coverage Details
Monthly plan premium$10.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$545.00
Out-of-pocket maximum($1.00)
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $15.00
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $35.00
Inpatient hospital careIn-Network:

Acute Hospital Services:
$295.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Urgent care
Urgent Care:
Copayment for Urgent Care $35.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $100.00
Emergency room visit
Emergency Care:
Copayment for Emergency Care $100.00

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100.00
Copayment for Worldwide Emergency Transportation $100.00
Ambulance transportationIn-Network:

Ground Ambulance:
Coinsurance for Ground Ambulance Services 20%

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

Health Care Services and Medical Supplies

Humana Gold Choice H8145-091 (PFFS) covers a range of additional benefits. Learn more about Humana Gold Choice H8145-091 (PFFS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic services
Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 35%
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Supplies 10% to 20%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10.00
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Durable medical equipment (DME)
Out-of-Network:

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

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 35%
Coinsurance for Medicare Covered Lab Services 35%
Coinsurance for Medicare Covered Diagnostic Radiological Services 35%
Coinsurance for Medicare Covered Therapeutic Radiological Services 35%
Coinsurance for Medicare Covered Outpatient X-Ray Services 35%
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Mental health inpatient care
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 35%
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $35.00
Copayment for Medicare-covered Group Sessions $35.00
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $35.00
Coinsurance for Medicare Covered Outpatient Hospital Services 25%

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $295.00

Ambulatory Surgical Center Services:
Coinsurance for Ambulatory Surgical Center Services 20%
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $35.00
Coinsurance for Medicare-covered Individual Sessions 25%
Copayment for Medicare-covered Group Sessions $35.00
Coinsurance for Medicare-covered Group Sessions 25%
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $250.00 every month
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $35.00
Skilled Nursing Facility (SNF) care
Out-of-Network:
35% per day for days 1 to 100

Dental Benefits

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

Coverage Details
Dental careIn Network:
0% coinsurance for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. 0% coinsurance for emergency diagnostic exam up to 1 per year. 0% coinsurance for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for necessary anesthesia with covered service up to unlimited per year. $25 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $25 copayment for scaling for moderate inflammation up to 1 every 3 years. $25 copayment for bridge recementation, crown recementation up to 1 every 5 years. $25 copayment per tooth for amalgam and/or composite filling, simple or surgical extraction up to 2 per year. $25 copayment for emergency treatment for pain up to 2 per year. 50% coinsurance for occlusal adjustment up to 1 every 3 years. 50% coinsurance for bridges-pontic up to 1 every 5 years. 50% coinsurance for bridges-crown up to 2 every 5 years. 50% coinsurance for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. 50% coinsurance for oral surgery up to 2 per year. $2,000 combined maximum benefit coverage amount per year for all preventive and comprehensive benefits.

Out of Network:
0% coinsurance for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. 0% coinsurance for emergency diagnostic exam up to 1 per year. 0% coinsurance for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for necessary anesthesia with covered service up to unlimited per year. $25 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $25 copayment for scaling for moderate inflammation up to 1 every 3 years. $25 copayment for bridge recementation, crown recementation up to 1 every 5 years. $25 copayment per tooth for amalgam and/or composite filling, simple or surgical extraction up to 2 per year. $25 copayment for emergency treatment for pain up to 2 per year. 50% coinsurance for occlusal adjustment up to 1 every 3 years. 50% coinsurance for bridges-pontic up to 1 every 5 years. 50% coinsurance for bridges-crown up to 2 every 5 years. 50% coinsurance for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. 50% coinsurance for oral surgery up to 2 per year. $2,000 combined maximum benefit coverage amount per year for all 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.

Coverage Details
Vision benefits
Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 35%
Coinsurance for Medicare Covered Eyewear 35%
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $0.00
Copayment for Non-Medicare Covered Eyewear $0.00

Hearing Benefits

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

Coverage Details
Hearing benefits
Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 35%
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams 50%
Coinsurance for Non-Medicare Covered Hearing Aids 50%

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.

Coverage Details
Preventive services and health/wellness education programs
Out-of-Network:

Medicare-covered Zero Dollar Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0.00
Coinsurance for Medicare Covered Medicare-covered Preventive Services 35%

Prescription Drug Costs and Coverage

The Humana Gold Choice H8145-091 (PFFS) offers prescription drug coverage, with an annual drug deductible of $545.00 (excludes Tiers 1, 2 and 3)

Coverage
Cost
Coverage & Cost
Annual drug deductible$545.00 (excludes Tiers 1, 2 and 3)
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
    • Tier 3
  • Standard retail $47.00
  • Preferred mail order $47.00
  • Standard mail order $47.00
    •
    Annual drug deductible$545.00 (excludes Tiers 1, 2 and 3)
    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
    • Tier 3
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
    •
    Annual drug deductible$545.00 (excludes Tiers 1, 2 and 3)
    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
    • Tier 3
  • Standard retail $141.00
  • Preferred mail order $131.00
  • Standard mail order $141.00
    •

    When reviewing Virginia 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 Virginia that offer similar benefits at similar or lower prices than the plan above. Call 1-855-298-6309 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

    Plan Documents

    Links to plan documents

    Virginia Counties Served

    Bristol City Buchanan Dickenson Grayson Lee Russell Smyth Tazewell Washington Wise Wythe

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