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Humana Gold Plus H4007-012 (HMO) - H4007-012-000

4 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

Humana Gold Plus H4007-012 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H4007-012-000

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

$0.00

Monthly Premium

Puerto Rico 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 Puerto Rico Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Enrollment may be limited to certain times of the year. See why you may be able to enroll.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$5,000.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-Network:

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

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0
Referral Required for Doctor Specialty Visit
Members will receive a referral waiver for the following provider specialties in-network: Cardiology, Orthopedics, Endocrinology, Gastroenterology, Pulmonology, Rheumatology, Ophthalmology, Urology, and Neurology
Inpatient hospital careIn-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $25
Prior Authorization Required for Acute Hospital Services
Urgent care
Urgent Care:
Copayment for Urgent Care $10

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $50
Emergency room visit
Emergency Care:
Copayment for Emergency Care $50
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 $50
Copayment for Worldwide Emergency Transportation $50
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $50

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

Health Care Services and Medical Supplies

Humana Gold Plus H4007-012 (HMO) covers a range of additional benefits. Learn more about Humana Gold Plus H4007-012 (HMO) 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 $0
Copayment for Routine Care $0
  • Maximum 12 Routine Care every year
Referral Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Copayment for Medicare-covered Durable Medical Equipment $0
Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $20
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Referral Required for Outpatient Diag Procs/Tests/Lab Services
$20 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$0 OP Diag Proc & Tests - SPC$10 OP Diag Proc & Tests - UCC$20 Sleep Study (Fac Based) - OPH$0 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 $25
Copayment for Medicare-covered Therapeutic Radiological Services $0
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $10
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $25
Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $25
Prior Authorization Required for Outpatient Hospital Services
$20 Diag Colonoscopy - OPH$20 Mental Health - OPH$25 Surgery Svcs - OPH$0 Wound Care - OPH_

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $25
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $20
Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0 to $20
Copayment for Medicare-covered Group Sessions $0 to $20
$20 OP Substance Abuse Care - OPH$0 OP Substance Abuse Care - SPC_
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $20 every month for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $20 every month
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
Copayment for Skilled Nursing Facility Services per Stay $0
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

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

CoverageDetails
Dental care0% coinsurance for bitewing x-rays up to 1 set(s) every 2 years.
0% coinsurance for periodontal surgery up to 1 per quadrant every 3 years.
0% coinsurance for amalgam and/or composite filling up to 1 per tooth every 3 years.
0% coinsurance for comprehensive oral exam, cone beam CT imaging, panoramic film up to 1 every 3 years.
0% coinsurance for crown, implant supported prosthetics up to 1 per tooth every 5 years.
0% coinsurance for bridges, complete dentures, complete or partial denture reline, partial dentures up to 1 every 5 years.
0% coinsurance for implant services, other restorative services - core buildup and prefabricated post and core up to 1 per tooth per lifetime.
0% coinsurance for scaling and root planing (deep cleaning) up to 1 per quadrant per year.
0% coinsurance for periodontal debridement up to 1 per year.
0% coinsurance for pulp vitality test up to 2 per quadrant per year.
0% coinsurance for periodic oral exam, periodontal maintenance, prophylaxis (cleaning) up to 2 per year.
0% coinsurance for complete or partial denture repair up to 3 per year.
0% coinsurance for intraoral x-rays up to 6 per year.
0% coinsurance for adjustments to dentures, extractions, root canal up to unlimited per year.
$2,000 maximum benefit coverage amount per year for adjustments to dentures, bridges, complete dentures, complete or partial denture reline, complete or partial denture repair, crown, implant services, implant supported prosthetics, other restorative services - core buildup and prefabricated post and core, partial dentures comprehensive benefits.

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
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
Copayment for Eyeglasses (lenses and frames) $0
Maximum Plan Benefit of $500 every year

Hearing Benefits

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

CoverageDetails
Hearing careIn-Network:

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

Hearing Aids:
Maximum Plan Allowance of $750 every year

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

    When reviewing Puerto Rico 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 Puerto Rico 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

    Puerto Rico 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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