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Humana Gold Plus H4007-020 (HMO) - H4007-020-000
$0.00
Monthly Premium
Humana Gold Plus H4007-020 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H4007-020-000
* 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.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| 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 | $8,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $3.00 |
| Inpatient hospital care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $50.00 Your plan covers an unlimited number of days for an inpatient stay. Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $10.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $85.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $85.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $85.00 Copayment for Worldwide Emergency Transportation $85.00 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $45.00 Air Ambulance: Coinsurance for Air Ambulance Services 20% Please see Evidence of Coverage for Prior Authorization rules |
Health Care Services and Medical Supplies
Humana Gold Plus H4007-020 (HMO) covers a range of additional benefits. Learn more about Humana Gold Plus H4007-020 (HMO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $3.00 |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Copayment for Medicare-covered Durable Medical Equipment $0.00 Prior Authorization Required for Durable Medical Equipment |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $35.00 Copayment for Medicare-covered Lab Services $0.00 to $3.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $45.00 Copayment for Medicare-covered Therapeutic Radiological Services $3.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0.00 to $15.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $50.00 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $3.00 Copayment for Medicare-covered Group Sessions $3.00 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $3.00 to $45.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $0.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $25.00 Prior Authorization Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $3.00 to $45.00 Copayment for Medicare-covered Group Sessions $3.00 to $45.00 |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $3.00 |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: Copayment for Skilled Nursing Facility Services per Stay $0.00 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.
| Coverage | Details |
|---|---|
| Dental care | In Network: 0% 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. $1,500 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. Out of Network: |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $3.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00 Copayment for Eyeglasses (lenses and frames) $0.00 Maximum Plan Benefit of $400.00 every year for all Non-Medicare covered eyewear |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $3.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $0.00
|
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 | 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:
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 1-888-876-5731 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
- Adjuntas
- Aguada
- Aguadilla
- Aguas Buenas
- Aibonito
- Anasco
- Arecibo
- Arroyo
- Barceloneta
- Barranquitas
- Bayamon
- Cabo Rojo
- Caguas
- Camuy
- Canovanas
- Carolina
- Catano
- Cayey
- Ceiba
- Ciales
- Cidra
- Coamo
- Comerio
- Corozal
- Culebra
- Dorado
- Fajardo
- Florida
- Guanica
- Guayama
- Guayanilla
- Guaynabo
- Gurabo
- Hatillo
- Hormigueros
- Humacao
- Isabela
- Jayuya
- Juana Diaz
- Juncos
- Lajas
- Lares
- Las Marias
- Las Piedras
- Loiza
- Luquillo
- Manati
- Maricao
- Maunabo
- Mayaguez
- Moca
- Morovis
- Naguabo
- Naranjito
- Orocovis
- Patillas
- Penuelas
- Ponce
- Quebradillas
- Rincon
- Rio Grande
- Sabana Grande
- Salinas
- San German
- San Juan
- San Lorenzo
- San Sebastian
- Santa Isabel
- Toa Alta
- Toa Baja
- Trujillo Alto
- Utuado
- Vega Alta
- Vega Baja
- Vieques
- Villalba
- Yabucoa
- Yauco
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.