Humana Gold Choice H8145-125 (PFFS) H8145-125-000 2023 Plan Details and Costs

Missouri, Kansas and Oklahoma 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 Missouri, Kansas and Oklahoma 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	$53.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$195.00
Out-of-pocket maximum	($1.00)
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$7,400.00
Primary care doctor visit	Out-of-Network: Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 30%
Specialty doctor visit	Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 30%
Inpatient hospital care	Out-of-Network: Coinsurance for Acute Hospital Services per Stay 30%
Urgent care	Urgent Care: Copayment for Urgent Care $30.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $95.00
Emergency room visit	Emergency Care: Copayment for Emergency Care $95.00 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $95.00 Copayment for Worldwide Emergency Transportation $95.00
Ambulance transportation	Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $265.00 Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

Humana Gold Choice H8145-125 (PFFS) covers a range of additional benefits. Learn more about Humana Gold Choice H8145-125 (PFFS) 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 $10.00
Diabetes supplies, training, nutrition therapy and monitoring	Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies and Services 30%
Durable medical equipment (DME)	Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 25%
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 30% Coinsurance for Medicare Covered Lab Services 30% Coinsurance for Medicare Covered Diagnostic Radiological Services 30% Coinsurance for Medicare Covered Therapeutic Radiological Services 30% Coinsurance for Medicare Covered Outpatient X-Ray Services 30%
Home health care	In-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 30%
Mental health outpatient care	Out-of-Network: Outpatient Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 30% Coinsurance for Medicare Covered Group Sessions 30%
Outpatient services/surgery	Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 30% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%
Outpatient substance abuse care	In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $30.00 Coinsurance for Medicare-covered Individual Sessions 25% Copayment for Medicare-covered Group Sessions $30.00 Coinsurance for Medicare-covered Group Sessions 25%
Podiatry services	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $30.00
Skilled Nursing Facility (SNF) care	In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $178.00 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.

Coverage	Details
Dental care	Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 30% Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Copayment for Non-Medicare Covered Comprehensive Dental $0.00

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	In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $30.00 Copayment for Routine Eye Exams $0.00 Maximum 1 Routine Eye Exam every year Maximum Plan Benefit of $75.00 every year for in and out of network services combined Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00 Maximum 1 Pair every year Copayment for Eyeglasses (lenses and frames) $0.00 Maximum 1 Pair every year Maximum Plan Benefit of $100.00 every year for all Non-Medicare covered eyewear for in and out of network services combined

Coverage

Details

Vision benefits

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $30.00
Copayment for Routine Eye Exams $0.00

Maximum 1 Routine Eye Exam every year

Maximum Plan Benefit of $75.00 every year for in and out of network services combined

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00

Maximum 1 Pair every year

Copayment for Eyeglasses (lenses and frames) $0.00

Maximum 1 Pair every year

Maximum Plan Benefit of $100.00 every year for all Non-Medicare covered eyewear for in and out of network services combined

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 30% Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $0.00 Copayment for Non-Medicare Covered Hearing Aids $399.00 to $699.00

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	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 30%

Prescription Drug Costs and Coverage

The Humana Gold Choice H8145-125 (PFFS) offers prescription drug coverage, with an annual drug deductible of $195.00 (excludes Tiers 1 and 2)

Coverage	Cost
Coverage & Cost
Annual drug deductible	$195.00 (excludes Tiers 1 and 2)
Tier 1	Standard retail $8.00 Preferred mail order $8.00 Standard mail order $10.00
Tier 2	Standard retail $15.00 Preferred mail order $15.00 Standard mail order $20.00
Annual drug deductible	$195.00 (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	$195.00 (excludes Tiers 1 and 2)
Tier 1	Standard retail $24.00 Preferred mail order $0.00 Standard mail order $30.00
Tier 2	Standard retail $45.00 Preferred mail order $0.00 Standard mail order $60.00

When reviewing Missouri, Kansas and Oklahoma 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 Missouri, Kansas and Oklahoma 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	Summary of benefits Evidence of coverage Star ratings

Links to plan documents

Missouri Counties Served

Atchison Barry Benton Bollinger Boone Butler Callaway Camden Carroll Carter Cedar Chariton Christian Clay Cole Crawford Dade Dallas Dekalb Douglas Greene Grundy Henry Hickory Holt Jackson Jasper Jefferson Laclede Lawrence Lewis Macon Marion Mercer Miller Mississippi Montgomery Newton Ozark Pemiscot Perry Phelps Pike Platte Polk Pulaski Ralls Reynolds Saint Charles Saint Clair Saint Louis Saint Louis City Stoddard Stone Taney Vernon Wright

Kansas Counties Served

Chase Coffey Jewell Lyon Mitchell Norton Phillips Riley Smith Washington

Oklahoma Counties Served

Atoka Choctaw Mccurtain