Humana Gold Plus H5619-137 (HMO)

4 out of 5 stars* for plan year 2023
$26.00 Monthly Premium

Humana Gold Plus H5619-137 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5619-137-000

$26.00 Monthly Premium

Maine and New Hampshire 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 Maine and New Hampshire 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$26.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$400.00
Out-of-pocket maximum$6,400.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty doctor visitIn-Network:

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

Acute Hospital Services:
$325.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
Urgent care
Urgent Care:
Copayment for Urgent Care $25.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $95.00
Emergency room visit
Emergency Care:
Copayment for Emergency Care $95.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $95.00
Copayment for Worldwide Emergency Transportation $95.00
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $290.00

Air Ambulance:
Copayment for Air Ambulance Services $290.00

Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Humana Gold Plus H5619-137 (HMO) covers a range of additional benefits. Learn more about Humana Gold Plus H5619-137 (HMO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15.00
Prior Authorization Required for Chiropractic Services
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 $0.00
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
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 $0.00 to $90.00
Copayment for Medicare-covered Lab Services $0.00 to $35.00
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 $325.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00 to $85.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$325.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
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
Prior Authorization Required for Outpatient Mental Health Services
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $35.00 to $360.00
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 $310.00
Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $35.00 to $100.00
Copayment for Medicare-covered Group Sessions $35.00 to $100.00
Prior Authorization Required for Outpatient Substance Abuse Services
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $30.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $35.00
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
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 careIn-Network:

Comprehensive Dental:
Copayment for Medicare-covered Benefits $35.00
Prior Authorization Required for Comprehensive Dental

Vision Benefits

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

Coverage Details
Vision benefitsIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $35.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Prior Authorization Required for Eye Exams

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 $200.00 every year for all Non-Medicare covered eyewear
Prior Authorization Required for 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 benefitsIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $35.00
Prior Authorization Required for Hearing Exams

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 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 Plus H5619-137 (HMO) offers prescription drug coverage, with an annual drug deductible of $400.00 (excludes Tiers 1, 2 and 3)

    Coverage
    Cost
    Coverage & Cost
    Annual drug deductible$400.00 (excludes Tiers 1, 2 and 3)
    Tier 1
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $10.00
  • Tier 2
  • Standard retail $5.00
  • Preferred mail order $5.00
  • Standard mail order $20.00
  • Tier 3
  • Standard retail $47.00
  • Preferred mail order $47.00
  • Standard mail order $47.00
  • Annual drug deductible$400.00 (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$400.00 (excludes Tiers 1, 2 and 3)
    Tier 1
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $30.00
  • Tier 2
  • Standard retail $15.00
  • 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 Maine and New Hampshire 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 Maine and New Hampshire 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

    Maine Counties Served

    Kennebec Knox Lincoln Oxford Penobscot Waldo

    New Hampshire Counties Served

    Belknap Carroll Cheshire Coos Grafton Hillsborough Merrimack Oxford Rockingham Sullivan
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