Humana Gold Plus H1036-335 (HMO-POS)
Medicare Advantage Health Plan Details
Health insurance company offering plan: Humana
- Rx
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $0 copay
Out-of-network: $5 copay
Out-of-network: $0 copay
Emergency Room
$150 copay
Ambulance Coverage
In-network: $335 copay
Out-of-network: $335 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $0-$120 copay
Out-of-network: $0-$120 copay
Lab services:
In-network: $0-$65 copay
Out-of-network: $0-$65 copay
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $0-$335 copay
Out-of-network: $0-$335 copay
Outpatient x-rays:
In-network: $0-$130 copay
Out-of-network: $0-$130 copay
Hospital Services
Inpatient hospital coverage:
In-network:
Tier 1
$295 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Outpatient hospital coverage:
In-network: $0-$395 copay
Out-of-network: $0-$395 copay
Rehabilitation Coverage
Occupational therapy services:
In-network: $25 copay
Out-of-network: $25 copay
Urgent Care Coverage
$150 copay
Skilled Nursing Facility (SNF)
In-network:
Tier 1
$20 per day for days 1-20
$218 per day for days 21-100
Out-of-network:
$ per stay
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $35 copay
Out-of-network: $35 copay
Outpatient individual therapy with a psychiatrist:
In-network: $35 copay
Out-of-network: $35 copay
Outpatient group therapy visits:
In-network: $35 copay
Out-of-network: $35 copay
Outpatient individual therapy visit:
In-network: $35 copay
Out-of-network: $35 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Vision Benefits
Routine eye exams:
In-network: $0 copay
Out-of-network: $0 copay
Contact Lenses:
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses:
In-network: $0 copay
Out-of-network: $0 copay
Hearing Benefits
Hearing exam:
In-network: $0 copay
Out-of-network: $0 copay
Fitting/evaluation:
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - prescription:
In-network: $499-$799 copay
Out-of-network: $499-$799 copay
Hearing aids - over the counter:
In-network: $0 copay
Out-of-network: $0 copay
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$5.00 copay (30-day supply)
$15.00 copay (90-day supply)
Tier 3: Preferred Brand
$47.00 copay (30-day supply)
$141.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
50% coinsurance (30-day supply)
50% coinsurance (90-day supply)
Tier 5: Specialty Tier
30% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$10.00 copay (30-day supply)
$30.00 copay (90-day supply)
Tier 2: Generic
$20.00 copay (30-day supply)
$60.00 copay (90-day supply)
Tier 3: Preferred Brand
$47.00 copay (30-day supply)
$141.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
50% coinsurance (30-day supply)
50% coinsurance (90-day supply)
Tier 5: Specialty Tier
30% coinsurance (30-day supply)
Rx Drug Coverage - Preferred Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$5.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
$47.00 copay (30-day supply)
$131.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
50% coinsurance (30-day supply)
50% coinsurance (90-day supply)
Tier 5: Specialty Tier
30% coinsurance (30-day supply)
Additional Added Benefits
Plan Links
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