2016 Medicare Advantage Humana Gold Choice H8145-123 (PFFS)

Humana Gold Choice H8145-123 (PFFS) H8145-123 is a 2016 Medicare Advantage or Medicare Part-C plan by Humana Insurance Company available to residents in Colorado New Mexico. This plan includes additional Medicare prescription drug (Part-D) coverage. The Humana Gold Choice H8145-123 (PFFS) has a monthly premium of $98.00 and has a in-network Maximum Out-of-Pocket limit of N/A (MOOP). This means that if you get sick or need a high cost procedure your co-pays are capped once you pay out of pocket N/A this can be a very nice safety net.

Humana Gold Choice H8145-123 (PFFS) is a PFFS. A Private Fee-For-Service (PFFS) plan is a Medicare Advantage (MA) health plan offered by a contract with the Centers for Medicare & Medicaid Services (CMS) to provide you with benefits. Humana Insurance Company (instead of Medicare) will decide on how much it will cover and how much you will pay for the services you get. You may go to any Medicare approved doctor or hospital or any other health care provider that accepts both Medicare and your plans payment. A PFFS plan has no provider network, and you dont need a referral or a primary care physician for any health care or services. PFFS plans are the most flexible but a doctor will make a visit-by-visit decisions on whether to accept your provider.

This plan from Humana Insurance Company works with Medicare to give you significant coverage beyond Part A and Part B benefits. If you decide to sign up for Humana Gold Choice H8145-123 (PFFS) you still retain Original Medicare. But you will get additional Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from Humana Insurance Company and not Original Medicare. With Medicare Advantage plans your always covered for urgently needed and emergency care and you receive all of the benefits of Original Medicare from this plan except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.

2016 Humana Insurance Company Medicare Advantage Plan Details

Plan Name:	Humana Gold Choice H8145-123 (PFFS)
Plan ID:	H8145-123
Provider:	Humana Insurance Company
Parent:	Humana Inc.
Plan Year:	2016
Plan Type:	PFFS
Monthly Premium C+D:	$98.00
MOOP:	N/A

Plan Services

Monthly premium deductible and limits on how much you pay for covered services

$98 per month. In addition you must keep paying your Medicare Part B premium. This plan has deductibles for some hospital and medical services and Part D prescription drugs. $300 per year for Part D prescription drugs except for drugs listed on Tier 1 Tier 2 and Tier 3 which are excluded from the deductible. Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan:

$6 700 for services you receive from any provider.

If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply.

Doctor's office visits

Primary care physician visit:

In-network: $15 copay

Out-of-network: $15 copay

Specialist visit:

In-network: $50 copay

Out-of-network: $50 copay

Durable medical equipment (wheelchairs oxygen etc.)

In-network: 20% of the cost

Out-of-network: 25% of the cost

If you go to a preferred vendor your cost may be less. Contact us for a list of preferred vendors.

Emergency care

$75 copay

Foot care (podiatry services)

Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:

In-network: $50 copay

Out-of-network: $50 copay

Hearing services

Exam to diagnose and treat hearing and balance issues:

In-network: $50 copay

Out-of-network: $50 copay

Home health care

In-network: You pay nothing

Out-of-network: You pay nothing

Mental health care

Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.

In-network:

$300 copay per day for days 1 through 5
You pay nothing per day for days 6 through 90

Out-of-network:

$300 copay per day for days 1 through 5
You pay nothing per day for days 6 through 90

In-network: $40 copay

Out-of-network: $40 copay

In-network: $40 copay

Out-of-network: $40 copay

Outpatient rehabilitation

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):

In-network: $50 copay

Out-of-network: $50 copay

Occupational therapy visit:

In-network: $40 copay

Out-of-network: $40 copay

Physical therapy and speech and language therapy visit:

In-network: $40 copay

Out-of-network: $40 copay

Outpatient substance abuse

Group therapy visit:

In-network: $40-100 copay depending on the service

Out-of-network: $40-100 copay depending on the service

Individual therapy visit:

In-network: $40-100 copay depending on the service

Out-of-network: $40-100 copay depending on the service

Outpatient surgery

Ambulatory surgical center:

In-network: 20% of the cost

Out-of-network: 25% of the cost

Outpatient hospital:

In-network: 25% of the cost

Out-of-network: 25% of the cost

Acupuncture

Not covered

Over-the-counter items

Please visit our website to see our list of covered over-the-counter items.

Prosthetic devices (braces artificial limbs etc.)

Prosthetic devices:

In-network: 20% of the cost

Out-of-network: 25% of the cost

Related medical supplies:

In-network: 20% of the cost

Out-of-network: 25% of the cost

Renal dialysis

In-network: 20% of the cost

Out-of-network: 20% of the cost

Transportation

Not covered

Urgently needed services

$15-50 copay depending on the service

Vision services

Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):

In-network: $0-50 copay depending on the service

Out-of-network: $0-50 copay depending on the service

Routine eye exam:

In-network: You pay nothing. You are covered for up to 1 every year.

Out-of-network: You pay nothing. There may be a limit to how often these services are covered.

Our plan pays up to $130 every year for routine eye exams from any provider. Eyeglasses or contact lenses after cataract surgery:

In-network: $25 copay

Out-of-network: $25 copay

Preventive care

In-network: You pay nothing

Out-of-network: You pay nothing

Our plan covers many preventive services including:

Abdominal aortic aneurysm screening
Alcohol misuse counseling
Bone mass measurement
Breast cancer screening (mammogram)
Cardiovascular disease (behavioral therapy)
Cardiovascular screenings
Cervical and vaginal cancer screening
Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
Depression screening
Diabetes screenings
HIV screening
Medical nutrition therapy services
Obesity screening and counseling
Prostate cancer screenings (PSA)
Sexually transmitted infections screening and counseling
Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
"Welcome to Medicare" preventive visit (one-time)
Yearly "Wellness" visit

Any additional preventive services approved by Medicare during the contract year will be covered.

Hospice

You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.

Inpatient hospital care

Our plan covers an unlimited number of days for an inpatient hospital stay.

In-network:

$325 copay per day for days 1 through 5
You pay nothing per day for days 6 through 90
You pay nothing per day for days 91 and beyond

Out-of-network:

$325 copay per day for days 1 through 5
You pay nothing per day for days 6 through 90

Inpatient mental health care

For inpatient mental health care see the "Mental Health Care" section.

Skilled Nursing Facility (SNF)

Our plan covers up to 100 days in a SNF.

In-network:

You pay nothing per day for days 1 through 20
$160 copay per day for days 21 through 100

Out-of-network:

You pay nothing per day for days 1 through 20
$160 copay per day for days 21 through 100

Outpatient prescription drugs

For Part B drugs such as chemotherapy drugs:

In-network: 20% of the cost

Out-of-network: 25% of the cost

Other Part B drugs:

In-network: 20% of the cost

Out-of-network: 25% of the cost

After you pay your yearly deductible you pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing

Tier	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	$7 copay	$21 copay
Tier 2 (Generic)	$15 copay	$45 copay
Tier 3 (Preferred Brand)	$47 copay	$141 copay
Tier 4 (Non-Preferred Brand)	$100 copay	$300 copay
Tier 5 (Specialty Tier)	26% of the cost	Not Offered

Standard Mail Order Cost-Sharing

Tier	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	$7 copay	$21 copay
Tier 2 (Generic)	$15 copay	$45 copay
Tier 3 (Preferred Brand)	$47 copay	$141 copay
Tier 4 (Non-Preferred Brand)	$100 copay	$300 copay
Tier 5 (Specialty Tier)	26% of the cost	Not Offered

Preferred Mail Order Cost-Sharing

Tier	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	$7 copay	$0
Tier 2 (Generic)	$15 copay	$0
Tier 3 (Preferred Brand)	$47 copay	$131 copay
Tier 4 (Non-Preferred Brand)	$100 copay	$290 copay
Tier 5 (Specialty Tier)	26% of the cost	Not Offered

If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310.

After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap.

Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
Standard Retail Cost-Sharing

Tier	Drugs Covered	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	Some	$7 copay	$21 copay
Tier 2 (Generic)	Some	$15 copay	$45 copay
Tier 3 (Preferred Brand)	Some	$47 copay	$141 copay
Tier 4 (Non-Preferred Brand)	Some	$100 copay	$300 copay
Tier 5 (Specialty Tier)	Some	26% of the cost	Not Offered

Standard Mail Order Cost-Sharing

Tier	Drugs Covered	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	Some	$7 copay	$21 copay
Tier 2 (Generic)	Some	$15 copay	$45 copay
Tier 3 (Preferred Brand)	Some	$47 copay	$141 copay
Tier 4 (Non-Preferred Brand)	Some	$100 copay	$300 copay
Tier 5 (Specialty Tier)	Some	26% of the cost	Not Offered

Preferred Mail Order Cost-Sharing

Tier	Drugs Covered	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	Some	$7 copay	$0
Tier 2 (Generic)	Some	$15 copay	$0
Tier 3 (Preferred Brand)	Some	$47 copay	$131 copay
Tier 4 (Non-Preferred Brand)	Some	$100 copay	$290 copay
Tier 5 (Specialty Tier)	Some	26% of the cost	Not Offered

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:

5% of the cost or

$2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.

Ambulance

In-network: $300 copay

Out-of-network: $300 copay

Chiropractic care

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):

In-network: $20 copay

Out-of-network: $40 copay

Dental services

Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):

In-network: $50 copay

Out-of-network: $50 copay

Preventive dental services:

Cleaning:

In-network: You pay nothing. You are covered for up to 1 every year.

Out-of-network: 50% of the cost

Dental x-ray(s):

In-network: You pay nothing. You are covered for up to 1 every year.

Out-of-network: 50% of the cost

Oral exam:

In-network: You pay nothing. You are covered for up to 1 every year.

Out-of-network: 50% of the cost

Diabetes supplies and services

Diabetes monitoring supplies:

In-network: 0-20% of the cost depending on the supply

Out-of-network: 25% of the cost

Diabetes self-management training:

In-network: You pay nothing

Out-of-network: You pay nothing

Therapeutic shoes or inserts:

In-network: $10 copay

Out-of-network: 25% of the cost

Diagnostic tests lab and radiology services and x-rays (Costs for these services may be different if received in an outpatient surgery setting)

Diagnostic radiology services (such as MRIs CT scans):

In-network: $50-275 copay or 20-25% of the cost depending on the service

Out-of-network: $50-275 copay or 25% of the cost depending on the service

Diagnostic tests and procedures:

In-network: $0-100 copay or 25% of the cost depending on the service

Out-of-network: $0-100 copay or 25% of the cost depending on the service

Lab services:

In-network: $0-50 copay depending on the service

Out-of-network: $0-50 copay depending on the service

Outpatient x-rays:

In-network: $15-100 copay depending on the service

Out-of-network: $15-100 copay depending on the service

Therapeutic radiology services (such as radiation treatment for cancer):

In-network: $50 copay or 20% of the cost depending on the service

Out-of-network: $50-275 copay or 25% of the cost depending on the service

Coverage Area for Humana Gold Choice H8145-123 (PFFS)

(Click county to compare all available plans)

State:	Colorado New Mexico
County:	Adams, Alamosa, Arapahoe, Boulder, Broomfield, Chaffee, Costilla, Crowley, Custer, Delta, Denver, Douglas, El Paso, Elbert, Fremont, Gilpin, Grand, Huerfano, Jefferson, Larimer, Mesa, Montrose, Morgan, Otero, Park, Pueblo, Weld, Bernalillo, Colfax, Dona Ana, Grant, Lincoln, Luna, Otero, Rio Arriba, San Miguel, Sandoval, Santa Fe, Sierra, Taos, Torrance, Valencia,

Ratings for Humana Gold Choice H8145-123 (PFFS) H8145

2016 Overall Rating
Part C Summary Rating
Part D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing

Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Timely Care and Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination

Member Complaints and Changes in Humana Gold Choice H8145-123 (PFFS) Plans Performance

Total Rating
Members Leaving the Plan
Complaints about Health Plan
Beneficiary Access
Health Plan Quality Improvement

Health Plan Customer Service Rating for Humana Gold Choice H8145-123 (PFFS)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language

Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancel Screening
Annual Flu Vaccine
Improving Physical
Improving Mental Health
Monitoring Physical Activity
Adult BMI Assessment

Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Pain Screening
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Rheumatoid Arthritis
Improving Bladder Control
Reducing Risk of Falling
Plan - Cause Readmissions

Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs

Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
High Risk Medication
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR

Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Beneficiary Access
Drug Plan Quality Improvement

Humana Gold Choice H8145-123 (PFFS) Drug Plan Customer Service ratings

Total Rating
Appeals Auto Forward
Appeals Upheld
Call Center, TTY, Foreign Language

Part-C Premium

Humana Insurance Company plan charges a $57.30 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

Part-D Deductible and Premium

The Humana Gold Choice H8145-123 (PFFS) plan has a monthly drug premium of $35.20 and a $300.00 drug deductible. This Humana Insurance Company plan offers a $35.20 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $5.50 this Premium covers any enhanced plan benefits offered by Humana Insurance Company above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $40.70. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.

Premium Assistance

Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Humana Gold Choice H8145-123 (PFFS) medicare insurance plan offers a $14.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $20.60 for 75% low income subsidy $27.30 for 50% and $34.00 for 25%.

Part C Premium:	$57.30
Part D (Drug) Premium:	$35.20
Part D Supplemental Premium	$5.50
Total Part D Premium:	$40.70
Drug Deductible:	$300.00
Tiers with No Deductible:	1
Benchmark:	not below the regional benchmark
Type of Medicare Health Plan:	Enhanced Alternative
Drug Benefit Type:	Enhanced
Full LIS Premium:	$14.00
75% LIS Premium:	$20.60
50% LIS Premium:	$27.30
25% LIS Premium:	$34.00
Gap Coverage:	Yes

Gap Coverage

In 2016 once you and your plan provider have spent $3,310 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 45% for brand-name drugs and 58% on generic drugs unless your plan offers additional coverage. This Humana Insurance Company plan does offer additional coverage through the gap.

Source: CMS.

Plans as of September 9, 2015.

Star Rating as of September 30, 2015.

For More Information on Ratings Please See the CMS Tech Notes Here.

Notes: Data are subject to change as contracts are finalized. For 2016, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit

Includes 2016 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.