Humana Gold Plus H6622-056 (HMO) H6622-056 2024 Plan Details and Costs (2024)

In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00
Prior Authorization Required for Doctor Specialty Visit
Referral Required for Doctor Specialty Visit
Prior authorization required

In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0.00
Your plan covers an unlimited number of days for an inpatient stay.
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services
Prior authorization required

Copayment for Urgent Care $10.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $135.00

Copayment for Emergency Care $135.00

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $135.00
Copayment for Worldwide Emergency Transportation $135.00

In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $180.00

Air Ambulance:
Copayment for Air Ambulance Services $180.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $30.00
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Referral Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00 to $5.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Referral Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required

In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0.00
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services
Prior authorization required

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $30.00
Prior Authorization Required for Outpatient Hospital Services
Referral 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
Referral Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services
Prior authorization required

In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $75.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit

In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Copayment for Routine Foot Care $0.00

• Maximum 6 visits every year

Prior Authorization Required for Podiatry Services
Prior authorization required

In-Network:

Skilled Nursing Facility Services:
$20.00 per day for days 1 to 20
$125.00 per day for days 21 to 28
$0.00 per day for days 29 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services
Prior authorization required

In Network:
Plan covers up to $2,500 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire.Your benefit can be used for most dental treatments such as:Preventive dental services, such as exams, routine cleanings, etc.Basic dental services, such as fillings, extractions, etc.Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges, implants, etc.Note: The allowance cannot be used on cosmetic services.

Out of Network:

In-Network:

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

• Maximum 1 Routine Eye Exam every year

Prior Authorization Required for Eye Exams
Referral 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 $300.00 every year for all Non-Medicare covered eyewear
Prior Authorization Required for Eyewear
Referral Required for Eyewear
Prior authorization required

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00

• Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0.00
Prior Authorization Required for Hearing Exams
Referral Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $599.00 to $899.00

• Maximum 2 Hearing Aids every year

Prior authorization required

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 & vagin*l 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

Tobacco use cessation
Yearly "Wellness" visit