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Humana Gold Plus H5619-143 (HMO) - H5619-143-000
$0.00
Monthly Premium
Humana Gold Plus H5619-143 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5619-143-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Washington 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 Washington Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $5,900.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $50 Prior Authorization Required for Doctor Specialty Visit Referral Required for Doctor Specialty Visit |
| Inpatient hospital care | In-Network: Acute Hospital Services: $375 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $55 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $125 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Copayment for Worldwide Emergency Transportation $125 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $315 Air Ambulance: Copayment for Air Ambulance Services $1250 Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
Humana Gold Plus H5619-143 (HMO) covers a range of additional benefits. Learn more about Humana Gold Plus H5619-143 (HMO) 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 $20 Prior Authorization Required for Chiropractic Services Referral Required for Chiropractic Services |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Supplies 10% to 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 |
| 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-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $55 Copayment for Medicare-covered Lab Services $0 to $55 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services $10 Coumadin Clinic Svcs - OPH$50 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$50 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC$50 Sleep Study (Fac Based) - OPH$30 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_ Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $375 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $150 |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Referral Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $375 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $375 Coinsurance for Medicare Covered Outpatient Hospital Services 20% Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services $0 Diag Colonoscopy - OPH$10 Hyperbaric Oxygen Treatment - OPH20% Mental Health - OPH$375 Surgery Svcs - OPH$10 Wound Care - OPH_ Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $375 Prior Authorization Required for Outpatient Observation Services Referral Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $200 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services $0 Diag Colonoscopy - ASC$200 Surgery Svcs - ASC_ |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $30 Coinsurance for Medicare-covered Individual Sessions 20% Copayment for Medicare-covered Group Sessions $30 Coinsurance for Medicare-covered Group Sessions 20% Prior Authorization Required for Outpatient Substance Abuse Services 20% OP Substance Abuse Care - OPH$30 OP Substance Abuse Care - SPC_ |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $50 Prior Authorization Required for Podiatry Services Referral Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $10 per day for days 1 to 20 $214 per day for days 21 to 50 $0 per day for days 51 to 100 Prior Authorization Required for Skilled Nursing Facility Services Referral 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 care | $0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years. $0 copayment for bridge recementation, bridges-pontic, complete dentures, crown recementation, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years. $0 copayment for bridges-crown up to 2 every 5 years. $0 copayment for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. $0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. $0 copayment for adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, tissue conditioning up to 1 per year. $0 copayment for emergency treatment for pain, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year. $1,500 maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits. |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $50 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0
Referral Required for Eyewear Members must use Humana's Medicare Insight Network, a national network of providers, which includes standard or PLUS providers. The allowance for the standard network is $50 less than the PLUS network. |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $50 Copayment for Routine Hearing Exams $0
Prior Authorization Required for Hearing Exams Referral Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $699 to $999
|
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 | 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 & 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:
Yearly "Wellness" visit |
When reviewing Washington 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 Washington that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Washington Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.