Humana Gold Choice H2944-004 (PFFS)

Medicare Advantage Plan for Nebraska

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PARTCRX

Plan Summary

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderHumana
Plan IDH2944-4-0
CMS Rating1
Plan TypePFFS
Annual Deductible$405.00

What To Know About This Plan

  • This plan has health and drug coverage

Why We Like This Plan

  • has both Health and Drug Coverage

Plan Details

Costs and Other Important Information

Plan Year:
2018
Optional Supplemental Benefits
Yes
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$6,700 In and Out-of-network
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$33.40
Monthly Health Plan Premium
$63.60

Benefits

Service
Cost
Inpatient hospital coverage
In-Network:
$454 for days 1 through 4
$0 for days 5 through 90
$0 for days 91 and beyond
Out-of-Network:
Not Applicable
Outpatient hospital coverage
In-Network:
$450 per visit
Doctor visits
Primary:In-Network:
$20 per visit
Specialist:In-Network:
$50 per visit
Preventive care
In-Network:
$0 copay
Emergency care/Urgent care
Emergency:$80 per visit (always covered)
Urgent care:$20-50 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:In-Network:
$0-100
Lab services:In-Network:
$0-40
Diagnostic radiology services (e.g., MRI):In-Network:
$40-450
Outpatient x-rays:In-Network:
$20-100
Mental health services
In-Network:
$405 for days 1 through 4
$0 for days 5 through 90
Out-of-Network:
Not Applicable
Outpatient group therapy visit with a psychiatrist:In-Network:
$40
Outpatient individual therapy visit with a psychiatrist:In-Network:
$40
Outpatient group therapy visit:In-Network:
$40
Outpatient individual therapy visit:In-Network:
$40
Skilled Nursing Facility
In-Network:
$0 for days 1 through 20
$167.50 for days 21 through 100
Out-of-Network:
Not Applicable
Rehabilitation services
Occupational therapy visit:In-Network:
$40
Physical therapy and speech and language therapy visit:In-Network:
$40
Ambulance
In-Network:
$265 or 20%
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:In-Network:
$50
Routine foot care:Not covered
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):In-Network:
20% per item. Out-of-Network:
30% per item
Prosthetics (e.g., braces, artificial limbs):In-Network:
20% per item
Diabetes supplies:In-Network:
$0 or 10-20% per item. Out-of-Network:
30% per item
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:In-Network:
20%
Other Part B drugs:In-Network:
20%

Coverage Area for Humana Gold Choice H2944-004 (PFFS)

StateNebraska
CountyDouglas

Cost Sharing Information

All cost-sharing assumes in-network healthcare providers.

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$4 copay$10 copay$4 copay
Tier 2: Non-Preferred Generic$16 copay$20 copay$16 copay
Tier 3: Preferred Brand Name$47 copay$47 copay$47 copay
Tier 4: Non-Preferred Brand Name$99 copay$100 copay$99 copay
Tier 5: Specialty Tier25% coinsurance25% coinsurance25% coinsurance
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$12 copay$30 copay$0 copay
Tier 2: Non-Preferred Generic$48 copay$60 copay$0 copay
Tier 3: Preferred Brand Name$141 copay$141 copay$131 copay
Tier 4: Non-Preferred Brand Name$297 copay$300 copay$287 copay
Tier 5: Specialty Tier

CMS Ratings

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Adult BMI assessment

Managing Chronic Conditions

Special needs plan care management
Not Rated
Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not Rated
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Controlling blood pressure
Rheumatoid arthritis management
Reducing the risk of falling
Plan all-cause readmissions

Member Experience with Health Plan

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan
Care Coordination

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health plan
Members choosing to leave the health plan
Beneficiary access and performance problems
Health plan quality improvement

Health Plan Customer Service

Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability - Medical

Drug Plan Customer Service

Call center – foreign language interpreter and TTY/TDD availability - Drugs
Appeals auto-forward
Appeals upheld

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug plan
Members choosing to leave the drug plan
Not Rated
Beneficiary access and performance problems
Drug plan quality improvement

Member Experience with Drug Plan

Rating of drug plan
Getting needed prescription drugs

Drug Pricing and Patient Safety

MPF Price Accuracy
High risk medication
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate

Physician Finder

Physicians that accept Humana Gold Choice H2944-004 (PFFS) for Nebraska

/
JARZYNKA, MICHELE
1905 N 54TH ST
OMAHA, NE 68104
ZANONE, DANA
2734 N 61ST ST
OMAHA, NE 68104
TOUMEH, MOHAMED
5719 NW RADIAL HWY
OMAHA, NE 68104
YORK, GLENN
6069 MAPLE ST
OMAHA, NE 68104
HADDADIN, MAEN
2734 N 61ST ST
OMAHA, NE 68104
STOEWE, JUDITH
4343 N 52ND ST
OMAHA, NE 68104
HATCHER, JEFFRY
2734 N 61ST ST
OMAHA, NE 68104
SHARMA, SANJEEV
2734 N 61ST ST
OMAHA, NE 68104
BICHALA, SHALINI
5002 UNDERWOOD AVE
OMAHA, NE 68132
SAUER, TODD
702 N 58TH ST
OMAHA, NE 68132
SPECHT, PAT
119 N 51ST ST
OMAHA, NE 68132
MOORE, MICHAEL
119 N 51ST ST
OMAHA, NE 68132
LOUCKS, ERIN
119 N 51ST ST
OMAHA, NE 68132
DAVIDIAN, MICHAEL
5002 UNDERWOOD AVE
OMAHA, NE 68132
MANHART, CAROLYN
119 N 51ST ST
OMAHA, NE 68132
FROCK, JAMES
7710 MERCY ROAD
OMAHA, NE 68132
BABCOCK, NITA
6508 DAVENPORT PLZ
OMAHA, NE 68132
HAMMER, SHARON
988102 NEBRASKA MEDICAL CTR
OMAHA, NE 68198
DEVETTEN, MARCEL
988095 NEBRASKA MEDICAL CTR
OMAHA, NE 68198
SIEBLER, JUSTIN
989265 NEBRASKA MEDICAL CTR
OMAHA, NE 68198
BERTONI, JOHN
UNMC NEUROLOGY
OMAHA, NE 68198
WICHMAN, TAMMY
EMILE 42ND ST
OMAHA, NE 68198
Details
MICHELE JARZYNKA, OTR/L
Phone Number
(402) 558-8116
Office Locations
1905 N 54TH ST
OMAHA, NE 68104
1905 N 54TH ST OMAHA NE, 68104

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