Plan Details
Costs and Other Important Information
Benefits
$0 for days 6 through 90
$0 for days 91 and beyond
$10 per visit
Specialist:
$45 per visit
$80 per visit (always covered)
Urgent care:
$10-45 per visit (always covered)
$0-105
Lab services:
$0-45
Diagnostic radiology services (e.g., MRI):
$45-320
Outpatient x-rays:
$10-100
$0 for days 5 through 90
Outpatient group therapy visit with a psychiatrist:
$40
Outpatient individual therapy visit with a psychiatrist:
$40
Outpatient group therapy visit:
$40
Outpatient individual therapy visit:
$40
$167.50 for days 21 through 100
$10-40
Physical therapy and speech and language therapy visit:
$10-40
$45
Routine foot care:
Not covered
20% per item
Prosthetics (e.g., braces, artificial limbs):
20% per item
Diabetes supplies:
$0 or 10-20% per item
20%
Other Part B drugs:
20%
Coverage Area for Humana Gold Plus H5619-042 (HMO)
State | Virginia |
---|---|
County | Chesapeake City |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | $7 copay | $10 copay | $7 copay |
Tier 2: Non-Preferred Generic | $17 copay | $20 copay | $17 copay |
Tier 3: Preferred Brand Name | $47 copay | $47 copay | $47 copay |
Tier 4: Non-Preferred Brand Name | $97 copay | $100 copay | $97 copay |
Tier 5: Specialty Tier | 29% coinsurance | 29% coinsurance | 29% coinsurance |
90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | $21 copay | $30 copay | $0 copay |
Tier 2: Non-Preferred Generic | $51 copay | $60 copay | $0 copay |
Tier 3: Preferred Brand Name | $141 copay | $141 copay | $131 copay |
Tier 4: Non-Preferred Brand Name | $291 copay | $300 copay | $281 copay |
Tier 5: Specialty Tier |
CMS Ratings
Staying healthy - screenings, tests and vaccines
Managing Chronic Conditions
Member Experience with Health Plan
Member Complaints, and Changes in Health Plan's Performance
Health Plan Customer Service
Drug Plan Customer Service
Member Complaints, and Changes in Drug Plan's Performance
Member Experience with Drug Plan
Drug Pricing and Patient Safety
Physician Finder
Physicians that accept Humana Gold Plus H5619-042 (HMO) for Virginia