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Humana Gold Plus H4007-012 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Gold Plus H4007-012 (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Humana Gold Plus H4007-012 (HMO) in 2025, please refer to our full plan details page.
Humana Gold Plus H4007-012 (HMO) is a HMO plan offered by Humana Inc. available for enrollment in 2025 to people living in Puerto Rico Island Wide. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Humana Gold Plus H4007-012 (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Humana Gold Plus H4007-012 (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Humana Gold Plus H4007-012 (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $9.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $5000.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Humana Gold Plus H4007-012 (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay varying copays or coinsurance depending on the drug tier and pharmacy used. For example, preferred generic drugs have no copay, while standard generic drugs have a $5 or $6 copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you will pay nothing for your Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Humana Gold Plus H4007-012 (HMO) plan offers comprehensive coverage for various medical services. This plan includes no copay for many services, such as primary care visits, preventive services, vision and dental exams, and home health services. The plan also includes coverage for inpatient and outpatient hospital services, ambulance services, and emergency care, with varying copays and coinsurance depending on the specific service. Additionally, the plan provides benefits like hearing services, diagnostic and radiological services, and other services such as acupuncture, an OTC benefit, and a meal benefit.
Inpatient Hospital See details
Inpatient Hospital benefits with the Humana Gold Plus H4007-012 (HMO) plan include Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, each with a $25 copay per admission or stay for Medicare-covered stays. Additional days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, as well as additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric, are not covered.
Outpatient Services See details
Outpatient services include coverage for all outpatient hospital services with a copay between $0 and $25, observation services with a $25 copay, and ambulatory surgical center (ASC) services with a $20 copay. Outpatient substance abuse services are covered with a copay between $0 and $20 for both individual and group sessions, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Humana Gold Plus H4007-012 (HMO) plan, with no copay required. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required. Ground ambulance services have a $50 copay, while air ambulance services have a 20% coinsurance. Transportation Services to a plan-approved health-related location are covered with no copay for up to 12 one-way trips per year. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Humana Gold Plus H4007-012 (HMO) plan. Emergency Services have a $50 copay, Urgently Needed Services have a $10 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $50 copay.
Primary Care See details
The Humana Gold Plus H4007-012 (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Primary care physician services, chiropractic services, physician specialist services, individual and group mental health and psychiatric sessions, and other health care professional services have no copay. Occupational therapy services and physical therapy and speech-language pathology services have a $6 copay. Additional telehealth benefits have a copay between $0 and $10, and opioid treatment program services have a copay between $0 and $20.
Preventive Services See details
The Humana Gold Plus H4007-012 (HMO) plan covers preventive services, including an annual physical exam with no copay. This plan also covers additional preventive services such as Fitness Benefit, Home and Bathroom Safety Devices and Modifications, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay.
Hearing Services See details
The Humana Gold Plus H4007-012 (HMO) plan covers hearing exams and OTC hearing aids with no copay, and covers prescription hearing aids with a $750 maximum benefit per ear per year. Routine hearing exams and fitting/evaluation for hearing aids are covered with no copay, with a limit of one visit per year. Prescription hearing aids are covered for all types, but specific sub-services like "Prescription Hearing Aids - Inner Ear", "Prescription Hearing Aids - Outer Ear", and "Prescription Hearing Aids - Over the Ear" are not covered.
Vision Services See details
The Humana Gold Plus H4007-012 (HMO) plan covers vision services including eye exams and eyewear. Eye exams and eyewear have no copay. The plan does not cover eyeglass lenses, eyeglass frames, or upgrades.
Dental Services See details
The Humana Gold Plus H4007-012 (HMO) plan covers a variety of dental services. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), endodontics, oral and maxillofacial surgery, and implant services are covered with no coinsurance, while fluoride treatment, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, with coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs also have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Humana Gold Plus H4007-012 (HMO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment is covered under the Humana Gold Plus H4007-012 (HMO) plan. Durable Medical Equipment (DME) has no coinsurance and a copay of $0, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have no coinsurance and a copay of $0. Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no coinsurance and a copay of $0.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic services, are covered with a doctor referral and prior authorization, with copays of $0-$20 for diagnostic procedures/tests and no copay for lab services. Radiological services are covered, with a copay of up to $25 for diagnostic radiological services and a coinsurance of at least 20% for therapeutic radiological services; outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered under the Humana Gold Plus H4007-012 (HMO) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover the following sub-services: Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered. Prior authorization is required, and details about the copay are available in the plan documents.
Other Services See details
The Humana Gold Plus H4007-012 (HMO) plan covers acupuncture with no copay, up to 20 treatments per year. The plan also offers an Over-the-Counter (OTC) benefit with a monthly allowance of $20, and a meal benefit with no copay. Other services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and more are not covered.
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