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Humana Gold Plus Giveback H4141-022 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Gold Plus Giveback H4141-022 (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 Giveback H4141-022 (HMO) in 2025, please refer to our full plan details page.
Humana Gold Plus Giveback H4141-022 (HMO) is a HMO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select counties in Georgia. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Humana Gold Plus Giveback H4141-022 (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 Giveback H4141-022 (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 Giveback H4141-022 (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 $114.00. 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 a $450.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $9350.00 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 Giveback H4141-022 (HMO) plan has a $450 deductible. After the deductible is met, you will pay a copay or coinsurance for your prescriptions. For preferred generic drugs, there is no copay at a standard or preferred mail pharmacy, and a $20 copay at a standard mail pharmacy. For standard generic drugs, the copay is $47.00 at all pharmacies. For preferred brand drugs, you pay 40% coinsurance, and for non-preferred drugs, you pay 27% coinsurance.
Additional Benefits
The Humana Gold Plus Giveback H4141-022 (HMO) plan offers a range of benefits with varying cost-sharing. You can expect no copay for primary care, preventive services, outpatient blood services, and home health services. Other services such as inpatient hospital stays, emergency services, and specialist visits have copays between $45 and $395, while some services like ambulance and dental services have a copay of $315 or $45, respectively. This plan also provides coverage for hearing, vision, and dental services, with some services having no copay, while others have copays up to $45. Diagnostic and radiological services have copays up to $325, and durable medical equipment has a 10% coinsurance. Additionally, the plan covers skilled nursing facility stays, with a $0 copay for the first 20 days and a $214 copay for days 21-100.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $395 copay for days 1-6, and no copay for days 7-90, and no coinsurance. Additional days for Inpatient Hospital-Acute have no copay. For Inpatient Hospital Psychiatric, you pay a $395 copay for days 1-5, and no copay for days 6-90, and no coinsurance. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a copay of $0-$450, observation services with a $395 copay, ambulatory surgical center (ASC) services with no copay, outpatient substance abuse services with a copay of $45-$100 for individual and group sessions, and outpatient blood services with no copay. Prior authorization is required for most services.
Partial Hospitalization See details
Partial Hospitalization is covered under the Humana Gold Plus Giveback H4141-022 (HMO) plan, with a copay of $80.00. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
For the Humana Gold Plus Giveback H4141-022 (HMO) plan, ambulance services are covered, with a $315 copay for both ground and air ambulance services and no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including urgently needed and worldwide emergency services, are covered. Emergency services have a $110 copay, urgently needed services have a $45 copay, and worldwide emergency services have a $110 copay. There is no coinsurance for any of these services.
Primary Care See details
The Humana Gold Plus Giveback H4141-022 (HMO) plan covers primary care physician services with no copay. Chiropractic services have a $15 copay, while occupational therapy services have a $25 copay. Physician specialist services have a $45 copay, and mental health and psychiatric services have a $45 copay for individual and group sessions. Physical therapy and speech-language pathology services have a $25 copay, and additional telehealth benefits have a copay ranging from $0 to $45. Opioid treatment program services have a copay between $45 and $100.
Preventive Services See details
Preventive Services include an annual physical exam with no copay. Other preventive services include Medicare-covered Glaucoma Screening, Medicare-covered Diabetes Self-Management Training, Medicare-covered Barium Enemas, Medicare-covered Digital Rectal Exams, and Medicare-covered EKG following Welcome Visit, all with no copay. Additional preventive services such as Health Education, In-Home Safety Assessment, and others are not covered.
Hearing Services See details
The Humana Gold Plus Giveback H4141-022 (HMO) plan covers hearing exams with a $45 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are partially covered, but inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay between $0 and $45, and eyewear with no copay and a combined maximum benefit of $150 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $45 copay, Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), and Other Preventive Dental Services with no copay. Fluoride Treatment, Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Humana Gold Plus Giveback H4141-022 (HMO) plan, with a coinsurance of 20%. Prior authorization is required for this service.
Medical Equipment See details
Medical Equipment is covered under the Humana Gold Plus Giveback H4141-022 (HMO) plan, with no copay for Durable Medical Equipment (DME), and a 10% coinsurance. Prosthetic devices and medical supplies have a 15% coinsurance, and diabetic supplies have a 10% coinsurance and diabetic therapeutic shoes/inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic services and radiological services. Diagnostic Procedures/Tests have a copay of at most $120, and Lab Services have no copay, while Diagnostic Radiological Services have a copay of at most $325. Therapeutic Radiological Services have a copay of at most $10 and coinsurance of at most 20%, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Humana Gold Plus Giveback H4141-022 (HMO) plan with no copay and no coinsurance. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but none of the sub-services are covered. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Humana Gold Plus Giveback H4141-022 (HMO) plan, with a $0 copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Humana Gold Plus Giveback H4141-022 (HMO) plan covers acupuncture with a $45 copay and a limit of 20 treatments per year, and meal benefits with no copay. Over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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