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Humana Gold Plus H4461-035 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Gold Plus H4461-035 (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 H4461-035 (HMO) in 2025, please refer to our full plan details page.
Humana Gold Plus H4461-035 (HMO) is a HMO plan offered by Humana Inc. available for enrollment in 2025 to people living in East Tennessee. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Humana Gold Plus H4461-035 (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 H4461-035 (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 H4461-035 (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 $4.00. 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 $590.00 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 $3850.00 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 H4461-035 (HMO) plan has a $590.00 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy type. For example, generic drugs have a copay of $10.00 - $47.00, while brand-name drugs have a 50% coinsurance. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Humana Gold Plus H4461-035 (HMO) plan offers a range of benefits, including inpatient hospital stays with a copay, and outpatient services with varying copays. You can receive primary care services with no copay, and also have no copay for preventive services like annual physical exams and fitness benefits. The plan also covers hearing, vision, and dental services, with copays and varying costs for specific services, such as hearing aids and eyewear. This plan includes ambulance services with a copay, and emergency services with a copay, as well as services for home infusion, dialysis, and medical equipment with copays and coinsurance. The plan covers diagnostic and radiological services with copays, and home health services with no copay. It also offers coverage for other services like acupuncture, over-the-counter items, and a meal benefit.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a $285 copay for days 1-6 and no copay for days 7-90. Additional days for inpatient hospital-acute have no copay, while non-Medicare-covered stays and upgrades for inpatient hospital-acute are not covered, and additional days for inpatient hospital psychiatric and non-Medicare-covered stays for inpatient hospital psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $250, observation services with a $285 copay, and Ambulatory Surgical Center (ASC) services with no copay. This plan also covers outpatient substance abuse services with a $30 copay for both individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Humana Gold Plus H4461-035 (HMO) plan. The copay for this benefit is $30.00.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Humana Gold Plus H4461-035 (HMO), with a $315 copay for ground ambulance services and a 20% coinsurance for air ambulance services. 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. Emergency Services have a $140 copay, Urgently Needed Services have a $65 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $140 copay.
Primary Care See details
The Humana Gold Plus H4461-035 (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, and occupational therapy services with a $20 copay. The plan also covers physician specialist services with a $30 copay, mental health specialty services with a $30 copay, physical therapy and speech-language pathology services with a $20 copay, and additional telehealth benefits with a copay ranging from $0 to $65.
Preventive Services See details
Preventive services include no copay for an annual physical exam, additional preventive services, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and an EKG following a welcome visit. Health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefit, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, and counseling services are not covered. Fitness benefit is covered with no copay.
Hearing Services See details
Hearing Services include hearing exams with a $30 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are partially covered, with Prescription Hearing Aids (all types) costing between $399 and $699 per pair and Inner Ear, Outer Ear, and Over the Ear prescriptions not covered. OTC hearing aids are covered up to $100 every three months.
Vision Services See details
The Humana Gold Plus H4461-035 (HMO) plan covers vision services, including eye exams with a copay between $0 and $30, and eyewear. Eyewear benefits include contact lenses and eyeglasses (lenses and frames) with no copay, and a combined maximum plan benefit of $200 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $30 copay, and other services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, all with no copay, but fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered. There is a $2,500 maximum plan benefit per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Humana Gold Plus H4461-035 (HMO) plan, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered by the Humana Gold Plus H4461-035 (HMO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Medical Supplies and Prosthetics/Medical Supplies - Non-Medicare benefit have a 20% coinsurance, and Diabetic Supplies have between a 10% and 20% coinsurance with no copay. Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with a copay between $0 and $100, and Lab Services with no copay. Diagnostic Radiological Services have a copay of up to $300, Therapeutic Radiological Services have a copay of $30, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Humana Gold Plus H4461-035 (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 not covered under the Humana Gold Plus H4461-035 (HMO) plan. This includes Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Humana Gold Plus H4461-035 (HMO) plan, but require prior authorization. For days 1-20, there is a $20 copay, and for days 21-100, there is a $214 copay. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes acupuncture with a $30 copay and a limit of 20 treatments per year, over-the-counter items with a $100 maximum benefit every three months, and a meal benefit with no copay. Some services, like Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and others, are not covered.
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