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Humana Gold Plus H4461-052 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Gold Plus H4461-052 (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 H4461-052 (HMO) in 2026, please refer to our full plan details page.
Humana Gold Plus H4461-052 (HMO) is a HMO plan offered by Humana Inc. available for enrollment in 2026 to people living in Cameron, Hidalgo and Willacy counties. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Humana Gold Plus H4461-052 (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 H4461-052 (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 H4461-052 (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 $1.00. 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 $615.00 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 $3400.00 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 H4461-052 (HMO) plan features an annual prescription drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic drugs, members pay no copay for a 1-month or 3-month supply at standard pharmacies and through preferred mail order. If utilizing standard mail order for these lower tiers, 1-month copays range from $10 to $20. For Tier 3 preferred brand drugs, the copay is $45 for a 1-month supply at standard pharmacies and preferred mail order, and $47 through standard mail order. Higher-tier medications require coinsurance, with Tier 4 non-preferred drugs at 48% coinsurance and Tier 5 specialty drugs at 25% coinsurance for standard pharmacies and mail order services.
Additional Benefits
The Humana Gold Plus H4461-052 (HMO) plan offers robust coverage with no copay and no coinsurance for primary care visits, home health services, and routine preventive care. For specialist visits, patients will pay a low $15 copay, while inpatient hospital stays require a $295 copay per admission with no coinsurance. Outpatient services generally feature no coinsurance, with no copay for ambulatory surgical centers and copays ranging up to $225 for outpatient hospital services. This plan also includes valuable dental, vision, and hearing benefits, featuring no copay for routine dental care up to a $3,000 annual limit and routine eye exams with copays up to $15 alongside a $400 eyewear allowance. Additionally, members can access up to 60 one-way transportation trips per year, acupuncture, and over-the-counter items with no copay and no coinsurance. Emergency room visits carry a $150 copay, urgent care requires a $65 copay, and durable medical equipment is covered with a 20% coinsurance.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Humana Gold Plus H4461-052 (HMO) with a $295 copay per admission and no coinsurance for Medicare-covered acute and psychiatric stays. Unlimited additional days are covered for acute stays, but upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Humana Gold Plus H4461-052 (HMO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital services carry a copay of $0 to $225 ($295 per stay for observation), while outpatient substance abuse sessions require a $20 to $35 copay.
Partial Hospitalization See details
Humana Gold Plus H4461-052 (HMO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to receive coverage for this benefit.
Ambulance and Transportation Services See details
Humana Gold Plus H4461-052 (HMO) covers ground ambulance services with a $335 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Transportation services are partially covered, offering up to 60 one-way trips per year to plan-approved locations with no copay and no coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
Humana Gold Plus H4461-052 (HMO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $65 copay and no coinsurance, and worldwide emergency, urgent, and transportation services are covered with a $150 copay and no coinsurance, with none of these costs counting toward a plan-level deductible.
Primary Care See details
Humana Gold Plus H4461-052 (HMO) offers primary care physician services with no copay and no coinsurance, and specialist visits with a $15 copay and no coinsurance. Physical, occupational, mental health, and psychiatric therapies are covered with a $20 copay and no coinsurance, but podiatry and chiropractic services are not covered.
Preventive Services See details
Humana Gold Plus H4461-052 (HMO) covers preventive services, including annual physical exams, kidney disease education, diabetes training, and a memory fitness benefit, with no copays and no coinsurance. However, additional preventive benefits are only partially covered, as services like health education, in-home safety assessments, medical nutrition therapy, and weight management programs are not covered.
Hearing Services See details
Humana Gold Plus H4461-052 (HMO) covers hearing services with a $15 copay and no coinsurance for Medicare-covered exams, while routine exams, fitting evaluations, and OTC hearing aids are available with no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $0 to $299, though inner ear, outer ear, and over-the-ear models are not covered.
Vision Services See details
Vision services are partially covered under the Humana Gold Plus H4461-052 (HMO) plan, offering routine eye exams and eyewear with no coinsurance, no deductibles, and copays ranging from $0 to $15, including a $400 annual allowance for eyewear. However, other eye exam services, individual eyeglass lenses, individual eyeglass frames, and upgrades are not covered.
Dental Services See details
Humana Gold Plus H4461-052 (HMO) partially covers dental services up to a $3,000 annual limit, excluding fluoride treatment, implants, orthodontics, and maxillofacial prosthetics. Medicare-covered dental services require a $15 copay and no coinsurance, while other covered preventive and comprehensive dental services are provided with no copay and no coinsurance.
Home Infusion bundled Services See details
Humana Gold Plus H4461-052 (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, carry a coinsurance ranging from no coinsurance to 20%, with insulin also requiring a $35 copay.
Dialysis Services See details
Humana Gold Plus H4461-052 (HMO) covers Dialysis Services with no copay and a 20% coinsurance. Both prior authorization and a referral are required to receive these covered services.
Medical Equipment See details
Humana Gold Plus H4461-052 (HMO) covers durable medical equipment, prosthetics, and medical supplies with a 20% coinsurance and no copay, subject to prior authorization. Diabetic supplies feature a 10% to 20% coinsurance with no copay, while diabetic therapeutic shoes and inserts require a $10 copay.
Diagnostic and Radiological Services See details
Humana Gold Plus H4461-052 (HMO) covers diagnostic and radiological services, featuring no copay for lab services and a $0 to $65 copay with no coinsurance for diagnostic procedures. Outpatient X-rays have no copay but require coinsurance, while therapeutic radiological services carry a $15 copay and a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Humana Gold Plus H4461-052 (HMO) with no copay and no coinsurance, although a referral and prior authorization are required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under Humana Gold Plus H4461-052 (HMO) with no coinsurance, but some services are covered while standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Humana Gold Plus H4461-052 (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $20 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization and a referral are required, and additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
Humana Gold Plus H4461-052 (HMO) covers other services including acupuncture, over-the-counter (OTC) items, and meal benefits with no copay and no coinsurance. Prior authorization is required for acupuncture, which is limited to 12 treatments per year, and meal benefits, while other miscellaneous services under this category are not covered.
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