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Humana Gold Plus H5619-012 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Humana Gold Plus H5619-012 (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 H5619-012 (HMO) in 2026, please refer to our full plan details page.
Humana Gold Plus H5619-012 (HMO) is a HMO plan offered by Humana Inc. available for enrollment in 2025 to people living in Fresno & Madera Counties. This plan received an overall rating of 3 out of 5 stars in 2026.
It's important to know that Humana Gold Plus H5619-012 (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 H5619-012 (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 H5619-012 (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 $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 $2200.00 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 H5619-012 (HMO) plan offers an Enhanced Alternative prescription drug benefit with an annual deductible of $615.00. During the initial coverage phase, Tier 1 preferred generic drugs cost a $5.00 copay at standard pharmacies and through preferred mail, while Tier 2 standard generics require a $47.00 copay. Tier 3 preferred brands require a 50% coinsurance, and Tier 4 non-preferred drugs carry a 25% coinsurance. For individuals who qualify for the low-income subsidy (LIS), prescription costs are reduced to no copay. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and will pay nothing for covered Medicare Part D drugs. This structured coverage plan provides clear cost-sharing phases to help you manage your healthcare expenses.
Additional Benefits
The Humana Gold Plus H5619-012 (HMO) plan provides comprehensive coverage with no copays and no coinsurance for primary care, specialist visits, home health services, and preventive care. For acute inpatient hospital stays, members pay a $175 daily copay for the first five days and no copay for remaining days, while emergency care has a $150 copay that is waived if admitted. Outpatient surgical services and lab tests are also covered with no copay. Supplemental benefits include dental coverage up to $1,750 per year and vision care up to $500 per year with no copays or coinsurance for most routine services. Routine hearing exams and over-the-counter hearing aids are also available with no copay, while prescription hearing aids require a copay up to $599. Additionally, durable medical equipment is covered with a 15% coinsurance and no copay.
Inpatient Hospital See details
Humana Gold Plus H5619-012 (HMO) partially covers inpatient hospital benefits, excluding upgrades, non-Medicare-covered stays, and additional psychiatric days. For acute care, members pay a $175 daily copay for days 1 through 5, no copay for days 6 through 999, and no coinsurance. Psychiatric stays require a $900 copay per admission and no coinsurance.
Outpatient Services See details
Outpatient services are covered by Humana Gold Plus H5619-012 (HMO) with no coinsurance and no copay for ambulatory surgical center and blood services. Members pay a $0 to $175 copay for outpatient hospital services, a $175 copay per stay for observation services, and a $25 to $35 copay for outpatient substance abuse sessions.
Partial Hospitalization See details
Humana Gold Plus H5619-012 (HMO) covers partial hospitalization services with a copay of $35.00 and no coinsurance. A doctor referral and prior authorization are required to receive coverage for this benefit.
Ambulance and Transportation Services See details
Humana Gold Plus H5619-012 (HMO) covers ground ambulance services with a $335 copay and air ambulance services with a $1,250 copay, both with no coinsurance and requiring prior authorization. Transportation services to any health-related or plan-approved locations are not covered.
Emergency Services See details
Humana Gold Plus H5619-012 (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, while worldwide emergency, urgent, and transportation services are covered with a $150 copay and no coinsurance.
Primary Care See details
Humana Gold Plus H5619-012 (HMO) covers primary care, specialist, therapy, and other health professional services with no copays and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance, excluding routine chiropractic care, while podiatry services are not covered. Mental health, psychiatric, telehealth, and opioid treatment services are also covered with copays ranging from $0 to $65 and no coinsurance.
Preventive Services See details
Preventive Services are partially covered by Humana Gold Plus H5619-012 (HMO) with no copay and no coinsurance for covered benefits like annual physicals, kidney disease education, and select screenings. However, several supplemental services are not covered, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, caregiver support, tobacco cessation, disease management, telemonitoring, remote access, home modifications, and counseling.
Hearing Services See details
Humana Gold Plus H5619-012 (HMO) covers routine hearing exams and OTC hearing aids with no copay, coinsurance, or deductible. Prescription hearing aids are partially covered with copays ranging from $0 to $599 and no coinsurance, though inner ear, outer ear, and over the ear devices are not covered.
Vision Services See details
Vision services are partially covered by Humana Gold Plus H5619-012 (HMO) with no copay and no coinsurance for covered services, which include one routine eye exam per year and eyewear up to a $500 annual limit. While contact lenses and combined eyeglasses (lenses and frames) are covered, individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Humana Gold Plus H5619-012 (HMO) partially covers dental services up to a maximum of $1,750 per year, offering most preventive and comprehensive services with no copay and no coinsurance. Fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered, while fixed and removable prosthodontics require a 30% coinsurance with no copay.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Humana Gold Plus H5619-012 (HMO) and require prior authorization. Covered Medicare Part B insulin drugs have a $35 copay and coinsurance ranging from no coinsurance to 20%, while chemotherapy, radiation, and other Part B drugs require no copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Humana Gold Plus H5619-012 (HMO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to access these covered services.
Medical Equipment See details
Medical equipment is covered by Humana Gold Plus H5619-012 (HMO), featuring durable medical equipment (DME) with a 15% coinsurance and no copay. Diabetic supplies require a 10% coinsurance and no copay, diabetic therapeutic shoes have a $10 copay, and prosthetic devices and medical supplies carry a 15% to 20% coinsurance with no copay.
Diagnostic and Radiological Services See details
Humana Gold Plus H5619-012 (HMO) covers diagnostic and radiological services with prior authorization and a doctor referral. Members pay no copay or coinsurance for lab services and outpatient X-rays, a $0 to $65 copay with no coinsurance for diagnostic procedures, a $0 to $300 copay with no coinsurance for diagnostic radiology, and a 20% coinsurance with no copay for therapeutic radiology.
Home Health Services See details
Home Health Services are covered by Humana Gold Plus H5619-012 (HMO) with no copay and no coinsurance. Prior authorization and a doctor referral are required to access this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Humana Gold Plus H5619-012 (HMO) plan. Although the plan mentions some coverage, all specific sub-services—including intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services—are not covered in practice.
Skilled Nursing Facility (SNF) See details
Humana Gold Plus H5619-012 (HMO) partially covers Skilled Nursing Facility (SNF) services, requiring prior authorization and a doctor referral, while excluding coverage for additional days beyond the Medicare-covered limit. Covered stays feature no copay and no coinsurance for days 1 through 20, followed by a $218 daily copay and no coinsurance for days 21 through 100.
Other Services See details
Other services covered by Humana Gold Plus H5619-012 (HMO) include acupuncture up to 20 treatments per year, chronic illness meal benefits, and partially covered over-the-counter items with no copay or coinsurance. Prior authorization is required for acupuncture and meal benefits, while dual eligible SNP services are not covered.
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