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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 2025, 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 3.5 out of 5 stars in 2025.
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 $5.00. 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 $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 has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, you may pay a $10 copay for preferred generic drugs at a standard or preferred mail pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. This plan offers an enhanced alternative drug benefit.
Additional Benefits
The Humana Gold Plus H5619-012 (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services have copays depending on the service. The plan also covers ambulance services with copays, as well as emergency services with copays. Additional benefits include no copays for primary care, preventive services, hearing exams, vision exams, and dental cleanings. There are also copays for hearing aids, and coinsurance for dental procedures, medical equipment, and dialysis services. The plan also covers other services such as home health and skilled nursing facilities with no copay for the first 20 days, as well as acupuncture with no copay.
Inpatient Hospital See details
Inpatient hospital coverage is provided, including acute and psychiatric care. For Inpatient Hospital-Acute, you will pay a $175 copay for days 1-5, and no copay for days 6-90. Inpatient Hospital Psychiatric has a $900 copay per admission or stay, and no coinsurance.
Outpatient Services See details
Outpatient services, including all outpatient hospital services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital services have a copay between $0 and $175, observation services have a $175 copay, and ambulatory surgical center services have no copay. Individual and group sessions for outpatient substance abuse have a copay between $5 and $100, while outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Humana Gold Plus H5619-012 (HMO) plan with a $55 copay, and requires prior authorization and a doctor's referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Humana Gold Plus H5619-012 (HMO) plan. Ground Ambulance Services have a $265 copay, while Air Ambulance Services have a $1250 copay, and there is no coinsurance for either service. 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 $10 copay, and Worldwide Emergency Services have a $140 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation.
Primary Care See details
The Humana Gold Plus H5619-012 (HMO) plan covers primary care physician services, physician specialist services, and physical therapy and speech-language pathology services with no copay. Chiropractic services have a $5 copay, while mental health and psychiatric services have a $5 copay for individual and group sessions. The plan also covers additional telehealth benefits with a copay between $0 and $10, and opioid treatment program services with a copay between $5 and $100. However, routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive services include coverage for Medicare-covered services with no copay, an annual physical exam with no copay, and additional preventive services with a copay, including fitness benefits. Other services such as health education, in-home safety assessments, and more are not covered.
Hearing Services See details
Humana Gold Plus H5619-012 (HMO) covers Hearing Services, including hearing exams with no copay, routine hearing exams once per year with no copay, fitting/evaluation for hearing aids with no copay, and OTC hearing aids with a maximum benefit of $75 every three months. Prescription Hearing Aids are partially covered, with a copay of $0 to $599 for prescription hearing aids (all types) every three years, but no coverage for inner ear, outer ear, or over the ear hearing aids.
Vision Services See details
Humana Gold Plus H5619-012 (HMO) covers vision services, including eye exams and eyewear with no copay. Contact lenses and eyeglasses (lenses and frames) are covered, with a combined maximum plan benefit of $350. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered, with a $1,500 annual maximum. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and other preventive dental services are covered with no copay. Prosthodontics (removable and fixed) have a 30% coinsurance and no copay, while fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay with coinsurance between 0-20%, while other Medicare Part B drugs have coinsurance between 0-20%.
Dialysis Services See details
Dialysis Services are covered under the Humana Gold Plus H5619-012 (HMO) plan and require prior authorization and a doctor's referral. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, are covered under the Humana Gold Plus H5619-012 (HMO) plan. DME has a 20% coinsurance and requires prior authorization, while Prosthetic Devices and Medical Supplies have a 20% coinsurance. Diabetic Supplies have a 10% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests with a copay between $0 and $50, lab services with no copay, diagnostic radiological services with a copay up to $250, therapeutic radiological services with up to 20% coinsurance, and outpatient X-ray services with no copay. Prior authorization and a doctor referral are required for all diagnostic and radiological services.
Home Health Services See details
Home Health Services are covered by the Humana Gold Plus H5619-012 (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 the specific services of Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Humana Gold Plus H5619-012 (HMO) plan, but require prior authorization and a doctor's referral. You will have no copay for days 1-20, and a $150 copay for days 21-100. Additional days beyond Medicare-covered, and non-Medicare-covered stays, are not covered.
Other Services See details
Under the Humana Gold Plus H5619-012 (HMO) plan, acupuncture is covered with no copay, and over-the-counter (OTC) items are covered with a maximum benefit of $75 every three months, and the meal benefit is covered with no copay. This plan does not cover Dual Eligible SNPs with Highly Integrated Services, and many other services.
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