Skip to main content

Humana Gold Plus H6622-004 (HMO)

Humana Inc.
Humana Gold Plus H6622-004 (HMO) H6622-004 Plan Details
3.5 out of 5 stars

Humana Gold Plus H6622-004 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H6622-004

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Humana Gold Plus H6622-004 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H6622-004

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Humana Inc.
Humana Gold Plus H6622-004 (HMO) H6622-004 Plan Details
3.5 out of 5 stars

Humana Gold Plus H6622-004 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H6622-004

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Virginia Counties Served

Accomack Hanover Gloucester Richmond City York Charles City James City Poquoson City Mathews Henrico Chesterfield Suffolk City Williamsburg City Isle of Wight Northampton Portsmouth City Chesapeake City Virginia Beach City Norfolk City Newport News City Hampton City Dinwiddie Petersburg City Prince George Surry Sussex Colonial Heights City Hopewell City

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $350
Out of Pocket Max In-Network: $9350
Out-of-Network: N/A
Initial Coverage Limit $2000
Catastrophic Coverage Limit $2,000
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $15
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$399 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $45

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $110
Emergency Room Visit
Copayment for Emergency Care $110
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $110
Copayment for Worldwide Emergency Transportation $110
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $315

Air Ambulance:
Copayment for Air Ambulance Services $315
Prior Authorization Required for Air Ambulance
Prior authorization required

Health Care Services and Medical Supplies

Humana Gold Plus H6622-004 (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $15
Prior Authorization Required for Chiropractic Services
Prior authorization required
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0
Coinsurance for Medicare-covered Diabetic Supplies 10% to 20%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $120
Copayment for Medicare-covered Lab Services $0 to $50
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
$120 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$15 OP Diag Proc & Tests - SPC$45 OP Diag Proc & Tests - UCC$120 Sleep Study (Fac Based) - OPH$15 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $325
Copayment for Medicare-covered Therapeutic Radiological Services $15
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $130
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$399 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $45
Copayment for Medicare-covered Group Sessions $45
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $450
Prior Authorization Required for Outpatient Hospital Services
$0 Diag Colonoscopy - OPH$100 Mental Health - OPH$450 Surgery Svcs - OPH$15 Wound Care - OPH_

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $399
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $400
Prior Authorization Required for Ambulatory Surgical Center Services
$0 Diag Colonoscopy - ASC$400 Surgery Svcs - ASC_
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $45 to $100
Copayment for Medicare-covered Group Sessions $45 to $100
Prior Authorization Required for Outpatient Substance Abuse Services
$100 OP Substance Abuse Care - OPH$45 OP Substance Abuse Care - SPC_
Prior authorization required
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $50 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $50 every three months
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $15
Prior Authorization Required for Podiatry Services
Prior authorization required
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$214 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years.
$0 copayment for bridge recementation, bridges-pontic, complete dentures, crown recementation, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 every 5 years.
$0 copayment for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime.
$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
$0 copayment for adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, tissue conditioning up to 1 per year.
$0 copayment for emergency treatment for pain, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year.
$2,500 maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $15
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
  • Maximum 1 Pair every year
Copayment for Eyeglasses (lenses and frames) $0
  • Maximum 1 Pair every year
Maximum Plan Benefit of $350 every year
Members must use Humana's Medicare Insight Network, a national network of providers, which includes standard or PLUS providers. The allowance for the standard network is $50 less than the PLUS network.

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $15
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $599 to $899
  • Maximum 2 Hearing Aids every year

Prior authorization required

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
    • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The Humana Gold Plus H6622-004 (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $350 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $350 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard mail order $10.00
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    Generic
    • Standard mail order $20.00
    • Standard retail $5.00
    • Preferred cost-share mail order $5.00
    Annual Drug Deductible $350 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard mail order N/A
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    Generic
    • Standard mail order N/A
    • Standard retail N/A
    • Preferred cost-share mail order N/A
    Annual Drug Deductible $350 (excludes Tiers 1 and 2)
    Preferred Generic
    • Standard mail order $30.00
    • Standard retail $0.00
    • Preferred cost-share mail order $0.00
    Generic
    • Standard mail order $60.00
    • Standard retail $15.00
    • Preferred cost-share mail order $0.00
    Back to Plans in Virginia