Humana Gold Choice PFFS

Looking into Humana Gold Choice PFFS? This Medicare Advantage plan is designed to give you provider flexibility and clear cost information. We’re here to demystify how it works, what you’ll pay, and how to enroll.

Get ready for an uncomplicated breakdown of Humana Gold Choice PFFS for 2025, aimed to help you make a smart decision about your health coverage.


Key Takeaways


  • The plan includes structured cost-sharing options, with a $250 deductible for higher-tier drugs, and a maximum of $35 for a one-month supply of insulin, but prior authorization might be required for certain medications.


  • Humana Gold Choice PFFS underscores non-discrimination, providing accessibility to individuals regardless of race, color, national origin, age, or disability, and offers free language interpreter services to ensure effective communication in healthcare

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What is Humana Gold Choice PFFS?


Humana Gold Choice PFFS, What is Humana Gold Choice PFFS?


Humana Gold Choice PFFS, a private fee-for-service plan provided by Humana, offers coverage equivalent to Original Medicare, covering Medicare Part A and Part B. This plan stands out from other Medicare Advantage HMO and PPO plans due to its unique structure.

Unlike most Medicare Advantage HMO PPO plans, Humana Gold Choice PFFS operates without a network of participating providers, offering members the flexibility to choose a wider range of healthcare providers.

Specific criteria must be met by individuals to be eligible for the Humana Gold Choice PFFS.

They must:


  • Be enrolled in Medicare Part B


  • Reside in the service area, which includes states like CA, CT, DC, DE, and many more


  • Have a status military or veteran


Key Features of Humana Gold Choice PFFS


Humana Gold Choice PFFS,Key Features of Humana Gold Choice PFFS


Key features that characterize Humana Gold Choice PFFS include provider network flexibility, structured cost-sharing options, and prescription drug coverage.

These features have been shaped to align with the needs of plan members, providing them with the freedom to choose their healthcare providers, a clear understanding of their cost responsibilities, and comprehensive prescription drug coverage.


Provider Network Flexibility

One of the major advantages of Humana Gold Choice PFFS is its provider network flexibility. This plan grants members the freedom to seek care from any Medicare-approved physician who accepts the plan’s terms, regardless of their origin, age, disability, or sex.

This flexibility extends to specialist care as well, with no referrals necessary for members seeking such services.

Furthermore, using out-of-network providers is permissible with Humana Gold Choice PFFS, ensuring that members of any sex. This is managed through the provision of a fully networked PFFS plan, offering benefits for services both within and outside the network.


Cost-Sharing Options

For managing healthcare expenses, understanding cost-sharing mechanisms is vital. Humana Gold Choice PFFS implements a structured cost-sharing system, which includes deductibles, coinsurance, and copayments, ensuring that all members, regardless of their national origin or age, have access to the healthcare services they need.

The Humana Gold Choice PFFS plan includes:

  • A $250 deductible for Tier 4 and Tier 5 drugs


  • Cost-sharing for covered services and medications, with variations, until total yearly drug costs reach $5,030


  • For insulin, the maximum cost for a one-month supply is $35, irrespective of the cost-sharing tier


These cost-sharing options may vary in terms of deductibles, premiums, and coinsurance in comparison to other Medicare Advantage plans, presenting a distinct structure tailored to this plan.


Preferred Pharmacies and Prescription Drug Coverage

A key feature of Humana Gold Choice PFFS is prescription drug coverage. This plan includes:

  • A network of lower cost preferred pharmacies, which can be located via the official Humana website


  • Advantages such as potentially reduced expenses for preferred generic and generic drugs


  • Comprehensive prescription drug coverage, making it easier for members to pay for their medications.


Most Humana Gold Choice PFFS plans provide prescription drug coverage, and all plans include emergency coverage both domestically and internationally. In cases where drug coverage is not included, joining a separate Medicare Part D plan may be necessary.

Keep in mind that Humana Gold Choice PFFS may require prior authorization before covering certain medications. To determine the coverage of your medication, you can review the formulary or utilize the MyHumana website to search for the specific drug.

Non-Discrimination and Inclusivity

A steadfast commitment to non-discrimination and inclusivity is upheld by Humana Gold Choice PFFS. Adhering to relevant federal civil rights laws, the plan refrains from engaging in discriminatory practices based on national origin, age, disability, sex, and disability.

If a member believes they have been discriminated against, they are afforded the opportunity to file a complaint or grievance, either by contacting Discrimination Grievances at P.O. Box 14618, Lexington, KY 40512-4618, or by calling 1-877-320-1235 or using TTY at 711.

A core principle of Humana Gold Choice PFFS is inclusivity, which is achieved through the utilization of hiring policies, network resource groups, and the Executive Inclusion program. The plan also provides services for individuals with disabilities, ensuring accessibility and inclusivity for all its members.


Additional Benefits and Services



Humana Gold Choice PFFS, Additional Benefits and Services

In addition to the core benefits, Humana Gold Choice PFFS also offers a suite of additional benefits and services that enhance the overall value of the plan. These include emergency care coverage, provision for durable medical equipment, and complimentary language interpreter services.


Emergency Care Coverage

Comprehensive emergency care coverage is one of the key additional benefits of Humana Gold Choice PFFS.

This plan offers coverage for emergency care both within and outside the United States, ensuring that members have access to emergency services whenever they are required. Ambulance services are also included in this coverage.

However, bear in mind that the Humana Gold Choice PFFS plan may involve some incurred expenses for emergency care. For further details, it is advised to refer to the Humana website.


Durable Medical Equipment

Another crucial facet of the benefits offered by Humana Gold Choice PFFS is Durable Medical Equipment (DME). This category of equipment, primarily intended for home use, is covered under Medicare Part B, and is included in this Medicare Advantage option.

Under the Humana Gold Choice PFFS plan, the member is accountable for 20% of the Medicare-approved amount for durable medical equipment, with Medicare Part B covering the remaining 80% after the member fulfills their deductible.

When using out-of-network providers, the coverage percentage varies, with the member being responsible for 14% of the Medicare-approved cost for DME in states like MD, ME MI, MN.


Free Language Interpreter Services

Recognizing the importance of effective communication in healthcare, Humana Gold Choice PFFS provides support. To this end, it offers plan members access to free language interpreter services. These services have been designed to provide communication support for members who are not proficient in English or require additional assistance.

These language interpreter services cover various languages for individuals who do not speak English. Members can avail themselves of these services by reaching out to Humana for complimentary auxiliary aids, such as proficient sign language interpreters and video remote interpretation.

The delivery of language interpreter services is versatile and accommodating, with options for face-to-face, over the phone, or video interpretation. However, bear in mind that Humana Gold Choice PFFS may impose limitations on telehealth services for free language interpreter services.

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Understanding Plan Limitations

Humana Gold Choice PFFS, Understanding Plan Limitations

Understanding the plan’s limitations is equally important, despite the host of benefits and features offered by Humana Gold Choice PFFS.

For instance, while the provider network flexibility allows members to use out-of-network services, this may result in increased out-of-pocket expenses, and not all healthcare providers may be willing to accept this plan.

Moreover, Humana Gold Choice PFFS typically does not provide coverage for services deemed medically unnecessary, unless explicitly listed in the plan. Similarly, while most Humana Gold Choice PFFS plans provide prescription drug coverage, in cases where drug coverage is not included, joining a separate Medicare Part D plan may be necessary.

Comparing Costs, Coverage, and Benefits by Location

Depending on your location, the cost, coverage, and benefits of Humana Gold Choice PFFS can vary. Factors such as the plan premium, the monthly Medicare Part B premium, and the range of coverage options available can influence the cost of the plan in different locations.

Similarly, the benefits provided by Humana Gold Choice PFFS plans, as well as the specifics of coverage, may differ depending on the member’s location.

For instance, the services eligible for cost-sharing and the extent to which different services are covered can vary by location. To get the most accurate information, members should consult the plan’s Evidence of Coverage, which can offer location-specific information.

Navigating Evidence of Coverage Documents


Humana Gold Choice PFFS, Navigating Evidence of Coverage Documents


For Humana Gold Choice PFFS plan members, the Evidence of Coverage (EOC) document is an essential resource. This document contains details on:

  • Accessing medical care


  • Health benefits, services, and prescription drug coverage available to plan members


  • Obtaining medical care


  • Member rights and responsibilities


  • Coverage specifics


  • Member costs


  • Procedure for lodging a complaint


Accessing a copy on Humana’s official website or contacting their customer service can help you understand the EOC document.

The EOC elucidates the benefits and entitlements, encompassing the plan premium, cost sharing, and medical benefits. Furthermore, it furnishes a comprehensive inventory of coverage and services.

How to Enroll in a Humana Gold Choice PFFS Plan

Once Humana Gold Choice PFFS has been determined as the right plan for you, enrollment is the next step. Individuals aiming to enroll in the Humana Gold Choice PFFS plan must meet the criteria, including entitlement to Medicare Part A, enrollment in Medicare Part B, and residency in the plan’s service area.

Enrollment can be completed either online through the Humana website or over the phone. When enrolling online, it is important to:

  • Verify your eligibility for Medicare Part A


  • Verify your enrollment in Medicare Part B


  • Verify your residency in the service area prior to initiating the enrollment process.


Alternatively, you can enroll over the phone by contacting OSB sales at 1-888-413-7026.


Humana Gold Choice PFFS presents a unique blend of comprehensive coverage, flexible network structure, and additional benefits, making it an attractive option for those eligible for Medicare.

With its distinctive features such as provider network flexibility, cost-sharing options, prescription drug coverage, and additional benefits like emergency care coverage, durable medical equipment provision, and free language interpreter services, it offers a tailored approach to healthcare.

However, understanding its limitations and variations in benefits based on location is crucial to optimize its value. With this guide, you are now equipped to make an informed decision.


Frequently Asked Questions


→  What is the difference between a PPO and an PFFS?

A PPO plan allows you to go out of network, but costs may increase, while a PFFS plan lets you go out of network if the provider accepts the payment terms and agrees to treat you.

HMOs and PPOs use cost-controlling measures, while PFFS plans do not use such measures.


→  What does PFFS mean in Medicare?

PFFS in Medicare stands for Private Fee-for-Service plans, which are offered by private companies and provide beneficiaries with Medicare benefits along with any additional benefits decided by the company.

These plans have a yearly contract with the Centers for Medicare & Medicaid Services (CMS).


  What is Humana Gold Choice Medicare?

Humana Gold Choice H8145-006 is a Medicare Advantage PFFS plan with a Medicare contract, offering coverage and associated costs.

It is important to note that enrollment in this plan depends on contract renewal.


  Is Humana Gold a PPO or HMO?

Humana Gold Plus H8908-004 is an HMO-POS plan, which has a network of providers and may not cover services outside of the network.


 Are there any limitations on prescription drug coverage with Humana Gold Choice PFFS?

Yes, most Humana Gold Choice PFFS plans offer prescription drug coverage, but in some cases, you may need to join a separate Medicare Part D plan for drug coverage.

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