HumanaChoice H5216-142 (PPO)

Health Insurance Company: Humana

Medicare Advantage Plan Details

Humana
$7 /mo
monthly premium
HumanaChoice H5216-142 (PPO)
Additional Coverage
Overall Star Rating (2024)
  • Rx
  • Vision
  • Hearing
4.5
out of 5 stars

General Plan Details

Medical Deductible
$500
Out-of-Pocket Maximum
$7800
Rx Drug Coverage
Yes
Rx Deductible
$250

Additional Benefits

Dental Coverage
No
Vision Coverage
Yes
Mental Health Coverage
Yes
Chiropractic Coverage
No
Optional Supplemental Benefits
Yes
Part B Give Back
Yes

Doctor & Hospital Coverage

Primary Doctor Office Visit
In-network: $15 copay per visit
Out-of-network: 30% coinsurance per visit
Specialist Office Visit
In-network: $50 copay per visit
Out-of-network: 30% coinsurance per visit
Periodic Exam Coverage
In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance

Emergency Room

$100 copay per visit (always covered)

Ambulance Coverage

In-network: $300 copay
Out-of-network: $300 copay

Lab, X-Ray, Radiology Coverage

Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: In-network: $0-100 copay
Out-of-network: 30% coinsurance
Medicare-covered lab services: In-network: $0-50 copay
Out-of-network: 30% coinsurance
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): In-network: $0-325 copay
Out-of-network: 30% coinsurance
Medicare-covered x-ray services: In-network: $15-125 copay
Out-of-network: 30% coinsurance

Outpatient Surgery Coverage

Outpatient hospital:
Medicare-covered outpatient hospital services: In-network: $0-375 copay per visit
Out-of-network: 30% coinsurance per visit

Hospitalization Coverage

Inpatient hospital-acute:
In-network: $325 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 90 and beyond
Out-of-network: 30% per stay
Inpatient hospital psychiatric:
In-network: $325 per day for days 1 through 4
$0 per day for days 5 through 90
Out-of-network: 30% per stay

Rehabilitation Coverage

Occupational therapy services:
In-network: $25 copay
Out-of-network: 30% coinsurance
Physical therapy and speech and language therapy services:
In-network: $25 copay
Out-of-network: 30% coinsurance

Urgent Care Coverage

$50 copay per visit (always covered)

Skilled Nursing Facility (SNF)

In-network: $0 per day for days 1 through 20
$203 per day for days 21 through 100
Out-of-network: 30% per stay

Mental Health Coverage

Medicare-covered individual sessions: In-network: $45 copay
Out-of-network: 30% coinsurance
Medicare-covered group sessions: In-network: $45 copay
Out-of-network: 30% coinsurance

Dental, Vision, Hearing Benefits

Dental Services

Oral exams: In-network: $0 copay
Out-of-network: $0 copay
Prophylaxis (cleaning): In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays: In-network: $0 copay
Out-of-network: $0 copay

Vision Benefits

Eye exams:
Routine eye exams: In-network: $0 copay
Out-of-network: $0 copay
Eyewear:
Contact Lenses: In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses: In-network: $0 copay
Out-of-network: $0 copay

Hearing Benefits

Hearing exams:
Routine hearing exams: In-network: $50 copay
Out-of-network: 30% coinsurance
Hearing aids:
Hearing aids (all types): In-network: $699-999 copay
Out-of-network: 50% coinsurance

Rx Drug Coverage - Standard Retail Cost

Tier 1: Preferred Generic

$4.00 copay (30-day supply)
$12.00 copay (90-day supply)

Tier 2: Generic

$12.00 copay (30-day supply)
$36.00 copay (90-day supply)

Tier 3: Preferred Brand

$47.00 copay (30-day supply)
$141.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

$100.00 copay (30-day supply)
$300.00 copay (90-day supply)

Tier 5: Specialty Tier

29% coinsurance (30-day supply)

Rx Drug Coverage - Standard Mail Order Cost

Tier 1: Preferred Generic

$10.00 copay (30-day supply)
$30.00 copay (90-day supply)

Tier 2: Generic

$20.00 copay (30-day supply)
$60.00 copay (90-day supply)

Tier 3: Preferred Brand

$47.00 copay (30-day supply)
$141.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

$100.00 copay (30-day supply)
$300.00 copay (90-day supply)

Tier 5: Specialty Tier

29% coinsurance (30-day supply)

Rx Drug Coverage - Preferred Mail Order Cost

Tier 1: Preferred Generic

$4.00 copay (30-day supply)
$0.00 copay (90-day supply)

Tier 2: Generic

$12.00 copay (30-day supply)
$0.00 copay (90-day supply)

Tier 3: Preferred Brand

$47.00 copay (30-day supply)
$131.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

$100.00 copay (30-day supply)
$290.00 copay (90-day supply)

Tier 5: Specialty Tier

29% coinsurance (30-day supply)

Plan Links

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Where This Plan is Available

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Additional Plan Info

Year:
2024
Plan ID:
H5216-142-2
Insurance Company Website:
Humana

Health Insurance Companies Offering Plans

Medicare Advantage and Part D plans and benefits offered by the following carriers:

  • Aetna Medicare
  • Anthem Blue Cross Blue Shield
  • Aspire Health Plan
  • Dean Health Plan
  • Devoted Health
  • GlobalHealth
  • Health Care Service Corporation
  • Cigna Healthcare
  • Humana
  • Medica Central Health Plan
  • Molina Healthcare
  • Mutual of Omaha
  • Premera Blue Cross
  • SCAN Health Plan
  • Scott and White Health Plan now part of Baylor Scott & White Health
  • UnitedHealthcareⓇ
  • Wellcare