HumanaChoice H5216-428 (PPO)
HumanaChoice H5216-428 (PPO) H5216-428 Plan Details
HumanaChoice H5216-428 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-428
HelpAdvisor Editorial Team analysis of data from the 2024 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
HumanaChoice H5216-428 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-428
HelpAdvisor Editorial Team analysis of data from the 2024 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.
HumanaChoice H5216-428 (PPO) H5216-428 Plan Details
HumanaChoice H5216-428 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-428
HelpAdvisor Editorial Team analysis of data from the 2024 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
Oregon Counties Served
Utah Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $125 |
| Out of Pocket Max |
In-Network: $6750 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 Out-of-Network: Doctor Office Visit Services: Coinsurance for Medicare Covered Primary Care Office Visit 50% |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $45 Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit 50% |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $495 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Acute Hospital Services: Coinsurance for Acute Hospital Services per Stay 50% |
| Urgent Care | Copayment for Urgent Care $55 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 |
| Emergency Room Visit | Copayment for Emergency Care $125 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 $125 Copayment for Worldwide Emergency Transportation $125 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $315 Air Ambulance: Copayment for Air Ambulance Services $1250 Prior Authorization Required for Air Ambulance Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $315 Copayment for Medicare Covered Ambulance Services - Air $1250 |
Health Care Services and Medical Supplies
HumanaChoice H5216-428 (PPO) 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 $20 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 50% |
| 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 $0 Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 50% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 10% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 50% |
| 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 $55 Copayment for Medicare-covered Lab Services $0 to $55 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services $50 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$45 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC$50 Sleep Study (Fac Based) - OPH$50 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 $495 Copayment for Medicare-covered Therapeutic Radiological Services $25 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $150 Prior authorization required Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 50% Coinsurance for Medicare Covered Lab Services 50% Coinsurance for Medicare Covered Diagnostic Radiological Services 50% Coinsurance for Medicare Covered Therapeutic Radiological Services 50% Coinsurance for Medicare Covered Outpatient X-Ray Services 50% $50 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$45 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC$50 Sleep Study (Fac Based) - OPH$50 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_ |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 50% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $458 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 Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 50% |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 Out-of-Network: Medicare Covered Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $495 Prior Authorization Required for Outpatient Hospital Services $0 Diag Colonoscopy - OPH$40 Mental Health - OPH$495 Surgery Svcs - OPH$10 Wound Care - OPH_ Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $495 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $350 Prior Authorization Required for Ambulatory Surgical Center Services $0 Diag Colonoscopy - ASC$350 Surgery Svcs - ASC_ Prior authorization required Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 50% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50% $0 Diag Colonoscopy - OPH$40 Mental Health - OPH$495 Surgery Svcs - OPH$10 Wound Care - OPH_ |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40 to $45 Copayment for Medicare-covered Group Sessions $40 to $45 Prior Authorization Required for Outpatient Substance Abuse Services $40 OP Substance Abuse Care - OPH$45 OP Substance Abuse Care - SPC_ Prior authorization required Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% $40 OP Substance Abuse Care - OPH$45 OP Substance Abuse Care - SPC_ |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $45 Prior Authorization Required for Podiatry Services Prior authorization required Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 50% |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $10 per day for days 1 to 20 $214 per day for days 21 to 70 $0 per day for days 71 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. $1,500 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.Out of Network$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. $1,500 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | Out-of-Network: Medicare Covered Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 50% Copayment for Medicare Covered Eyewear $0 |
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 $45 Prior Authorization Required for Hearing Exams Prior authorization required Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 50% |
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:
Yearly "Wellness" visit Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 Coinsurance for Medicare Covered Medicare-covered Preventive Services 50% |
Prescription Drug Costs and Coverage
The HumanaChoice H5216-428 (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $125 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $125 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $125 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $125 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
