Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5216-145-000
Plan Organization Humana
Plan Type Local PPO
Plan Name HumanaChoice H5216-145 (PPO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 4 Stars
Plan Cost Sharing
Premium $34.00
Total Premium (Includes Part B) $169.50
Monthly Part C Premium $11.10
Monthly Part D Basic Premium $22.90
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $22.90
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $5.70
Monthly Part D Premium 50% Assistance $11.40
Monthly Part D Premium 25% Assistance $17.20
Part D Drug Deductible $75.00
Annual Drug Deductible $75.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6700.00
Gap Coverage No
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Endodontics Yes Out-of-Network Yes No $0 copay
Restorative services Yes Out-of-Network Yes No $0 copay
Non-routine services Yes In-Network Yes No $0 copay
Periodontics Yes In-Network Yes No $0 copay
Extractions Yes In-Network Yes No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No $0 copay
Diagnostic services No - - - Not covered
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - In-Network Yes No $45
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $270
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes In-Network Yes No $0 copay
Hearing aids Yes In-Network No No $199-499
Hearing exam - Out-of-Network Yes No 35%
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $298 per day for days 1 through 7 $0 per day for days 8 through 90 $0 per day for days 91 and beyond
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 35% per item
Durable medical equipment (e.g., wheelchairs, oxygen) - In-Network Yes - 20% per item
Prosthetics (e.g., braces, artificial limbs) - In-Network Yes - 20% per item
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - In-Network Yes No $587 per day for days 1 through 3 $0 per day for days 4 through 90
Outpatient group therapy visit - Out-of-Network Yes No 35%
Outpatient individual therapy visit with a psychiatrist - In-Network Yes No $40
Outpatient individual therapy visit - Out-of-Network Yes No 35%
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 35%
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Dental x-ray(s) Yes In-Network No No $0 copay
Oral exam Yes Out-of-Network No No $0 copay
Fluoride treatment Yes In-Network No No $0 copay
Cleaning Yes Out-of-Network No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 35%
Occupational therapy visit - Out-of-Network Yes No 35%
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $0 per day for days 1 through 20 $178 per day for days 21 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes Out-of-Network Yes No 50%
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Eyeglasses (frames and lenses) Yes Out-of-Network Yes No $0 copay
Other No - - - Not covered
Contact lenses Yes Out-of-Network Yes No $0 copay
Routine eye exam Yes Out-of-Network Yes No $0 copay
Upgrades - - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglass frames No - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - In-Network Yes No $45-510
Diagnostic tests and procedures - Out-of-Network Yes No 35%
Outpatient x-rays - In-Network Yes No $5-100
Lab services - Out-of-Network Yes No 35%
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 35% per visit
Specialist - In-Network No No $45 per visit
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - In-Network Yes - 20%
Other Part B drugs - Out-of-Network Yes - 35%
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $45-345 per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No $0 or 35%
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - $5-45 or 35% per visit (always covered)
Emergency - - - - $90 per visit (always covered)
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $10,000 In and Out-of-network $6,700 In-network
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Baker County, Georgia, Barrow County, Georgia, Bartow County, Georgia, Bibb County, Georgia, Butts County, Georgia, Carroll County, Georgia, Catoosa County, Georgia, Chattahoochee County, Georgia, Chattooga County, Georgia, Cherokee County, Georgia, Clarke County, Georgia, Clayton County, Georgia, Cobb County, Georgia, Coweta County, Georgia, Crawford County, Georgia, Dade County, Georgia, Dawson County, Georgia, Dekalb County, Georgia, Dougherty County, Georgia, Douglas County, Georgia, Fayette County, Georgia, Floyd County, Georgia, Forsyth County, Georgia, Fulton County, Georgia, Gordon County, Georgia, Gwinnett County, Georgia, Haralson County, Georgia, Harris County, Georgia, Heard County, Georgia, Henry County, Georgia, Houston County, Georgia, Jackson County, Georgia, Jasper County, Georgia, Jones County, Georgia, Lamar County, Georgia, Lee County, Georgia, Madison County, Georgia, Marion County, Georgia, Meriwether County, Georgia, Monroe County, Georgia, Murray County, Georgia, Muscogee County, Georgia, Newton County, Georgia, Oconee County, Georgia, Oglethorpe County, Georgia, Paulding County, Georgia, Peach County, Georgia, Pickens County, Georgia, Pike County, Georgia, Polk County, Georgia, Rockdale County, Georgia, Spalding County, Georgia, Stewart County, Georgia, Sumter County, Georgia, Talbot County, Georgia, Terrell County, Georgia, Troup County, Georgia, Twiggs County, Georgia, Upson County, Georgia, Walton County, Georgia, Webster County, Georgia, Worth County, Georgia

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