Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5216-157-000
Plan Organization Humana
Plan Type Local PPO *
Plan Name HumanaChoice H5216-157 (PPO)
Drugs Covered No
Doctors Choice Any Doctor
Overall Star Rating 4 Stars
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6700.00
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Extractions Yes In-Network Yes No $0 copay
Non-routine services Yes Out-of-Network Yes No $0 copay
Periodontics Yes In-Network Yes No $0 copay
Restorative services Yes Out-of-Network Yes No $0 copay
Endodontics 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
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
Outpatient x-rays - Out-of-Network Yes No 30%
Diagnostic tests and procedures - Out-of-Network Yes No 30%
Lab services - In-Network Yes No $0-45
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - In-Network - - $10 per visit
Specialist - Out-of-Network No No 30% per visit
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network Yes No 30%
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 $399-699
Hearing exam - Out-of-Network Yes No 30%
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 30% per item
Prosthetics (e.g., braces, artificial limbs) - In-Network Yes - 20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) - In-Network Yes - 20% per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 30%
Other Part B drugs - Out-of-Network Yes - 30%
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit - In-Network Yes No $40
Outpatient individual therapy visit - In-Network Yes No $40
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 30%
Inpatient hospital - psychiatric - In-Network Yes No $587 per day for days 1 through 3 $0 per day for days 4 through 90
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 30%
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $45-345 per visit
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Dental x-ray(s) 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
Oral exam Yes In-Network No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Physical therapy and speech and language therapy visit - In-Network Yes No $25-40
Occupational therapy visit - Out-of-Network Yes No 30%
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 30% per stay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes In-Network Yes No $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 per visit (always covered)
Urgent care - - - - $10-45 or 30% 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
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network No No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes Out-of-Network Yes No $0 copay
Eyeglasses (frames and lenses) Yes In-Network Yes No $0 copay
Routine eye exam Yes Out-of-Network Yes No $0 copay
Eyeglass lenses No - - - Not covered
Other No - - - Not covered
Eyeglass frames No - - - Not covered
Upgrades - - - - Not covered
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $245 per day for days 1 through 7 $0 per day for days 8 through 90 $0 per day for days 91 and beyond
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
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Abbeville County, South Carolina, Aiken County, South Carolina, Allendale County, South Carolina, Anderson County, South Carolina, Appling County, Georgia, Atkinson County, Georgia, Bacon County, Georgia, Baker County, Georgia, Baldwin County, Georgia, Bamberg County, South Carolina, Banks County, Georgia, Barnwell County, South Carolina, Barrow County, Georgia, Bartow County, Georgia, Beaufort County, South Carolina, Ben Hill County, Georgia, Berkeley County, South Carolina, Berrien County, Georgia, Bibb County, Georgia, Bleckley County, Georgia, Brantley County, Georgia, Brooks County, Georgia, Bryan County, Georgia, Bulloch County, Georgia, Burke County, Georgia, Butts County, Georgia, Calhoun County, Georgia, Calhoun County, South Carolina, Camden County, Georgia, Candler County, Georgia, Carroll County, Georgia, Catoosa County, Georgia, Charleston County, South Carolina, Charlton County, Georgia, Chatham County, Georgia, Chattahoochee County, Georgia, Chattooga County, Georgia, Cherokee County, Georgia, Cherokee County, South Carolina, Chester County, South Carolina, Chesterfield County, South Carolina, Clarendon County, South Carolina, Clarke County, Georgia, Clay County, Georgia, Clayton County, Georgia, Clinch County, Georgia, Cobb County, Georgia, Colleton County, South Carolina, Colquitt County, Georgia, Columbia County, Georgia, Cook County, Georgia, Coweta County, Georgia, Crawford County, Georgia, Crisp County, Georgia, Dade County, Georgia, Darlington County, South Carolina, Dawson County, Georgia, Decatur County, Georgia, Dekalb County, Georgia, Dillon County, South Carolina, Dodge County, Georgia, Dooly County, Georgia, Dorchester County, South Carolina, Dougherty County, Georgia, Douglas County, Georgia, Early County, Georgia, Echols County, Georgia, Edgefield County, South Carolina, Effingham County, Georgia, Elbert County, Georgia, Emanuel County, Georgia, Evans County, Georgia, Fairfield County, South Carolina, Fannin County, Georgia, Fayette County, Georgia, Florence County, South Carolina, Floyd County, Georgia, Forsyth County, Georgia, Franklin County, Georgia, Fulton County, Georgia, Georgetown County, South Carolina, Gilmer County, Georgia, Glascock County, Georgia, Glynn County, Georgia, Gordon County, Georgia, Grady County, Georgia, Greene County, Georgia, Greenville County, South Carolina, Greenwood County, South Carolina, Gwinnett County, Georgia, Habersham County, Georgia, Hall County, Georgia, Hampton County, South Carolina, Hancock County, Georgia, Haralson County, Georgia, Harris County, Georgia, Hart County, Georgia, Heard County, Georgia, Henry County, Georgia, Horry County, South Carolina, Houston County, Georgia, Irwin County, Georgia, Jackson County, Georgia, Jasper County, Georgia, Jasper County, South Carolina, Jeff Davis County, Georgia, Jefferson County, Georgia, Jenkins County, Georgia, Johnson County, Georgia, Jones County, Georgia, Kershaw County, South Carolina, Lamar County, Georgia, Lancaster County, South Carolina, Laurens County, Georgia, Laurens County, South Carolina, Lee County, Georgia, Lee County, South Carolina, Lexington County, South Carolina, Liberty County, Georgia, Lincoln County, Georgia, Long County, Georgia, Lumpkin County, Georgia, Macon County, Georgia, Madison County, Georgia, Marion County, Georgia, Marion County, South Carolina, Marlboro County, South Carolina, Mccormick County, South Carolina, Mcduffie County, Georgia, Mcintosh County, Georgia, Meriwether County, Georgia, Miller County, Georgia, Mitchell County, Georgia, Monroe County, Georgia, Montgomery County, Georgia, Morgan County, Georgia, Murray County, Georgia, Muscogee County, Georgia, Newberry County, South Carolina, Newton County, Georgia, Oconee County, Georgia, Oconee County, South Carolina, Oglethorpe County, Georgia, Orangeburg County, South Carolina, Paulding County, Georgia, Peach County, Georgia, Pickens County, Georgia, Pickens County, South Carolina, Pierce County, Georgia, Pike County, Georgia, Polk County, Georgia, Pulaski County, Georgia, Putnam County, Georgia, Quitman County, Georgia, Rabun County, Georgia, Randolph County, Georgia, Richland County, South Carolina, Richmond County, Georgia, Rockdale County, Georgia, Saluda County, South Carolina, Schley County, Georgia, Screven County, Georgia, Seminole County, Georgia, Spalding County, Georgia, Spartanburg County, South Carolina, Stephens County, Georgia, Stewart County, Georgia, Sumter County, Georgia, Talbot County, Georgia, Taliaferro County, Georgia, Tattnall County, Georgia, Taylor County, Georgia, Telfair County, Georgia, Terrell County, Georgia, Thomas County, Georgia, Tift County, Georgia, Toombs County, Georgia, Towns County, Georgia, Treutlen County, Georgia, Troup County, Georgia, Turner County, Georgia, Twiggs County, Georgia, Union County, Georgia, Union County, South Carolina, Upson County, Georgia, Walton County, Georgia, Ware County, Georgia, Warren County, Georgia, Washington County, Georgia, Wayne County, Georgia, Webster County, Georgia, Wheeler County, Georgia, White County, Georgia, Wilcox County, Georgia, Wilkes County, Georgia, Wilkinson County, Georgia, Williamsburg County, South Carolina, Worth County, Georgia, York County, South Carolina

NOTE: Information on MedicarePolicyHelper.com is for educational purposes only. We are not affiliated with Medicare, or CMS. Medicare has not reviewed or endorsed the information on our site. All plan data on our site comes directly from medicare.gov and is subject to change.