Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5216-207-000
Plan Organization Humana
Plan Type Local PPO
Plan Name HumanaChoice H5216-207 (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 $0.00
Total Premium (Includes Part B) $135.50
Monthly Part D Basic Premium $0.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $0.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $0.00
Monthly Part D Premium 50% Assistance $0.00
Monthly Part D Premium 25% Assistance $0.00
Part D Drug Deductible $195.00
Annual Drug Deductible $195.00
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 No - - - Not covered
Restorative services Yes Out-of-Network Yes No 55-75%
Extractions Yes In-Network Yes No 50%
Prosthodontics, other oral/maxillofacial surgery, other services Yes In-Network Yes No 70%
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Diagnostic services No - - - Not covered
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - In-Network - - $20 per visit
Specialist - In-Network No No $50 per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 per visit (always covered)
Urgent care - - - - $20-50 per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network Yes No $40-55
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 Out-of-Network Yes No $0 copay
Hearing aids Yes In-Network No No $699-999
Hearing exam - Out-of-Network Yes No $40-55
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - $10 or 20%
Other Part B drugs - Out-of-Network Yes - $10 or 20%
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No $40-55
Outpatient individual therapy visit - In-Network Yes No $40
Outpatient group therapy visit - In-Network Yes No $40
Outpatient individual therapy visit with a psychiatrist - In-Network Yes No $40
Inpatient hospital - psychiatric - In-Network Yes No $587 per day for days 1 through 3 $0 per day for days 4 through 90
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $40-510 per visit
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Dental x-ray(s) Yes Out-of-Network No No 50%
Cleaning Yes Out-of-Network No No 50%
Oral exam Yes In-Network No No $0 copay
Fluoride treatment No - - - Not covered
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 $25-40
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-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 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
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes No $40-510
Diagnostic tests and procedures - Out-of-Network Yes No $0-100
Lab services - Out-of-Network Yes No $0-50
Outpatient x-rays - In-Network Yes No $20-100
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $375 per day for days 1 through 5 $0 per day for days 6 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,700 In and Out-of-network $6,700 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - In-Network Yes - $0 or 10-20% 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
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
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
Eyeglass lenses No - - - Not covered
Routine eye exam Yes Out-of-Network Yes No $0 copay
Upgrades - - - - Not covered
Eyeglass frames No - - - Not covered
Other No - - - Not 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
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
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Appling County, Georgia, Atkinson County, Georgia, Bacon County, Georgia, Baldwin County, Georgia, Banks County, Georgia, Ben Hill County, Georgia, Berrien County, Georgia, Bleckley County, Georgia, Brantley County, Georgia, Brooks County, Georgia, Calhoun County, Georgia, Candler County, Georgia, Charlton County, Georgia, Clay County, Georgia, Clinch County, Georgia, Colquitt County, Georgia, Cook County, Georgia, Crisp County, Georgia, Decatur County, Georgia, Dodge County, Georgia, Dooly County, Georgia, Early County, Georgia, Echols County, Georgia, Elbert County, Georgia, Emanuel County, Georgia, Evans County, Georgia, Fannin County, Georgia, Franklin County, Georgia, Gilmer County, Georgia, Glascock County, Georgia, Grady County, Georgia, Greene County, Georgia, Habersham County, Georgia, Hancock County, Georgia, Hart County, Georgia, Irwin County, Georgia, Jeff Davis County, Georgia, Jefferson County, Georgia, Johnson County, Georgia, Laurens County, Georgia, Lumpkin County, Georgia, Macon County, Georgia, Miller County, Georgia, Mitchell County, Georgia, Montgomery County, Georgia, Morgan County, Georgia, Pierce County, Georgia, Pulaski County, Georgia, Putnam County, Georgia, Quitman County, Georgia, Rabun County, Georgia, Randolph County, Georgia, Schley County, Georgia, Seminole County, Georgia, Stephens County, Georgia, Taliaferro County, Georgia, Tattnall County, Georgia, Taylor County, Georgia, Telfair County, Georgia, Thomas County, Georgia, Tift County, Georgia, Toombs County, Georgia, Towns County, Georgia, Treutlen County, Georgia, Turner County, Georgia, Union County, Georgia, Ware County, Georgia, Warren County, Georgia, Washington County, Georgia, Wayne County, Georgia, Wheeler County, Georgia, White County, Georgia, Wilcox County, Georgia, Wilkes County, Georgia, Wilkinson County, Georgia

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.