Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5216-200-000
Plan Organization Humana
Plan Type Local PPO *
Plan Name Humana Honor (PPO)
Drugs Covered No
Doctors Choice Any Doctor
Overall Star Rating 4
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $95.50
Monthly Part C Premium $0.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6700.00

Medicare Advantage Plan Health Benefits


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
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services No - - - Not covered
Endodontics Yes Out-of-Network Yes No $0 copay
Extractions Yes Out-of-Network Yes No $0 copay
Non-routine services Yes Out-of-Network Yes No $0 copay
Periodontics Yes Out-of-Network Yes No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No $0 copay
Restorative services Yes Out-of-Network Yes No $0 copay
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 $50 copay or 30% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes No $0-50 copay or 30% coinsurance
Lab services - Out-of-Network Yes No $35-50 copay or 30% coinsurance
Outpatient x-rays - Out-of-Network Yes No $35-50 copay or 30% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $35 copay per visit
Specialist - Out-of-Network No No $50 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $0-50 copay or 30% coinsurance 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 $50 copay
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $265 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $1,000 annual deductible
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes Out-of-Network Yes No $0 copay
Hearing aids Yes Out-of-Network No No $699-999 copay
Hearing exam - Out-of-Network Yes No $50 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 30% per stay
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
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 20-30% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 16% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 30% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 30% coinsurance
Other Part B drugs - Out-of-Network Yes - 30% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No 30% per stay
Outpatient group therapy visit - Out-of-Network Yes No $50 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No $50 copay
Outpatient individual therapy visit - Out-of-Network Yes No $50 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No $50 copay
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
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $50 copay or 30% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No $0-50 copay or 30% coinsurance
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes Out-of-Network No No $0 copay
Dental x-ray(s) Yes Out-of-Network No No $0 copay
Fluoride treatment Yes Out-of-Network No No $0 copay
Oral exam Yes Out-of-Network No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes No 30% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 30% coinsurance
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 Out-of-Network Yes No 50% coinsurance
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes Out-of-Network Yes No $0 copay
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) Yes Out-of-Network Yes No $0 copay
Other No - - - Not covered
Routine eye exam Yes Out-of-Network Yes No $0 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Adams County, Mississippi, Amite County, Mississippi, Attala County, Mississippi, Benton County, Mississippi, Bolivar County, Mississippi, Calhoun County, Mississippi, Carroll County, Mississippi, Chickasaw County, Mississippi, Choctaw County, Mississippi, Claiborne County, Mississippi, Clarke County, Mississippi, Coahoma County, Mississippi, Copiah County, Mississippi, Covington County, Mississippi, Desoto County, Mississippi, Forrest County, Mississippi, Franklin County, Mississippi, George County, Mississippi, Greene County, Mississippi, Hancock County, Mississippi, Harrison County, Mississippi, Hinds County, Mississippi, Holmes County, Mississippi, Humphreys County, Mississippi, Issaquena County, Mississippi, Jackson County, Mississippi, Jasper County, Mississippi, Jefferson County, Mississippi, Jefferson Davis County, Mississippi, Jones County, Mississippi, Kemper County, Mississippi, Lafayette County, Mississippi, Lamar County, Mississippi, Lauderdale County, Mississippi, Lawrence County, Mississippi, Leake County, Mississippi, Leflore County, Mississippi, Madison County, Mississippi, Marion County, Mississippi, Marshall County, Mississippi, Monroe County, Mississippi, Montgomery County, Mississippi, Neshoba County, Mississippi, Newton County, Mississippi, Noxubee County, Mississippi, Panola County, Mississippi, Pearl River County, Mississippi, Perry County, Mississippi, Pike County, Mississippi, Quitman County, Mississippi, Rankin County, Mississippi, Scott County, Mississippi, Sharkey County, Mississippi, Simpson County, Mississippi, Smith County, Mississippi, Stone County, Mississippi, Sunflower County, Mississippi, Tallahatchie County, Mississippi, Tate County, Mississippi, Tunica County, Mississippi, Walthall County, Mississippi, Warren County, Mississippi, Wayne County, Mississippi, Wilkinson County, Mississippi, Winston County, Mississippi, Yalobusha County, Mississippi, Yazoo County, Mississippi

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