Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5216-105-000
Plan Organization Humana
Plan Type Local PPO *
Plan Name HumanaChoice H5216-105 (PPO)
Drugs Covered No
Doctors Choice Any Doctor
Overall Star Rating 4
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $4500.00

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 No - - - Not covered
Extractions Yes Out-of-Network Yes No 55-75% coinsurance
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No 55-75% coinsurance
Restorative services Yes Out-of-Network Yes No 55-75% coinsurance
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 30% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes No $0 copay or 30% coinsurance
Lab services - Out-of-Network Yes No 30% coinsurance
Outpatient x-rays - Out-of-Network Yes No 30% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 30% coinsurance per visit
Specialist - Out-of-Network No No 30% coinsurance per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $10-35 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 30% coinsurance
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $270 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
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 $499-799 copay
Hearing exam - Out-of-Network Yes No 30% coinsurance
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$4,500 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 30% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 30% 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 30% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 30% coinsurance
Outpatient individual therapy visit - Out-of-Network Yes No 30% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 30% coinsurance
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 30% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No $0 copay or 30% coinsurance
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes Out-of-Network No No 50% coinsurance
Dental x-ray(s) Yes Out-of-Network No No 50% coinsurance
Fluoride treatment No - - - Not covered
Oral exam Yes Out-of-Network No No 50% coinsurance
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
Adair County, Kentucky, Allen County, Kentucky, Anderson County, Kentucky, Ballard County, Kentucky, Barbour County, West Virginia, Barren County, Kentucky, Bath County, Kentucky, Bell County, Kentucky, Berkeley County, West Virginia, Boone County, Kentucky, Boone County, West Virginia, Bourbon County, Kentucky, Boyd County, Kentucky, Boyle County, Kentucky, Bracken County, Kentucky, Braxton County, West Virginia, Breathitt County, Kentucky, Breckinridge County, Kentucky, Brooke County, West Virginia, Bullitt County, Kentucky, Butler County, Kentucky, Cabell County, West Virginia, Caldwell County, Kentucky, Calhoun County, West Virginia, Calloway County, Kentucky, Campbell County, Kentucky, Carlisle County, Kentucky, Carroll County, Kentucky, Carter County, Kentucky, Casey County, Kentucky, Christian County, Kentucky, Clark County, Kentucky, Clay County, Kentucky, Clay County, West Virginia, Clinton County, Kentucky, Crittenden County, Kentucky, Cumberland County, Kentucky, Daviess County, Kentucky, Doddridge County, West Virginia, Edmonson County, Kentucky, Elliott County, Kentucky, Estill County, Kentucky, Fayette County, Kentucky, Fayette County, West Virginia, Fleming County, Kentucky, Floyd County, Kentucky, Franklin County, Kentucky, Fulton County, Kentucky, Gallatin County, Kentucky, Garrard County, Kentucky, Gilmer County, West Virginia, Grant County, Kentucky, Grant County, West Virginia, Graves County, Kentucky, Grayson County, Kentucky, Green County, Kentucky, Greenbrier County, West Virginia, Greenup County, Kentucky, Hampshire County, West Virginia, Hancock County, Kentucky, Hancock County, West Virginia, Hardin County, Kentucky, Hardy County, West Virginia, Harlan County, Kentucky, Harrison County, Kentucky, Harrison County, West Virginia, Hart County, Kentucky, Henderson County, Kentucky, Henry County, Kentucky, Hickman County, Kentucky, Hopkins County, Kentucky, Jackson County, Kentucky, Jackson County, West Virginia, Jefferson County, Kentucky, Jefferson County, West Virginia, Jessamine County, Kentucky, Johnson County, Kentucky, Kanawha County, West Virginia, Kenton County, Kentucky, Knott County, Kentucky, Knox County, Kentucky, Larue County, Kentucky, Laurel County, Kentucky, Lawrence County, Kentucky, Lee County, Kentucky, Leslie County, Kentucky, Letcher County, Kentucky, Lewis County, Kentucky, Lewis County, West Virginia, Lincoln County, Kentucky, Lincoln County, West Virginia, Livingston County, Kentucky, Logan County, Kentucky, Logan County, West Virginia, Lyon County, Kentucky, Madison County, Kentucky, Magoffin County, Kentucky, Marion County, Kentucky, Marion County, West Virginia, Marshall County, Kentucky, Marshall County, West Virginia, Martin County, Kentucky, Mason County, Kentucky, Mason County, West Virginia, Mccracken County, Kentucky, Mccreary County, Kentucky, Mcdowell County, West Virginia, Mclean County, Kentucky, Meade County, Kentucky, Menifee County, Kentucky, Mercer County, Kentucky, Mercer County, West Virginia, Metcalfe County, Kentucky, Mineral County, West Virginia, Mingo County, West Virginia, Monongalia County, West Virginia, Monroe County, Kentucky, Monroe County, West Virginia, Montgomery County, Kentucky, Morgan County, Kentucky, Morgan County, West Virginia, Muhlenberg County, Kentucky, Nelson County, Kentucky, Nicholas County, Kentucky, Nicholas County, West Virginia, Ohio County, Kentucky, Ohio County, West Virginia, Oldham County, Kentucky, Owen County, Kentucky, Owsley County, Kentucky, Pendleton County, Kentucky, Pendleton County, West Virginia, Perry County, Kentucky, Pike County, Kentucky, Pleasants County, West Virginia, Pocahontas County, West Virginia, Powell County, Kentucky, Preston County, West Virginia, Pulaski County, Kentucky, Putnam County, West Virginia, Raleigh County, West Virginia, Randolph County, West Virginia, Ritchie County, West Virginia, Roane County, West Virginia, Robertson County, Kentucky, Rockcastle County, Kentucky, Rowan County, Kentucky, Russell County, Kentucky, Scott County, Kentucky, Shelby County, Kentucky, Simpson County, Kentucky, Spencer County, Kentucky, Summers County, West Virginia, Taylor County, Kentucky, Taylor County, West Virginia, Todd County, Kentucky, Trigg County, Kentucky, Trimble County, Kentucky, Tucker County, West Virginia, Tyler County, West Virginia, Union County, Kentucky, Upshur County, West Virginia, Warren County, Kentucky, Washington County, Kentucky, Wayne County, Kentucky, Wayne County, West Virginia, Webster County, Kentucky, Webster County, West Virginia, Wetzel County, West Virginia, Whitley County, Kentucky, Wirt County, West Virginia, Wolfe County, Kentucky, Wood County, West Virginia, Woodford County, Kentucky, Wyoming County, West Virginia

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