HumanaChoice H5216-154 (PPO) | 2021 Medicare Advantage Plan

Plan Basics

Contract Year	2021
Medicare Type	Medicare Advantage Plan (Part C)
CMS Plan ID	H5216-154-000
Plan Organization	Humana
Plan Type	Local PPO
Plan Name	HumanaChoice H5216-154 (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

Plan Cost Sharing

Premium	$0.00
Total Premium (Includes Part B)	$85.50
Monthly Part C Premium	$0.00
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	$400.00
Annual Drug Deductible	$400.00
Tiers Excluded From Deductible	1
Part D Initial Coverage Limit	$4130.00
Part D Catastrophic Coverage Threshold	$6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP)	$7550.00
Gap Coverage	No

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	No	-	-	-	Not covered
Non-routine services	No	-	-	-	Not covered
Periodontics	No	-	-	-	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	No	-	-	-	Not covered
Restorative services	No	-	-	-	Not 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	45% coinsurance
Diagnostic tests and procedures	-	Out-of-Network	Yes	No	$0 copay or 45% coinsurance
Lab services	-	Out-of-Network	Yes	No	45% coinsurance
Outpatient x-rays	-	Out-of-Network	Yes	No	45% coinsurance

Doctor Visits

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Primary	-	Out-of-Network	-	-	45% coinsurance per visit
Specialist	-	Out-of-Network	No	No	45% 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	-	-	-	-	$20-50 copay or 45% 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	45% 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
	-	-	-	-	$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	$599-899 copay
Hearing exam	-	Out-of-Network	Yes	No	45% coinsurance

Inpatient Hospital Coverage

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
	-	Out-of-Network	Yes	No	45% per stay

Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
	-	-	-	-	$11,300 In and Out-of-network$7,550 In-network

Medical Equipment/supplies

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Diabetes supplies	-	Out-of-Network	Yes	-	45% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	-	Out-of-Network	Yes	-	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	-	Out-of-Network	Yes	-	25% coinsurance per item

Medicare Part B Drugs

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Chemotherapy	-	Out-of-Network	Yes	-	45% coinsurance
Other Part B drugs	-	Out-of-Network	Yes	-	45% coinsurance

Mental Health Services

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Inpatient hospital - psychiatric	-	Out-of-Network	Yes	No	50% per stay
Outpatient group therapy visit	-	Out-of-Network	Yes	No	45% coinsurance
Outpatient group therapy visit with a psychiatrist	-	Out-of-Network	Yes	No	45% coinsurance
Outpatient individual therapy visit	-	Out-of-Network	Yes	No	45% coinsurance
Outpatient individual therapy visit with a psychiatrist	-	Out-of-Network	Yes	No	45% coinsurance

Optional Supplemental Benefits

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
	-	-	-	-	Yes

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	45% coinsurance per visit

Preventive Care

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
	-	Out-of-Network	No	No	$0 copay or 45% coinsurance

Preventive Dental

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Cleaning	No	-	-	-	Not covered
Dental x-ray(s)	No	-	-	-	Not covered
Fluoride treatment	No	-	-	-	Not covered
Oral exam	No	-	-	-	Not covered

Rehabilitation Services

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
Occupational therapy visit	-	Out-of-Network	Yes	No	45% coinsurance
Physical therapy and speech and language therapy visit	-	Out-of-Network	Yes	No	45% coinsurance

Skilled Nursing Facility

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
	-	Out-of-Network	Yes	No	45% per stay

Transportation

Service	Cap	Network	Auth. Req.	Ref. Req.	Cost Share
	-	-	-	-	Not covered

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

Medicare Plan Packages

Package #1

Category	Cost Sharing Type	Cost Share
Comprehensive dental	Monthly Premium	$19.50
Preventive dental	Monthly Premium	$19.50

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

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HumanaChoice H5216-154 (PPO) - 2021

HumanaChoice H5216-154 (PPO) - Humana - Local PPO