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
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, Coffee 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, Lanier County, Georgia, 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, Sumter County, South Carolina, 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, Whitfield County, Georgia, Wilcox County, Georgia, Wilkes County, Georgia, Wilkinson County, Georgia, Williamsburg County, South Carolina, Worth County, Georgia, York County, South Carolina

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