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 |
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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