Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5216-207-000
Plan Organization Humana
Plan Type Local PPO
Plan Name HumanaChoice H5216-207 (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) $135.50
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 $75.00
Annual Drug Deductible $75.00
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 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 $45-495 copay
Diagnostic tests and procedures - Out-of-Network Yes No $0-100 copay
Lab services - Out-of-Network Yes No $0-100 copay
Outpatient x-rays - Out-of-Network Yes No $10-100 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $10-100 copay per visit
Specialist - Out-of-Network No No $45 copay or 20% 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 - - - - $10-45 copay 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 copay or 20% coinsurance
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $290 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 $699-999 copay
Hearing exam - Out-of-Network Yes No $45 copay or 20% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $375 per day for days 1 through 5$0 per day for days 6 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $7,550 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 - $10 copay or 20% 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 - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 20% coinsurance
Other Part B drugs - Out-of-Network Yes - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No $587 per day for days 1 through 3$0 per day for days 4 through 90
Outpatient group therapy visit - Out-of-Network Yes No $40-100 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No $40-100 copay
Outpatient individual therapy visit - Out-of-Network Yes No $40-100 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No $40-100 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 $45-495 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No $0 copay
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 $25-40 copay
Physical therapy and speech and language therapy visit - Out-of-Network Yes No $25-40 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $0 per day for days 1 through 20$184 per day for days 21 through 100
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
Appling County, Georgia, Atkinson County, Georgia, Bacon County, Georgia, Baldwin County, Georgia, Banks County, Georgia, Ben Hill County, Georgia, Berrien County, Georgia, Bleckley County, Georgia, Brantley County, Georgia, Brooks County, Georgia, Calhoun County, Georgia, Candler County, Georgia, Catoosa County, Georgia, Charlton County, Georgia, Clay County, Georgia, Clinch County, Georgia, Coffee County, Georgia, Colquitt County, Georgia, Cook County, Georgia, Crisp County, Georgia, Dade County, Georgia, Decatur County, Georgia, Dodge County, Georgia, Dooly County, Georgia, Early County, Georgia, Echols County, Georgia, Elbert County, Georgia, Emanuel County, Georgia, Evans County, Georgia, Fannin County, Georgia, Franklin County, Georgia, Gilmer County, Georgia, Glascock County, Georgia, Grady County, Georgia, Greene County, Georgia, Habersham County, Georgia, Hancock County, Georgia, Hart County, Georgia, Irwin County, Georgia, Jeff Davis County, Georgia, Jefferson County, Georgia, Johnson County, Georgia, Lanier County, Georgia, Laurens County, Georgia, Lumpkin County, Georgia, Macon County, Georgia, Miller County, Georgia, Mitchell County, Georgia, Montgomery County, Georgia, Morgan County, Georgia, Murray County, Georgia, Pierce County, Georgia, Pulaski County, Georgia, Putnam County, Georgia, Quitman County, Georgia, Rabun County, Georgia, Randolph County, Georgia, Schley County, Georgia, Seminole County, Georgia, Stephens County, Georgia, Taliaferro County, Georgia, Tattnall County, Georgia, Taylor County, Georgia, Telfair County, Georgia, Thomas County, Georgia, Tift County, Georgia, Toombs County, Georgia, Towns County, Georgia, Treutlen County, Georgia, Turner County, Georgia, Union County, Georgia, Ware County, Georgia, Warren County, Georgia, Washington County, Georgia, Wayne County, Georgia, Wheeler County, Georgia, White County, Georgia, Whitfield County, Georgia, Wilcox County, Georgia, Wilkes County, Georgia, Wilkinson County, Georgia

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