Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5216-241-000
Plan Organization Humana
Plan Type Local PPO
Plan Name HumanaChoice H5216-241 (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 $28.70
Total Premium (Includes Part B) $164.20
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $28.70
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $28.70
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $7.20
Monthly Part D Premium 50% Assistance $14.40
Monthly Part D Premium 25% Assistance $21.50
Part D Drug Deductible $445.00
Annual Drug Deductible $445.00
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 Yes Out-of-Network Yes No 50% coinsurance
Extractions Yes Out-of-Network Yes No 50% coinsurance
Non-routine services Yes Out-of-Network Yes No 50% coinsurance
Periodontics Yes Out-of-Network Yes No 50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No 50% coinsurance
Restorative services Yes Out-of-Network Yes No 50% 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 $15-495 copay
Diagnostic tests and procedures - Out-of-Network Yes No $0-100 copay
Lab services - Out-of-Network Yes No $0-15 copay
Outpatient x-rays - Out-of-Network Yes No $0-100 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $0 copay
Specialist - Out-of-Network No No $15 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $0-15 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 $15 copay
Routine foot care Yes Out-of-Network Yes No $15 copay
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 $299-599 copay
Hearing exam - Out-of-Network Yes No $15 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $325 per day for days 1 through 6$0 per day for days 7 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 - $0-10 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 $15-495 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 Yes Out-of-Network No No 50% coinsurance
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 $15 copay
Physical therapy and speech and language therapy visit - Out-of-Network Yes No $15 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
- - Yes 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
Abbeville County, South Carolina, Aiken County, South Carolina, Allendale County, South Carolina, Anderson County, South Carolina, Bamberg County, South Carolina, Barnwell County, South Carolina, Barrow County, Georgia, Bartow County, Georgia, Beaufort County, South Carolina, Berkeley County, South Carolina, Bryan County, Georgia, Burke County, Georgia, Butts County, Georgia, Calhoun County, South Carolina, Carroll County, Georgia, Charleston County, South Carolina, Chatham County, Georgia, Chattahoochee County, Georgia, Cherokee County, Georgia, Cherokee County, South Carolina, Chester County, South Carolina, Chesterfield County, South Carolina, Clarendon County, South Carolina, Clarke County, Georgia, Clayton County, Georgia, Cobb County, Georgia, Colleton County, South Carolina, Columbia County, Georgia, Coweta County, Georgia, Darlington County, South Carolina, Dawson County, Georgia, Dekalb County, Georgia, Dillon County, South Carolina, Dorchester County, South Carolina, Douglas County, Georgia, Edgefield County, South Carolina, Effingham County, Georgia, Fairfield County, South Carolina, Fayette County, Georgia, Florence County, South Carolina, Floyd County, Georgia, Forsyth County, Georgia, Fulton County, Georgia, Georgetown County, South Carolina, Gordon County, Georgia, Greenville County, South Carolina, Greenwood County, South Carolina, Gwinnett County, Georgia, Hall County, Georgia, Hampton County, South Carolina, Haralson County, Georgia, Harris County, Georgia, Heard County, Georgia, Henry County, Georgia, Horry County, South Carolina, Jackson County, Georgia, Jasper County, Georgia, Jasper County, South Carolina, Kershaw County, South Carolina, Lamar County, Georgia, Lancaster County, South Carolina, Laurens County, South Carolina, Lee County, South Carolina, Lexington County, South Carolina, Liberty County, Georgia, Lincoln County, Georgia, Madison County, Georgia, Marion County, Georgia, Marion County, South Carolina, Marlboro County, South Carolina, Mccormick County, South Carolina, Mcduffie County, Georgia, Meriwether 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, Pickens County, Georgia, Pickens County, South Carolina, Pike County, Georgia, Polk County, Georgia, Richland County, South Carolina, Richmond County, Georgia, Rockdale County, Georgia, Saluda County, South Carolina, Spalding County, Georgia, Spartanburg County, South Carolina, Sumter County, South Carolina, Troup County, Georgia, Union County, South Carolina, Upson County, Georgia, Walton County, Georgia, Williamsburg County, South Carolina, York County, South Carolina

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