Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID R0923-002-000
Plan Organization Humana
Plan Type Regional PPO
Plan Name HumanaChoice R0923-002 (Regional PPO)
Plan Organization Type Regional CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 3.5
Plan Cost Sharing
Premium $63.00
Total Premium (Includes Part B) $198.50
Monthly Part C Premium $33.40
Monthly Part D Basic Premium $29.60
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $29.60
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $7.40
Monthly Part D Premium 50% Assistance $14.80
Monthly Part D Premium 25% Assistance $22.20
Part D Drug Deductible $0.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6700.00
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 - - Yes, contact plan for further details
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 20% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes No $0 copay or 20% coinsurance
Lab services - Out-of-Network Yes No 20% coinsurance
Outpatient x-rays - Out-of-Network Yes No 20% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 20% coinsurance per visit
Specialist - Out-of-Network No No 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 - - - - $15-45 copay or 20% 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 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
- - - - $500 annual deductible
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation No - - - Not covered
Hearing aids - inner ear No - - - Not covered
Hearing aids - outer ear No - - - Not covered
Hearing aids - over the ear No - - - Not covered
Hearing exam - Out-of-Network Yes No 20% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 20% per stay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $10,000 In and Out-of-network$6,700 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 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 20% per stay
Outpatient group therapy visit - Out-of-Network Yes No 20% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 20% coinsurance
Outpatient individual therapy visit - Out-of-Network Yes No 20% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 20% 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 20% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No $0 copay or 20% 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 20% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 20% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 20% 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 No - - - Not covered
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) No - - - Not covered
Other No - - - Not covered
Routine eye exam No - - - Not covered
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 $18.10
Preventive dental Monthly Premium $18.10
Package #2
Category Cost Sharing Type Cost Share
Eye exams Monthly Premium $15.30
Eyewear Monthly Premium $15.30
Package #3
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $21.50
Preventive dental Monthly Premium $21.50
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
Adams County, Pennsylvania, Allegheny County, Pennsylvania, Armstrong County, Pennsylvania, Barbour County, West Virginia, Beaver County, Pennsylvania, Bedford County, Pennsylvania, Berkeley County, West Virginia, Berks County, Pennsylvania, Blair County, Pennsylvania, Boone County, West Virginia, Bradford County, Pennsylvania, Braxton County, West Virginia, Brooke County, West Virginia, Bucks County, Pennsylvania, Butler County, Pennsylvania, Cabell County, West Virginia, Calhoun County, West Virginia, Cambria County, Pennsylvania, Cameron County, Pennsylvania, Carbon County, Pennsylvania, Centre County, Pennsylvania, Chester County, Pennsylvania, Clarion County, Pennsylvania, Clay County, West Virginia, Clearfield County, Pennsylvania, Clinton County, Pennsylvania, Columbia County, Pennsylvania, Crawford County, Pennsylvania, Cumberland County, Pennsylvania, Dauphin County, Pennsylvania, Delaware County, Pennsylvania, Doddridge County, West Virginia, Elk County, Pennsylvania, Erie County, Pennsylvania, Fayette County, Pennsylvania, Fayette County, West Virginia, Forest County, Pennsylvania, Franklin County, Pennsylvania, Fulton County, Pennsylvania, Gilmer County, West Virginia, Grant County, West Virginia, Greenbrier County, West Virginia, Greene County, Pennsylvania, Hampshire County, West Virginia, Hancock County, West Virginia, Hardy County, West Virginia, Harrison County, West Virginia, Huntingdon County, Pennsylvania, Indiana County, Pennsylvania, Jackson County, West Virginia, Jefferson County, Pennsylvania, Jefferson County, West Virginia, Juniata County, Pennsylvania, Kanawha County, West Virginia, Lackawanna County, Pennsylvania, Lancaster County, Pennsylvania, Lawrence County, Pennsylvania, Lebanon County, Pennsylvania, Lehigh County, Pennsylvania, Lewis County, West Virginia, Lincoln County, West Virginia, Logan County, West Virginia, Luzerne County, Pennsylvania, Lycoming County, Pennsylvania, Marion County, West Virginia, Marshall County, West Virginia, Mason County, West Virginia, Mcdowell County, West Virginia, Mckean County, Pennsylvania, Mercer County, Pennsylvania, Mercer County, West Virginia, Mifflin County, Pennsylvania, Mineral County, West Virginia, Mingo County, West Virginia, Monongalia County, West Virginia, Monroe County, Pennsylvania, Monroe County, West Virginia, Montgomery County, Pennsylvania, Montour County, Pennsylvania, Morgan County, West Virginia, Nicholas County, West Virginia, Northampton County, Pennsylvania, Northumberland County, Pennsylvania, Ohio County, West Virginia, Pendleton County, West Virginia, Perry County, Pennsylvania, Philadelphia County, Pennsylvania, Pike County, Pennsylvania, Pleasants County, West Virginia, Pocahontas County, West Virginia, Potter County, Pennsylvania, Preston County, West Virginia, Putnam County, West Virginia, Raleigh County, West Virginia, Randolph County, West Virginia, Ritchie County, West Virginia, Roane County, West Virginia, Schuylkill County, Pennsylvania, Snyder County, Pennsylvania, Somerset County, Pennsylvania, Sullivan County, Pennsylvania, Summers County, West Virginia, Susquehanna County, Pennsylvania, Taylor County, West Virginia, Tioga County, Pennsylvania, Tucker County, West Virginia, Tyler County, West Virginia, Union County, Pennsylvania, Upshur County, West Virginia, Venango County, Pennsylvania, Warren County, Pennsylvania, Washington County, Pennsylvania, Wayne County, Pennsylvania, Wayne County, West Virginia, Webster County, West Virginia, Westmoreland County, Pennsylvania, Wetzel County, West Virginia, Wirt County, West Virginia, Wood County, West Virginia, Wyoming County, Pennsylvania, Wyoming County, West Virginia, York County, Pennsylvania

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