Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID R1390-001-000
Plan Organization Humana
Plan Type Regional PPO *
Plan Name HumanaChoice R1390-001 (Regional PPO)
Drugs Covered No
Doctors Choice Any Doctor
Overall Star Rating 3.5
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $5400.00

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 $50-275 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 $15-110 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $15-110 copay per visit
Specialist - Out-of-Network No No $50 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 - - - - $15-50 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 $50 copay
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
- - - - $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 $399-699 copay
Hearing exam - Out-of-Network Yes No $50 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $275 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
- - - - $5,400 In and Out-of-network$5,400 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - $10 copay or 10-20% 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 $275 per day for days 1 through 6$0 per day for days 7 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
- - - - 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 $50-275 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 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 $10-40 copay
Physical therapy and speech and language therapy visit - Out-of-Network Yes No $10-40 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$178 per day for days 21 through 100
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 $22.00
Preventive dental Monthly Premium $22.00
Package #2
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $26.80
Preventive dental Monthly Premium $26.80
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
Accomack County, Virginia, Alamance County, North Carolina, Albemarle County, Virginia, Alexander County, North Carolina, Alexandria City County, Virginia, Alleghany County, North Carolina, Alleghany County, Virginia, Amelia County, Virginia, Amherst County, Virginia, Anson County, North Carolina, Appomattox County, Virginia, Arlington County, Virginia, Ashe County, North Carolina, Augusta County, Virginia, Avery County, North Carolina, Bath County, Virginia, Beaufort County, North Carolina, Bedford County, Virginia, Bertie County, North Carolina, Bladen County, North Carolina, Bland County, Virginia, Botetourt County, Virginia, Bristol City County, Virginia, Brunswick County, North Carolina, Brunswick County, Virginia, Buchanan County, Virginia, Buckingham County, Virginia, Buena Vista City County, Virginia, Buncombe County, North Carolina, Burke County, North Carolina, Cabarrus County, North Carolina, Caldwell County, North Carolina, Camden County, North Carolina, Campbell County, Virginia, Caroline County, Virginia, Carroll County, Virginia, Carteret County, North Carolina, Caswell County, North Carolina, Catawba County, North Carolina, Charles City County, Virginia, Charlotte County, Virginia, Charlottesville City County, Virginia, Chatham County, North Carolina, Cherokee County, North Carolina, Chesapeake City County, Virginia, Chesterfield County, Virginia, Chowan County, North Carolina, Clarke County, Virginia, Clay County, North Carolina, Cleveland County, North Carolina, Colonial Heights City County, Virginia, Columbus County, North Carolina, Covington City County, Virginia, Craig County, Virginia, Craven County, North Carolina, Culpeper County, Virginia, Cumberland County, North Carolina, Cumberland County, Virginia, Currituck County, North Carolina, Danville City County, Virginia, Dare County, North Carolina, Davidson County, North Carolina, Davie County, North Carolina, Dickenson County, Virginia, Dinwiddie County, Virginia, Duplin County, North Carolina, Durham County, North Carolina, Edgecombe County, North Carolina, Emporia City County, Virginia, Essex County, Virginia, Fairfax City County, Virginia, Fairfax County, Virginia, Falls Church City County, Virginia, Fauquier County, Virginia, Floyd County, Virginia, Fluvanna County, Virginia, Forsyth County, North Carolina, Franklin City County, Virginia, Franklin County, North Carolina, Franklin County, Virginia, Frederick County, Virginia, Fredericksburg City County, Virginia, Galax City County, Virginia, Gaston County, North Carolina, Gates County, North Carolina, Giles County, Virginia, Gloucester County, Virginia, Goochland County, Virginia, Graham County, North Carolina, Granville County, North Carolina, Grayson County, Virginia, Greene County, North Carolina, Greene County, Virginia, Greensville County, Virginia, Guilford County, North Carolina, Halifax County, North Carolina, Halifax County, Virginia, Hampton City County, Virginia, Hanover County, Virginia, Harnett County, North Carolina, Harrisonburg City County, Virginia, Haywood County, North Carolina, Henderson County, North Carolina, Henrico County, Virginia, Henry County, Virginia, Hertford County, North Carolina, Highland County, Virginia, Hoke County, North Carolina, Hopewell City County, Virginia, Hyde County, North Carolina, Iredell County, North Carolina, Isle Of Wight County, Virginia, Jackson County, North Carolina, James City County, Virginia, Johnston County, North Carolina, Jones County, North Carolina, King And Queen County, Virginia, King George County, Virginia, King William County, Virginia, Lancaster County, Virginia, Lee County, North Carolina, Lee County, Virginia, Lenoir County, North Carolina, Lexington City County, Virginia, Lincoln County, North Carolina, Loudoun County, Virginia, Louisa County, Virginia, Lunenburg County, Virginia, Lynchburg City County, Virginia, Macon County, North Carolina, Madison County, North Carolina, Madison County, Virginia, Manassas City County, Virginia, Manassas Park City County, Virginia, Martin County, North Carolina, Martinsville City County, Virginia, Mathews County, Virginia, Mcdowell County, North Carolina, Mecklenburg County, North Carolina, Mecklenburg County, Virginia, Middlesex County, Virginia, Mitchell County, North Carolina, Montgomery County, North Carolina, Montgomery County, Virginia, Moore County, North Carolina, Nash County, North Carolina, Nelson County, Virginia, New Hanover County, North Carolina, New Kent County, Virginia, Newport News City County, Virginia, Norfolk City County, Virginia, Northampton County, North Carolina, Northampton County, Virginia, Northumberland County, Virginia, Norton City County, Virginia, Nottoway County, Virginia, Onslow County, North Carolina, Orange County, North Carolina, Orange County, Virginia, Page County, Virginia, Pamlico County, North Carolina, Pasquotank County, North Carolina, Patrick County, Virginia, Pender County, North Carolina, Perquimans County, North Carolina, Person County, North Carolina, Petersburg City County, Virginia, Pitt County, North Carolina, Pittsylvania County, Virginia, Polk County, North Carolina, Poquoson City County, Virginia, Portsmouth City County, Virginia, Powhatan County, Virginia, Prince Edward County, Virginia, Prince George County, Virginia, Prince William County, Virginia, Pulaski County, Virginia, Radford County, Virginia, Randolph County, North Carolina, Rappahannock County, Virginia, Richmond City County, Virginia, Richmond County, North Carolina, Richmond County, Virginia, Roanoke City County, Virginia, Roanoke County, Virginia, Robeson County, North Carolina, Rockbridge County, Virginia, Rockingham County, North Carolina, Rockingham County, Virginia, Rowan County, North Carolina, Russell County, Virginia, Rutherford County, North Carolina, Salem County, Virginia, Sampson County, North Carolina, Scotland County, North Carolina, Scott County, Virginia, Shenandoah County, Virginia, Smyth County, Virginia, Southampton County, Virginia, Spotsylvania County, Virginia, Stafford County, Virginia, Stanly County, North Carolina, Staunton City County, Virginia, Stokes County, North Carolina, Suffolk City County, Virginia, Surry County, North Carolina, Surry County, Virginia, Sussex County, Virginia, Swain County, North Carolina, Tazewell County, Virginia, Transylvania County, North Carolina, Tyrrell County, North Carolina, Union County, North Carolina, Vance County, North Carolina, Virginia Beach City County, Virginia, Wake County, North Carolina, Warren County, North Carolina, Warren County, Virginia, Washington County, North Carolina, Washington County, Virginia, Watauga County, North Carolina, Wayne County, North Carolina, Waynesboro City County, Virginia, Westmoreland County, Virginia, Wilkes County, North Carolina, Williamsburg City County, Virginia, Wilson County, North Carolina, Winchester City County, Virginia, Wise County, Virginia, Wythe County, Virginia, Yadkin County, North Carolina, Yancey County, North Carolina, York County, Virginia

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