Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID R7315-002-000
Plan Organization Humana
Plan Type Regional PPO
Plan Name HumanaChoice R7315-002 (Regional PPO)
Plan Organization Type Regional CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Basic Alternative
Special Needs Plan No
Overall Star Rating 3.5
Plan Cost Sharing
Premium $71.00
Total Premium (Includes Part B) $206.50
Monthly Part C Premium $29.50
Monthly Part D Basic Premium $41.50
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $41.50
Monthly Part D Premium Full Assistance $11.30
Monthly Part D Premium 75% Assistance $18.80
Monthly Part D Premium 50% Assistance $26.40
Monthly Part D Premium 25% Assistance $33.90
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) $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 - - 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 40% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes No $0 copay or 40% coinsurance
Lab services - Out-of-Network Yes No 40% coinsurance
Outpatient x-rays - Out-of-Network Yes No 40% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 40% coinsurance per visit
Specialist - Out-of-Network No No 40% 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 - - - - $20-45 copay or 40% 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 40% 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
- - - - $250 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 40% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 40% 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 - 25% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 20-40% coinsurance
Other Part B drugs - Out-of-Network Yes - 20-40% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No 40% per stay
Outpatient group therapy visit - Out-of-Network Yes No 40% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 40% coinsurance
Outpatient individual therapy visit - Out-of-Network Yes No 40% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 40% 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 40% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No $0 copay or 40% 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 40% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 40% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 40% 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 $16.30
Preventive dental Monthly Premium $16.30
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
Anderson County, Tennessee, Autauga County, Alabama, Baldwin County, Alabama, Barbour County, Alabama, Bedford County, Tennessee, Benton County, Tennessee, Bibb County, Alabama, Bledsoe County, Tennessee, Blount County, Alabama, Blount County, Tennessee, Bradley County, Tennessee, Bullock County, Alabama, Butler County, Alabama, Calhoun County, Alabama, Campbell County, Tennessee, Cannon County, Tennessee, Carroll County, Tennessee, Carter County, Tennessee, Chambers County, Alabama, Cheatham County, Tennessee, Cherokee County, Alabama, Chester County, Tennessee, Chilton County, Alabama, Choctaw County, Alabama, Claiborne County, Tennessee, Clarke County, Alabama, Clay County, Alabama, Clay County, Tennessee, Cleburne County, Alabama, Cocke County, Tennessee, Coffee County, Alabama, Coffee County, Tennessee, Colbert County, Alabama, Conecuh County, Alabama, Coosa County, Alabama, Covington County, Alabama, Crenshaw County, Alabama, Crockett County, Tennessee, Cullman County, Alabama, Cumberland County, Tennessee, Dale County, Alabama, Dallas County, Alabama, Davidson County, Tennessee, Decatur County, Tennessee, Dekalb County, Alabama, Dekalb County, Tennessee, Dickson County, Tennessee, Dyer County, Tennessee, Elmore County, Alabama, Escambia County, Alabama, Etowah County, Alabama, Fayette County, Alabama, Fayette County, Tennessee, Fentress County, Tennessee, Franklin County, Alabama, Franklin County, Tennessee, Geneva County, Alabama, Gibson County, Tennessee, Giles County, Tennessee, Grainger County, Tennessee, Greene County, Alabama, Greene County, Tennessee, Grundy County, Tennessee, Hale County, Alabama, Hamblen County, Tennessee, Hamilton County, Tennessee, Hancock County, Tennessee, Hardeman County, Tennessee, Hardin County, Tennessee, Hawkins County, Tennessee, Haywood County, Tennessee, Henderson County, Tennessee, Henry County, Alabama, Henry County, Tennessee, Hickman County, Tennessee, Houston County, Alabama, Houston County, Tennessee, Humphreys County, Tennessee, Jackson County, Alabama, Jackson County, Tennessee, Jefferson County, Alabama, Jefferson County, Tennessee, Johnson County, Tennessee, Knox County, Tennessee, Lake County, Tennessee, Lamar County, Alabama, Lauderdale County, Alabama, Lauderdale County, Tennessee, Lawrence County, Alabama, Lawrence County, Tennessee, Lee County, Alabama, Lewis County, Tennessee, Limestone County, Alabama, Lincoln County, Tennessee, Loudon County, Tennessee, Lowndes County, Alabama, Macon County, Alabama, Macon County, Tennessee, Madison County, Alabama, Madison County, Tennessee, Marengo County, Alabama, Marion County, Alabama, Marion County, Tennessee, Marshall County, Alabama, Marshall County, Tennessee, Maury County, Tennessee, Mcminn County, Tennessee, Mcnairy County, Tennessee, Meigs County, Tennessee, Mobile County, Alabama, Monroe County, Alabama, Monroe County, Tennessee, Montgomery County, Alabama, Montgomery County, Tennessee, Moore County, Tennessee, Morgan County, Alabama, Morgan County, Tennessee, Obion County, Tennessee, Overton County, Tennessee, Perry County, Alabama, Perry County, Tennessee, Pickens County, Alabama, Pickett County, Tennessee, Pike County, Alabama, Polk County, Tennessee, Putnam County, Tennessee, Randolph County, Alabama, Rhea County, Tennessee, Roane County, Tennessee, Robertson County, Tennessee, Russell County, Alabama, Rutherford County, Tennessee, Saint Clair County, Alabama, Scott County, Tennessee, Sequatchie County, Tennessee, Sevier County, Tennessee, Shelby County, Alabama, Shelby County, Tennessee, Smith County, Tennessee, Stewart County, Tennessee, Sullivan County, Tennessee, Sumner County, Tennessee, Sumter County, Alabama, Talladega County, Alabama, Tallapoosa County, Alabama, Tipton County, Tennessee, Trousdale County, Tennessee, Tuscaloosa County, Alabama, Unicoi County, Tennessee, Union County, Tennessee, Van Buren County, Tennessee, Walker County, Alabama, Warren County, Tennessee, Washington County, Alabama, Washington County, Tennessee, Wayne County, Tennessee, Weakley County, Tennessee, White County, Tennessee, Wilcox County, Alabama, Williamson County, Tennessee, Wilson County, Tennessee, Winston County, Alabama

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