HumanaChoice SNP-DE H5216-219 (PPO D-SNP)

Medicare Plan Details (2022 Plan)


Monthly Premium

 

by Humana
Additional Coverage
HearingVisionDental
Overall Government Star Rating
 4.0
out of 5 stars

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Plan Type

Medicare Advantage (Part C) with Prescription Drug (Part D)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D

 

$0
$0
$0
$0
$5,150 In and Out-of-network
$3,450 In-network
No
Yes
Yes
Yes

Doctor Services

In-network: $0 copay
Out-of-network: 20% coinsurance per visit
In-network: $0 copay
Out-of-network: 20% coinsurance per visit

Tests, labs, & imaging

In-network: $0 copay
Out-of-network: $0 copay or 20% coinsurance
In-network: $0 copay
Out-of-network: $0 copay or 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance
$0 copay
$0 copay

Hospital Services

In-network: $0 copay
Out-of-network: $2,524 per stay
In-network: $0 copay
Out-of-network: 20% coinsurance per visit

Skilled nursing facility

In-network: $0 copay
Out-of-network: $0 per day for days 1 through 20
$188 per day for days 21 through 100

Preventive services

In-network: $0 copay
Out-of-network: $0 copay

Ambulance

In-network: $0 copay
Out-of-network: 20% coinsurance

Therapy services

In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance

Mental health services

In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: 20% coinsurance

Opioid treatment services

Covered

Other services

In-network: $0 copay
Out-of-network: 19% coinsurance per item
In-network: $0 copay
Out-of-network: 20% coinsurance per item
In-network: $0 copay
Out-of-network: $0 copay

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseGap coverage phaseCatastrophic coverage phase
Preferred Generic$10.00 copay


Generic drugs :
25%

Brand-name drugs :
25%


Generic drugs :
$3.95 copay or 5% (whichever costs more)

Brand-name drugs :
$9.85 copay or 5% (whichever costs more)

Generic$20.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug$100.00 copay
Specialty Tier25%

Part B Drugs

In-network: $0 copay
Out-of-network: $0 copay or 20% coinsurance
In-network: $0 copay
Out-of-network: $0 copay or 20% coinsurance

Hearing

In-network: $0 copay
Out-of-network: 20% coinsurance
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Preventive Dental

In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
Not covered
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Not covered
Not covered
In-network: $0 copay
Out-of-network: $0 copay
Not covered
Not covered
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay

Vision

In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
Not covered
Not covered
Not covered

Other benefits

Limited coverage
Limited coverage
Limited coverage
Not covered
Limited coverage
Limited coverage
Limited coverage
 4.5
 4
 4
 4
 4
 5
 4.5
 5
 5
 4
 4

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