HumanaChoice H5216-203 (PPO)


Medicare Plan Details

2021 Plan
Monthly Premium
(select county for price)

 

by Humana
Additional Coverage
Hearing Vision Dental
Overall Government Star Rating
 4.0
out of 5 stars

State: Georgia

Select your county to view the price for this plan

 


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
$11,300 In and Out-of-network
$7,550 In-network
No
Yes
Yes
Yes

Medical Benefits

Doctor Services

In-network: $5 copay per visit
Out-of-network: 40% coinsurance per visit
In-network: $35 copay per visit
Out-of-network: 40% coinsurance per visit

Tests, labs, & imaging

In-network: $0-100 copay
Out-of-network: $0 copay or 40% coinsurance
In-network: $0-45 copay
Out-of-network: 40% coinsurance
In-network: $35-495 copay
Out-of-network: 40% coinsurance
In-network: $5-100 copay
Out-of-network: 40% coinsurance
$90 copay per visit (always covered)
$5-35 copay or 40% coinsurance per visit (always covered)

Hospital Services

In-network: $298 per day for days 1 through 7
$0 per day for days 8 through 90
$0 per day for days 91 and beyond
Out-of-network: 40% per stay
In-network: $35-345 copay per visit
Out-of-network: 40% coinsurance per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$184 per day for days 21 through 100
Out-of-network: 40% per stay

Preventive services

In-network: $0 copay
Out-of-network: $0 copay or 40% coinsurance

Ambulance

In-network: $290 copay
Out-of-network: $290 copay

Therapy services

In-network: $25-40 copay
Out-of-network: 40% coinsurance
In-network: $25-40 copay
Out-of-network: 40% coinsurance

Mental health services

In-network: $40 copay
Out-of-network: 40% coinsurance
In-network: $40 copay
Out-of-network: 40% coinsurance
In-network: $40 copay
Out-of-network: 40% coinsurance
In-network: $40 copay
Out-of-network: 40% coinsurance

Opioid treatment services

Covered

Other services

In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
In-network: $0 copay or 10-20% coinsurance per item
Out-of-network: 40% coinsurance per item

Prescription Drug Benefits

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 :
$3.70 copay or 5% (whichever costs more)

Brand-name drugs :
$9.20 copay or 5% (whichever costs more)

Generic$20.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug$100.00 copay
Specialty Tier33%

Part B Drugs

In-network: 20% coinsurance
Out-of-network: 40% coinsurance
In-network: 20% coinsurance
Out-of-network: 40% coinsurance

Extra Benefits

Hearing

In-network: $35 copay
Out-of-network: 40% coinsurance
In-network: $0 copay
Out-of-network: $0 copay
In-network: $699-999 copay
Out-of-network: $699-999 copay

Preventive Dental

In-network: $0 copay
Out-of-network: 50% coinsurance
In-network: $0 copay
Out-of-network: 50% coinsurance
In-network: $0 copay
Out-of-network: 50% coinsurance
In-network: $0 copay
Out-of-network: 50% coinsurance

Comprehensive dental

In-network: 50% coinsurance
Out-of-network: 55-75% coinsurance
Not covered
In-network: 50-70% coinsurance
Out-of-network: 55-75% coinsurance
In-network: 70% coinsurance
Out-of-network: 55-75% coinsurance
In-network: 70% coinsurance
Out-of-network: 55-75% coinsurance
In-network: 50% coinsurance
Out-of-network: 55-75% coinsurance
In-network: 70% coinsurance
Out-of-network: 55-75% coinsurance

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
Not covered
Not covered
Limited coverage
Limited coverage
Limited coverage
 3.5
 4
 4
 4
 4
 5
 3.5
 4
 4
 3
 4

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