HumanaChoice H5216-207 (PPO)

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

Doctor Services

In-network: $5 copay per visit
Out-of-network: $5-100 copay per visit
In-network: $45 copay per visit
Out-of-network: $45 copay per visit

Tests, labs, & imaging

In-network: $0-100 copay
Out-of-network: $0-400 copay
In-network: $0-45 copay
Out-of-network: $0-400 copay
In-network: $0-375 copay
Out-of-network: $0-400 copay
In-network: $5-100 copay
Out-of-network: $5-100 copay
$90 copay per visit (always covered)
$5-45 copay per visit (always covered)

Hospital Services

In-network: $375 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 91 and beyond
Out-of-network: $375 per day for days 1 through 5
$0 per day for days 6 through 90
In-network: $0-400 copay per visit
Out-of-network: $0-400 copay per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$188 per day for days 21 through 100
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: $290 copay
Out-of-network: $290 copay

Therapy services

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

Mental health services

In-network: $40 copay
Out-of-network: $40-100 copay
In-network: $40 copay
Out-of-network: $40-100 copay
In-network: $40 copay
Out-of-network: $40-100 copay
In-network: $40 copay
Out-of-network: $40-100 copay

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: $10 copay or 20% coinsurance per item

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 Tier31%

Part B Drugs

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

Hearing

In-network: $45 copay
Out-of-network: $45 copay
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
Not covered
In-network: $0 copay
Out-of-network: 50% coinsurance

Comprehensive dental

Not covered
Not covered
In-network: 50-70% coinsurance
Out-of-network: 55-75% coinsurance
Not covered
Not covered
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
 4.5
 4
 4
 4
 4
 5
 4.5
 5
 5
 4
 4

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