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HumanaChoice H5216-185 (PPO)
Medicare Plan Details (2022 Plan)
Monthly Premium

by Humana
Additional Coverage
HearingVisionDental
Overall Government Star Rating
4.0out of 5 stars
Ready to Enroll Online?
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
Plan Details
$0
$0
$0
$0
$10,000 In and Out-of-network
$6,700 In-network
$6,700 In-network
No
Yes
Yes
Yes
Medical Benefits
Doctor Services
In-network: $5 copay per visit
Out-of-network: $0-105 copay per visit
Out-of-network: $0-105 copay per visit
In-network: $40 copay per visit
Out-of-network: $40 copay or 20% coinsurance per visit
Out-of-network: $40 copay or 20% coinsurance per visit
Tests, labs, & imaging
In-network: $0-105 copay
Out-of-network: $0-105 copay
Out-of-network: $0-105 copay
In-network: $0-40 copay
Out-of-network: $0-105 copay
Out-of-network: $0-105 copay
In-network: $40-380 copay
Out-of-network: $40-380 copay
Out-of-network: $40-380 copay
In-network: $5-100 copay
Out-of-network: $5-100 copay
Out-of-network: $5-100 copay
$90 copay per visit (always covered)
$5-40 copay per visit (always covered)
Hospital Services
In-network: $360 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: $360 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 6 through 90
$0 per day for days 91 and beyond
Out-of-network: $360 per day for days 1 through 5
$0 per day for days 6 through 90
In-network: $40-360 copay per visit
Out-of-network: $40-380 copay per visit
Out-of-network: $40-380 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
$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
Out-of-network: $0 copay
Ambulance
In-network: $290 copay
Out-of-network: $290 copay
Out-of-network: $290 copay
Therapy services
In-network: $20-40 copay
Out-of-network: $20-40 copay
Out-of-network: $20-40 copay
In-network: $20-40 copay
Out-of-network: $20-40 copay
Out-of-network: $20-40 copay
Mental health services
In-network: $40 copay
Out-of-network: $40 copay or 20% coinsurance
Out-of-network: $40 copay or 20% coinsurance
In-network: $40 copay
Out-of-network: $40 copay or 20% coinsurance
Out-of-network: $40 copay or 20% coinsurance
In-network: $40 copay
Out-of-network: $40 copay or 20% coinsurance
Out-of-network: $40 copay or 20% coinsurance
In-network: $40 copay
Out-of-network: $40 copay or 20% coinsurance
Out-of-network: $40 copay or 20% coinsurance
Opioid treatment services
Covered
Other services
In-network: 11% coinsurance per item
Out-of-network: 11% coinsurance per item
Out-of-network: 11% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: $40 copay or 20% coinsurance per item
Out-of-network: $40 copay or 20% coinsurance per item
In-network: $0 copay or 10-20% coinsurance per item
Out-of-network: $10 copay or 10-20% coinsurance per item
Out-of-network: $10 copay or 10-20% coinsurance per item
Prescription Drug Benefits
Tier drug costs for: Standard retail pharmacy drug cost for 1-month
Tiers | Initial coverage phase | Gap coverage phase | Catastrophic coverage phase |
---|---|---|---|
Preferred Generic | $10.00 copay |
Brand-name drugs :
|
Brand-name drugs :
|
Generic | $20.00 copay | ||
Preferred Brand | $47.00 copay | ||
Non-Preferred Drug | $100.00 copay | ||
Specialty Tier | 33% |
Part B Drugs
In-network: 15% coinsurance
Out-of-network: 15% coinsurance
Out-of-network: 15% coinsurance
In-network: 15% coinsurance
Out-of-network: 15% coinsurance
Out-of-network: 15% coinsurance
Extra Benefits
Hearing
In-network: $40 copay
Out-of-network: $40 copay or 20% coinsurance
Out-of-network: $40 copay or 20% coinsurance
Not covered
Not covered
Not covered
Not covered
Preventive Dental
In-network: $0 copay
Out-of-network: 50-75% coinsurance
Out-of-network: 50-75% coinsurance
In-network: 0-70% coinsurance
Out-of-network: 50-75% coinsurance
Out-of-network: 50-75% coinsurance
In-network: $0 copay
Out-of-network: 50-75% coinsurance
Out-of-network: 50-75% coinsurance
In-network: $0 copay
Out-of-network: 50-75% coinsurance
Out-of-network: 50-75% coinsurance
Comprehensive dental
Not covered
Not covered
In-network: 50% coinsurance
Out-of-network: 55-75% coinsurance
Out-of-network: 55-75% coinsurance
Not covered
In-network: 70% coinsurance
Out-of-network: 55-75% coinsurance
Out-of-network: 55-75% coinsurance
In-network: 50% coinsurance
Out-of-network: 55-75% coinsurance
Out-of-network: 55-75% coinsurance
Not covered
Vision
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-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
Health Plan Star Ratings
(government star ratings are out of 5 stars)
Prescription Drug Plan Star Ratings
(government star ratings are out of 5 stars)
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