HumanaChoice H5525-042 (PPO)

Medicare Plan Details

2021 Plan

Monthly Premium

(select county for price)

by Humana

Additional Coverage

Hearing Vision

Overall Government Star Rating

4.0

out of 5 stars

State: Ohio

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

Monthly Premium

Health Portion of Premium

Drug Portion of Premium

Health Plan Deductible

Health Plan Max Out-of-Pocket

$7,550 In and Out-of-network
$7,550 In-network

Nationwide Coverage included

Hearing Coverage included

Yes

Vision Coverage included

Yes

Dental Coverage included

Doctor Lookup Link

http://www.humana.com/medicare

Plan Link

http://www.humana.com/medicare

Medical Benefits

Doctor Services

Primary doctor visit

In-network: $20 copay per visit
Out-of-network: $20-50 copay per visit

Specialist visit

In-network: $50 copay per visit
Out-of-network: $50 copay per visit

Tests, labs, & imaging

Diagnostic tests & procedures

In-network: $0-50 copay or 20% coinsurance
Out-of-network: $0-50 copay or 20% coinsurance

Lab services

In-network: $0-35 copay or 20% coinsurance
Out-of-network: $0-50 copay or 20% coinsurance

Diagnostic radiology services (like MRI)

In-network: $50-400 copay or 20% coinsurance
Out-of-network: $50-465 copay or 20% coinsurance

Outpatient x-rays

In-network: $20-110 copay or 20% coinsurance
Out-of-network: $20-110 copay or 20% coinsurance

Emergency care

$90 copay per visit (always covered)

Urgent care

$20-50 copay or 20% coinsurance per visit (always covered)

Hospital Services

Inpatient hospital coverage

In-network: $490 per day for days 1 through 4
$0 per day for days 5 through 90
$0 per day for days 91 and beyond
Out-of-network: $490 per day for days 1 through 4
$0 per day for days 5 through 90

Outpatient hospital coverage

In-network: $50-465 copay per visit
Out-of-network: $50-465 copay or 20% 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: $0 per day for days 1 through 20
$184 per day for days 21 through 100

Preventive services

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

Ambulance

Ground ambulance

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

Therapy services

Occupational therapy visit

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

Physical therapy & speech & language therapy visit

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

Mental health services

Outpatient group therapy with a psychiatrist

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

Outpatient individual therapy with a psychiatrist

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

Outpatient group therapy visit

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

Outpatient individual therapy visit

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

Opioid treatment services

Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)

In-network: 19% coinsurance per item
Out-of-network: 19% coinsurance per item

Prosthetics (like braces, artificial limbs)

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

Diabetes supplies

In-network: $0 copay or 10-20% coinsurance per item
Out-of-network: $10-40 copay or 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	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 Tier	28%

Part B Drugs

Chemotherapy drugs

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

Other Part B drugs

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

Extra Benefits

Hearing

Hearing exam

In-network: $50 copay
Out-of-network: $50 copay

Fitting/evaluation

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

Hearing aids - All types

In-network: $699-999 copay
Out-of-network: $699-999 copay

Preventive Dental

Oral exam

Not covered

Cleaning

Not covered

Fluoride treatment

Not covered

Dental x-rays

Not covered

Comprehensive dental

Non-routine services

Not covered

Diagnostic services

Not covered

Restorative services

Not covered

Endodontics

Not covered

Periodontics

Not covered

Extractions

Not covered

Prosthodontics, other oral/maxillofacial surgery, other services

Not covered

Vision

Routine eye exam

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

Contact lenses

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

Eyeglasses (frames & lenses)

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

Eyeglass frames (only)

Not covered

Eyeglass lenses (only)

Not covered

Upgrades

Not covered

Other benefits

Fitness benefit

Not covered

Over the counter drug benefits

Not covered

In-home support services

Not covered

Home and bathroom safety devices

Not covered

Meals for short duration

Not covered

Annual physical exams

Limited coverage

Telehealth

Limited coverage

Summary rating of health plan quality

Staying healthy: screenings, tests, & vaccines

Managing chronic (long term) conditions

Member experience with health plan

Member complaints & changes in the health plan's performance

Health plan customer service

Summary rating of drug plan quality

Drug plan customer service

Member complaints & changes in the drug plan's performance

Member experience with the drug plan

Drug safety & accuracy of drug pricing

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