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
4.0out 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
Plan Details
$0
$0
$0
$0
$7,550 In and Out-of-network
$7,550 In-network
$7,550 In-network
No
Yes
Yes
No
Medical Benefits
Doctor Services
In-network: $20 copay per visit
Out-of-network: $20-50 copay per visit
Out-of-network: $20-50 copay per visit
In-network: $50 copay per visit
Out-of-network: $50 copay per visit
Out-of-network: $50 copay per visit
Tests, labs, & imaging
In-network: $0-50 copay or 20% coinsurance
Out-of-network: $0-50 copay or 20% coinsurance
Out-of-network: $0-50 copay or 20% coinsurance
In-network: $0-35 copay or 20% coinsurance
Out-of-network: $0-50 copay or 20% coinsurance
Out-of-network: $0-50 copay or 20% coinsurance
In-network: $50-400 copay or 20% coinsurance
Out-of-network: $50-465 copay or 20% coinsurance
Out-of-network: $50-465 copay or 20% coinsurance
In-network: $20-110 copay or 20% coinsurance
Out-of-network: $20-110 copay or 20% coinsurance
Out-of-network: $20-110 copay or 20% coinsurance
$90 copay per visit (always covered)
$20-50 copay or 20% coinsurance per visit (always covered)
Hospital Services
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
$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
In-network: $50-465 copay per visit
Out-of-network: $50-465 copay or 20% coinsurance 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
$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
Out-of-network: $0 copay
Ambulance
In-network: $290 copay
Out-of-network: $290 copay
Out-of-network: $290 copay
Therapy services
In-network: $10-40 copay
Out-of-network: $10-40 copay or 20% coinsurance
Out-of-network: $10-40 copay or 20% coinsurance
In-network: $10-40 copay
Out-of-network: $10-40 copay or 20% coinsurance
Out-of-network: $10-40 copay or 20% coinsurance
Mental health services
In-network: $40 copay
Out-of-network: $40-100 copay
Out-of-network: $40-100 copay
In-network: $40 copay
Out-of-network: $40-100 copay
Out-of-network: $40-100 copay
In-network: $40 copay
Out-of-network: $40-100 copay
Out-of-network: $40-100 copay
In-network: $40 copay
Out-of-network: $40-100 copay
Out-of-network: $40-100 copay
Opioid treatment services
Covered
Other services
In-network: 19% coinsurance per item
Out-of-network: 19% coinsurance per item
Out-of-network: 19% coinsurance per item
In-network: 20% coinsurance per item
Out-of-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: $10-40 copay or 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 |
Brand-name drugs :
|
Brand-name drugs :
|
Generic | $20.00 copay | ||
Preferred Brand | $47.00 copay | ||
Non-Preferred Drug | $100.00 copay | ||
Specialty Tier | 28% |
Part B Drugs
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Out-of-network: 20% coinsurance
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Out-of-network: 20% coinsurance
Extra Benefits
Hearing
In-network: $50 copay
Out-of-network: $50 copay
Out-of-network: $50 copay
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
In-network: $699-999 copay
Out-of-network: $699-999 copay
Out-of-network: $699-999 copay
Preventive Dental
Not covered
Not covered
Not covered
Not covered
Comprehensive dental
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
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
Not covered
Not covered
Not covered
Not covered
Not covered
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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