HumanaChoice H5216-264 (PPO)

Medicare Plan Details (2022 Plan)


Monthly Premium

 

by Humana
Additional Coverage
HearingDental
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
$10,000 In and Out-of-network
$7,550 In-network
No
Yes
No
Yes

Doctor Services

In-network: $10 copay per visit
Out-of-network: 30% coinsurance per visit
In-network: $50 copay per visit
Out-of-network: 30% coinsurance per visit

Tests, labs, & imaging

In-network: $0-90 copay
Out-of-network: $0 copay or 30% coinsurance
In-network: $0-50 copay
Out-of-network: 30% coinsurance
In-network: $50-360 copay
Out-of-network: 30% coinsurance
In-network: $10-90 copay
Out-of-network: 30% coinsurance
$90 copay per visit (always covered)
$10-50 copay or 30% coinsurance 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: 30% per stay
In-network: $40-360 copay per visit
Out-of-network: 30% coinsurance 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: 30% per stay

Preventive services

In-network: $0 copay
Out-of-network: $0 copay or 30% coinsurance

Ambulance

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

Therapy services

In-network: $35 copay
Out-of-network: 30% coinsurance
In-network: $35 copay
Out-of-network: 30% coinsurance

Mental health services

In-network: $10 copay
Out-of-network: 30% coinsurance
In-network: $10 copay
Out-of-network: 30% coinsurance
In-network: $10 copay
Out-of-network: 30% coinsurance
In-network: $10 copay
Out-of-network: 30% coinsurance

Opioid treatment services

Covered

Other services

In-network: 15% coinsurance per item
Out-of-network: 30% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
In-network: $0 copay or 10-20% coinsurance per item
Out-of-network: 30% 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 Tier29%

Part B Drugs

In-network: 20% coinsurance
Out-of-network: 20-30% coinsurance
In-network: 20% coinsurance
Out-of-network: 20-30% coinsurance

Hearing

In-network: $50 copay
Out-of-network: 30% coinsurance
Not covered
Not covered
Not covered
Not covered

Preventive Dental

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

Comprehensive dental

Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered

Vision

Not covered
Not covered
Not covered
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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