HumanaChoice H5216-266 (PPO)

Medicare Plan Details (2023 Plan)

Monthly Premium

by Humana

Additional Coverage

HearingVisionDental

Overall Government Star Rating

4.5

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

Monthly Premium

Health Portion of Premium

Drug Portion of Premium

Health Plan Deductible

Health Plan Max Out-of-Pocket

$8,950 In and Out-of-network
$5,400 In-network

Nationwide Coverage included

Hearing Coverage included

Yes

Vision Coverage included

Yes

Dental Coverage included

Yes

Doctor Lookup Link

https://finder.humana.com/finder/medical

Plan Link

http://www.humana.com/medicare

Doctor Services

Primary doctor visit

In-network: $0 copay
Out-of-network: 40% coinsurance per visit

Specialist visit

In-network: $30 copay per visit
Out-of-network: 40% coinsurance per visit

Tests, labs, & imaging

Diagnostic tests & procedures

In-network: $0-80 copay
Out-of-network: 40% coinsurance

Lab services

In-network: $0-50 copay
Out-of-network: 40% coinsurance

Diagnostic radiology services (like MRI)

In-network: $30-295 copay
Out-of-network: 40% coinsurance

Outpatient x-rays

In-network: $0-90 copay
Out-of-network: 40% coinsurance

Emergency care

$110 copay per visit (always covered)

Urgent care

$20 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage

In-network: $325 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: 40% per stay

Outpatient hospital coverage

In-network: $30-325 copay per visit
Out-of-network: 40% coinsurance per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$196 per day for days 21 through 48
$0 per day for days 49 through 100
Out-of-network: 40% per stay

Preventive services

In-network: $0 copay
Out-of-network: $0 copay or 40% coinsurance

Ambulance

Ground ambulance

In-network: $300 copay
Out-of-network: $300 copay

Therapy services

Occupational therapy visit

In-network: $10-30 copay
Out-of-network: 40% coinsurance

Physical therapy & speech & language therapy visit

In-network: $10-30 copay
Out-of-network: 40% coinsurance

Mental health services

Outpatient group therapy with a psychiatrist

In-network: $30 copay
Out-of-network: 40% coinsurance

Outpatient individual therapy with a psychiatrist

In-network: $30 copay
Out-of-network: 40% coinsurance

Outpatient group therapy visit

In-network: $30 copay
Out-of-network: 40% coinsurance

Outpatient individual therapy visit

In-network: $30 copay
Out-of-network: 40% coinsurance

Opioid treatment services

Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)

In-network: 20% coinsurance per item
Out-of-network: 40% coinsurance per item

Prosthetics (like braces, artificial limbs)

In-network: 20% coinsurance per item
Out-of-network: 40% coinsurance per item

Diabetes supplies

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

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

Tiers	Initial coverage phase	Gap coverage phase	Catastrophic coverage phase
Preferred Generic	$0.00 copay	Generic drugs : 25% Brand-name drugs : 25%	Generic drugs : $4.15 copay or 5% (whichever costs more) Brand-name drugs : $10.35 copay or 5% (whichever costs more)
Generic	$0.00 copay
Preferred Brand	$47.00 copay
Non-Preferred Drug	$100.00 copay
Specialty Tier	33%

Part B Drugs

Chemotherapy drugs

In-network: 20% coinsurance
Out-of-network: 20-40% coinsurance

Other Part B drugs

In-network: 20% coinsurance
Out-of-network: 20-40% coinsurance