HumanaChoice H5216-280 (PPO) H5216-280 2024 Plan Details and Costs (2024)

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Have Medicare questions? Have Medicare questions? Have Medicare questions? Georgia Counties Served South Carolina Counties Served Basic Costs and Coverage Health Care Services and Medical Supplies Dental Benefits Vision Benefits Hearing Benefits Preventive Services and Health/Wellness Education Programs Prescription Drug Costs and Coverage References
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HumanaChoice H5216-280 (PPO) H5216-280 2024 Plan Details and Costs (1)

HumanaChoice H5216-280 (PPO) H5216-280 Plan Details

4.5 out of 5 stars

HumanaChoice H5216-280 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-280

$44.20

Monthly Premium

HumanaChoice H5216-280 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-280

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HumanaChoice H5216-280 (PPO) H5216-280 2024 Plan Details and Costs (2)

See Also
HumanaChoice H5216-023 (PPO) H5216-023 2024 Plan Details and Costs

HumanaChoice H5216-280 (PPO) H5216-280 Plan Details

4.5 out of 5 stars

HumanaChoice H5216-280 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-280

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help

$44.20

Monthly Premium

Georgia Counties Served

Spalding Butts Upson Jasper Pike Lamar Russell Gwinnett Clayton Barrow Chatham Cobb Bartow Rockdale Henry Gordon Fulton Hall Dekalb Carroll Oconee Clarke Muscogee Oglethorpe Polk Effingham Chattahoochee Mcduffie Meriwether Floyd Richmond Marion Pickens Madison Heard Harris Bryan Jackson Walton Burke Newton Lincoln Haralson Columbia Liberty Dawson Troup Coweta Paulding Douglas Cherokee Forsyth

South Carolina Counties Served

York Fairfield Spartanburg Union Pickens Chester Kershaw Cherokee Greenville Anderson Lancaster Bamberg Clarendon Abbeville Edgefield Hampton Chesterfield Charleston Marlboro Lexington Greenwood Newberry Florence Darlington Calhoun Allendale Colleton Lee Oconee Williamsburg Saluda Beaufort Berkeley Laurens Jasper Georgetown Mccormick Orangeburg Horry Marion Richland Aiken Dillon Dorchester Sumter Barnwell

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $545
Out of Pocket Max In-Network: $8850
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit

In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00

Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $0.00
Specialty Doctor Visit

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00

Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $0.00
Inpatient Hospital Care

In-Network:

Acute Hospital Services:
$295.00 per day for days 1 to 8
$0.00 per day for days 9 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required

Out-of-Network:
$295.00 per day for days 1 to 8
$0.00 per day for days 9 to 90
Urgent Care

Copayment for Urgent Care $50.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $100.00
Emergency Room Visit

Copayment for Emergency Care $100.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100.00
Copayment for Worldwide Emergency Transportation $100.00
Ambulance Transportation

In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $300.00

Air Ambulance:
Copayment for Air Ambulance Services $300.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $300.00
Copayment for Medicare Covered Ambulance Services - Air $300.00

Health Care Services and Medical Supplies

HumanaChoice H5216-280 (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services

In-Network:
Copayment for Medicare-covered Chiropractic Services $15.00
Copayment for Routine Care $0.00

  • Maximum 12 Routine Care every year

Prior Authorization Required for Chiropractic Services
Prior authorization required

Out-of-Network:
Copayment for Medicare Covered Chiropractic Services $15.00 Copayment for Non-Medicare Covered Chiropractic Services $0.00
Diabetes Supplies, Training, Nutrition Therapy and Monitoring

In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Supplies 10% to 20%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10.00
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required

Out-of-Network:
Copayment for Medicare Covered Diabetic Supplies and Services $0.00 to $10.00
Coinsurance for Medicare Covered Diabetic Supplies and Services 20%
Durable Medical Eqipment (DME)

In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required

Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 20%
Diagnostic Tests, Lab and Radiology Services, and X-Rays

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $120.00
Copayment for Medicare-covered Lab Services $0.00 to $50.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $300.00
Copayment for Medicare-covered Therapeutic Radiological Services $0.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00 to $125.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required

Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00 to $120.00
Copayment for Medicare Covered Lab Services $0.00 to $50.00
Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $300.00
Copayment for Medicare Covered Therapeutic Radiological Services $0.00
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Copayment for Medicare Covered Outpatient X-Ray Services $0.00 to $125.00
Home Health Care

In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required

Out-of-Network:
Copayment for Medicare Covered Home Health $0.00
Mental Health Inpatient Care

In-Network:

Psychiatric Hospital Services:
$587.00 per day for days 1 to 3
$0.00 per day for days 4 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required

Out-of-Network:
$587.00 per day for days 1 to 3
$0.00 per day for days 4 to 90
Mental Health Outpatient Care

In-Network:
Copayment for Medicare-covered Individual Sessions $45.00
Copayment for Medicare-covered Group Sessions $45.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required

Out-of-Network:
Copayment for Medicare Covered Individual Sessions $45.00
Copayment for Medicare Covered Group Sessions $45.00
Outpatient Services / Surgery

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $375.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $350.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $370.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required

Out-of-Network:

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $375.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $370.00
Outpatient Substance Abuse Care

In-Network:
Copayment for Medicare-covered Individual Sessions $45.00 to $100.00
Copayment for Medicare-covered Group Sessions $45.00 to $100.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required

Out-of-Network:
Copayment for Medicare Covered Individual or Group Sessions $45.00 to $100.00
Podiatry Services

In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Copayment for Routine Foot Care $0.00

  • Maximum 6 visits every year

Prior Authorization Required for Podiatry Services
Prior authorization required

Out-of-Network:
Copayment for Medicare Covered Podiatry Services $0.00 Copayment for Non-Medicare Covered Podiatry Services $0.00
Skilled Nursing Facility Care

In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Out-of-Network:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 100

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care

In Network:
Plan covers up to $2,000 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire.Your benefit can be used for most dental treatments such as:Preventive dental services, such as exams, routine cleanings, etc.Basic dental services, such as fillings, extractions, etc.Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc.Note: The allowance cannot be used on cosmetic services and implants.

Out of Network:
Plan covers up to $2,000 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire.Your benefit can be used for most dental treatments such as:Preventive dental services, such as exams, routine cleanings, etc.Basic dental services, such as fillings, extractions, etc.Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc.Note: The allowance cannot be used on cosmetic services and implants.Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00

  • Maximum 1 Routine Eye Exam every year

Maximum Plan Benefit of $75.00 every year for in and out of network services combined
Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00

  • Maximum 1 Pair every year

Copayment for Eyeglasses (lenses and frames) $0.00

  • Maximum 1 Pair every year

Maximum Plan Benefit of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Prior Authorization Required for Eyewear
Prior authorization required

Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $0.00
Copayment for Medicare Covered Eyewear $0.00
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $0.00
Copayment for Non-Medicare Covered Eyewear $0.00

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00

  • Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0.00
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $99.00 to $399.00

  • Maximum 2 Hearing Aids every year

$99 copayment per ear per year for advanced level hearing aid purchase or $399 copayment per ear per year for premium level hearing aid purchase.
Prior authorization required

Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $0.00
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams 50%
Coinsurance for Non-Medicare Covered Hearing Aids 50%

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs

In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vagin*l cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots

    • Tobacco use cessation
    Yearly "Wellness" visit

    Out-of-Network:

    Medicare-covered Zero Dollar Preventive Services:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0.00

    Prescription Drug Costs and Coverage

    The HumanaChoice H5216-280 (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $545 (excludes Tier 1) per year.

    Coverage

    Cost

    Coverage & Cost
    Annual Drug Deductible $545 (excludes Tier 1)
    Preferred Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $1.00
    Annual Drug Deductible $545 (excludes Tier 1)
    Preferred Generic
    • Preferred cost-share mail order N/A
    • Standard retail N/A
    • Standard mail order N/A
    Annual Drug Deductible $545 (excludes Tier 1)
    Preferred Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $3.00

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    HumanaChoice H5216-280 (PPO) H5216-280 2024 Plan Details and Costs (2024)

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