HumanaChoice H5216-363 (PPO) H5216-363-000 2024 Plan Details and Costs (2024)

Basic Costs and Coverage

Coverage	Details
Monthly plan premium	$38.50
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$545.00
Out-of-pocket maximum	$7,550.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$8,000.00
Primary care doctor visit	In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00
Specialty doctor visit	In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00
Inpatient hospital care	In-Network: Acute Hospital Services: $295.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services
Urgent care	Urgent Care: Copayment for Urgent Care $15.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00
Emergency room visit	Emergency Care: 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	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 H5216-363 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-363 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage	Details
Chiropractic services	Out-of-Network: Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $15.00 Chiropractic Services: Copayment for Non-Medicare Covered Chiropractic Services $0.00
Diabetes supplies, training, nutrition therapy and monitoring	Out-of-Network: Diabetic Supplies and Services: Copayment for Medicare Covered Diabetic Supplies and Services $0.00 to $10.00 Coinsurance for Medicare Covered Diabetic Supplies and Services 20%
Durable medical equipment (DME)	In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-rays	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: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services
Mental health inpatient care	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	Out-of-Network: Outpatient Mental Health Services: 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 $370.00 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 $325.00 Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse care	Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual or Group Sessions $45.00 to $100.00
Podiatry services	Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $0.00 Podiatry Services: Copayment for Non-Medicare Covered Podiatry Services $0.00
Skilled Nursing Facility (SNF) care	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, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
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.

Coverage

Details

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, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Vision benefits	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, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Hearing benefits	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, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
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

Coverage

Details

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

Prescription Drug Costs and Coverage

The HumanaChoice H5216-363 (PPO) offers prescription drug coverage, with an annual drug deductible of $545.00 (excludes Tier 1)

Coverage	Cost
Coverage & Cost
Annual drug deductible	$545.00 (excludes Tier 1)
Tier 1	Standard retail $0.00 Preferred mail order $0.00 Standard mail order $1.00
Annual drug deductible	$545.00 (excludes Tier 1)
Tier 1	Standard retail N/A Preferred mail order N/A Standard mail order N/A
Annual drug deductible	$545.00 (excludes Tier 1)
Tier 1	Standard retail $0.00 Preferred mail order $0.00 Standard mail order $3.00

When reviewing Virginia Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Virginia that offer similar benefits at similar or lower prices than the plan above. Call 1-855-298-6309 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Summary of benefits
Evidence of coverage
Star ratings

Virginia Counties Served

Accomack Albemarle Alexandria City Alleghany Amelia Amherst Appomattox Arlington Augusta Bath Bedford Bland Botetourt Brunswick Buckingham Buena Vista City Campbell Caroline Carroll Charles City Charlottesville City Chesapeake City Chesterfield Clarke Colonial Heights City Covington City Craig Culpeper Cumberland Danville City Dinwiddie Emporia City Essex Fairfax Fairfax City Falls Church City Fauquier Floyd Fluvanna Franklin Franklin City Frederick Fredericksburg City Galax City Giles Gloucester Goochland Greene Greensville Halifax Hampton City Hanover Harrisonburg City Henrico Henry Highland Hopewell City Isle Of Wight James City Jefferson King And Queen King George King William Lancaster Lexington City Loudoun Louisa Lunenburg Lynchburg City Madison Manassas City Manassas Park City Martinsville City Mathews Mecklenburg Middlesex Montgomery Nelson New Kent Newport News City Norfolk City Northampton Northumberland Nottoway Orange Page Patrick Petersburg City Pittsylvania Poquoson City Portsmouth City Powhatan Prince Edward Prince George Prince William Pulaski Radford Rappahannock Richmond Richmond City Roanoke Roanoke City Rockbridge Rockingham Salem Shenandoah Southampton Spotsylvania Stafford Staunton City Suffolk City Surry Sussex Virginia Beach City Warren Waynesboro City Westmoreland Williamsburg City Winchester City York

We represent carriers such as Humana, UnitedHealthcare^®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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