Humana Value Plus H5216-193 (PPO)

4.5 out of 5 stars* for plan year 2023
$28.10 Monthly Premium

Humana Value Plus H5216-193 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5216-193-000

$28.10 Monthly Premium

Indiana Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Indiana Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage Details
Monthly plan premium$28.10
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$260.00
Out-of-pocket maximum$7,550.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 20%
Inpatient hospital careIn-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $1600.00
Your plan covers an unlimited number of days for an inpatient stay.
Prior Authorization Required for Acute Hospital Services
Urgent care
Urgent Care:
Coinsurance for Urgent Care 20%

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Emergency room visit
Emergency Care:
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $90.00
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $270.00

Air Ambulance:
Copayment for Air Ambulance Services $270.00

Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Humana Value Plus H5216-193 (PPO) covers a range of additional benefits. Learn more about Humana Value Plus H5216-193 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic servicesIn-Network:

Chiropractic Services:
Coinsurance for Medicare-covered Chiropractic Services 20%
Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Supplies 20%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Durable medical equipment (DME)
Out-of-Network:

Durable Medical Equipment:
Coinsurance for Medicare Covered Durable Medical Equipment 18%
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
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
20%
Copayment for Medicare Covered Lab Services
$0.00
Coinsurance for Medicare Covered Lab Services
20%
Copayment for Medicare Covered Diagnostic Radiological Services $0.00
Coinsurance for Medicare Covered Diagnostic Radiological Services 20%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Copayment for Medicare Covered Outpatient X-Ray Services $0.00
Coinsurance for Medicare Covered Outpatient X-Ray Services 20%
Home health care
Out-of-Network:

Home Health Services:
Copayment for Medicare Covered Home Health $0.00
Mental health inpatient care
Out-of-Network:
Copayment for Psychiatric Hospital Services per Stay $1400.00
Mental health outpatient care
Out-of-Network:

Outpatient Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 20%
Coinsurance for Medicare Covered Group Sessions 20%
Outpatient services/surgery
Out-of-Network:

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $65.00
Coinsurance for Medicare Covered Outpatient Hospital Services 19% to 20%
Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 19%
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $65.00
Coinsurance for Medicare-covered Individual Sessions 20%
Copayment for Medicare-covered Group Sessions $65.00
Coinsurance for Medicare-covered Group Sessions 20%
Prior Authorization Required for Outpatient Substance Abuse Services
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $100.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry services
Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 20%
Podiatry Services:
Copayment for Non-Medicare Covered Podiatry Services $10.00
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$184.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Dental careIn-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 3 visits (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Coinsurance for Medicare-covered Benefits 20%
Copayment for Diagnostic Services $0.00
  • Maximum 1 visit every three years
Copayment for Restorative Services $0.00
  • Maximum 3 visits every year
Copayment for Extractions $0.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
  • Maximum 7 visits (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental

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
Coinsurance for Medicare Covered Eye Exams 20%
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 benefitsIn-Network:

Hearing Exams:
Coinsurance for Medicare Covered Benefits 20%
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 $0.00
  • Maximum 2 Hearing Aids every three years

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
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 Humana Value Plus H5216-193 (PPO) offers prescription drug coverage, with an annual drug deductible of $260.00 (excludes Tier 1)

Coverage
Cost
Coverage & Cost
Annual drug deductible$260.00 (excludes Tier 1)
Tier 1
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • Annual drug deductible$260.00 (excludes Tier 1)
    Tier 1
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
  • Annual drug deductible$260.00 (excludes Tier 1)
    Tier 1
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • When reviewing Indiana 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 Indiana 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

    Indiana Counties Served

    Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clay Clinton Crawford Daviess Dearborn Decatur Dekalb Delaware Dubois Elkhart Fayette Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko La Porte Lagrange Lake Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush Scott Shelby Spencer St Joseph Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley
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