HumanaChoice - Diabetes and Heart (PPO C-SNP) H5216-244-000 2024 Plan Details and Costs

South Carolina 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 South Carolina 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	$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$145.00
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 $40.00
Inpatient hospital care	In-Network: Acute Hospital Services: $350.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services
Urgent care	Urgent Care: Copayment for Urgent Care $50.00 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	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

Health Care Services and Medical Supplies

HumanaChoice - Diabetes and Heart (PPO C-SNP) covers a range of additional benefits. Learn more about HumanaChoice - Diabetes and Heart (PPO C-SNP) 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 $60.00
Diabetes supplies, training, nutrition therapy and monitoring	In-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)	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	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 $40.00 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
Home health care	Out-of-Network: Home Health Services: Copayment for Medicare Covered Home Health $0.00
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	Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $365.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $325.00
Outpatient substance abuse care	Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual or Group Sessions $45.00 to $100.00
Over-the-counter items	In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $600.00 every year Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry services	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $40.00 Copayment for Routine Foot Care $40.00 Maximum 6 visits every year Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) 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

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: 0% coinsurance for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. 0% coinsurance for emergency diagnostic exam up to 1 per year. 0% coinsurance for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for necessary anesthesia with covered service up to unlimited per year. $25 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $25 copayment for scaling for moderate inflammation up to 1 every 3 years. $25 copayment for crown recementation, bridge recementation up to 1 every 5 years. $25 copayment for emergency treatment for pain up to 2 per year. $25 copayment per tooth for amalgam and/or composite filling, simple or surgical extraction up to unlimited per year. 50% coinsurance for occlusal adjustment up to 1 every 3 years. 50% coinsurance for bridges-pontic, complete dentures, partial dentures up to 1 every 5 years. 50% coinsurance for bridges-crown up to 2 every 5 years. 50% coinsurance for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. 50% coinsurance for adjustments to dentures, denture rebase, denture reline, denture repair, tissue conditioning up to 1 per year. 50% coinsurance for oral surgery up to 2 per year. $2,000 combined maximum benefit coverage amount per year for preventive and comprehensive benefits. Out of Network: 0% coinsurance for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. 0% coinsurance for emergency diagnostic exam up to 1 per year. 0% coinsurance for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for necessary anesthesia with covered service up to unlimited per year. $25 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $25 copayment for scaling for moderate inflammation up to 1 every 3 years. $25 copayment for crown recementation, bridge recementation up to 1 every 5 years. $25 copayment for emergency treatment for pain up to 2 per year. $25 copayment per tooth for amalgam and/or composite filling, simple or surgical extraction up to unlimited per year. 50% coinsurance for occlusal adjustment up to 1 every 3 years. 50% coinsurance for bridges-pontic, complete dentures, partial dentures up to 1 every 5 years. 50% coinsurance for bridges-crown up to 2 every 5 years. 50% coinsurance for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. 50% coinsurance for adjustments to dentures, denture rebase, denture reline, denture repair, tissue conditioning up to 1 per year. 50% coinsurance for oral surgery up to 2 per year. $2,000 combined maximum benefit coverage amount per year for preventive and comprehensive benefits. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Coverage

Details

Dental care

In Network:
0% coinsurance for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. 0% coinsurance for emergency diagnostic exam up to 1 per year. 0% coinsurance for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for necessary anesthesia with covered service up to unlimited per year. $25 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $25 copayment for scaling for moderate inflammation up to 1 every 3 years. $25 copayment for crown recementation, bridge recementation up to 1 every 5 years. $25 copayment for emergency treatment for pain up to 2 per year. $25 copayment per tooth for amalgam and/or composite filling, simple or surgical extraction up to unlimited per year. 50% coinsurance for occlusal adjustment up to 1 every 3 years. 50% coinsurance for bridges-pontic, complete dentures, partial dentures up to 1 every 5 years. 50% coinsurance for bridges-crown up to 2 every 5 years. 50% coinsurance for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. 50% coinsurance for adjustments to dentures, denture rebase, denture reline, denture repair, tissue conditioning up to 1 per year. 50% coinsurance for oral surgery up to 2 per year. $2,000 combined maximum benefit coverage amount per year for preventive and comprehensive benefits.

Out of Network:
0% coinsurance for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. 0% coinsurance for panoramic film or diagnostic x-rays up to 1 every 5 years. 0% coinsurance for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. 0% coinsurance for emergency diagnostic exam up to 1 per year. 0% coinsurance for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. 0% coinsurance for necessary anesthesia with covered service up to unlimited per year. $25 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $25 copayment for scaling for moderate inflammation up to 1 every 3 years. $25 copayment for crown recementation, bridge recementation up to 1 every 5 years. $25 copayment for emergency treatment for pain up to 2 per year. $25 copayment per tooth for amalgam and/or composite filling, simple or surgical extraction up to unlimited per year. 50% coinsurance for occlusal adjustment up to 1 every 3 years. 50% coinsurance for bridges-pontic, complete dentures, partial dentures up to 1 every 5 years. 50% coinsurance for bridges-crown up to 2 every 5 years. 50% coinsurance for crown, other restorative services - core buildup and prefabricated post and core, root canal, root canal retreatment up to 1 per tooth per lifetime. 50% coinsurance for adjustments to dentures, denture rebase, denture reline, denture repair, tissue conditioning up to 1 per year. 50% coinsurance for oral surgery up to 2 per year. $2,000 combined maximum benefit coverage amount per year for preventive and comprehensive benefits. 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 to $40.00 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 $40.00 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	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 - Diabetes and Heart (PPO C-SNP) offers prescription drug coverage, with an annual drug deductible of $145.00 (excludes Tiers 1, 2, 3 and 6)

Coverage	Cost
Coverage & Cost
Annual drug deductible	$145.00 (excludes Tiers 1, 2, 3 and 6)
Tier 1	Standard retail $0.00 Preferred mail order $0.00 Standard mail order $10.00
Tier 2	Standard retail $0.00 Preferred mail order $0.00 Standard mail order $20.00
Tier 3	Standard retail $47.00 Preferred mail order $47.00 Standard mail order $47.00
Tier 6	Standard retail $0.00 Preferred mail order $0.00 Standard mail order $0.00
Annual drug deductible	$145.00 (excludes Tiers 1, 2, 3 and 6)
Tier 1	Standard retail N/A Preferred mail order N/A Standard mail order N/A
Tier 2	Standard retail N/A Preferred mail order N/A Standard mail order N/A
Tier 3	Standard retail N/A Preferred mail order N/A Standard mail order N/A
Tier 6	Standard retail N/A Preferred mail order N/A Standard mail order N/A
Annual drug deductible	$145.00 (excludes Tiers 1, 2, 3 and 6)
Tier 1	Standard retail $0.00 Preferred mail order $0.00 Standard mail order $30.00
Tier 2	Standard retail $0.00 Preferred mail order $0.00 Standard mail order $60.00
Tier 3	Standard retail $141.00 Preferred mail order $131.00 Standard mail order $141.00
Tier 6	Standard retail $0.00 Preferred mail order $0.00 Standard mail order $0.00

When reviewing South Carolina 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 South Carolina 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 Star ratings

Links to plan documents

South Carolina Counties Served

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