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HumanaChoice Giveback H7617-127 (PPO) - H7617-127-000
$0.00
Monthly Premium
HumanaChoice Giveback H7617-127 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H7617-127-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
New Jersey 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 additional benefits Original Medicare doesn’t cover.
Learn more about New Jersey 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 | $700.00 |
| Out-of-pocket maximum | $8,250.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $20 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $45 Prior Authorization Required for Doctor Specialty Visit |
| Inpatient hospital care | Out-of-Network: Acute Hospital Services: Coinsurance for Acute Hospital Services per Stay 30% |
| Urgent care | Urgent Care: Copayment for Urgent Care $40 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $40 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $115 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $115 Copayment for Worldwide Emergency Transportation $325 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $325 Air Ambulance: Coinsurance for Air Ambulance Services 20% Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
HumanaChoice Giveback H7617-127 (PPO) covers a range of additional benefits. Learn more about HumanaChoice Giveback H7617-127 (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: Coinsurance for Medicare Covered Chiropractic Services 40% |
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 30% to 50% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50% |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 17% 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 to $175 Copayment for Medicare-covered Lab Services $0 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services $120 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$45 OP Diag Proc & Tests - SPC$40 OP Diag Proc & Tests - UCC$175 Sleep Study (Fac Based) - OPH$100 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $780 Copayment for Medicare-covered Therapeutic Radiological Services $45 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 to $145 |
| Home health care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 50% |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $225 per day for days 1 to 7 $0 per day for days 8 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | Out-of-Network: Mental Health Services: Copayment for Medicare Covered Individual Sessions $50 Copayment for Medicare Covered Group Sessions $50 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $650 Prior Authorization Required for Outpatient Hospital Services $0 Diag Colonoscopy - OPH$35 Mental Health - OPH$650 Surgery Svcs - OPH$45 Wound Care - OPH Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $380 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $550 Prior Authorization Required for Ambulatory Surgical Center Services $0 Diag Colonoscopy - ASC$550 Surgery Svcs - ASC |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare Covered Individual Sessions $50 to $90 Copayment for Medicare Covered Group Sessions $50 to $90 |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $45 Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | Out-of-Network: Skilled Nursing Facility Services: Coinsurance for Skilled Nursing Facility per Stay 30% |
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 crown recementation up to 1 every 2 years. 0% coinsurance for root canal retreatment up to 1 per tooth per lifetime. 0% coinsurance for bridge recementation up to 1 per year. 0% coinsurance for oral surgery up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. $0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. $0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years. $0 copayment for bitewing x-rays up to 1 per year. $0 copayment for emergency diagnostic exam, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for intraoral x-rays up to 6 per year. 50% coinsurance for amalgam and/or composite filling up to 1 per tooth per surface every 2 years. 50% coinsurance for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. 50% coinsurance for occlusal adjustment up to 1 every 3 years. 50% coinsurance for crown-porcelain fused to high noble metal, crown-porcelain fused to noble metal, crown-porcelain/ceramic, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years. 50% coinsurance for bridges-pontic up to 1 every 5 years. 50% coinsurance for bridges-crown-porcelain fused to high noble metal, bridges-crown-porcelain fused to noble metal, bridges-crown-porcelain/ceramic up to 2 every 5 years. 50% coinsurance per tooth for root canal, simple or surgical extraction up to 1 per lifetime. 50% coinsurance for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit. 50% coinsurance for scaling for moderate inflammation up to 1 per year. 50% coinsurance for emergency treatment for pain, necessary general anesthesia with covered service up to 2 per year. 50% coinsurance for necessary incremental anesthesia with covered service up to as needed with covered codes per year. $1,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits. Out-of-Network: 0% coinsurance for crown recementation up to 1 every 2 years. 0% coinsurance for root canal retreatment up to 1 per tooth per lifetime. 0% coinsurance for bridge recementation up to 1 per year. 0% coinsurance for oral surgery up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. $0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years. $0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years. $0 copayment for bitewing x-rays up to 1 per year. $0 copayment for emergency diagnostic exam, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for intraoral x-rays up to 6 per year. 50% coinsurance for amalgam and/or composite filling up to 1 per tooth per surface every 2 years. 50% coinsurance for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. 50% coinsurance for occlusal adjustment up to 1 every 3 years. 50% coinsurance for crown-porcelain fused to high noble metal, crown-porcelain fused to noble metal, crown-porcelain/ceramic, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years. 50% coinsurance for bridges-pontic up to 1 every 5 years. 50% coinsurance for bridges-crown-porcelain fused to high noble metal, bridges-crown-porcelain fused to noble metal, bridges-crown-porcelain/ceramic up to 2 every 5 years. 50% coinsurance per tooth for root canal, simple or surgical extraction up to 1 per lifetime. 50% coinsurance for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit. 50% coinsurance for scaling for moderate inflammation up to 1 per year. 50% coinsurance for emergency treatment for pain, necessary general anesthesia with covered service up to 2 per year. 50% coinsurance for necessary incremental anesthesia with covered service up to as needed with covered codes per year. $1,000 combined maximum benefit coverage amount per year for all diagnostic/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 care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $45 Copayment for Routine Eye Exams $0
$0 Diab Eye Exam - All POTs$45 Vision Svcs (MC) - SPC Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0
Members must use Humana's Medicare Insight Network, a national network of providers, which includes standard or PLUS providers. The allowance for the standard network is $50 less than the PLUS network. |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | Out-of-Network: Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 40% |
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 Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
When reviewing New Jersey 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 New Jersey that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
New Jersey Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, HealthspringSM or Kaiser Permanente.