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HumanaChoice H5216-044 (PPO) - H5216-044-000

4.5 out of 5 stars* for plan year 2024

$30.00

Monthly Premium

HumanaChoice H5216-044 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5216-044-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$30.00

Monthly Premium

Idaho and Oregon 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 Idaho and Oregon 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

CoverageDetails
Monthly plan premium$30.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$200.00
Out-of-pocket maximum$6,000.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 20%
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 35%
Inpatient hospital careIn-Network:

Acute Hospital Services:
$360.00 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 $55.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $120.00
Emergency room visit
Emergency Care:
Copayment for Emergency Care $120.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $120.00
Copayment for Worldwide Emergency Transportation $120.00
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $300.00
Copayment for Medicare Covered Ambulance Services - Air $1250.00

Health Care Services and Medical Supplies

HumanaChoice H5216-044 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-044 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic services
Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 35%
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies and Services 35%
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:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20% to 35%
Coinsurance for Medicare Covered Lab Services 20% to 35%
Coinsurance for Medicare Covered Diagnostic Radiological Services 20% to 35%
Coinsurance for Medicare Covered Therapeutic Radiological Services 35%
Coinsurance for Medicare Covered Outpatient X-Ray Services 20% to 35%
Home health careIn-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:
Coinsurance for Psychiatric Hospital Services per Stay 35%
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Prior Authorization Required for Outpatient Mental Health Services
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $360.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $360.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $200.00
Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $40.00 to $50.00
Copayment for Medicare-covered Group Sessions $40.00 to $50.00
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 $30.00 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 35%
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$10.00 per day for days 1 to 20
$203.00 per day for days 21 to 65
$0.00 per day for days 66 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.

CoverageDetails
Dental careIn Network:
Plan covers up to $1,000 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 $1,000 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

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $40.00
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 $150.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Prior Authorization Required for Eyewear

Hearing Benefits

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

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $40.00
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 $499.00 to $799.00
  • Maximum 2 Hearing Aids every year

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.

CoverageDetails
Preventive services and health/wellness education programsIn-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 & vaginal 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 H5216-044 (PPO) offers prescription drug coverage, with an annual drug deductible of $200.00 (excludes Tiers 1 and 2)

    Coverage & Cost
    Coverage
    Cost
    Annual drug deductible$200.00 (excludes Tiers 1 and 2)
    Tier 1
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $10.00
    Tier 2
    • Standard retail $8.00
    • Preferred mail order $8.00
    • Standard mail order $20.00
    Annual drug deductible$200.00 (excludes Tiers 1 and 2)
    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
    Annual drug deductible$200.00 (excludes Tiers 1 and 2)
    Tier 1
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $30.00
    Tier 2
    • Standard retail $24.00
    • Preferred mail order $0.00
    • Standard mail order $60.00

    When reviewing Idaho and Oregon 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 Idaho and Oregon 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

    Idaho Counties Served

    Oregon Counties Served

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

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