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HumanaChoice H5216-103 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-103-000
North Dakota and South Dakota 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 North Dakota and South Dakota Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Coverage | Details |
---|---|
Monthly plan premium | $105.00 |
Vision coverage | |
Dental coverage | |
Hearing coverage | |
Prescription drugs | |
Medical deductible | $200.00 |
Out-of-pocket maximum | $3,250.00 |
Initial drug coverage limit | $0.00 |
Catastrophic drug coverage limit | $7,400.00 |
Primary care doctor visit | Out-of-Network: Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 20% |
Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $20.00 |
Inpatient hospital care | In-Network: Acute Hospital Services: $100.00 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 $20.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125.00 |
Emergency room visit | Emergency Care: Copayment for Emergency Care $125.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125.00 Copayment for Worldwide Emergency Transportation $125.00 |
Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $290.00 Air Ambulance: Coinsurance for Air Ambulance Services 20% Please see Evidence of Coverage for Prior Authorization rules |
HumanaChoice H5216-103 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-103 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
Coverage | Details |
---|---|
Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $20.00 Prior Authorization Required for Chiropractic Services |
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 10% to 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 20% |
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% Coinsurance for Medicare Covered Lab Services 20% Coinsurance for Medicare Covered Diagnostic Radiological Services 20% Coinsurance for Medicare Covered Therapeutic Radiological Services 20% Coinsurance for Medicare Covered Outpatient X-Ray Services 20% |
Home health care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 20% |
Mental health inpatient care | Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 20% |
Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 Prior Authorization Required for Outpatient Mental Health Services |
Outpatient services/surgery | Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 20% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20% |
Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual or Group Sessions 20% |
Over-the-counter items | Out-of-Network: Over-The-Counter (OTC) Items: Coinsurance for Non-Medicare Covered Over-The-Counter (OTC) Items 50% Maximum Plan Benefit of $50.00 |
Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $20.00 Prior Authorization Required for Podiatry Services |
Skilled Nursing Facility (SNF) care | Out-of-Network: Coinsurance for Skilled Nursing Facility Services per Stay 20% |
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: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $20.00 Copayment for Diagnostic Services $0.00
Prior Authorization Required for Comprehensive Dental |
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
Coverage | Details |
---|---|
Vision benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $20.00 Copayment for Routine Eye Exams $0.00
Prior Authorization Required for Eye Exams Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00
Prior Authorization Required for Eyewear |
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: Coinsurance for Medicare Covered Hearing Exams 20% Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $0.00 Copayment for Non-Medicare Covered Hearing Aids $699.00 to $999.00 |
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 Coinsurance for Medicare Covered Medicare-covered Preventive Services 20% |
The HumanaChoice H5216-103 (PPO) offers prescription drug coverage, with an annual drug deductible of $200.00 (excludes Tiers 1, 2 and 3)
Coverage |
Cost
|
---|---|
Coverage & Cost
|
|
Annual drug deductible | $200.00 (excludes Tiers 1, 2 and 3) |
Tier 1 | |
Tier 2 | |
Tier 3 | |
Annual drug deductible | $200.00 (excludes Tiers 1, 2 and 3) |
Tier 1 | |
Tier 2 | |
Tier 3 | |
Annual drug deductible | $200.00 (excludes Tiers 1, 2 and 3) |
Tier 1 | |
Tier 2 | |
Tier 3 |
When reviewing North Dakota and South Dakota 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 North Dakota and South Dakota 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.
Links to plan documents |
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
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