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HumanaChoice H5216-107 (PPO) - H5216-107-000

4.5 out of 5 stars* for plan year 2024

$123.00

Monthly Premium

HumanaChoice H5216-107 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5216-107-000

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

$123.00

Monthly Premium

Kentucky and 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 Kentucky and 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

CoverageDetails
Monthly plan premium$123.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$200.00
Out-of-pocket maximum$6,700.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $10.00
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40.00
Inpatient hospital careIn-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $750.00
Your plan covers an unlimited number of days for an inpatient stay.
Prior Authorization Required for Acute Hospital Services
Urgent care
Urgent Care:
Copayment for Urgent Care $55.00

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
Out-of-Network:

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

Health Care Services and Medical Supplies

HumanaChoice H5216-107 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-107 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15.00
Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies and Services 50%
Durable medical equipment (DME)
Out-of-Network:

Durable Medical Equipment:
Coinsurance for Medicare Covered Durable Medical Equipment 50%
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 50%
Coinsurance for Medicare Covered Lab Services 50%
Coinsurance for Medicare Covered Diagnostic Radiological Services 50%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Coinsurance for Medicare Covered Outpatient X-Ray Services 50%
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 50%
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
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 50%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50%
Outpatient substance abuse care
Out-of-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual or Group Sessions 50%
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 $75.00
Podiatry services
Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 50%
Skilled Nursing Facility (SNF) careIn-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.

CoverageDetails
Dental careIn Network:
$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, intraoral x-rays up to 1 set(s) per year. $0 copayment for emergency diagnostic exam up to 1 per year. $0 copayment for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for necessary anesthesia with covered service up to unlimited per year. $25 copayment per tooth for amalgam and/or composite filling up to 2 per year. $1,000 combined maximum benefit coverage amount per year for preventive and comprehensive benefits.

Out of Network:
$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, intraoral x-rays up to 1 set(s) per year. $0 copayment for emergency diagnostic exam up to 1 per year. $0 copayment for fluoride treatment, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for necessary anesthesia with covered service up to unlimited per year. $25 copayment per tooth for amalgam and/or composite filling up to 2 per year. $1,000 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

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 $100.00 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 $399.00 to $699.00
  • 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 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 50%

Prescription Drug Costs and Coverage

The HumanaChoice H5216-107 (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 $5.00
  • Preferred mail order $5.00
  • Standard mail order $10.00
Tier 2
  • Standard retail $15.00
  • Preferred mail order $15.00
  • 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 $15.00
  • Preferred mail order $0.00
  • Standard mail order $30.00
Tier 2
  • Standard retail $45.00
  • Preferred mail order $0.00
  • Standard mail order $60.00

When reviewing Kentucky and 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 Kentucky and Indiana 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

Kentucky Counties Served

Indiana 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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