HumanaChoice H5216-180 (PPO)
HumanaChoice H5216-180 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-180-000
Tennessee 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 Tennessee 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 | $350.00 |
| Out-of-pocket maximum | $6,700.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $7,400.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $10.00 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40.00 |
| Inpatient hospital care | Out-of-Network: $450.00 per day for days 1 to 4 $0.00 per day for days 5 to 90 |
| Urgent care | Urgent Care: Copayment for Urgent Care $40.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $95.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $95.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $95.00 Copayment for Worldwide Emergency Transportation $95.00 |
| Ambulance transportation | In-Network: Ground Ambulance: Coinsurance for Ground Ambulance Services 20% Air Ambulance: Coinsurance for Air Ambulance Services 20% Please see Evidence of Coverage for Prior Authorization rules |
Health Care Services and Medical Supplies
HumanaChoice H5216-180 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-180 (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 Copayment for Routine Care $20.00
|
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network: Diabetic Supplies and Services: Copayment for Medicare Covered Diabetic Supplies and Services $0.00 Coinsurance for Medicare Covered Diabetic Supplies and Services 40% |
| Durable medical equipment (DME) | Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 15% |
| 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 $80.00 Copayment for Medicare-covered Lab Services $0.00 to $40.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 Coinsurance for Medicare-covered Diagnostic Radiological Services 20% Copayment for Medicare-covered Therapeutic Radiological Services $40.00 Copayment for Medicare-covered X-Ray Services $10.00 to $40.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $450.00 per day for days 1 to 4 $0.00 per day for days 5 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | Out-of-Network: Outpatient Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Outpatient services/surgery | Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual or Group Sessions 40% |
| 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 $250.00 |
| Podiatry services | Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% Podiatry Services: Coinsurance for Non-Medicare Covered Podiatry Services 40% |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $196.00 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: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $40.00 Copayment for Non-routine Services $0.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
Prior Authorization Required for Comprehensive Dental |
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: Coinsurance for Medicare Covered Eye Exams 40% Coinsurance for Medicare Covered Eyewear 40% 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: Coinsurance for Medicare Covered Hearing Exams 40% Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $0.00 Copayment for Non-Medicare Covered Hearing Aids $0.00 |
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 Coinsurance for Medicare Covered Medicare-covered Preventive Services 40% |
Prescription Drug Costs and Coverage
The HumanaChoice H5216-180 (PPO) offers prescription drug coverage, with an annual drug deductible of $350.00 (excludes Tier 1)
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual drug deductible | $350.00 (excludes Tier 1) |
| Tier 1 | |
| Annual drug deductible | $350.00 (excludes Tier 1) |
| Tier 1 | |
| Annual drug deductible | $350.00 (excludes Tier 1) |
| Tier 1 | |
When reviewing Tennessee 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 Tennessee 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 |
