HumanaChoice H5216-309 (PPO)

4.5 out of 5 stars* for plan year 2023
$0.00 Monthly Premium

HumanaChoice H5216-309 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5216-309-000

$0.00 Monthly Premium

Ohio, Indiana and Kentucky 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 Ohio, Indiana and Kentucky 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$6,500.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45.00
Inpatient hospital care
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 40%
Urgent care
Urgent Care:
Copayment for Urgent Care $35.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Emergency room visit
Emergency Care:
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $90.00
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $250.00
Copayment for Medicare Covered Ambulance Services - Air $250.00

Health Care Services and Medical Supplies

HumanaChoice H5216-309 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-309 (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%
Chiropractic Services:
Copayment for Non-Medicare Covered Chiropractic Services $0.00
Diabetes supplies, training, nutrition therapy and monitoringIn-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 $10.00
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-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $105.00
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $395.00
Copayment for Medicare-covered Therapeutic Radiological Services $0.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00 to $110.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
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 careIn-Network:

Psychiatric Hospital Services:
$400.00 per day for days 1 to 3
$0.00 per day for days 4 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/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $375.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $0.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $325.00
Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $20.00 to $85.00
Copayment for Medicare-covered Group Sessions $20.00 to $85.00
Prior Authorization Required for Outpatient Substance Abuse Services
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
Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 40%
Podiatry Services:
Copayment for Non-Medicare Covered Podiatry Services $10.00
Skilled Nursing Facility (SNF) care
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 40%

Dental Benefits

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

Coverage Details
Dental careIn-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 3 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 6 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 3 visits (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $45.00
Copayment for Non-routine Services $0.00
  • Maximum 2 visits every year
Copayment for Diagnostic Services $0.00
  • Maximum 1 visit every three years
Copayment for Restorative Services $0.00
  • Maximum 3 visits (Please see Evidence of Coverage for details)
Copayment for Endodontics $0.00
  • Maximum 2 visits (Please see Evidence of Coverage for details)
Copayment for Periodontics $0.00
  • Maximum 2 visits every three years
Copayment for Extractions $0.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
  • Maximum 4 visits (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
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%
Copayment for Medicare Covered Eyewear $0.00
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 $399.00 to $999.00

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 H5216-309 (PPO) offers prescription drug coverage, with an annual drug deductible of $350.00 (excludes Tiers 1 and 2)

Coverage
Cost
Coverage & Cost
Annual drug deductible$350.00 (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 $5.00
  • Preferred mail order $5.00
  • Standard mail order $20.00
  • Annual drug deductible$350.00 (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$350.00 (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 $15.00
  • Preferred mail order $0.00
  • Standard mail order $60.00
  • When reviewing Ohio, Indiana and Kentucky 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 Ohio, Indiana and Kentucky 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

    Ohio Counties Served

    Adams Allen Ashland Ashtabula Athens Auglaize Belmont Brown Butler Carroll Champaign Clark Clermont Clinton Columbiana Coshocton Crawford Cuyahoga Darke Defiance Delaware Erie Fairfield Fayette Franklin Fulton Gallia Geauga Greene Guernsey Hamilton Hancock Hardin Harrison Henry Highland Hocking Holmes Huron Jackson Jefferson Knox Lake Lawrence Licking Logan Lorain Lucas Madison Mahoning Marion Medina Meigs Mercer Miami Monroe Montgomery Morgan Morrow Muskingum Noble Ottawa Paulding Perry Pickaway Pike Portage Preble Putnam Richland Ross Sandusky Scioto Seneca Shelby Stark Summit Trumbull Tuscarawas Union Van Wert Vinton Warren Washington Wayne Williams Wood Wyandot

    Indiana Counties Served

    Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clay Clinton Crawford Daviess Dearborn Decatur Dekalb Delaware Dubois Elkhart Fayette Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Johnson Knox Kosciusko La Porte Lagrange Lake Lawrence Madison Marion Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush Scott Shelby Spencer St Joseph Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley

    Kentucky Counties Served

    Boone Campbell Grant Henderson Kenton Pendleton
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