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HumanaChoice H5216-465 (PPO) - H5216-465-000
$0.00
Monthly Premium
HumanaChoice H5216-465 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-465-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Hawaii 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 additional benefits Original Medicare doesn’t cover.
Learn more about Hawaii Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $615.00 |
| Out-of-pocket maximum | $6,400.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $45 Prior Authorization Required for Doctor Specialty Visit |
| Inpatient hospital care | Out-of-Network: Acute Hospital Services: Coinsurance for Acute Hospital Services per Stay 20% |
| Urgent care | Urgent Care: Copayment for Urgent Care $50 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $130 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $130 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $130 Copayment for Worldwide Emergency Transportation $130 |
| Ambulance transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $195 Copayment for Medicare Covered Ambulance Services - Air $1250 |
Health Care Services and Medical Supplies
HumanaChoice H5216-465 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-465 (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% |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Supplies 10% to 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10 |
| Durable medical equipment (DME) | Out-of-Network: Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 50% $0 Continuous Glucose Monitor - DME Prov$0 Continuous Glucose Monitor - Pharmacy20% DME - DME Prov20% DME - Pharmacy |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $40 to $80 Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% Copayment for Medicare Covered Lab Services $40 to $65 Coinsurance for Medicare Covered Lab Services 40% Copayment for Medicare Covered Diagnostic Radiological Services $0 Coinsurance for Medicare Covered Diagnostic Radiological Services 40% Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Copayment for Medicare Covered Outpatient X-Ray Services $40 to $50 Coinsurance for Medicare Covered Outpatient X-Ray Services 40% $200 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$45 OP Diag Proc & Tests - SPC$50 OP Diag Proc & Tests - UCC20% Sleep Study (Fac Based) - OPH20% Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home |
| Home health care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 50% |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $375 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | Out-of-Network: 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 Services: Copayment for Medicare Covered Outpatient Hospital Services $0 Coinsurance for Medicare Covered Outpatient Hospital Services 40% Copayment for Medicare Covered Ambulatory Surgical Center Services $0 Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% $0 Diag Colonoscopy - OPH$35 Mental Health - OPH$350 Surgery Svcs - OPH$50 Wound Care - OPH |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $25 to $35 Copayment for Medicare-covered Group Sessions $25 to $35 Prior Authorization Required for Outpatient Substance Abuse Services $35 OP Substance Abuse Care - OPH$25 OP Substance Abuse Care - SPC |
| Podiatry services | Out-of-Network: Podiatry Services: Copayment for Medicare Covered Podiatry Services $35 |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $10 per day for days 1 to 20 $218 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 | $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 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 as needed with covered codes per year. $25 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $25 copayment for scaling for moderate inflammation up to 1 every 3 years. $25 copayment per tooth for amalgam and/or composite filling up to unlimited per year. $1,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits. |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | Out-of-Network: Eye Exams Services: Copayment for Medicare Covered Eye Exams $80 Coinsurance for Medicare Covered Eye Exams 40% Coinsurance for Medicare Covered Eyewear 40% $0 Diab Eye Exam - All POTs$45 Vision Svcs (MC) - SPC |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | Out-of-Network: Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $80 |
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 | In-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:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The HumanaChoice H5216-465 (PPO) offers prescription drug coverage, with an annual drug deductible of $615.00 (excludes Tiers 1, 2, and 3)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $615.00 (excludes Tiers 1, 2, and 3) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 3 |
|
| Annual drug deductible | $615.00 (excludes Tiers 1, 2, and 3) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 3 |
|
| Annual drug deductible | $615.00 (excludes Tiers 1, 2, and 3) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 3 |
|
When reviewing Hawaii 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 Hawaii 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 |
Hawaii Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Healthspring, Wellcare, or Kaiser Permanente.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.