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HumanaChoice H5525-005 (PPO) - H5525-005-000
$39.00
Monthly Premium
HumanaChoice H5525-005 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5525-005-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$39.00
Monthly Premium
Pennsylvania and West Virginia 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 Pennsylvania and West Virginia 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 | $39.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $700.00 |
| Out-of-pocket maximum | $8,300.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| Primary care doctor visit | Out-of-Network: Doctor Office Visit Services: Coinsurance for Medicare Covered Primary Care Office Visit 20% |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40 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 $40 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $40 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $115 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 $115 Copayment for Worldwide Emergency Transportation $325 |
| Ambulance transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $325 Coinsurance for Medicare Covered Ambulance Services - Air 20% |
Health Care Services and Medical Supplies
HumanaChoice H5525-005 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5525-005 (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 $15 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 20% to 50% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50% |
| Durable medical equipment (DME) | Out-of-Network: Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 50% |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $40 Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20% to 50% Coinsurance for Medicare Covered Lab Services 50% Copayment for Medicare Covered Diagnostic Radiological Services $0 Coinsurance for Medicare Covered Diagnostic Radiological Services 50% Coinsurance for Medicare Covered Therapeutic Radiological Services 50% Copayment for Medicare Covered Outpatient X-Ray Services $40 Coinsurance for Medicare Covered Outpatient X-Ray Services 20% to 50% $120 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$40 OP Diag Proc & Tests - SPC$40 OP Diag Proc & Tests - UCC$175 Sleep Study (Fac Based) - OPH$100 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: $400 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 20% Coinsurance for Medicare Covered Group Sessions 20% |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $850 Prior Authorization Required for Outpatient Hospital Services $0 Diag Colonoscopy - OPH$35 Mental Health - OPH$850 Surgery Svcs - OPH$40 Wound Care - OPH Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $379 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $750 Prior Authorization Required for Ambulatory Surgical Center Services $0 Diag Colonoscopy - ASC$750 Surgery Svcs - ASC |
| Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 20% Coinsurance for Medicare Covered Group Sessions 20% |
| Over-the-counter items | In-Network: $50 quarterly allowance to buy approved over-the-counter health and wellness products available through our OTC Mail Order provider. Unused amount rolls over to the next quarter and expires at the end of the plan year. Out-of-Network: 95% coinsurance for approved over-the-counter health and wellness products up to $50 quarterly allowance amount. Member is required to pay the full cost at the time of service when utilizing an out-of-network provider. To receive reimbursement from Humana for eligible items/services, the member must submit required documentation. Reimbursement will be limited to up to 5% of the allowed amount on eligible items/services. Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $40 Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $221 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: 0% coinsurance for crown recementation up to 1 every 2 years. 0% coinsurance for root canal retreatment up to 1 per tooth per lifetime. 0% coinsurance for bridge recementation up to 1 per year. 0% coinsurance for oral surgery up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. $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 up to 1 per year. $0 copayment for emergency diagnostic exam, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for intraoral x-rays up to 6 per year. 30% coinsurance for amalgam and/or composite filling up to 1 per tooth per surface every 2 years. 30% coinsurance for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. 30% coinsurance for occlusal adjustment up to 1 every 3 years. 30% coinsurance for crown-porcelain fused to high noble metal, crown-porcelain fused to noble metal, crown-porcelain/ceramic, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years. 30% coinsurance for bridges-pontic up to 1 every 5 years. 30% coinsurance for bridges-crown-porcelain fused to high noble metal, bridges-crown-porcelain fused to noble metal, bridges-crown-porcelain/ceramic up to 2 every 5 years. 30% coinsurance per tooth for root canal, simple or surgical extraction up to 1 per lifetime. 30% coinsurance for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit. 30% coinsurance for scaling for moderate inflammation up to 1 per year. 30% coinsurance for emergency treatment for pain, necessary general anesthesia with covered service up to 2 per year. 30% coinsurance for necessary incremental anesthesia with covered service up to as needed with covered codes per year. $750 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits. Out-of-Network: 0% coinsurance for crown recementation up to 1 every 2 years. 0% coinsurance for root canal retreatment up to 1 per tooth per lifetime. 0% coinsurance for bridge recementation up to 1 per year. 0% coinsurance for oral surgery up to 2 per year. 0% coinsurance for periodontal maintenance up to 4 per year. $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 up to 1 per year. $0 copayment for emergency diagnostic exam, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for intraoral x-rays up to 6 per year. 30% coinsurance for amalgam and/or composite filling up to 1 per tooth per surface every 2 years. 30% coinsurance for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. 30% coinsurance for occlusal adjustment up to 1 every 3 years. 30% coinsurance for crown-porcelain fused to high noble metal, crown-porcelain fused to noble metal, crown-porcelain/ceramic, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years. 30% coinsurance for bridges-pontic up to 1 every 5 years. 30% coinsurance for bridges-crown-porcelain fused to high noble metal, bridges-crown-porcelain fused to noble metal, bridges-crown-porcelain/ceramic up to 2 every 5 years. 30% coinsurance per tooth for root canal, simple or surgical extraction up to 1 per lifetime. 30% coinsurance for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit. 30% coinsurance for scaling for moderate inflammation up to 1 per year. 30% coinsurance for emergency treatment for pain, necessary general anesthesia with covered service up to 2 per year. 30% coinsurance for necessary incremental anesthesia with covered service up to as needed with covered codes per year. $750 combined maximum benefit coverage amount per year for all diagnostic/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
| Coverage | Details |
|---|---|
| Vision care | Out-of-Network: Eye Exams Services: Copayment for Medicare Covered Eye Exams $0 Coinsurance for Medicare Covered Eye Exams 50% Coinsurance for Medicare Covered Eyewear 20% $0 Diab Eye Exam - All POTs$40 Vision Svcs (MC) - SPC Please see the Summary of Benefits for additional benefit details. |
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 | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $40 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $575 to $750
|
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 Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
When reviewing Pennsylvania and West Virginia 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 Pennsylvania and West Virginia 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 |
Pennsylvania Counties Served
- Armstrong
- Bradford
- Carbon
- Centre
- Chester
- Clinton
- Columbia
- Crawford
- Delaware
- Erie
- Jefferson
- Lackawanna
- Lawrence
- Luzerne
- Lycoming
- Mckean
- Mercer
- Monroe
- Montgomery
- Montour
- Northampton
- Philadelphia
- Potter
- Schuylkill
- Sullivan
- Susquehanna
- Tioga
- Union
- Warren
- Wayne
- Wyoming
West Virginia Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, HealthspringSM or Kaiser Permanente.