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Savannah River Mission Completion Low Plan - H5216-805-603

4.5 out of 5 stars* for plan year 2024

$102.58

Monthly Premium

Savannah River Mission Completion Low Plan is a Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5216-805-603

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

$102.58

Monthly Premium

South Dakota, Utah, Pennsylvania, Texas, Georgia, Louisiana, Iowa, Tennessee, Ohio, Colorado, and Wisconsin 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 South Dakota, Utah, Pennsylvania, Texas, Georgia, Louisiana, Iowa, Tennessee, Ohio, Colorado, and Wisconsin 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$102.58
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$2,000.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn or Out of Network: $0 copayment
Specialty doctor visitIn or Out of Network: $20 copayment
Inpatient hospital careIn or Out of Network: $150 copayment/admit
Urgent careIn or Out of Network: $0 - $20 copayment
Emergency room visitIn or Out of Network: $75 copayment |Waived if admitted within 24 hours.|Worldwide Coverage: 20% coinsurance. $100 deductible per year, $25,000 Maximum Benefit per year or 60 consecutive days, whichever is reached first. Limited to emergency Medicare-covered services.
Ambulance transportationIn or Out of Network: $75 copayment per date of service. |Limited to Medicare-covered transportation.

Health Care Services and Medical Supplies

Savannah River Mission Completion Low Plan covers a range of additional benefits. Learn more about Savannah River Mission Completion Low Plan benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn or Out of Network: |Medicare-covered Chiropractic Services: $20 copayment
Diabetes supplies, training, nutrition therapy and monitoringDiabetes Self-Management Services|In or Out of Network: $0 copayment|Diabetes Supplies and Services|In or Out of Network: $0 copayment
Durable medical equipment (DME)In or Out of Network: $0 copayment
Diagnostic tests, lab and radiology services, and X-raysDiagnostic Tests, Lab and Radiology Services, and X-Rays|In or Out of Network: $0 - $75 copayment|Medicare-Covered diagnostic procedures and tests|In or Out of Network: $0 - $75 copayment|Medicare-covered diagnostic radiology services (not including x-rays)|In or Out of Network: $0 - $75 copayment|Medicare-covered lab services|In or Out of Network: $0 copayment|Medicare-covered therapeutic radiology services|In or Out of Network: $0 - $50 copayment|Medicare-covered X-rays|In or Out of Network: $0 - $75 copayment
Home health careIn or Out of Network: $0 copayment, excludes Personal Home Care
Mental health inpatient careIn or Out of Network: $150 copayment/admit |190 day lifetime limit in a psychiatric facility
Mental health outpatient careIn or Out of Network: $0 - $40 copayment
Outpatient services/surgeryAmbulatory Surgery Center|In or Out of Network: $50 copayment|Outpatient Services/Surgery|In or Out of Network: $0 - $75 copayment
Outpatient substance abuse careIn or Out of Network: $0 - $40 copayment
Over-the-counter itemsIn Network: $25 maximum benefit coverage per quarter (3 months) for select over-the-counter health and wellness products through CenterWell Pharmacy. |Unused amount expires at the end of the quarter.
Podiatry servicesIn or Out of Network: $20 copayment for Medicare-covered podiatry services
Skilled Nursing Facility (SNF) careIn or Out of Network: |$0 copayment per day for days 1-20 |$25 copayment per day for days 21-100 |Plan pays $0 after 100 days.

Dental Benefits

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

CoverageDetails
Dental careIn or Out of Network: $20 copayment for Medicare-covered dental services. |$0 copayment for the following preventive and comprehensive dental services: Oral evaluation or periodontal exam up to 1 every 3 years. Panoramic film or diagnostic x-rays up to 1 every 5 years. Bitewing x-rays up to 1 set(s) per year. Emergency diagnostic exam, intraoral x-rays up to 1 per year. Amalgam and/or composite filling, fluoride treatment, prophylaxis (cleaning), or simple or surgical extraction up to 2 per year. Periodontal maintenance up to 4 per year. Necessary anesthesia (inhalation of nitrous oxide/analgesia, anxiolysis) with covered service. |$500 combined maximum benefit coverage amount per year for all 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 careOut of Network: $20 copayment for Medicare-covered vision services. |$0 copayment for routine eye exam (includes refraction) up to 1 per year. $175 combined maximum benefit coverage amount per year for routine exam. $100 combined maximum benefit coverage amount per year for contact lenses, eyeglasses (lenses and frames), including lens options such as ultraviolet protection and scratch resistant coating, fitting for eyeglasses (lenses and frames). |Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

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: $20 copayment for Medicare-covered hearing services. |$0 copayment for routine hearing exams up to 1 per year, $299 copayment for each Advanced level hearing aid up to 1 per ear per year. $599 copayment for each Premium level hearing aid up to 1 per ear per year. Includes 80 batteries per aid and a 3 year warranty. |Members must utilize a TruHearing provider.

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 programsGlaucoma Screening|In or Out of Network: $0 copayment|Preventive Services|In or Out of Network: $0 copayment

When reviewing South Dakota, Utah, Pennsylvania, Texas, Georgia, Louisiana, Iowa, Tennessee, Ohio, Colorado, and Wisconsin 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 South Dakota, Utah, Pennsylvania, Texas, Georgia, Louisiana, Iowa, Tennessee, Ohio, Colorado, and Wisconsin 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

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Utah Counties Served

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Texas Counties Served

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Louisiana Counties Served

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Tennessee Counties Served

Ohio Counties Served

Colorado Counties Served

Wisconsin 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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