HumanaChoice H5216-034 (PPO) Plan Details

Arizona Counties Served

Plan Details and Plan Costs

HumanaChoice H5216-034 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered in Arizona by HumanaChoice. The plan ID is H5216:034-0.

Monthly Premium: $120
Plan Deductible: $0.00
Out of Pocket Spending Max: $7550

Primary Care Doctor Visit

In Network: Copayment for Primary Care Office Visit $10.00

Out of Network: Coinsurance for Medicare Covered Primary Care Office Visit %40

Specialist Doctor Visit

In Network:

$45 Copayment for Physician Specialist Office Visit

Out of Network:

Coinsurance for Medicare Covered Physician Specialist Office Visit 40%

Inpatient Hospital Care

In Network:

$335.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services

Out of Network:

40% Coinsurance for Acute Hospital Services per Stay

Urgent Care

Copayment for Urgent Care $10.00 to $45.00

Coinsurance for Urgent Care: 40%

In Network:

Primary Care Physician (PCP): $10.00
Specialist: $45.00
Urgent Care Center: $45.00

Out-Of-Network

PCP: 40% Coinsurance
Specialist: 40% Coinsurance
Urgent Care Center: 40% coinsurance

Copayment for Worldwide Urgent Coverage: $90.00

Emergency Room (ER) Visits

In Network:

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

In Network:

Ground Ambulance: $265 copayment
Air Ambulance: 20% Coinsurance
Please see Evidence of Coverage for Prior Authorization rules

Out of Network:

Ground Ambulance: $265 copayment
Air Ambulance: 20% Coinsurance

Additional Covered Health Care Services and Medical Supplies

HumanaChoice H5216-034 (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Home Health Care

In Network: $0.00 Copay

Prior Authorization Required for Home Health Services

Out of Network: 40% Coinsurance

Skilled Nursing Facility (SNF) Care

In Network:

$0.00 per day for days 1 to 20
$172.00 per day for days 21 to 100
$0.00 per day for days 61 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Out of Network:

Coinsurance for Skilled Nursing Facility Services per Stay 40%

Medical Diagnostic Tests, Labs and Radiology Services

Outpatient Diagnostic Procedures, Tests and Lab Services:

Copayment for Medicare-covered Diagnostic Procedures/Tests: $0.00 to $264.00
Copayment for Medicare-covered Lab Services: $0.00 to $50.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diagnostic and Therapeutic Radiology Services:

Copayment for Medicare-covered Diagnostic Radiological Services: $10 to $335
Copayment for Medicare-covered Therapeutic Radiological Services: $10.00 to 105.00
Coinsurance for Medicare-covered Therapeutic Radiological Services: 20%
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

Diabetes Supplies, Training, Nutrition Therapy and Monitoring

In-Network:

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: $0
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)

In Network:

Coinsurance for Medicare-covered Durable Medical Equipment 20%

Out of Network:

Coinsurance for Medicare Covered Durable Medical Equipment 40%

Chiropractic Services

In Network:

Copayment for Medicare-covered Chiropractic Services: $20.00
Prior Authorization Required for Chiropractic Services

Out of Network:

Coinsurance for Medicare Covered Chiropractic Services 40%

Mental Health Inpatient Care

In Network:

$335.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services

Out of Network:

Coinsurance for Psychiatric Hospital Services per Stay: 40%

Mental Health Outpatient Care

In Network:

Copayment for Medicare-covered Individual Sessions: $20
Copayment for Medicare-covered Group Sessions: $20
Prior Authorization Required for Outpatient Mental Health Services

Outpatient Substance Abuse Care

In Network:

Coinsurance for Medicare-covered Individual Sessions: 40%
Coinsurance for Medicare-covered Group Sessions: 40%

Podiatry Services

In Network:

Copayment for Medicare-Covered Podiatry Services: $40.00
Copayment for Routine Foot Care: $0.00
Maximum 12 visits every year
Prior Authorization Required for Podiatry Services

Over-the-Counter (OTC) Items

Copayment for Over-The-Counter (OTC) Items: $0.00

Maximum Plan Benefit of $50.00 every three months
Nicotine Replacement Therapy (NRT) offered as a Part C OTC benefit

Dental Benefits

The following dental services are covered from in-network providers.

Preventative Dental Care

Medicare-Covered Benefits:

Oral Exams: Coinsurance for Oral Exams 0%
Maximum 3 visits (Please see Evidence of Coverage for details)
Teeth Cleaning: Coinsurance for Prophylaxis (Cleaning) 0%
Maximum 2 visits every year
Dental X-Rays: Coinsurance for Dental X-Rays 0% (Maximum 1 visit per year)

Comprehensive Dental Care

Medicare-Covered Benefits:

Copayment for Medicare-covered Benefits: $45.00
Prior Authorization Required for Comprehensive Dental

Vision Benefits

The following vision services are covered from in-network providers.

Eye Exams

Medicare-Covered Benefits:

Copayment for Medicare Covered Benefits: $0.00

Routine Eye Exams:

Copayment for Routine Eye Exams: $0.00
Maximum 1 Routine Eye Exam every year

Eyewear

Medicare-Covered Benefits:

Copayment for Medicare-Covered Benefits: $0.00
Prior Authorization Required for Eyewear
Maximum Plan Benefit: Maximum Plan Benefit of $40.00 every year for all Non-Medicare covered eyewear for in and out of network services combined

Hearing Benefits

The following vision services are covered from in-network providers.

Hearing Exams

Medicare-Covered Benefits:

Copayment for Medicare Covered Benefits: $45.00
Routine Hearing Exams: Copayment for Routine Hearing Exams $0.00
Maximum 1 visit per year
Prior Authorization Required for Hearing Exams
Copayment for Fitting/Evaluation for Hearing Aid $0.00 (1 per year)

Hearing Aids

Copayment for Hearing Aids $699.00 to $999.00
Maximum 2 Hearing Aids every year
Maximum Plan Benefit: $699 copayment per ear per year for advanced level hearing aid purchase or $999 copayment per ear per year for premium level hearing aid purchase.

Preventive Services and Health/Wellness Education Programs

The following preventive services and wellness education programs are covered from in-network providers with $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
Tobacco use cessation

Shots:

Flu shots
Hepatitis B shots
Pneumococcal shots

Prescription Drug Costs and Coverage

The HumanaChoice H5216-224 (PPO) plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $195 per year.

Preferred Generic Drugs

Preferred Retail Cost Sharing (30 Day Supply) $5.00
Preferred Mail Order Cost Sharing (90 Day Supply) $0.00
Standard Retail Cost Sharing (30 Day Supply) $10.00
Standard Mail Order Cost Sharing (90 Day Supply) $30.00

Generic Drugs

Preferred Retail Cost Sharing (30 Day Supply) $15.00
Preferred Mail Order Cost Sharing (90 Day Supply) $0.00
Standard Retail Cost Sharing (30 Day Supply) $20.00
Standard Mail Order Cost Sharing (90 Day Supply) $60.00

Preferred Brand Name Drugs

Preferred Retail Cost Sharing (30 Day Supply) $47.00
Preferred Mail Order Cost Sharing (90 Day Supply) $131.00
Standard Retail Cost Sharing (30 Day Supply) $47.00
Standard Mail Order Cost Sharing (90 Day Supply) $141.00

Non-Preferred Drugs

Preferred Retail Cost Sharing (30 Day Supply) $100.00
Preferred Mail Order Cost Sharing (90 Day Supply) $290.00
Standard Retail Cost Sharing (30 Day Supply) $100.00
Standard Mail Order Cost Sharing (90 Day Supply) $300.00

Specialty Tier Drugs

Preferred Retail Cost Sharing (30 Day Supply) 29%
Standard Retail Cost Sharing (30 Day Supply) 29%