HumanaChoice H5216-034 (PPO) Plan Details
- Learn more about HumanaChoice R7220-002 (Regional PPO) R7220:002-0 Plan Details, including how much you can expect to pay for coinsurance, deductibles, premiums and copays for various services covered by the plan.
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%


