HumanaChoice H5216-198 (PPO) Plan Details

In this article...
  • Learn more about HumanaChoice H5216-198, including how much you can expect to pay for coinsurance, deductibles, premiums and copays for various services covered by the plan.

Arizona Counties Served

La Paz County

Yuma County

Greenlee County

Graham County

Cocochino County

Apache County

Yavapai County

Mohave County

Plan Details and Plan Costs

HumanaChoice H5216-198 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered in Arizona by HumanaChoice. The plan ID is H5216:198-0.

  • Monthly Premium: $31
  • Plan Deductible: $0.00
  • Out of Pocket Spending Max: $4,900

Primary Care Doctor Visit

In Network: Copayment for Primary Care Office Visit: $0.00

Out of Network: Copayment for Medicare Covered Primary Care Office Visit: $35.00

Specialist Doctor Visit

In Network:

  • Copayment for Physician Specialist Office Visit: $40.00

Out of Network:

  • Copayment: $65.00

Inpatient Hospital Care

In Network:

  • $275.00 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 $0.00 to $65.00

Coinsurance for Urgent Care: 40%

In Network:

  • Primary Care Physician (PCP): $0.00 
  • Specialist: $40.00
  • Urgent Care Center: $25.00

Out-Of-Network

  • PCP: $35.00
  • Specialist: $65.00
  • 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 H5216-198 (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
  • $178.00 per day for days 21 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 $150.00
  • Copayment for Medicare-covered Lab Services: $0.00 to $10.00
  • Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diagnostic and Therapeutic Radiology Services:

  • Copayment for Medicare-covered Diagnostic Radiological Services: $0.00 to $275.00
  • Coinsurance for Medicare-covered Therapeutic Radiological Services: 20%
  • 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:

  • Copayment for Medicare Covered Chiropractic Services: $65.00

Mental Health Inpatient Care

In Network:

  • $275.00 per day for days 1 to 6
  • $0.00 per day for days 7 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: $40.00
  • 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 to $40.00

Routine Eye Exams:

  • Copayment for Routine Eye Exams: $0.00
  • Maximum 1 Routine Eye Exam every year
  • Maximum Plan Benefit of $75.00 every year for in and out of network services combined
  • Prior Authorization Required for Eye Exams

Eyewear

Medicare-Covered Benefits:

  • Copayment for Medicare-Covered Benefits: $0.00
  • Prior Authorization Required for Eyewear
  • Copayment for Contact Lenses: $0.00
    • Maximum 1 Pair every year
  • Copayment for Eyeglasses (lenses and frames): $0.00
    • Maximum 1 Pair every year
  • Maximum Plan Benefit: Maximum Plan Benefit of $200.00 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: $40.00
  • 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 H5216-198 (PPO) plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $295 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) $10.00
  • 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) 27%
  • Standard Retail Cost Sharing (30 Day Supply) 27%
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