Humana Value Plus H5216-197 (PPO) Plan Details

In this article...
  • 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

Pinal County

Yavapai County

Mohave County

Yuma County

Santa Cruz County

Pima County

Maricopa County

La Paz County

Greenlee County

Graham County

Coconino County

Cochise County

Apache County

Plan Details and Plan Costs

Humana Value Plus H5216-197 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered in Arizona by Humana. The plan ID is H5216:197-0.

  • Monthly Premium: $20.90
  • Plan Deductible: $0.00
  • Out of Pocket Spending Max: $7550

Primary Care Doctor Visit

In Network: Coinsurance for Primary Care Office Visit 20%

Out of Network: Coinsurance for Medicare Covered Primary Care Office Visit %20

Specialist Doctor Visit

In Network:

  • 20% Coinsurance for Physician Specialist Office Visit

Out of Network:

  • Coinsurance for Medicare Covered Physician Specialist Office Visit 20%

Inpatient Hospital Care

In Network:

  • Copayment for Acute Hospital Services per Stay $1625.00
  • Your plan covers an unlimited number of days for an inpatient stay.
  • Prior Authorization Required for Acute Hospital Services

Out of Network:

  • Copayment for Acute Hospital Services per Stay $1625.00

Urgent Care

Coinsurance for Urgent Care: 20%

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: 20% Coinsurance
  • Air Ambulance: 20% Coinsurance

Out of Network:

  • Ground Ambulance: 20% Coinsurance
  • Air Ambulance: 20% Coinsurance

Additional Covered Health Care Services and Medical Supplies

Humana Value Plus H5216-197 (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: $0 Copay

Skilled Nursing Facility (SNF) Care

In Network:

  • $0.00 per day for days 1 to 20
  • $184.00 per day for days 21 to 100
  • Prior Authorization Required for Skilled Nursing Facility Services

Out of Network:

  • $0.00 per day for days 1 to 20
  • $184.00 per day for days 21 to 100

Medical Diagnostic Tests, Labs and Radiology Services

Outpatient Diagnostic Procedures, Tests and Lab Services:

  • Copayment for Medicare-covered Diagnostic Procedures/Tests: $0.00
  • Coinsurance for Medicare-covered Diagnostic Procedures/Tests: 20%
  • Copayment for Medicare-covered Lab Services: $0.00, 20% Coinsurance
  • Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diagnostic and Therapeutic Radiology Services:

  • Coinsurance for Medicare-covered Diagnostic Radiological Services: 20%
  • Coinsurance for Medicare-covered Therapeutic Radiological Services: 20%
  • Coinsurance for Medicare-covered Therapeutic Radiological Services: 20%
  • Coinsurance for Medicare-covered X-Ray 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 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%
  • Prior Authorization Required for Durable Medical Equipment

Out of Network:

  • Coinsurance for Medicare Covered Durable Medical Equipment 20%

Chiropractic Services

In Network:

  • Coinsurance for Medicare-covered Chiropractic Services: 20%
  • Prior Authorization Required for Chiropractic Services
  • Copayment for Routine Care $0.00
  • Maximum 12 Routine Care every year

Out of Network:

  • Coinsurance for Medicare Covered Chiropractic Services 40%

Mental Health Inpatient Care

In Network:

  • In Network: Copayment for Psychiatric Hospital Services per Stay $1625.00
  • Prior Authorization Required for Psychiatric Hospital Services

Out of Network:

  • Copayment for Psychiatric Hospital Services per Stay $1625.00

Mental Health Outpatient Care

In Network:

  • Coinsurance for Medicare-covered Individual Sessions 20%
  • Coinsurance for Medicare-covered Group Sessions 20%
  • Prior Authorization Required for Outpatient Mental Health Services

Out of Network: 

  • Coinsurance for Medicare-covered Individual Sessions 20%
  • Coinsurance for Medicare-covered Group Sessions 20%

Outpatient Substance Abuse Care

In Network:

  • Coinsurance for Medicare-covered Individual Sessions: 20%
  • Coinsurance for Medicare-covered Group Sessions: 20%
  • Prior Authorization Required for Outpatient Substance Abuse Services

Transportation Services

 

  • Copayment for Transportation Services $0.00
  • Prior Authorization Required for Transportation Services
  • Plan allows 24 one way trips to a Plan-approved location every year
  • Services arranged by the plan's transportation provider to approved locations by means of car, van, or wheelchair access vehicle that provide members access to health benefits. This benefit is not to exceed 50 miles per trip

Podiatry Services

In Network:

  • Coinsurance for Medicare-Covered Podiatry Services: 20%
  • 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: Copayment for Oral Exams $0
  • Maximum 3 visits (Please see Evidence of Coverage for details)
  • Teeth Cleaning: Copayment for Prophylaxis (Cleaning) 0%
  • Maximum 2 visits every year
  • Fluoride Treatment: Copayment for Fluoride Treatment $0.00
  • Maximum 2 visits every year
  • Dental X-Rays: Coinsurance for Dental X-Rays 0% (Maximum 3 visit per year), Please see Evidence of Coverage for details

Comprehensive Dental Care

Medicare-Covered Benefits:

  • Medicare-Covered Benefits: Coinsurance for Medicare-covered Benefits 20%
  • Non-Routine services: Copayment for Non-routine Services $0.00, Maximum 2 visits every year
  • Restorative Services: Copayment for Restorative Services $0.00, Maximum 5 visits (Please see Evidence of Coverage for details)
  • Endodontics: Copayment for Endodontics $0.00, Maximum 1 visit every year
  • Periodontics: Copayment for Periodontics $0.00, Maximum 5 visits (Please see Evidence of Coverage for details)
  • Teeth Extractions: Copayment for Extractions $0.00
  • Prosthodontics, Oral/Maxillofacial Surgery, Other Services: Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00, Maximum 6 visits (Please see Evidence of Coverage for details)
  • Maximum Plan Benefit: Maximum Plan Benefit of $3000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
  • 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
  • Coinsurance for Medicare Covered Benefits 20%

Routine Eye Exams:

  • Copayment for Routine Eye Exams: $0.00
  • Maximum 1 Routine Eye Exam every year
  • Maximum Plan Benefit of $40.00 every year for in and out of network services combined
    Prior Authorization Required for Eye Exams

Eyewear

Medicare-Covered Benefits:

  • Medicare-Covered Benefits: Copayment for Medicare-Covered Benefits $0.00
  • Contact Lenses: Copayment for Contact Lenses $0.00
  • Maximum 1 Pair every year
  • Eyeglasses (lenses and frames): Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every year
  • Maximum Plan Benefit: Maximum Plan Benefit of $300.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
  • Prior Authorization Required for Eyewear

Hearing Benefits

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

Hearing Exams

Medicare-Covered Benefits:

  • Coinsurance for Medicare Covered Benefits: 20%
  • 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 $0.00
  • Maximum 2 Hearing Aids every three years

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)

Shots:

  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots

Prescription Drug Costs and Coverage

The Humana Value Plus H5216-197 (PPO) plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $435 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) $16.00
  • 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) 25%
  • Standard Retail Cost Sharing (30 Day Supply) 25%
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