Humana Value Plus H5525-040 (PPO)

Humana Inc.
Humana Value Plus H5525-040 (PPO) H5525-040 Plan Details
4 out of 5 stars

Humana Value Plus H5525-040 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H5525-040.

$29.00
Monthly Premium

Humana Value Plus H5525-040 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H5525-040.

Humana Inc.
Humana Value Plus H5525-040 (PPO) H5525-040 Plan Details
4 out of 5 stars

Humana Value Plus H5525-040 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H5525-040.

$29.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $260
Out of Pocket Max In-Network: $7550
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $10.00
Out-of-Network:

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 20%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Coinsurance for Physician Specialist Office Visit 18%
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 20%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $2019.00
Your plan covers an unlimited number of days for an inpatient stay.
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 20%
Urgent Care
Copayment for Urgent Care $10.00
Coinsurance for Urgent Care 18% to 20%

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Emergency Room Visit
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:
Coinsurance for Ground Ambulance Services 18%

Air Ambulance:
Coinsurance for Air Ambulance Services 18%

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
Out-of-Network:

Ambulance Services:
Coinsurance for Medicare Covered Ambulance Services - Ground 20%
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

Humana Value Plus H5525-040 (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Coinsurance for Medicare-covered Chiropractic Services 18%
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 20%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Supplies 18%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Diabetic Supplies and Services 20%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 18%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 20%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $10.00
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 18%
Copayment for Medicare-covered Lab Services $0.00
Coinsurance for Medicare-covered Lab Services 18%
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Coinsurance for Medicare-covered Diagnostic Radiological Services 18%
Coinsurance for Medicare-covered Therapeutic Radiological Services 18%
Copayment for Medicare-covered X-Ray Services $10.00
Coinsurance for Medicare-covered X-Ray Services 18%
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20%
Coinsurance for Medicare Covered Lab Services 20%
Coinsurance for Medicare Covered Diagnostic Radiological Services 20%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Coinsurance for Medicare Covered Outpatient X-Ray Services 20%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Home Health $0.00
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $1871.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 20%
Mental Health Outpatient Care
In-Network:
Coinsurance for Medicare-covered Individual Sessions 18%
Coinsurance for Medicare-covered Group Sessions 18%
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Individual Sessions 20%
Coinsurance for Medicare Covered Group Sessions 20%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 18%
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $0.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Coinsurance for Ambulatory Surgical Center Services 18%
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20%
Outpatient Substance Abuse Care
In-Network:
Coinsurance for Medicare-covered Individual Sessions 18%
Coinsurance for Medicare-covered Group Sessions 18%
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Individual or Group Sessions 20%
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $20.00 every month
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Out-of-Network:

Over-The-Counter (OTC) Items:
Coinsurance for Non-Medicare Covered Over-The-Counter (OTC) Items 50%
Maximum Plan Benefit of $20.00
Podiatry Services
In-Network:
Coinsurance for Medicare-Covered Podiatry Services 18%
Prior Authorization Required for Podiatry Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 20%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 20%

Dental Benefits

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

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 4 visits (Please see Evidence of Coverage for details)
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 6 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 3 visits (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $2000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Coinsurance for Medicare-covered Benefits 18%
Copayment for Restorative Services $0.00
Copayment for Periodontics $0.00
  • Maximum 2 visits every three years
Maximum Plan Benefit of $2000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined
Prior Authorization Required for Comprehensive Dental
Prior authorization required
Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 20%
Non-Medicare Covered Dental Services:
Coinsurance for Non-Medicare Covered Preventive Dental 0%
Coinsurance for Non-Medicare Covered Comprehensive Dental 0%

Vision Benefits

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

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Coinsurance for Medicare Covered Benefits 18%
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:
Copayment for Medicare-Covered Benefits $0.00
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 of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Prior Authorization Required for Eyewear
Prior authorization required
Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $0.00
Coinsurance for Medicare Covered Eye Exams 20%
Coinsurance for Medicare Covered Eyewear 20%
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $0.00
Copayment for Non-Medicare Covered Eyewear $0.00

Hearing Benefits

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

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Coinsurance for Medicare Covered Benefits 18%
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0.00
  • Maximum 2 Hearing Aids every three years

Prior authorization required
Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 20%
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $0.00
Copayment for Non-Medicare Covered Hearing Aids $0.00

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$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
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    Out-of-Network:

    Medicare-covered Zero Dollar Preventive Services:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0.00
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 20%

    Prescription Drug Costs and Coverage

    The Humana Value Plus H5525-040 (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $260 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $260 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $0.00
    Generic
    • Preferred retail $15.00
    • Standard retail $20.00
    • Preferred mail order $15.00
    • Standard mail order $20.00
    Annual Drug Deductible $260 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail N/A
    • Standard retail N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    Generic
    • Preferred retail N/A
    • Standard retail N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    Annual Drug Deductible $260 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $0.00
    Generic
    • Preferred retail $45.00
    • Standard retail $60.00
    • Preferred mail order $0.00
    • Standard mail order $60.00