HumanaChoice - Diabetes and Heart (PPO C-SNP)

In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $55
Prior Authorization Required for Doctor Specialty Visit

In-Network:

Acute Hospital Services:
$375 per day for days 1 to 7
$0 per day for days 8 to 90
Prior Authorization Required for Acute Hospital Services

Urgent Care:
Copayment for Urgent Care $40

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $40

Emergency Care:
Copayment for Emergency Care $115
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $115
Copayment for Worldwide Emergency Transportation $325

In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $325

Air Ambulance:
Copayment for Air Ambulance Services $335
Prior Authorization Required for Air Ambulance

Out-of-Network:

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $15
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Prior Authorization Required for Chiropractic Services

Out-of-Network:

Diabetic Supplies and Services:
Copayment for Medicare Covered Diabetic Supplies $0
Coinsurance for Medicare Covered Diabetic Supplies 20%
Copayment for Medicare Covered Diabetic Therapeutic Shoes or Inserts $0

Out-of-Network:

Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 20%

Out-of-Network:

Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0 to $120
Copayment for Medicare Covered Lab Services $0
Copayment for Medicare Covered Diagnostic Radiological Services $0 to $335
Copayment for Medicare Covered Therapeutic Radiological Services $55
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Copayment for Medicare Covered Outpatient X-Ray Services $0 to $130
$120 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$55 OP Diag Proc & Tests - SPC$40 OP Diag Proc & Tests - UCC$100 Sleep Study (Fac Based) - OPH$40 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home

Out-of-Network:

Home Health Services:
Copayment for Medicare Covered Home Health $0

In-Network:

Psychiatric Hospital Services:
$375 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services

Out-of-Network:

Mental Health Services:
Copayment for Medicare Covered Individual Sessions $35
Copayment for Medicare Covered Group Sessions $35

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $450
Prior Authorization Required for Outpatient Hospital Services
$0 Diag Colonoscopy - OPH$35 Mental Health - OPH$450 Surgery Svcs - OPH$55 Wound Care - OPH

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $375
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $375
Prior Authorization Required for Ambulatory Surgical Center Services
$0 Diag Colonoscopy - ASC$375 Surgery Svcs - ASC

In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $35
Copayment for Medicare-covered Group Sessions $35
Prior Authorization Required for Outpatient Substance Abuse Services

Out-of-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare Covered Individual Sessions $35
Copayment for Medicare Covered Group Sessions $35

In-Network:
$25 monthly allowance on a prepaid spending card. All plan members receive this amount to buy approved over the counter (OTC) health and wellness products at participating retailers or through the plan’s approved OTC mail order vendor. Plus, members may also use this money for eligible groceries, utilities, rent, and more if they have certain qualifying chronic condition(s) and meet other program criteria. Any unused amount rolls over each month and expires at the end of the plan year or upon disenrollment, whichever occurs first.

Out-of-Network:
95% coinsurance.
Member is required to pay the full cost at the time of service when utilizing an out-of-network provider. To receive reimbursement from Humana for eligible items/services, the member must submit required documentation. Reimbursement will be limited to up to 5% of the allowed amount on eligible items/services.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $55
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $55
Copayment for Routine Foot Care $55

• Maximum 6 visits every year

Prior Authorization Required for Podiatry Services

Out-of-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$218 per day for days 21 to 100

In-Network:
0% coinsurance for crown recementation up to 1 every 2 years.
0% coinsurance for root canal retreatment up to 1 per tooth per lifetime.
0% coinsurance for bridge recementation up to 1 per year.
0% coinsurance for oral surgery up to 2 per year.
0% coinsurance for periodontal maintenance up to 4 per year.
$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for bitewing x-rays up to 1 per year.
$0 copayment for emergency diagnostic exam, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for intraoral x-rays up to 6 per year.
50% coinsurance for amalgam and/or composite filling up to 1 per tooth per surface every 2 years.
50% coinsurance for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
50% coinsurance for occlusal adjustment up to 1 every 3 years.
50% coinsurance for crown-porcelain fused to high noble metal, crown-porcelain fused to noble metal, crown-porcelain/ceramic, denture repair - additions, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years.
50% coinsurance for bridges-pontic, complete dentures, partial dentures up to 1 every 5 years.
50% coinsurance for bridges-crown-porcelain fused to high noble metal, bridges-crown-porcelain fused to noble metal, bridges-crown-porcelain/ceramic up to 2 every 5 years.
50% coinsurance per tooth for root canal, simple or surgical extraction up to 1 per lifetime.
50% coinsurance for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
50% coinsurance for denture rebase, denture reline, scaling for moderate inflammation, tissue conditioning up to 1 per year.
50% coinsurance for denture repair - broken teeth up to 2 per tooth per year.
50% coinsurance for adjustments to dentures, denture repair - base and framework, emergency treatment for pain, necessary general anesthesia with covered service up to 2 per year.
50% coinsurance for necessary incremental anesthesia with covered service up to as needed with covered codes per year.
$1,500 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.

Out-of-Network:
0% coinsurance for crown recementation up to 1 every 2 years.
0% coinsurance for root canal retreatment up to 1 per tooth per lifetime.
0% coinsurance for bridge recementation up to 1 per year.
0% coinsurance for oral surgery up to 2 per year.
0% coinsurance for periodontal maintenance up to 4 per year.
$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for bitewing x-rays up to 1 per year.
$0 copayment for emergency diagnostic exam, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for intraoral x-rays up to 6 per year.
50% coinsurance for amalgam and/or composite filling up to 1 per tooth per surface every 2 years.
50% coinsurance for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
50% coinsurance for occlusal adjustment up to 1 every 3 years.
50% coinsurance for crown-porcelain fused to high noble metal, crown-porcelain fused to noble metal, crown-porcelain/ceramic, denture repair - additions, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years.
50% coinsurance for bridges-pontic, complete dentures, partial dentures up to 1 every 5 years.
50% coinsurance for bridges-crown-porcelain fused to high noble metal, bridges-crown-porcelain fused to noble metal, bridges-crown-porcelain/ceramic up to 2 every 5 years.
50% coinsurance per tooth for root canal, simple or surgical extraction up to 1 per lifetime.
50% coinsurance for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
50% coinsurance for denture rebase, denture reline, scaling for moderate inflammation, tissue conditioning up to 1 per year.
50% coinsurance for denture repair - broken teeth up to 2 per tooth per year.
50% coinsurance for adjustments to dentures, denture repair - base and framework, emergency treatment for pain, necessary general anesthesia with covered service up to 2 per year.
50% coinsurance for necessary incremental anesthesia with covered service up to as needed with covered codes per year.
$1,500 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.
Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions.

Out-of-Network:

Eye Exams Services:
Copayment for Medicare Covered Eye Exams $0 to $55
Copayment for Medicare Covered Eyewear $0
$0 Diab Eye Exam - All POTs$55 Vision Svcs (MC) - SPC

Out-of-Network:

Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $55

Out-of-Network:

Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0