HumanaChoice - Diabetes and Heart (PPO C-SNP)

In-Network:

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

Out-of-Network:

Doctor Specialty Visit Services:
Coinsurance for Medicare Covered Physician Specialist Office Visit $20%

In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $2241
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

Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $325
Copayment for Medicare Covered Ambulance Services - Air $1800

In-Network:

Chiropractic Services:
Coinsurance for Medicare-covered Chiropractic Services 20%
Copayment for Routine Care $0

• Maximum 12 Routine Care every year

Prior Authorization Required for Chiropractic Services

Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 20%

In-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

In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment

Out-of-Network:

Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0 to $40
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20%
Copayment for Medicare Covered Lab Services $0 to $30
Coinsurance for Medicare Covered Lab Services 20%
Copayment for Medicare Covered Diagnostic Radiological Services $0 to $345
Coinsurance for Medicare Covered Diagnostic Radiological Services 20%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Copayment for Medicare Covered Outpatient X-Ray Services $0 to $40
Coinsurance for Medicare Covered Outpatient X-Ray Services 20%
20% OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP20% OP Diag Proc & Tests - SPC$40 OP Diag Proc & Tests - UCC20% Sleep Study (Fac Based) - OPH20% 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:
Copayment for Psychiatric Hospital Services per Stay $2091
Prior Authorization Required for Psychiatric Hospital Services

In-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $35
Copayment for Medicare-covered Group Sessions $35

Out-of-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $35
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Copayment for Medicare Covered Ambulatory Surgical Center Services $0
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20%
$0 Diag Colonoscopy - OPH$35 Mental Health - OPH20% Surgery Svcs - OPH20% Wound Care - OPH

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:
$75 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.

In-Network:

Podiatry Services:
Coinsurance for Medicare-Covered Podiatry Services 20%
Copayment for Routine Foot Care $0

• Maximum 12 visits every year

Prior Authorization Required for Podiatry Services

Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 20%

In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$221 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

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, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years.
50% coinsurance for bridges-pontic 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 scaling for moderate inflammation up to 1 per year.
50% coinsurance for 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.
$750 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, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years.
50% coinsurance for bridges-pontic 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 scaling for moderate inflammation up to 1 per year.
50% coinsurance for 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.
$750 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
Coinsurance for Medicare Covered Eye Exams 20%
Copayment for Medicare Covered Eyewear $0
$0 Diab Eye Exam - All POTs20% Vision Svcs (MC) - SPC

Out-of-Network:

Hearing Exams Services:
Coinsurance for Medicare Covered Hearing Exams 20%

Out-of-Network:

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