HumanaChoice Giveback H5216-154 (PPO)

Out-of-Network:

Doctor Office Visit Services:
Coinsurance for Medicare Covered Primary Care Office Visit $25%

Out-of-Network:

Doctor Specialty Visit Services:
Coinsurance for Medicare Covered Physician Specialist Office Visit $25%

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

Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $325
Coinsurance for Medicare Covered Ambulance Services - Air $20%

In-Network:

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

Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 25%

In-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Coinsurance for Medicare-covered Diabetic Supplies 10% to 20%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10

In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 16%
Prior Authorization Required for Durable Medical Equipment

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $180
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
$15 Coumadin Clinic Svcs - OPH$180 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$50 OP Diag Proc & Tests - SPC$40 OP Diag Proc & Tests - UCC$175 Sleep Study (Fac Based) - OPH$100 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $345
Copayment for Medicare-covered Therapeutic Radiological Services $50
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $145

In-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services

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

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
Coinsurance for Medicare Covered Outpatient Hospital Services 25% to 50%
Copayment for Medicare Covered Ambulatory Surgical Center Services $0
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50%
$0 Diag Colonoscopy - OPH$35 Mental Health - OPH$475 Surgery Svcs - OPH$50 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:
Coinsurance for Medicare Covered Individual Sessions 25% to 45%
Coinsurance for Medicare Covered Group Sessions 25% to 45%

In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $50
Prior Authorization Required for Podiatry Services

Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 25%

Out-of-Network:

Skilled Nursing Facility Services:
Coinsurance for Skilled Nursing Facility per Stay 50%

In-Network:
$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 necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$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 periodontal maintenance up to 4 per year.

Out-of-Network:
$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 necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$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 periodontal maintenance up to 4 per year.
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 25%
Copayment for Medicare Covered Eyewear $0
$0 Diab Eye Exam - All POTs$50 Vision Svcs (MC) - SPC

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $50
Copayment for Routine Hearing Exams $0

• Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0

• Maximum 4 visits every year

Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $575 to $750

• Maximum 2 Hearing Aids every year

Out-of-Network:

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