HumanaChoice H5216-207 (PPO)

Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $0

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $50
Prior Authorization Required for Doctor Specialty Visit

Out-of-Network:

Acute Hospital Services:
$380 per day for days 1 to 7
$0 per day for days 8 to 90

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:
Coinsurance for Air Ambulance Services $20%
Prior Authorization Required for Air Ambulance

In-Network:

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

Out-of-Network:

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $15

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
$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

Out-of-Network:

Psychiatric Hospital Services:
$380 per day for days 1 to 5
$0 per day for days 6 to 90

Out-of-Network:

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 $475
Copayment for Medicare Covered Ambulatory Surgical Center Services $0 to $400
$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:
Copayment for Medicare Covered Individual Sessions $35
Copayment for Medicare Covered Group Sessions $35

In-Network:

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

Out-of-Network:

Podiatry Services:
Copayment for Medicare Covered Podiatry Services $50

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:
Plan covers up to $1000 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire.
Your benefit can be used for most dental treatments such as:
Preventive dental services, such as exams, routine cleanings, etc.
Basic dental services, such as fillings, extractions, etc.
Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc.
30% coinsurance applies to most major and comprehensive services.
Frequency limits may apply.
Note: The allowance cannot be used on fluoride, cosmetic services and implants.

Out-of-Network:
Plan covers up to $1000 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire.
Your benefit can be used for most dental treatments such as:
Preventive dental services, such as exams, routine cleanings, etc.
Basic dental services, such as fillings, extractions, etc.
Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc.
30% coinsurance applies to most major and comprehensive services.
Frequency limits may apply.
Note: The allowance cannot be used on fluoride, cosmetic services and implants.
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 $50
Copayment for Medicare Covered Eyewear $0
$0 Diab Eye Exam - All POTs$50 Vision Svcs (MC) - SPC

Out-of-Network:

Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $50

Out-of-Network:

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