HumanaChoice H5216-316 (PPO)

Out-of-Network:

Doctor Office Visit Services:
Coinsurance for Medicare Covered Primary Care Office Visit $50%

Out-of-Network:

Doctor Specialty Visit Services:
Coinsurance for Medicare Covered Physician Specialist Office Visit $50%

In-Network:

Acute Hospital Services:
$320 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services

Urgent Care:
Copayment for Urgent Care $50

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $50

Emergency Care:
Copayment for Emergency Care $130
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 $130
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%

Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 50%
In-Network:

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

Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 50%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 50%

Out-of-Network:

Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 50%

Out-of-Network:

Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $50
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 50%
Copayment for Medicare Covered Lab Services $50
Coinsurance for Medicare Covered Lab Services 50%
Copayment for Medicare Covered Diagnostic Radiological Services $0
Coinsurance for Medicare Covered Diagnostic Radiological Services 50%
Coinsurance for Medicare Covered Therapeutic Radiological Services 50%
Copayment for Medicare Covered Outpatient X-Ray Services $50
Coinsurance for Medicare Covered Outpatient X-Ray Services 50%
$100 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$30 OP Diag Proc & Tests - SPC$50 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

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:
$320 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:
Coinsurance for Medicare Covered Individual Sessions 50%
Coinsurance for Medicare Covered Group Sessions 50%

Out-of-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0
Coinsurance for Medicare Covered Outpatient Hospital Services 50%
Copayment for Medicare Covered Ambulatory Surgical Center Services $0
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50%
$0 Diag Colonoscopy - OPH$20 Mental Health - OPH$400 Surgery Svcs - OPH$30 Wound Care - OPH

In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $20
Copayment for Medicare-covered Group Sessions $20
Prior Authorization Required for Outpatient Substance Abuse Services

Out-of-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 50%
Coinsurance for Medicare Covered Group Sessions 50%

In-Network:
$60 quarterly allowance to buy approved over-the-counter health and wellness products available through our OTC Mail Order provider.
Unused amount rolls over to the next quarter and expires at the end of the plan year.

Out-of-Network:
95% coinsurance for approved over-the-counter health and wellness products up to $60 quarterly allowance amount.
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:
Coinsurance for Medicare Covered Podiatry Services 50%
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $30
Prior Authorization Required for Podiatry Services

Out-of-Network:

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

In-Network:
$0 copayment for amalgam and/or composite filling up to 1 per tooth per surface every 2 years.
$0 copayment for crown recementation up to 1 every 2 years.
$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment up to 1 every 3 years.
$0 copayment for crown, denture repair - additions, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years.
$0 copayment for bridges-pontic, complete dentures, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 every 5 years.
$0 copayment per tooth for root canal, root canal retreatment, simple or surgical extraction up to 1 per lifetime.
$0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$0 copayment for bitewing x-rays, bridge recementation, denture rebase, denture reline, scaling for moderate inflammation, tissue conditioning up to 1 per year.
$0 copayment for denture repair - broken teeth up to 2 per tooth per year.
$0 copayment for adjustments to dentures, denture repair - base and framework, emergency diagnostic exam, emergency treatment for pain, necessary general anesthesia with covered service, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for intraoral x-rays up to 6 per year.
$0 copayment for necessary incremental anesthesia with covered service up to as needed with covered codes per year.
$2,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.

Out-of-Network:
$0 copayment for amalgam and/or composite filling up to 1 per tooth per surface every 2 years.
$0 copayment for crown recementation up to 1 every 2 years.
$0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
$0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment up to 1 every 3 years.
$0 copayment for crown, denture repair - additions, other restorative services - core buildup and prefabricated post and core up to 1 per tooth every 5 years.
$0 copayment for bridges-pontic, complete dentures, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years.
$0 copayment for bridges-crown up to 2 every 5 years.
$0 copayment per tooth for root canal, root canal retreatment, simple or surgical extraction up to 1 per lifetime.
$0 copayment for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
$0 copayment for bitewing x-rays, bridge recementation, denture rebase, denture reline, scaling for moderate inflammation, tissue conditioning up to 1 per year.
$0 copayment for denture repair - broken teeth up to 2 per tooth per year.
$0 copayment for adjustments to dentures, denture repair - base and framework, emergency diagnostic exam, emergency treatment for pain, necessary general anesthesia with covered service, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for intraoral x-rays up to 6 per year.
$0 copayment for necessary incremental anesthesia with covered service up to as needed with covered codes per year.
$2,000 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 50%
Coinsurance for Medicare Covered Eyewear 50%
$0 Diab Eye Exam - All POTs$30 Vision Svcs (MC) - SPC

Out-of-Network:

Hearing Exams Services:
Coinsurance for Medicare Covered Hearing Exams 50%

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