HumanaChoice H5216-463 (PPO)

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 $50%

In-Network:

Acute Hospital Services:
$440 per day for days 1 to 6
$0 per day for days 7 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
Copayment for Medicare Covered Ambulance Services - Air $1800

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 10% to 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$45 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

Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 50%

In-Network:

Psychiatric Hospital Services:
$440 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

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $550
Prior Authorization Required for Outpatient Hospital Services
$0 Diag Colonoscopy - OPH$35 Mental Health - OPH$550 Surgery Svcs - OPH$45 Wound Care - OPH

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $440
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $450
Prior Authorization Required for Ambulatory Surgical Center Services
$0 Diag Colonoscopy - ASC$450 Surgery Svcs - ASC

Out-of-Network:

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

In-Network:
$50 quarterly allowance on a prepaid spending card to buy approved over-the-counter health and wellness products at participating retail locations or through the plan's approved OTC mail order vendor.
Unused amount expires at the end of the quarter or upon disenrollment from the plan, 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:
Copayment for Medicare-Covered Podiatry Services $45
Prior Authorization Required for Podiatry Services

Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 50%

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.
$3,000 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.
$3,000 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%
Copayment for Medicare Covered Eyewear $0
$0 Diab Eye Exam - All POTs$45 Vision Svcs (MC) - SPC

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $45
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 $499 to $725

• Maximum 2 Hearing Aids every year

Out-of-Network:

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