HumanaChoice H5525-005 (PPO)

In-Network:

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

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40
Prior Authorization Required for Doctor Specialty Visit

In-Network:

Acute Hospital Services:
$379 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 $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 50%

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

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 $40
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20% to 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 $40
Coinsurance for Medicare Covered Outpatient X-Ray Services 20% to 50%
$120 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$40 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

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:
$400 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 $850
Prior Authorization Required for Outpatient Hospital Services
$0 Diag Colonoscopy - OPH$35 Mental Health - OPH$850 Surgery Svcs - OPH$40 Wound Care - OPH

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $379
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $750
Prior Authorization Required for Ambulatory Surgical Center Services
$0 Diag Colonoscopy - ASC$750 Surgery Svcs - ASC

Out-of-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 20%
Coinsurance for Medicare Covered Group Sessions 20%
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 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 $50 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.

In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $40
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 20%

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.
30% coinsurance for amalgam and/or composite filling up to 1 per tooth per surface every 2 years.
30% coinsurance for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
30% coinsurance for occlusal adjustment up to 1 every 3 years.
30% 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.
30% coinsurance for bridges-pontic up to 1 every 5 years.
30% 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.
30% coinsurance per tooth for root canal, simple or surgical extraction up to 1 per lifetime.
30% coinsurance for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
30% coinsurance for scaling for moderate inflammation up to 1 per year.
30% coinsurance for emergency treatment for pain, necessary general anesthesia with covered service up to 2 per year.
30% 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.
30% coinsurance for amalgam and/or composite filling up to 1 per tooth per surface every 2 years.
30% coinsurance for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years.
30% coinsurance for occlusal adjustment up to 1 every 3 years.
30% 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.
30% coinsurance for bridges-pontic up to 1 every 5 years.
30% 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.
30% coinsurance per tooth for root canal, simple or surgical extraction up to 1 per lifetime.
30% coinsurance for necessary nitrous oxide/analgesia with covered service up to 1 unit(s) per visit.
30% coinsurance for scaling for moderate inflammation up to 1 per year.
30% coinsurance for emergency treatment for pain, necessary general anesthesia with covered service up to 2 per year.
30% 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.

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $40
Copayment for Routine Eye Exams $0

• Maximum 1 Routine Eye Exams every year

Prior Authorization Required for Eye Exams
$0 Diab Eye Exam - All POTs$40 Vision Svcs (MC) - SPC

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0

• Maximum 1 Pair every year

Copayment for Eyeglasses (lenses and frames) $0

• Maximum 1 Pair every year

Maximum Plan Benefit of $250 every year
Members must use Humana's Medicare Insight Network, a national network of providers, which includes standard or PLUS providers. The allowance for the standard network is $100 less than the PLUS network.

Out-of-Network:

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

Out-of-Network:

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