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Humana Value Plus H5216-117 (PPO) - H5216-117-000
$28.70
Monthly Premium
Humana Value Plus H5216-117 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-117-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$28.70
Monthly Premium
Pennsylvania Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Pennsylvania Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $28.70 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $590.00 |
| Out-of-pocket maximum | $7,800.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $20 |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit 20% |
| Inpatient hospital care | In-Network: Acute Hospital Services: $680 per day for days 1 to 3 $0 per day for days 4 to 90 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $45 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $110 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 $110 Copayment for Worldwide Emergency Transportation $110 |
| Ambulance transportation | Out-of-Network: Ambulance Services: Coinsurance for Medicare Covered Ambulance Services - Ground 18% Coinsurance for Medicare Covered Ambulance Services - Air 18% |
Health Care Services and Medical Supplies
Humana Value Plus H5216-117 (PPO) covers a range of additional benefits. Learn more about Humana Value Plus H5216-117 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Coinsurance for Medicare-covered Chiropractic Services 18% Prior Authorization Required for Chiropractic Services |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Supplies 10% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Copayment for Medicare-covered Durable Medical Equipment $0 Coinsurance for Medicare-covered Durable Medical Equipment 16% Prior Authorization Required for Durable Medical Equipment 16% Continuous Glucose Monitor - DME Prov$0 Continuous Glucose Monitor - Pharmacy16% DME - DME Prov16% DME - Pharmacy_ |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $45 Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20% Copayment for Medicare Covered Lab Services $45 Coinsurance for Medicare Covered Lab Services 20% Coinsurance for Medicare Covered Diagnostic Radiological Services 20% Coinsurance for Medicare Covered Therapeutic Radiological Services 20% Copayment for Medicare Covered Outpatient X-Ray Services $45 Coinsurance for Medicare Covered Outpatient X-Ray Services 20% 18% OP Diag Proc & Tests - OPH$20 OP Diag Proc & Tests - PCP18% OP Diag Proc & Tests - SPC$45 OP Diag Proc & Tests - UCC18% Sleep Study (Fac Based) - OPH18% Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_ |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: Coinsurance for Psychiatric Hospital per Stay 20% |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Coinsurance for Medicare-covered Individual Sessions 18% Coinsurance for Medicare-covered Group Sessions 18% |
| Outpatient services/surgery | Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 20% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20% $0 Diag Colonoscopy - OPH18% Mental Health - OPH18% Surgery Svcs - OPH18% Wound Care - OPH_ |
| Outpatient substance abuse care | Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 20% Coinsurance for Medicare Covered Group Sessions 20% |
| Podiatry services | Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 20% |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | $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, scaling for moderate inflammation 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, intraoral x-rays up to 1 set(s) per year. $0 copayment for emergency diagnostic exam up to 1 per year. $0 copayment for periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for amalgam and/or composite filling, necessary anesthesia with covered service up to unlimited per year. $2,000 combined maximum benefit coverage amount per year for all diagnostic/preventive and comprehensive benefits.Out of Network$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, scaling for moderate inflammation 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, intraoral x-rays up to 1 set(s) per year. $0 copayment for emergency diagnostic exam up to 1 per year. $0 copayment for periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for amalgam and/or composite filling, necessary anesthesia with covered service up to unlimited 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. |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | Out-of-Network: Medicare Covered Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 20% to 50% Coinsurance for Medicare Covered Eyewear 20% |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Coinsurance for Medicare Covered Benefits 18% Copayment for Routine Hearing Exams $0
Prior Authorization Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $0
|
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 Coinsurance for Medicare Covered Medicare-covered Preventive Services 50% |
Prescription Drug Costs and Coverage
The Humana Value Plus H5216-117 (PPO) offers prescription drug coverage, with an annual drug deductible of $590.00 (excludes Tiers 1 and 2)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $590.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $590.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $590.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
When reviewing Pennsylvania Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Pennsylvania that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Pennsylvania Counties Served
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