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HumanaChoice H5216-023 (PPO) - H5216-023-000
$32.00
Monthly Premium
HumanaChoice H5216-023 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-023-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$32.00
Monthly Premium
Ohio, Kentucky, Indiana, and 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 Ohio, Kentucky, Indiana, and 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 | $32.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $350.00 |
| Out-of-pocket maximum | $6,750.00 |
| 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 $5 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $55 |
| Inpatient hospital care | Out-of-Network: Acute Hospital Services: Coinsurance for Acute Hospital Services per Stay 50% |
| Urgent care | Urgent Care: Copayment for Urgent Care $55 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $125 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 $125 Copayment for Worldwide Emergency Transportation $125 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $315 Air Ambulance: Copayment for Air Ambulance Services $315 Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
HumanaChoice H5216-023 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-023 (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: Copayment for Medicare-covered Chiropractic Services $20 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% to 20% Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $10 |
| Durable medical equipment (DME) | Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 20% |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 50% Coinsurance for Medicare Covered Lab Services 50% Coinsurance for Medicare Covered Diagnostic Radiological Services 50% Coinsurance for Medicare Covered Therapeutic Radiological Services 50% Coinsurance for Medicare Covered Outpatient X-Ray Services 50% $105 OP Diag Proc & Tests - OPH$5 OP Diag Proc & Tests - PCP$55 OP Diag Proc & Tests - SPC$60 OP Diag Proc & Tests - UCC$105 Sleep Study (Fac Based) - OPH$105 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_ |
| Home health care | Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 50% |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $490 per day for days 1 to 4 $0 per day for days 5 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | Out-of-Network: Medicare Covered Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% |
| Outpatient services/surgery | Out-of-Network: Medicare Covered Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $100 Coinsurance for Medicare Covered Outpatient Hospital Services 50% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50% $0 Diag Colonoscopy - OPH$100 Mental Health - OPH$440 Surgery Svcs - OPH$45 Wound Care - OPH_ |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $55 to $100 Copayment for Medicare-covered Group Sessions $55 to $100 Prior Authorization Required for Outpatient Substance Abuse Services $100 OP Substance Abuse Care - OPH$55 OP Substance Abuse Care - SPC_ |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $55 Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $10 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 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, 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 necessary anesthesia with covered service up to unlimited per year. $25 copayment per tooth for amalgam and/or composite filling up to 2 per year. $1,000 combined maximum benefit coverage amount per year for preventive and comprehensive benefits.Out of Network$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, 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 necessary anesthesia with covered service up to unlimited per year. $25 copayment per tooth for amalgam and/or composite filling up to 2 per year. $1,000 combined maximum benefit coverage amount per year for 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 50% Copayment for Medicare Covered Eyewear $0 |
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 | Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 50% |
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 | 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:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The HumanaChoice H5216-023 (PPO) offers prescription drug coverage, with an annual drug deductible of $350.00 (excludes Tiers 1 and 2)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $350.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $350.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $350.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
When reviewing Ohio, Kentucky, Indiana, and 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 Ohio, Kentucky, Indiana, and 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 |
Ohio Counties Served
- Adams
- Ashland
- Ashtabula
- Athens
- Brown
- Butler
- Carroll
- Champaign
- Clark
- Clermont
- Clinton
- Columbiana
- Coshocton
- Darke
- Delaware
- Fairfield
- Fayette
- Franklin
- Gallia
- Greene
- Guernsey
- Hamilton
- Harrison
- Highland
- Hocking
- Holmes
- Jackson
- Jefferson
- Knox
- Lawrence
- Licking
- Madison
- Mahoning
- Meigs
- Miami
- Montgomery
- Morgan
- Morrow
- Muskingum
- Noble
- Perry
- Pickaway
- Preble
- Richland
- Ross
- Scioto
- Shelby
- Stark
- Trumbull
- Tuscarawas
- Union
- Warren
- Washington
- Wayne
Kentucky Counties Served
Indiana Counties Served
Pennsylvania Counties Served
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