2018 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | HumanaChoice H5216-097 (PPO) | ||||
Location: | Sumner, Tennessee Click to see other locations | ||||
Plan ID: | H5216 - 097 - 0 Click to see other plans | ||||
Member Services: | |||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the HumanaChoice H5216-097 (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $72.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $150 (Tier 1 and 2 excluded from the Deductible.) | ||||
Annual Rx Initial Coverage Limit (ICL): | $3,750 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,829 drugs | Browse the HumanaChoice H5216-097 (PPO) Formulary | |||
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $5.00 | $15.00 | $47.00 | $97.00 | 30% |
• Number of Drugs per Tier: | 311 | 592 | 765 | 1502 | 659 |
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Sumner, Tennessee: | 318 members | ||||
Number of Members enrolled in this plan in Tennessee: | 1,162 members | ||||
Number of Members enrolled in this plan in (H5216 - 097): | 3,472 members | ||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 4 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Basic Premium | Part D Supplemental Premium | |
$72.00 | $30.80 | $41.20 | $0.00 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $10.60 | $18.20 | $25.90 | $33.50 | |
Total Monthly Premium with LIS (Parts C & D): | $41.40 | $49.00 | $56.70 | $64.30 |
— Plan Health Benefits — | |||||
** Benefit Highlights ** | |||||
Health plan deductible | |||||
• $1,000 annual deductible | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $10,000 In and Out-of-network $6,700 In-network | |||||
Optional supplemental benefits | |||||
• Yes | |||||
Other health plan deductibles? | |||||
• In-Network: No | |||||
Preventive care | |||||
• In-Network: $0 copay | |||||
Outpatient hospital coverage | |||||
• In-Network: $325 per visit | |||||
Inpatient hospital coverage | |||||
• In-Network: $325 for days 1 through 5 $0 for days 6 through 90 $0 for days 91 and beyond | |||||
• Out-of-Network: 40% per stay | |||||
Outpatient hospital coverage | |||||
• Out-of-Network: 40% per visit | |||||
Preventive care | |||||
• Out-of-Network: $0 or 40% | |||||
Doctor visits | |||||
• Primary: In-Network: $20 per visit | |||||
• Primary: Out-of-Network: 40% per visit | |||||
• Specialist: In-Network: $45 per visit | |||||
• Specialist: Out-of-Network: 40% per visit | |||||
Emergency care/Urgent care | |||||
• Emergency: $80 per visit (always covered) | |||||
• Urgent care: $20-45 or 40% per visit (always covered) | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: In-Network: $0-90 | |||||
• Diagnostic tests and procedures: Out-of-Network: 40% | |||||
• Lab services: In-Network: $0-45 | |||||
• Lab services: Out-of-Network: 40% | |||||
• Diagnostic radiology services (e.g., MRI): In-Network: $45-325 | |||||
• Diagnostic radiology services (e.g., MRI): Out-of-Network: 40% | |||||
• Outpatient x-rays: In-Network: $20-90 | |||||
• Outpatient x-rays: Out-of-Network: 40% | |||||
Transportation | |||||
• Not covered | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Mental health services | |||||
• In-Network: $325 for days 1 through 4 $0 for days 5 through 90 | |||||
Skilled Nursing Facility | |||||
• In-Network: $0 for days 1 through 20 $167 for days 21 through 100 | |||||
Ambulance | |||||
• In-Network: $265 or 20% | |||||
Mental health services | |||||
• Out-of-Network: 40% per stay | |||||
Skilled Nursing Facility | |||||
• Out-of-Network: 40% per stay | |||||
Ambulance | |||||
• Out-of-Network: $265 or 20% | |||||
Mental health services | |||||
• Outpatient group therapy visit with a psychiatrist: In-Network: $40 | |||||
• Outpatient group therapy visit with a psychiatrist: Out-of-Network: 40% | |||||
• Outpatient individual therapy visit with a psychiatrist: In-Network: $40 | |||||
• Outpatient individual therapy visit with a psychiatrist: Out-of-Network: 40% | |||||
• Outpatient group therapy visit: In-Network: $40 | |||||
• Outpatient group therapy visit: Out-of-Network: 40% | |||||
• Outpatient individual therapy visit: In-Network: $40 | |||||
• Outpatient individual therapy visit: Out-of-Network: 40% | |||||
Rehabilitation services | |||||
• Occupational therapy visit: In-Network: $20 | |||||
• Occupational therapy visit: Out-of-Network: 40% | |||||
• Physical therapy and speech and language therapy visit: In-Network: $20 | |||||
• Physical therapy and speech and language therapy visit: Out-of-Network: 40% | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: In-Network: $45 | |||||
• Foot exams and treatment: Out-of-Network: 40% | |||||
• Routine foot care: Not covered | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): In-Network: 20% per item | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): Out-of-Network: 20% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): In-Network: 20% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): Out-of-Network: 25% per item | |||||
• Diabetes supplies: In-Network: $0 or 10-20% per item | |||||
• Diabetes supplies: Out-of-Network: 20% per item | |||||
Medicare Part B drugs | |||||
• Chemotherapy: In-Network: 20% | |||||
• Chemotherapy: Out-of-Network: 20-40% | |||||
• Other Part B drugs: In-Network: 20% | |||||
• Other Part B drugs: Out-of-Network: 20-40% | |||||
** Benefits Services ** | |||||
Hearing | |||||
• Hearing exam: In-Network: $45 | |||||
• Hearing exam: Out-of-Network: 40% | |||||
• Fitting/evaluation: Not covered | |||||
• Hearing aids - inner ear: Not covered | |||||
• Hearing aids - outer ear: Not covered | |||||
• Hearing aids - over the ear: Not covered | |||||
Preventive dental | |||||
• Oral exam: Not covered | |||||
• Cleaning: Not covered | |||||
• Fluoride treatment: Not covered | |||||
• Dental x-ray(s): Not covered | |||||
Comprehensive dental | |||||
• Non-routine services: Not covered | |||||
• Diagnostic services: Not covered | |||||
• Restorative services: Not covered | |||||
• Endodontics: Not covered | |||||
• Periodontics: Not covered | |||||
• Extractions: Not covered | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered | |||||
Vision | |||||
• Routine eye exam: In-Network: $0 copay | |||||
• Routine eye exam: Out-of-Network: $0 copay | |||||
• Other: Not covered | |||||
• Contact lenses: Not covered | |||||
• Eyeglasses (frames and lenses): Not covered | |||||
• Eyeglass frames: Not covered | |||||
• Eyeglass lenses: Not covered | |||||
• Upgrades: Not covered | |||||
** Optional Supplemental Benefits ** | |||||
Package #1 | |||||
• Comprehensive dental services, Preventive dental services | |||||
Package #2 | |||||
• Eye exams, Eyewear | |||||
Package #3 | |||||
• Comprehensive dental services, Eye exams, Eyewear, Preventive dental services | |||||
Package #1 | |||||
• Monthly Premium: $17.00 | |||||
Package #2 | |||||
• Monthly Premium: $15.30 | |||||
Package #3 | |||||
• Monthly Premium: $19.60 | |||||
Package #1 | |||||
• Deductible: $50.00 | |||||
Package #2 | |||||
• Deductible: N/A | |||||
Package #3 | |||||
• Deductible: $50.00 |