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2019 Medicare Advantage Plan Benefit Details for the HumanaChoice R4182-004 (Regional PPO) - R4182-004-0

2019 Medicare Advantage Plan Details
Medicare Plan Name:HumanaChoice R4182-004 (Regional PPO)
Location:Fayette, Texas
Plan ID:R4182 - 004 - 0     Click to see other plans
Member Services:1-800-457-4708 TTY users 711
— Enrollment Options —
Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
Speak to a licensed sales agent to learn more and enroll.
Call Medicare Solutions at 855-373-9484 / TTY 711

Monday ‐ Friday 8:30am — 10pm EST
Email a copy of the HumanaChoice R4182-004 (Regional PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$48.00 (see Plan Premium Details below)
Annual Deductible:$175 (Tier 1 and 2 excluded from the Deductible.)
Health Plan Type:Regional PPO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$6,700
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,519 drugsBrowse the HumanaChoice R4182-004 (Regional PPO) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:
Number of Drugs per
Plan's Pharmacy Search:http:www.humana.com/medicare/medicare_prescription_drugs/
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Fayette, Texas:197 members
Number of Members enrolled in this plan in (R4182 - 004):28,235 members
Plan’s Summary Star Rating: 3.5 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:
Part C
Part D Base
Part D Supplemental
Monthly Premium with Extra Help Low-Income Subsidy (LIS):100%
Monthly Part D Premium with LIS:$0.00$6.00$11.90$17.90
Total Monthly Premium with LIS (Parts C & D):$24.10$30.10$36.00$42.00
— Plan Health Benefits —
** Benefit Highlights **
Health plan deductible $750 annual deductible
Other health plan deductibles? In-Network:  No
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
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? In-Network:  No
Inpatient hospital coverage In-Network:  $360 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 91 and beyond
  Out-of-Network:  40% per stay
Outpatient hospital coverage In-Network:  $325 per visit
  Out-of-Network:  40% per visit
Doctor visits Primary:  In-Network:  $25 per visit
  Primary:  Out-of-Network:  40% per visit
  Specialist:  In-Network:  $45 per visit
  Specialist:  Out-of-Network:  40% per visit
Preventive care In-Network:  $0 copay
  Out-of-Network:  $0 or 40-50%
Emergency care/Urgent care Emergency:  $90 per visit (always covered)
  Urgent care:  $25-45 or 40% per visit (always 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
Mental health services Inpatient hospital - psychiatric:  In-Network:  $360 per day for days 1 through 4
$0 per day for days 5 through 90
  Inpatient hospital - psychiatric:  Out-of-Network:  40% per stay
  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%
Skilled Nursing Facility In-Network:  $0 per day for days 1 through 20
$172 per day for days 21 through 100
  Out-of-Network:  40% per stay
Rehabilitation services Occupational therapy visit:  In-Network:  $25
  Occupational therapy visit:  Out-of-Network:  40%
  Physical therapy and speech and language therapy visit:  In-Network:  $25
  Physical therapy and speech and language therapy visit:  Out-of-Network:  40%
Ground ambulance In-Network:  $265
  Out-of-Network:  $265
Transportation Not covered
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:  25% per item
Wellness programs (e.g., fitness, nursing hotline) Covered
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 **
Diagnostic procedures/lab services/imaging Diagnostic tests and procedures:  In-Network:  $0-175
  Diagnostic tests and procedures:  Out-of-Network:  40%
  Lab services:  In-Network:  $0-70
  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:  $25-95
  Outpatient x-rays:  Out-of-Network:  40%
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
** Optional Supplemental Benefits **
Package #1 Comprehensive dental, Preventive dental
  Monthly Premium:  $16.60
  Deductible:  N/A
Package #2 Wellness programs (e.g., fitness, nursing hotline)
  Monthly Premium:  $15.00
  Deductible:  N/A

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