2022 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | HumanaChoice H5216-223 (PPO) | ||||
Location: | Boulder, Colorado Click to see other locations | ||||
Plan ID: | H5216 - 223 - 0 Click to see other plans | ||||
Member Services: | 1-800-457-4708 TTY users 711 | ||||
— 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 H5216-223 (PPO) benefit details
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— Medicare Plan Features — | |||||
Monthly Premium: | $28.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 | ||||
Annual Initial Coverage Limit (ICL): | $4,430 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $5,500 | ||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,491 drugs | Browse the HumanaChoice H5216-223 (PPO) Formulary | |||
This plan has 5 drug tiers.
See cost-sharing for all pharmacies and tiers.
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This plan offers select insulin at a $35 copay. Learn more. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $2.00 | $5.00 | $47.00 | $100.00 | 33% |
• Number of Drugs per Tier: | 315 | 583 | 828 | 1076 | 689 |
Plan Offers Mail Order? | Yes | ||||
Medicare Plan Pharmacy Numbers: | BIN: 015581 PCN: 03200000 See BIN/PCNs for all plans | ||||
Number of Members enrolled in this plan in Boulder, Colorado: | 199 members | ||||
Number of Members enrolled in this plan in Colorado: | 11,262 members | ||||
Number of Members enrolled in this plan in (H5216 - 223): | 11,687 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 Base Premium | Part D Supplemental Premium | |
$28.00 | $0.00 | $28.00 | $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: | $0.00 | $7.00 | $14.00 | $21.00 | |
Total Monthly Premium with LIS (Parts C & D): | $0.00 | $7.00 | $14.00 | $21.00 |
— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | |||||
• Health plan premium: $0 | |||||
• Drug plan premium: $28 | |||||
• You must continue to pay your Part B premium. | |||||
• Part B premium reduction: No | |||||
Deductible | |||||
• Health plan deductible: $0 | |||||
• Other health plan deductibles: In-network: No | |||||
• Drug plan deductible: No annual deductible | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $11 | |||||
Optional supplemental benefits | |||||
• No | |||||
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? | |||||
• In-network: Yes | |||||
Doctor visits | |||||
• Primary In-network: $0 copay | |||||
• Primary Out-of-network: $30-60 copay per visit | |||||
• Specialist In-network: $35 copay per visit | |||||
• Specialist Out-of-network: $60 copay or 50% coinsurance per visit | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures In-network: $0-100 copay (authorization required) | |||||
• Diagnostic tests and procedures Out-of-network: $0-60 copay or 40-50% coinsurance (authorization required) | |||||
• Lab services In-network: $0 copay (authorization required) | |||||
• Lab services Out-of-network: 50% coinsurance (authorization required) | |||||
• Diagnostic radiology services (e.g., MRI) In-network: $0-275 copay (authorization required) | |||||
• Diagnostic radiology services (e.g., MRI) Out-of-network: $500 copay or 40-50% coinsurance (authorization required) | |||||
• Outpatient x-rays In-network: $0-100 copay (authorization required) | |||||
• Outpatient x-rays Out-of-network: $30-60 copay or 40-50% coinsurance (authorization required) | |||||
Emergency care/Urgent care | |||||
• Emergency: $90 copay per visit (always covered) | |||||
• Urgent care: $0-60 copay or 50% coinsurance per visit (always covered) | |||||
Inpatient hospital coverage | |||||
• In-network: $250 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 91 and beyond (authorization required) | |||||
• Out-of-network: $500 per day for days 1 through 20 $0 per day for days 21 through 90 (authorization required) | |||||
Outpatient hospital coverage | |||||
• In-network: $20-250 copay per visit (authorization required) | |||||
• Out-of-network: 40-50% coinsurance per visit (authorization required) | |||||
Skilled Nursing Facility | |||||
• In-network: $0 per day for days 1 through 20 $188 per day for days 21 through 100 (authorization required) | |||||
• Out-of-network: 50% per stay (authorization required) | |||||
Preventive care | |||||
• In-network: $0 copay | |||||
• Out-of-network: $0 copay or 50% coinsurance | |||||
Ground ambulance | |||||
• In-network: $265 copay | |||||
• Out-of-network: $265 copay | |||||
Rehabilitation services | |||||
• Occupational therapy visit In-network: $30 copay (authorization required) | |||||
• Occupational therapy visit Out-of-network: 50% coinsurance (authorization required) | |||||
• Physical therapy and speech and language therapy visit In-network: $30 copay (authorization required) | |||||
• Physical therapy and speech and language therapy visit Out-of-network: 50% coinsurance (authorization required) | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric In-network: $250 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) | |||||
• Inpatient hospital - psychiatric Out-of-network: $500 per day for days 1 through 20 $0 per day for days 21 through 90 (authorization required) | |||||
• Outpatient group therapy visit with a psychiatrist In-network: $20 copay (authorization required) | |||||
• Outpatient group therapy visit with a psychiatrist Out-of-network: 50% coinsurance (authorization required) | |||||
• Outpatient individual therapy visit with a psychiatrist In-network: $20 copay (authorization required) | |||||
• Outpatient individual therapy visit with a psychiatrist Out-of-network: 50% coinsurance (authorization required) | |||||
• Outpatient group therapy visit In-network: $20 copay (authorization required) | |||||
• Outpatient group therapy visit Out-of-network: 50% coinsurance (authorization required) | |||||
• Outpatient individual therapy visit In-network: $20 copay (authorization required) | |||||
• Outpatient individual therapy visit Out-of-network: 50% coinsurance (authorization required) | |||||
Opioid treatment program services | |||||
• In-network: $20.00 copay (authorization required) | |||||
• Out-of-network: 50% coinsurance (authorization required) | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 18% coinsurance per item (authorization required) | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 25% coinsurance per item (authorization required) | |||||
• Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required) | |||||
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 50% coinsurance per item (authorization required) | |||||
• Diabetes supplies In-network: $0 copay or 10-20% coinsurance per item (authorization required) | |||||
• Diabetes supplies Out-of-network: $0 copay or 50% coinsurance per item (authorization required) | |||||
Dialysis | |||||
• 20% coinsurance (authorization required) | |||||
Hearing | |||||
• Hearing exam In-network: $35 copay (authorization required) | |||||
• Hearing exam Out-of-network: $60 copay or 50% coinsurance (authorization required) | |||||
• Fitting/evaluation In-network: $0 copay (authorization required) | |||||
• Fitting/evaluation Out-of-network: $0 copay (authorization required) | |||||
• Hearing aids In-network: $699-999 copay (limits apply) | |||||
• Hearing aids Out-of-network: $699-999 copay (limits apply) | |||||
Preventive dental | |||||
• Oral exam In-network: $0 copay (limits apply) | |||||
• Oral exam Out-of-network: 50% coinsurance (limits apply) | |||||
• Cleaning In-network: $0 copay (limits apply) | |||||
• Cleaning Out-of-network: 50% coinsurance (limits apply) | |||||
• Fluoride treatment: Not covered | |||||
• Dental x-ray(s) In-network: $0 copay (limits apply) | |||||
• Dental x-ray(s) Out-of-network: 50% coinsurance (limits apply) | |||||
Comprehensive dental | |||||
• Non-routine services: Not covered | |||||
• Diagnostic services: Not covered | |||||
• Restorative services In-network: 50-70% coinsurance (limits apply, authorization required) | |||||
• Restorative services Out-of-network: 55-75% coinsurance (limits apply, authorization required) | |||||
• Endodontics: Not covered | |||||
• Periodontics: Not covered | |||||
• Extractions In-network: 50% coinsurance (limits apply, authorization required) | |||||
• Extractions Out-of-network: 55-75% coinsurance (limits apply, authorization required) | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services In-network: 70% coinsurance (limits apply, authorization required) | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services Out-of-network: 55-75% coinsurance (limits apply, authorization required) | |||||
Vision | |||||
• Routine eye exam In-network: $0 copay (limits apply, authorization required) | |||||
• Routine eye exam Out-of-network: $0 copay (limits apply, authorization required) | |||||
• Other: Not covered | |||||
• Contact lenses In-network: $0 copay (limits apply, authorization required) | |||||
• Contact lenses Out-of-network: $0 copay (limits apply, authorization required) | |||||
• Eyeglasses (frames and lenses) In-network: $0 copay (limits apply, authorization required) | |||||
• Eyeglasses (frames and lenses) Out-of-network: $0 copay (limits apply, authorization required) | |||||
• Eyeglass frames: Not covered | |||||
• Eyeglass lenses: Not covered | |||||
• Upgrades: Not covered | |||||
Medically-approved non-opioid pain management services | |||||
• Chiropractic services: Not covered | |||||
• Acupuncture: Some coverage | |||||
• Therapeutic Massage: Not covered | |||||
• Alternative Therapies: Not covered | |||||
More benefits | |||||
• Over-the-counter drug benefits: Some coverage | |||||
• Meals for short duration: Some coverage | |||||
• Annual physical exams: Some coverage | |||||
• Telehealth: Some coverage | |||||
• WorldWide emergency transportation: Some coverage | |||||
• WorldWide emergency coverage: Some coverage | |||||
• WorldWide emergency urgent care: Some coverage | |||||
• Fitness Benefit: Some coverage | |||||
• In-Home Support Services: Not covered | |||||
• Bathroom Safety Devices: Not covered | |||||
• Health Education: Not covered | |||||
• In-Home Safety Assessment: Not covered | |||||
• Personal Emergency Response System (PERS): Not covered | |||||
• Medical Nutrition Therapy (MNT): Not covered | |||||
• Post discharge In-Home Medication Reconciliation: Not covered | |||||
• Re-admission Prevention: Not covered | |||||
• Wigs for Hair Loss Related to Chemotherapy: Not covered | |||||
• Weight Management Programs: Not covered | |||||
• Adult Day Health Services: Not covered | |||||
• Nutritional/Dietary Benefit: Not covered | |||||
• Home-Based Palliative Care: Not covered | |||||
• Support for Caregivers of Enrollees: Not covered | |||||
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered | |||||
• Enhanced Disease Management: Not covered | |||||
• Telemonitoring Services: Not covered | |||||
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Not covered | |||||
• Counseling Services: Not covered | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Transportation | |||||
• Not covered | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment In-network: $35 copay (authorization required) | |||||
• Foot exams and treatment Out-of-network: $60 copay or 50% coinsurance (authorization required) | |||||
• Routine foot care In-network: $0 copay (limits apply, authorization required) | |||||
• Routine foot care Out-of-network: $60 copay or 50% coinsurance (limits apply, authorization required) | |||||
Medicare Part B drugs | |||||
• Chemotherapy In-network: 20% coinsurance (authorization required) | |||||
• Chemotherapy Out-of-network: 50% coinsurance (authorization required) | |||||
• Other Part B drugs In-network: 20% coinsurance (authorization required) | |||||
• Other Part B drugs Out-of-network: 50% coinsurance (authorization required) |