Humana Value Choice (PPO)
Available to residents of Winnebago County, WI for 2027. Contract H3642, plan 001, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Winnebago County
- Plan website
- Browse the Humana Value Choice (PPO) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
New for 2027. This plan has no 2026 predecessor in the CMS crosswalk. Every WI plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $4,450.00? |
| In- and out-of-network out-of-pocket maximum | $6,300.00 |
| Drug deductible | $700.00Tier 1, 2 and 3 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | PPO? |
| Contract / plan | H3642-001-0 |
| Offered by | Humana |
| Parent organization | Humana Inc. |
| Formulary tiers | 5 |
| Formulary exception tier | 4? |
| Pharmacy search | www.humana.com/pharmacy/ |
| Member services | (888)873-0686TTY 711 |
CMS star ratings
- Overall
- —
- Health plan (Part C)
- —
- Drug plan (Part D)
- —
Published per contract — every plan under contract H3642 shares this rating.
Plan health benefits
| Service | In-network | Out-of-network? |
|---|---|---|
| Doctor visits | ||
| Primary care doctor | $0 copay | 50% coinsurance |
| Specialist | $35 copay(authorization required) | 50% coinsurance |
| Other health care professional | $0–$35 copay(authorization required) | 50% coinsurance |
| Additional telehealth services | $0–$50 copay | — |
| Preventive care | ||
| Medicare-covered preventive services | $0 copay | $0 copay |
| Annual physical exam | $0 copay | $0 copay |
| Kidney disease education | $0 copay | $0 copay |
| Glaucoma screening | $0 copay | $0 copay |
| Diabetes self-management training | $0 copay | $0 copay |
| Diagnostic tests, labs and imaging | ||
| Diagnostic tests and procedures | $0–$100 copay(authorization required) | $65 copay; 50% coinsurance |
| Lab services | $0 copay(authorization required) | $65 copay; 50% coinsurance |
| Diagnostic radiology (e.g. MRI, CT) | $0–$345 copay(authorization required) | $0 copay; 50% coinsurance |
| Therapeutic radiology | $35 copay; 20% coinsurance(authorization required) | 50% coinsurance |
| Outpatient x-rays | $0–$145 copay(authorization required) | $65 copay; 50% coinsurance |
| Emergency and urgent care | ||
| Emergency room | $130 copay | — |
| Urgent care | $50 copay | — |
| Worldwide emergency coverage | $130 copay | — |
| Worldwide urgent care | $50 copay | — |
| Worldwide emergency transportation | $325 copay | — |
| Hospital care | ||
| Inpatient hospital stay | $450 per day for days 1–6; $0 per day for days 7–90; $0 per day for days 91–999 (additional days)(authorization required) | 50% coinsurance per stay |
| Outpatient hospital services | $0–$400 copay(authorization required) | $0 copay; 50% coinsurance |
| Outpatient observation | $450 copay(authorization required) | 50% coinsurance |
| Ambulatory surgical center | $0–$300 copay(authorization required) | $0 copay; 50% coinsurance |
| Outpatient blood services | $0 copay(authorization required) | $0 copay |
| Skilled nursing and home health | ||
| Skilled nursing facility | $20 per day for days 1–20; $221 per day for days 21–100(authorization required) | 50% coinsurance per stay |
| Home health care | $0 copay(authorization required) | 50% coinsurance |
| Kidney dialysis | 20% coinsurance(authorization required) | 20% coinsurance |
| Rehabilitation | ||
| Occupational therapy | $40 copay(authorization required) | 50% coinsurance |
| Physical therapy and speech-language therapy | $40 copay(authorization required) | 50% coinsurance |
| Cardiac rehabilitation | $30 copay(authorization required) | 50% coinsurance |
| Pulmonary rehabilitation | $30 copay(authorization required) | 50% coinsurance |
| Mental health and substance use | ||
| Inpatient psychiatric hospital stay | $380 per day for days 1–6; $0 per day for days 7–90(authorization required) | 50% coinsurance per stay |
| Outpatient mental health, individual session | $35 copay(authorization required) | 50% coinsurance |
| Outpatient mental health, group session | $35 copay(authorization required) | 50% coinsurance |
| Psychiatrist, individual session | $35 copay(authorization required) | 50% coinsurance |
| Psychiatrist, group session | $35 copay(authorization required) | 50% coinsurance |
| Partial hospitalization | $35 copay(authorization required) | 50% coinsurance |
| Intensive outpatient program | $35 copay(authorization required) | 50% coinsurance |
| Outpatient substance use, individual session | $35 copay(authorization required) | 50% coinsurance |
| Outpatient substance use, group session | $35 copay(authorization required) | 50% coinsurance |
| Opioid treatment program | $35 copay(authorization required) | 50% coinsurance |
| Ambulance and transportation | ||
| Ground ambulance | $325 copay(authorization required) | $325 copay |
| Air ambulance | 20% coinsurance(authorization required) | 20% coinsurance |
| Transportation to plan-approved locations | Not covered | — |
| Medical equipment and supplies | ||
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) | 50% coinsurance |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) | 50% coinsurance |
| Medical supplies | 20% coinsurance(authorization required) | 50% coinsurance |
| Diabetes supplies | $0 copay; 10%–20% coinsurance(authorization required) | 10%–50% coinsurance |
| Diabetic therapeutic shoes or inserts | $10 copay(authorization required) | 50% coinsurance |
| Chiropractic, acupuncture and foot care | ||
| Chiropractic (Medicare-covered) | $15 copay(authorization required) | 50% coinsurance |
| Routine chiropractic care | Not covered | — |
| Acupuncture | $35 copay(authorization required, limits apply) | $35 copay |
| Foot exams and treatment (Medicare-covered) | $35 copay(authorization required) | 50% coinsurance |
| Routine foot care | Not covered | — |
| Dental? | ||
| Medicare-covered dental services | $35 copay(authorization required) | 50% coinsurance |
| Preventive dental plan limit | $1,500 plan limit every year | — |
| Oral exams | $0 copay(limits apply) | $0 copay |
| Cleanings | $0 copay(limits apply) | $0 copay |
| Fluoride treatment | Not covered | — |
| Dental x-rays | $0 copay(limits apply) | $0 copay |
| Other diagnostic dental services | Not covered | — |
| Other preventive dental services | Not covered | — |
| Dentures and other removable prosthodontics | 50% coinsurance(authorization required, limits apply) | 50% coinsurance |
| Maxillofacial prosthetics | Not covered | — |
| Implants | Not covered | — |
| Orthodontics | Not covered | — |
| Adjunctive general services | 50% coinsurance(authorization required, limits apply) | 50% coinsurance |
| Vision? | ||
| Eye exam (Medicare-covered) | $0–$35 copay(authorization required, limits apply) | $0 copay; 50% coinsurance |
| Routine eye exam | $0 copay(authorization required, limits apply) | $0 copay |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Eyewear plan limit | $100 plan limit every year | — |
| Contact lenses | $0 copay(authorization required, limits apply) | $0 copay |
| Eyeglasses (frames and lenses) | $0 copay(authorization required, limits apply) | $0 copay |
| Eyeglass lenses | Not covered | — |
| Eyeglass frames | Not covered | — |
| Eyewear upgrades | Not covered | — |
| Hearing? | ||
| Hearing exam (Medicare-covered) | $35 copay(authorization required) | 50% coinsurance |
| Routine hearing exam | $0 copay(authorization required, limits apply) | 95% coinsurance |
| Hearing aid fitting and evaluation | $0 copay(authorization required, limits apply) | 95% coinsurance |
| Hearing aids (all types) | $575–$750 copay(limits apply) | 95% coinsurance |
| Hearing aids, inner ear | Not covered | — |
| Hearing aids, outer ear | Not covered | — |
| Hearing aids, over the ear | Not covered | — |
| Medicare Part B drugs | ||
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) | 30%–50% coinsurance |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 50% coinsurance |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 30%–50% coinsurance |
| Other extra benefits? | ||
| Over-the-counter (OTC) allowance | Covered (allowance not stated) | — |
| Meals after a hospital stay or for a chronic condition | $0 copay(authorization required) | 95% coinsurance |
| Fitness benefit | $0 copay | 95% coinsurance |
| Health education | Not covered | — |
| Nutritional / dietary benefit | Not covered | — |
| Extra smoking and tobacco cessation counseling | Not covered | — |
| Enhanced disease management | Not covered | — |
| Telemonitoring | Not covered | — |
| Remote access technologies (web/phone, nurse line) | Not covered | — |
| Home and bathroom safety devices | Not covered | — |
| Counseling services | Not covered | — |
| In-home safety assessment | Not covered | — |
| Personal emergency response system (PERS) | Not covered | — |
| Medical nutrition therapy | Not covered | — |
| Post-discharge in-home medication reconciliation | Not covered | — |
| Re-admission prevention | Not covered | — |
| Wigs for hair loss from chemotherapy | Not covered | — |
| Weight management programs | Not covered | — |
| Alternative therapies | Not covered | — |
| Therapeutic massage | Not covered | — |
| Adult day health services | Not covered | — |
| Home-based palliative care | Not covered | — |
| In-home support services | Not covered | — |
| Support for caregivers | Not covered | — |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2027). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $10.00 |
| Tier 3 · Preferred Brand | 17% |
| Tier 4 · Non-Preferred Drug | 50% |
| Tier 5 · Specialty Tier | 25% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $10.00 | $10.00 | $10.00 | $30.00 | $30.00 | $0.00 |
| Tier 3: Preferred Brand | 17% | 17% | 17% | 17% | 17% | 15% |
| Tier 4: Non-Preferred Drug | 50% | 50% | 50% | 50% | 50% | 50% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Also available in 22 other WI counties
Benefits in plain text
Humana Value Choice (PPO) (H3642-001-0) is a 2027 PPO Medicare Advantage plan offered by Humana, available to residents of Winnebago County, WI.
The monthly premium is $0.00.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
Its in-network out-of-pocket maximum is $4,450.00.
The combined in- and out-of-network out-of-pocket maximum is $6,300.00.
The drug deductible is $700.00. Tier 1, 2 and 3 exempt.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $10.00; tier 3 (Preferred Brand): 17%; tier 4 (Non-Preferred Drug): 50%; tier 5 (Specialty Tier): 25%.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.