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HumanaChoice H5216-157 (PPO) - H5216-157-000

3.5 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

HumanaChoice H5216-157 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5216-157-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

South Carolina and Georgia 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 South Carolina and Georgia 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

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible-$1.00
Out-of-pocket maximum$9,350.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit Services:
Coinsurance for Medicare Covered Primary Care Office Visit 50%
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit Services:
Coinsurance for Medicare Covered Physician Specialist Office Visit 50%
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 $45

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $110
Emergency room visit
Emergency Care:
Copayment for Emergency Care $110
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 $110
Copayment for Worldwide Emergency Transportation $110
Ambulance transportationIn-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 H5216-157 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-157 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic services
Out-of-Network:

Medicare Covered Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 50%
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Coinsurance for Medicare-covered Diabetic Supplies 10%
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%
$10 Coumadin Clinic Svcs - OPH$120 OP Diag Proc & Tests - OPH$5 OP Diag Proc & Tests - PCP$45 OP Diag Proc & Tests - SPC$45 OP Diag Proc & Tests - UCC$100 Sleep Study (Fac Based) - OPH$45 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 careIn-Network:

Psychiatric Hospital Services:
$399 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $45
Copayment for Medicare-covered Group Sessions $45
Outpatient services/surgery
Out-of-Network:

Medicare Covered Outpatient Hospital Services:
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$450 Surgery Svcs - OPH$45 Wound Care - OPH_
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $45 to $100
Copayment for Medicare-covered Group Sessions $45 to $100
Prior Authorization Required for Outpatient Substance Abuse Services
$100 OP Substance Abuse Care - OPH$45 OP Substance Abuse Care - SPC_
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $175 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $175 every three months
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $45
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0 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.

CoverageDetails
Dental carePlan covers up to $2500 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire.
Your benefit can be used for most dental treatments such as:
Preventive dental services, such as exams, routine cleanings, etc.
Basic dental services, such as fillings, extractions, etc.
Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc.
30% coinsurance applies to dentures.
30% - 40% coinsurance applies to bridges and crowns.
Frequency limits may apply.
Note: The allowance cannot be used on fluoride, cosmetic services and implants.
Out of Network
Plan covers up to $2500 allowance every year for non-Medicare covered preventive and comprehensive dental services. You are responsible for any amount above the dental coverage limit. Any amount unused at the end of the year will expire.
Your benefit can be used for most dental treatments such as:
Preventive dental services, such as exams, routine cleanings, etc.
Basic dental services, such as fillings, extractions, etc.
Major dental services, such as periodontal scaling, crowns, dentures, root canals, bridges etc.
30% coinsurance applies to dentures.
30% - 40% coinsurance applies to bridges and crowns.
Frequency limits may apply.
Note: The allowance cannot be used on fluoride, cosmetic services and implants.
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

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $45
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year
Maximum Plan Benefit of $75 every year

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
  • Maximum 1 Pair every year
Copayment for Eyeglasses (lenses and frames) $0
  • Maximum 1 Pair every year
Maximum Plan Benefit of $150 every year
Members must use Humana's Medicare Insight Network, a national network of providers, which includes standard or PLUS providers. The allowance for the standard network is $50 less than the PLUS network.

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $45
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $699 to $999
  • Maximum 2 Hearing Aids every year

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.

CoverageDetails
Preventive services and health/wellness education programs
Out-of-Network:

Medicare Covered Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0
Coinsurance for Medicare Covered Medicare-covered Preventive Services 50%

When reviewing South Carolina and Georgia 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 South Carolina and Georgia 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

South Carolina Counties Served

Georgia Counties Served

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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