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HumanaChoice H5525-030 (PPO) - H5525-030-000

na* for plan year 2025

$96.00

Monthly Premium

HumanaChoice H5525-030 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5525-030-000

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

$96.00

Monthly Premium

Ohio and Kentucky 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 Ohio and Kentucky Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Enrollment may be limited to certain times of the year. See why you may be able to enroll.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$96.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$350.00
Out-of-pocket maximum$4,150.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $10
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Medicare Covered Physician Specialist Office Visit $40
Inpatient hospital care
Out-of-Network:

Acute Hospital Services:
$360 per day for days 1 to 7
$0 per day for days 8 to 90
Urgent care
Urgent Care:
Copayment for Urgent Care $65

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $140
Emergency room visit
Emergency Care:
Copayment for Emergency Care $140
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 $140
Copayment for Worldwide Emergency Transportation $140
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 H5525-030 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5525-030 (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:
Copayment for Medicare Covered Chiropractic Services $20
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% to 20%
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:
Copayment for Medicare Covered Diagnostic Procedures/Tests
$0 to $90
Copayment for Medicare Covered Lab Services
$0 to $65
Copayment for Medicare Covered Diagnostic Radiological Services $0 to $600
Copayment for Medicare Covered Therapeutic Radiological Services $30
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Copayment for Medicare Covered Outpatient X-Ray Services $10 to $130
$90 OP Diag Proc & Tests - OPH$10 OP Diag Proc & Tests - PCP$40 OP Diag Proc & Tests - SPC$65 OP Diag Proc & Tests - UCC$90 Sleep Study (Fac Based) - OPH$90 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental health inpatient care
Out-of-Network:

Psychiatric Hospital Services:
$360 per day for days 1 to 7
$0 per day for days 8 to 90
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $40
Copayment for Medicare-covered Group Sessions $40
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $360
Prior Authorization Required for Outpatient Hospital Services
$0 Diag Colonoscopy - OPH$100 Mental Health - OPH$360 Surgery Svcs - OPH$30 Wound Care - OPH_

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $360
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $360
Prior Authorization Required for Ambulatory Surgical Center Services
$0 Diag Colonoscopy - ASC$360 Surgery Svcs - ASC_
Outpatient substance abuse care
Out-of-Network:

Medicare Covered Outpatient Substance Abuse Services:
Copayment for Medicare Covered Individual Sessions $40 to $100
Copayment for Medicare Covered Group Sessions $40 to $100
$100 OP Substance Abuse Care - OPH$40 OP Substance Abuse Care - SPC_
Podiatry services
Out-of-Network:

Medicare Covered Podiatry Services:
Copayment for Medicare Covered Podiatry Services $40
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$20 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 care$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
$0 copayment for emergency diagnostic exam up to 1 per year.
$0 copayment for periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for necessary anesthesia with covered service up to unlimited per year.
$25 copayment per tooth for amalgam and/or composite filling up to 2 per year.
$1,000 combined maximum benefit coverage amount per year for preventive and comprehensive benefits.
Out of Network
$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
$0 copayment for emergency diagnostic exam up to 1 per year.
$0 copayment for periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for necessary anesthesia with covered service up to unlimited per year.
$25 copayment per tooth for amalgam and/or composite filling up to 2 per year.
$1,000 combined maximum benefit coverage amount per year for preventive and comprehensive benefits.
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 care
Out-of-Network:

Medicare Covered Eye Exams Services:
Copayment for Medicare Covered Eye Exams $0 to $40
Copayment for Medicare Covered Eyewear $0

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 $40
Prior Authorization Required for Hearing Exams

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

Prescription Drug Costs and Coverage

The HumanaChoice H5525-030 (PPO) offers prescription drug coverage, with an annual drug deductible of $350.00 (excludes Tiers 1 and 2)

Coverage & Cost
Coverage
Cost
Annual drug deductible$350.00 (excludes Tiers 1 and 2)
Tier 1
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $10.00
Tier 2
  • Standard retail $15.00
  • Preferred mail order $15.00
  • Standard mail order $20.00
Annual drug deductible$350.00 (excludes Tiers 1 and 2)
Tier 1
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
Tier 2
  • Standard retail N/A
  • Preferred mail order N/A
  • Standard mail order N/A
Annual drug deductible$350.00 (excludes Tiers 1 and 2)
Tier 1
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $30.00
Tier 2
  • Standard retail $45.00
  • Preferred mail order $0.00
  • Standard mail order $60.00

When reviewing Ohio and Kentucky 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 Ohio and Kentucky 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

Ohio Counties Served

Kentucky 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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