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Humana

Plan ID: H5216-34-0

HumanaChoice H5216-034 (PPO)

2024 HumanaChoice H5216-034 (PPO) H5216 — 034 — 0 is a Medicare Advantage plan with drug coverage. It has received a 4.5-out-of-5 star rating from CMS for 2024.

Learn more about HumanaChoice H5216-034 (PPO) H5216 - 034 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

4.5 / 5 stars for 2024

$72.50 /mo

Monthly premium

$500 annual deductible

Health deductible

$225.00

Drug deductible

$7550.00

Out-of-pocket maximum

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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!

Overview Benefits & Costs Drug Coverage Additional Benefits

Plan Overview

2024 HumanaChoice H5216-034 (PPO) H5216 — 034 — 0 is a Local PPO offered in Select Counties in Arizona by Humana. It has a monthly premium of $125.00.

Premium Breakdown

Standard Part B Premium

$174.70

Part B premium reduction

- $0

Monthly Plan Premium

$125.00

Total Premium:

$299.70

Note:

The standard Part B premium for 2024 is $174.70. Your Part B premium may differ based on factors including late enrollment, income, and disability status. Higher-income beneficiaries may pay an income-related monthly adjustment amount (IRMAA). The Part B premium is required to be paid by everyone enrolled in Medicare Part B.

Special needs plan type

Out-of-pocket maximum

$7550.00

Plan Organization:

Humana

Plan Type:

Local PPO

Location:

Select Counties in Arizona

Drugs Covered:

Yes

Drug Formulary:

Formulary Link

Pharmacies:

Pharmacies Link

Doctor Choice:

Any Doctor

Doctors Link:

Doctors Link

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Health deductible

$500 annual deductible

Drug deductible

$225

Note:

This plan does not charge an annual deductible for all drugs. The $225.00 annual deductible only applies to drugs in certain tiers.

Other Plan Notes

This plan does not charge an annual deductible for all drugs. The $225.00 annual deductible only applies to drugs on certain tiers.
This plan's deductible only applies to out-of-network services.

Sign up for HumanaChoice H5216-034 (PPO)

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Drug Coverage

HumanaChoice H5216-034 (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Benefit Type

Enhanced

Prescription drug deductible

$225.00

Increased initial coverage limit

Additional gap coverage

Part D Premium Reduction

This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.

Part D	LIS 25%	LIS 50%	LIS 75%	LIS Full
$72.50	$72.50	$72.50	$72.50	$29.30

Initial Coverage Phase

After you pay your $225.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.

30 Days

60 Days

90 Days

Tier	Preferred Pharmacy	Standard Pharmacy	Preferred Mail	Standard Mail
1. Preferred Generic	-	$5.00 copay	$5.00 copay	$10.00 copay
2. Standard Generic	-	$15.00 copay	$15.00 copay	$20.00 copay
3. Preferred Brand	-	$45.00 copay	$45.00 copay	$47.00 copay
4. Non-Preferred Drug	-	$100.00 copay	$100.00 copay	$100.00 copay
5. Specialty Tier	-	29%	29%	29%

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.

Generic Drugs

$4.15 copay or 5% (whichever costs more)

Brand-name

$10.35 copay or 5% (whichever costs more)

Additional Benefits

HumanaChoice H5216-034 (PPO) also provides the following benefits.

Note:

Limits, Authorizations, and Referrals may apply for the benefits below. Contact the plan for details.

Comprehensive dental

Non-routine services

Not covered

Diagnostic services

In-Network: $0 copay

Out-Of-Network: $0 copay

Restorative services

Not covered

Endodontics

Not covered

Periodontics

Not covered

Extractions

Not covered

Prosthodontics, other oral/maxillofacial surgery, other services

Not covered

Preventive dental

Oral exam

In-Network: $0 copay

Out-Of-Network: $0 copay

Cleaning

In-Network: $0 copay

Out-Of-Network: $0 copay

Fluoride treatment

In-Network: $0 copay

Out-Of-Network: $0 copay

Dental x-ray(s)

In-Network: $0 copay

Out-Of-Network: $0 copay

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures

In-Network: $0-264 copay

Out-Of-Network: 40% coinsurance

Lab services

In-Network: $0-50 copay

Out-Of-Network: 40% coinsurance

Diagnostic radiology services (eg, MRI)

In-Network: $0-335 copay

Out-Of-Network: 40% coinsurance

Outpatient x-rays

In-Network: $10-105 copay

Out-Of-Network: 40% coinsurance

Doctor visits

Primary

In-Network: $10 copay per visit

Out-Of-Network: 40% coinsurance per visit

Specialist

In-Network: $45 copay per visit

Out-Of-Network: 40% coinsurance per visit

Emergency care/Urgent care

Emergency

$90 copay per visit (always covered)

Urgent care

$45 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment

In-Network: $45 copay

Out-Of-Network: 40% coinsurance

Routine foot care

In-Network: $0 copay

Ground ambulance

Service

In-Network: $265 copay

Out-Of-Network: $265 copay

Hearing

Hearing exam

In-Network: $45 copay

Out-Of-Network: 40% coinsurance

Fitting/evaluation

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Hearing aids

In-Network: $699-999 copay

Out-Of-Network: 50% coinsurance

Inpatient hospital coverage

Service

In-Network: $335 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 90 and beyond

Out-Of-Network: 40% per stay

Outpatient hospital coverage

Service

In-Network: $0-335 copay per visit

Out-Of-Network: 40% coinsurance per visit

Optional benefits

Service

Yes

Medical equipment/supplies

Durable medical equipment (eg, wheelchairs, oxygen)

In-Network: 20% coinsurance per item

Out-Of-Network: 40% coinsurance per item

Prosthetics (eg, braces, artificial limbs)

In-Network: 20% coinsurance per item

Out-Of-Network: 40% coinsurance per item

Diabetes supplies

In-Network: $0 copay or 10-20% coinsurance per item

Out-Of-Network: $0 copay or 40% coinsurance per item

Medicare Part B drugs

Chemotherapy

In-Network: 0-20% coinsurance

Out-Of-Network: 50% coinsurance

Other Part B drugs

In-Network: 0-20% coinsurance

Out-Of-Network: 50% coinsurance

Part B Insulin drugs

In-Network: 0-20% coinsurance (up to $35)

Out-Of-Network: 50% coinsurance

Mental health services

Inpatient hospital - psychiatric

In-Network: $335 per day for days 1 through 5 $0 per day for days 6 through 90

Out-Of-Network: 40% per stay

Outpatient group therapy visit with a psychiatrist

In-Network: $20 copay

Out-Of-Network: 40% coinsurance

Outpatient individual therapy visit with a psychiatrist

In-Network: $20 copay

Out-Of-Network: 40% coinsurance

Outpatient group therapy visit

In-Network: $20 copay

Out-Of-Network: 40% coinsurance

Outpatient individual therapy visit

In-Network: $20 copay

Out-Of-Network: 40% coinsurance

Preventive care

Service

In-Network: $0 copay

Out-Of-Network: $0 copay or 40% coinsurance

Rehabilitation services

Occupational therapy visit

In-Network: $40 copay

Out-Of-Network: 40% coinsurance

Physical therapy and speech and language therapy visit

In-Network: $40 copay

Out-Of-Network: 40% coinsurance

Skilled Nursing Facility

Service

In-Network: $0 per day for days 1 through 20 $172 per day for days 21 through 60 $0 per day for days 61 through 100

Out-Of-Network: 40% per stay

Transportation

Service

Not covered

Vision

Routine eye exam

In-Network: $0 copay

Out-Of-Network: $0 copay

Other

Not covered

Contact lenses

In-Network: $0 copay

Out-Of-Network: $0 copay

Eyeglasses (frames and lenses)

In-Network: $0 copay

Out-Of-Network: $0 copay

Eyeglass frames

Not covered

Eyeglass lenses

Not covered

Upgrades

Not covered

Wellness programs (eg, fitness, nursing hotline)

Service

Covered

Plan Providers

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.

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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

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