HumanaChoice H5216-152 (PPO)
H5216 - 152 - 0
(4.5 / 5)
HumanaChoice H5216-152 (PPO) is a Medicare Advantage (Part C) Plan by Humana.
This page features plan details for 2024 HumanaChoice H5216-152 (PPO) H5216 – 152 – 0 available in Select counties in Virginia.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
HumanaChoice H5216-152 (PPO) is offered in the following locations.
Plan Overview
HumanaChoice H5216-152 (PPO) offers the following coverage and cost-sharing.
| Insurer: | Humana |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,400 In and Out-of-network $3,400 In-network |
| Drugs Covered: | No |
Ready to sign up for HumanaChoice H5216-152 (PPO) ?
Premium Breakdown
HumanaChoice H5216-152 (PPO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $174.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
HumanaChoice H5216-152 (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $3,400 In and Out-of-network $3,400 In-network |
| Yes |
| In-network | Yes, contact plan for further details |
| In-network | $0-300 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | $0-300 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| In-network Specialist | $35 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $35 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $135 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $50 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0-85 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | $0-85 copay (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0-50 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $0-50 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $35-295 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $35-295 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $0-95 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $0-95 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Hearing exam | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | 50% coinsurance (There are no limits.) (Authorization is required.) (Referral is not required.) |
| In-network Hearing aids | $699-999 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic services | $0-25 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Restorative services | $25 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Restorative services | $0-25 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Contact lenses | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $10-40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $10-40 copay (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $10-40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $10-40 copay (Authorization is required.) (Referral is not required.) |
| In-network | $300 copay (Not applicable.) (Not applicable.) |
| out-of-network | $300 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $35 copay (Authorization is required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay or 10-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | $10 copay or 10-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $460 per stay (Authorization is required.) (Referral is not required.) |
| out-of-network | $460 per stay (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $460 per stay (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $460 per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $196 per day for days 21 through 38 $0 per day for days 39 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | $0 per day for days 1 through 20 $196 per day for days 21 through 38 $0 per day for days 39 through 100 (Authorization is required.) (Referral is not required.) |
| Monthly Premium | $34.30 |
| Deductible | nan |
| Monthly Premium | $49.00 |
| Deductible | nan |
| Monthly Premium | $58.80 |
| Deductible | nan |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $22.80 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $22.80 |
| Comprehensive dental: | Deductible: | N/A |
Package #2
| Preventive dental: | Monthly Premium: | $22.80 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $22.80 |
| Comprehensive dental: | Deductible: | N/A |
Package #3
| Preventive dental: | Monthly Premium: | $27.80 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $27.80 |
| Comprehensive dental: | Deductible: | N/A |
Ready to sign up for HumanaChoice H5216-152 (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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