2016 HumanaChoice R5826-078 (Regional PPO) in MS Plan Benefits Details

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2016 Medicare Advantage Plan Benefit Details for the HumanaChoice R5826-078 (Regional PPO)

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2016 Medicare Advantage Plan Details
Medicare Plan Name:	HumanaChoice R5826-078 (Regional PPO)
Location:	Wilkinson, Mississippi Click to see other locations
Plan ID:	R5826 - 078 - 0 Click to see other plans
Member Services:	1-800-457-4708 TTY users 711
— This plan information is for research purposes only. — Click here to see plans for the current plan year
Medicare Contact Information:	Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance
Email a copy of the HumanaChoice R5826-078 (Regional PPO) benefit details
— Medicare Plan Features —
Monthly Premium:	$45.00 (see Plan Premium Details below)
Annual Deductible:	$360
Annual Initial Coverage Limit (ICL):	$3,310
Health Plan Type:	Regional PPO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):	$6,700
Additional Gap Coverage?	No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:	3,884 drugs	Browse the HumanaChoice R5826-078 (Regional PPO) Formulary
This plan has drug tiers. See cost-sharing for all pharmacies and tiers.
Formulary Drug Details:	Tier 1	Tier 2	Tier 3	Tier 4	Tier 5
• Preferred Pharmacy Cost-Sharing during initial coverage phase:	cost-sharing data not available.
• Number of Drugs per Tier:
Plan's Pharmacy Search:	http://www.humana.com/Medicare/medicare_prescription_drugs
Plan Offers Mail Order?	Yes
Number of Members enrolled in this plan in Wilkinson, Mississippi:		58 members
Number of Members enrolled in this plan in Mississippi:		10,005 members
Number of Members enrolled in this plan in (R5826 - 078):		15,152 members
Plan’s Summary Star Rating:		3.5 out of 5 Stars.
• Customer Service Rating:		5 out of 5 Stars.
• Member Experience Rating:		4 out of 5 Stars.
• Drug Cost Accuracy Rating:		4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔	Total Premium	Part C Premium	Part D Base Premium	Part D Supplemental Premium
The Monthly Premium is Split as Follows: ❔	$45.00	$18.30	$26.70	$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔		100% Subsidy	75% Subsidy	50% Subsidy	25% Subsidy
Monthly Part D Premium with LIS:		$0.00	$6.70	$13.30	$20.00
Total Monthly Premium with LIS (Parts C & D):		$18.30	$25.00	$31.60	$38.30
— Plan Health Benefits —
Cost
Monthly premium, deductible, and limits on how much you pay for covered services
$45 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical services and Part D prescription drugs.
$500 per year for out-of-network services.
$360 per year for Part D prescription drugs.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
$6 700 for services you receive from in-network providers.
$10 000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply.
Doctor and Hospital Choice
Acupuncture
Not covered
Extra Benefits
Inpatient mental health care
For inpatient mental health care see the "Mental Health Care" section.
Outpatient prescription drugs
For Part B drugs such as chemotherapy drugs¹: In-network: 20% of the cost
Out-of-network: 30% of the cost
Other Part B drugs¹: In-network: 20% of the cost
Out-of-network: 30% of the cost
After you pay your yearly deductible you pay 25% of the cost for all drugs covered by this plan until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and mail order pharmacies.
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap.
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of: 5% of the cost or $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
Important Information
Monthly premium, deductible, and limits on how much you pay for covered services
$45 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical services and Part D prescription drugs.
$500 per year for out-of-network services.
$360 per year for Part D prescription drugs.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
$6 700 for services you receive from in-network providers.
$10 000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply.
Outpatient Care and Services
Acupuncture
Not covered
Ambulance
In-network: $300 copay
Out-of-network: $300 copay
Chiropractic care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $20 copay
Out-of-network: 30% of the cost
Dental services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): In-network: $45 copay
Out-of-network: 30% of the cost
Diabetes supplies and services
Diabetes monitoring supplies: In-network: 0-20% of the cost depending on the supply
Out-of-network: 25-30% of the cost depending on the supply
Diabetes self-management training: In-network: You pay nothing
Out-of-network: 30% of the cost
Therapeutic shoes or inserts: In-network: $10 copay
Out-of-network: 25-30% of the cost depending on the supply
Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting)
Diagnostic radiology services (such as MRIs CT scans): In-network: $45-225 copay depending on the service
Out-of-network: 30% of the cost
Diagnostic tests and procedures: In-network: $0-100 copay depending on the service
Out-of-network: 30% of the cost
Lab services: In-network: $0-50 copay depending on the service
Out-of-network: 30% of the cost
Outpatient x-rays: In-network: $15-50 copay depending on the service
Out-of-network: 30% of the cost
Therapeutic radiology services (such as radiation treatment for cancer): In-network: $45-50 copay or 20% of the cost depending on the service
Out-of-network: 30% of the cost
Doctor's office visits
Primary care physician visit: In-network: $15 copay
Out-of-network: 30% of the cost
Specialist visit: In-network: $25-45 copay depending on the service
Out-of-network: 30% of the cost
Durable medical equipment (wheelchairs, oxygen, etc.)
In-network: 18% of the cost
Out-of-network: 18% of the cost
If you go to a preferred vendor your cost may be less. Contact us for a list of preferred vendors.
Emergency care
$75 copay
If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs.
Foot care (podiatry services)
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $45 copay
Out-of-network: 30% of the cost
Hearing services
Exam to diagnose and treat hearing and balance issues: In-network: $45 copay
Out-of-network: 30% of the cost
Routine hearing exam (for up to 1 every year): In-network: You pay nothing
Out-of-network: 25% of the cost
Hearing aid fitting/evaluation (for up to 1 every year): In-network: You pay nothing
Out-of-network: 25% of the cost
Hearing aid: In-network: You pay nothing
Out-of-network: 25% of the cost
Our plan pays up to $1 000 every three years for hearing aids from any provider.
Home health care
In-network: You pay nothing
Out-of-network: 30% of the cost
Mental health care
Inpatient visit:
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
Our plan covers 90 days for an inpatient hospital stay.
Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.

In-network:
$275 copay per day for days 1 through 5
You pay nothing per day for days 6 through 90


Out-of-network:
30% of the cost per stay

Outpatient group therapy visit: In-network: $40 copay
Out-of-network: 30% of the cost
Outpatient individual therapy visit: In-network: $40 copay
Out-of-network: 30% of the cost
Outpatient rehabilitation
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: $15 copay
Out-of-network: 30% of the cost
Occupational therapy visit: In-network: $15 copay
Out-of-network: 30% of the cost
Physical therapy and speech and language therapy visit: In-network: $15 copay
Out-of-network: 30% of the cost
Outpatient substance abuse
Group therapy visit: In-network: $40-50 copay depending on the service
Out-of-network: 30% of the cost
Individual therapy visit: In-network: $40-50 copay depending on the service
Out-of-network: 30% of the cost
Outpatient surgery
Ambulatory surgical center: In-network: $225 copay
Out-of-network: 30% of the cost
Outpatient hospital: In-network: $275 copay
Out-of-network: 30% of the cost
Over-the-counter items
Please visit our website to see our list of covered over-the-counter items.
Prosthetic devices (braces, artificial limbs, etc.)
Prosthetic devices: In-network: 20% of the cost
Out-of-network: 30% of the cost
Related medical supplies: In-network: 20% of the cost
Out-of-network: 30% of the cost
Renal dialysis
In-network: 20% of the cost
Out-of-network: 20% of the cost
Transportation
Not covered
Urgently needed services
$15-45 copay or 30% of the cost (up to $65) depending on the service
Vision services
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $0-45 copay depending on the service
Out-of-network: 30% of the cost
Routine eye exam (for up to 1 every year): In-network: You pay nothing
Out-of-network: You pay nothing
Our plan pays up to $40 every year for routine eye exams from any provider.
Contact lenses (for up to 1 every year): In-network: You pay nothing
Out-of-network: You pay nothing
Eyeglasses (frames and lenses) (for up to 1 every year): In-network: You pay nothing
Out-of-network: You pay nothing
Eyeglasses or contact lenses after cataract surgery: In-network: You pay nothing
Out-of-network: You pay nothing
Our plan pays up to $100 every year for contact lenses and eyeglasses (frames and lenses) from any provider.
Hospice
Hospice
You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.
Preventive Care
Preventive care
In-network: You pay nothing
Out-of-network: 0-30% of the cost depending on the service
Our plan covers many preventive services including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines including Flu shots Hepatitis B shots Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered.
Inpatient Care
Inpatient hospital care
Our plan covers an unlimited number of days for an inpatient hospital stay.

In-network:
$275 copay per day for days 1 through 7
You pay nothing per day for days 8 through 90
You pay nothing per day for days 91 and beyond


Out-of-network:
30% of the cost per stay

Inpatient mental health care
For inpatient mental health care see the "Mental Health Care" section.
Skilled Nursing Facility (SNF)
Our plan covers up to 100 days in a SNF.

In-network:
You pay nothing per day for days 1 through 20
$160 copay per day for days 21 through 100


Out-of-network:
30% of the cost per stay

Outpatient prescription drugs
For Part B drugs such as chemotherapy drugs¹: In-network: 20% of the cost
Out-of-network: 30% of the cost
Other Part B drugs¹: In-network: 20% of the cost
Out-of-network: 30% of the cost
After you pay your yearly deductible you pay 25% of the cost for all drugs covered by this plan until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and mail order pharmacies.
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap.
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of: 5% of the cost or $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
Outpatient Care
Diabetes supplies and services
Diabetes monitoring supplies: In-network: 0-20% of the cost depending on the supply
Out-of-network: 25-30% of the cost depending on the supply
Diabetes self-management training: In-network: You pay nothing
Out-of-network: 30% of the cost
Therapeutic shoes or inserts: In-network: $10 copay
Out-of-network: 25-30% of the cost depending on the supply
Foot care (podiatry services)
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $45 copay
Out-of-network: 30% of the cost
Hearing services
Exam to diagnose and treat hearing and balance issues: In-network: $45 copay
Out-of-network: 30% of the cost
Routine hearing exam (for up to 1 every year): In-network: You pay nothing
Out-of-network: 25% of the cost
Hearing aid fitting/evaluation (for up to 1 every year): In-network: You pay nothing
Out-of-network: 25% of the cost
Hearing aid: In-network: You pay nothing
Out-of-network: 25% of the cost
Our plan pays up to $1 000 every three years for hearing aids from any provider.
Outpatient Medical Services and Supplies
Outpatient substance abuse
Group therapy visit: In-network: $40-50 copay depending on the service
Out-of-network: 30% of the cost
Individual therapy visit: In-network: $40-50 copay depending on the service
Out-of-network: 30% of the cost
Prosthetic devices (braces, artificial limbs, etc.)
Prosthetic devices: In-network: 20% of the cost
Out-of-network: 30% of the cost
Related medical supplies: In-network: 20% of the cost
Out-of-network: 30% of the cost
Additional Benefits
Inpatient mental health care
For inpatient mental health care see the "Mental Health Care" section.
Cost
Monthly premium, deductible, and limits on how much you pay for covered services
Package 1: MyOption Dental - High PPO
Benefits include: Preventive Dental Comprehensive Dental
Additional $21.70 per month. You must keep paying your Medicare Part B premium and your $45 monthly plan premium.
$50 per year.
Our plan pays up to $1 500 every year. Our plan has additional coverage limits for certain benefits.
Important Information
Package 1: MyOption Dental - High PPO
Benefits include: Preventive Dental Comprehensive Dental
Additional $21.70 per month. You must keep paying your Medicare Part B premium and your $45 monthly plan premium.
$50 per year.
Our plan pays up to $1 500 every year. Our plan has additional coverage limits for certain benefits.

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