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2015 Medicare Advantage Plan Benefit Details


Medicare Advantage Plan Benefit Details for:
HumanaChoice H1418-007 (PPO)

2015 Medicare Advantage Plan Details
Plan Name:HumanaChoice H1418-007 (PPO)
Location (County, State ZIP):Scott, Illinois
Plan ID:H1418 - 007     Click to see other plans

Click here for the HumanaChoice H1418-007 (PPO) enrollment options and to have a copy of this chart sent to your email. Enroll in HumanaChoice H1418-007 (PPO)

— Plan Features —
Monthly Premium:$93.00 (See premium details below.)
Annual Rx Deductible:$320 (Tier 1 and 2 excluded from the Deductible.)
Health Plan Type:Local PPO
Maximum Out-of-Pocket Limit
for Parts A & B (MOOP):
$6,700
Gap Coverage:Yes
Total Number of Formulary Drugs:3630    Browse Plan Formulary
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
  — Cost-Sharing during
       initial coverage phase:
$6.00$15.00$45.00$95.0025%
  — Number of Drugs per Tier:2178277871374425
Plan’s Summary Star Rating: 4.00 out of 5 Stars.
   - Customer Service Rating: Insufficient data to rate this plan.
   - 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
$93.00$53.80$36.20$3.00
Monthly Premium with Low-Income Subsidy:100%
Subsidy
75%
Subsidy
50%
Subsidy
25%
Subsidy
$11.00$18.00$25.10$32.10

— Plan Health Benefits —
** Cost **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$93 per month. In addition you must keep paying your Medicare Part B premium.
$320 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 in-network benefits. Contact us for the services that apply.
** Doctor and Hospital Choice **
Acupuncture and Other Alternative Therapies
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:  50% of the cost
Other Part B drugs1:
  • In-network:  20% of the cost
  • Out-of-network:  50% of the cost
After you pay your yearly deductible you pay the following until your total yearly drug costs reach $2 960. 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.
Standard Retail Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$6 copay$18 copay
Tier 2 (Non-Preferred Generic)$15 copay$45 copay
Tier 3 (Preferred Brand)$45 copay$135 copay
Tier 4 (Non-Preferred Brand)$95 copay$285 copay
Tier 5 (Specialty Tier)25% of the costNot Offered
Preferred Mail Order Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$6 copay$0
Tier 2 (Non-Preferred Generic)$15 copay$0
Tier 3 (Preferred Brand)$45 copay$125 copay
Tier 4 (Non-Preferred Brand)$95 copay$275 copay
Tier 5 (Specialty Tier)25% of the costNot Offered
Standard Mail Order Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$6 copay$18 copay
Tier 2 (Non-Preferred Generic)$15 copay$45 copay
Tier 3 (Preferred Brand)$45 copay$135 copay
Tier 4 (Non-Preferred Brand)$95 copay$285 copay
Tier 5 (Specialty Tier)25% of the costNot Offered
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 but may pay more than you pay at 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 $2 960.

After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap.

Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
Standard Retail Cost-Sharing
TierDrugs CoveredOne-month supplyThree-month supply
Tier 1 (Preferred Generic)Some$6 copay$18 copay
Tier 2 (Non-Preferred Generic)Some$15 copay$45 copay
Tier 3 (Preferred Brand)Some$45 copay$135 copay
Tier 4 (Non-Preferred Brand)Some$95 copay$285 copay
Tier 5 (Specialty Tier)Some25% of the costNot Offered
Preferred Mail Order Cost-Sharing
TierDrugs CoveredOne-month supplyThree-month supply
Tier 1 (Preferred Generic)Some$6 copay$0
Tier 2 (Non-Preferred Generic)Some$15 copay$0
Tier 3 (Preferred Brand)Some$45 copay$125 copay
Tier 4 (Non-Preferred Brand)Some$95 copay$275 copay
Tier 5 (Specialty Tier)Some25% of the costNot Offered
Standard Mail Order Cost-Sharing
TierDrugs CoveredOne-month supplyThree-month supply
Tier 1 (Preferred Generic)Some$6 copay$18 copay
Tier 2 (Non-Preferred Generic)Some$15 copay$45 copay
Tier 3 (Preferred Brand)Some$45 copay$135 copay
Tier 4 (Non-Preferred Brand)Some$95 copay$285 copay
Tier 5 (Specialty Tier)Some25% of the costNot Offered
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the greater of:
  • 5% of the cost or
  • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.
** Important Information **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$93 per month. In addition you must keep paying your Medicare Part B premium.
$320 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 in-network benefits. Contact us for the services that apply.
** Outpatient Care and Services **
Acupuncture and Other Alternative Therapies
Not covered
Ambulance Services
  • In-network:  $200 copay
  • Out-of-network:  $200 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:  $10 copay
  • Out-of-network:  50% 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:  $40 copay
  • Out-of-network:  50% of the cost
Preventive dental services:
  • Cleaning (for up to 1 every year):
    • In-network:  You pay nothing
    • Out-of-network:  50% of the cost
  • Dental x-ray(s) (for up to 1 every year):
    • In-network:  You pay nothing
    • Out-of-network:  50% of the cost
  • Oral exam (for up to 1 every year):
    • In-network:  You pay nothing
    • Out-of-network:  50% of the cost
    Diabetes Supplies and Services
    Diabetes monitoring supplies:
    • In-network:  0-20% of the cost depending on the supply
    • Out-of-network:  50% of the cost
    Diabetes self-management training:
    • In-network:  You pay nothing
    • Out-of-network:  50% of the cost
    Therapeutic shoes or inserts:
    • In-network:  You pay nothing
    • Out-of-network:  50% of the cost
    Diagnostic Tests, Lab and Radiology Services, and X-Rays
    Diagnostic radiology services (such as MRIs CT scans):
    • In-network:  $10-270 copay depending on the service
    • Out-of-network:  50% of the cost
    Diagnostic tests and procedures:
    • In-network:  $0-40 copay depending on the service
    • Out-of-network:  50% of the cost
    Lab services:
    • In-network:  $0-40 copay depending on the service
    • Out-of-network:  50% of the cost
    Outpatient x-rays:
    • In-network:  $10-40 copay depending on the service
    • Out-of-network:  50% of the cost
    Therapeutic radiology services (such as radiation treatment for cancer):
    • In-network:  20% of the cost
    • Out-of-network:  50% of the cost
    Doctor’s Office Visits
    Primary care physician visit:
    • In-network:  $10 copay
    • Out-of-network:  50% of the cost
    Specialist visit:
    • In-network:  $40 copay
    • Out-of-network:  50% of the cost
    Durable Medical Equipment (wheelchairs, oxygen, etc.)
    • In-network:  15% of the cost
    • Out-of-network:  50% 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
    $65 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:  $40 copay
    • Out-of-network:  50% of the cost
    Routine foot care (for up to 2 visit(s) every year):
    • In-network:  $40 copay
    • Out-of-network:  50% of the cost
    Hearing Services
    Exam to diagnose and treat hearing and balance issues:
    • In-network:  $40 copay
    • Out-of-network:  50% of the cost
    Routine hearing exam (for up to 1 every year):
    • In-network:  $30 copay
    • Out-of-network:  $35 copay
    Home Health Care
    • In-network:  You pay nothing
    • Out-of-network:  50% 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:  
      • $220 copay per day for days 1 through 6
      • You pay nothing per day for days 7 through 90
        • Out-of-network:  
          • 50% of the cost per stay
          • Outpatient group therapy visit:
            • In-network:  $40 copay
            • Out-of-network:  50% of the cost
            Outpatient individual therapy visit:
            • In-network:  $40 copay
            • Out-of-network:  50% of the cost
            Outpatient Rehabilitation Services
            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:  $10 copay
            • Out-of-network:  50% of the cost
            Occupational therapy visit:
            • In-network:  $40 copay
            • Out-of-network:  50% of the cost
            Physical therapy and speech and language therapy visit:
            • In-network:  $40 copay
            • Out-of-network:  50% of the cost
            Outpatient Substance Abuse
            Group therapy visit:
            • In-network:  $100 copay
            • Out-of-network:  50% of the cost
            Individual therapy visit:
            • In-network:  $100 copay
            • Out-of-network:  50% of the cost
            Outpatient Surgery
            Ambulatory surgical center:
            • In-network:  $220 copay
            • Out-of-network:  50% of the cost
            Outpatient hospital:
            • In-network:  $10-270 copay or 20% of the cost depending on the service
            • Out-of-network:  20-50% of the cost depending on the service
            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:  50% of the cost
            Related medical supplies:
            • In-network:  20% of the cost
            • Out-of-network:  50% of the cost
            Renal Dialysis
            • In-network:  20% of the cost
            • Out-of-network:  20% of the cost
            Transportation
            Not covered
            Urgently Needed Care
            50% of the cost
            Vision Services
            Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
            • In-network:  $0-40 copay depending on the service
            • Out-of-network:  50% 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.
            Eyeglasses or contact lenses after cataract surgery:
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            ** 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:  0-50% 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
            • Colonoscopy
            • Colorectal cancer screenings
            • Depression screening
            • Diabetes screenings
            • Fecal occult blood test
            • Flexible sigmoidoscopy
            • 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:  
              • $270 copay per day for days 1 through 7
              • You pay nothing per day for days 8 through 60
              • $100 copay per day for days 61 through 90
              • You pay nothing per day for days 91 and beyond
                • Out-of-network:  
                  • 50% 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:  
                        • $0 copay per day for days 1 through 20
                        • $150 copay per day for days 21 through 100
                        • Out-of-network:  
                          • 50% 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:  50% of the cost
                            Other Part B drugs1:
                            • In-network:  20% of the cost
                            • Out-of-network:  50% of the cost
                            After you pay your yearly deductible you pay the following until your total yearly drug costs reach $2 960. 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.
                            Standard Retail Cost-Sharing
                            TierOne-month supplyThree-month supply
                            Tier 1 (Preferred Generic)$6 copay$18 copay
                            Tier 2 (Non-Preferred Generic)$15 copay$45 copay
                            Tier 3 (Preferred Brand)$45 copay$135 copay
                            Tier 4 (Non-Preferred Brand)$95 copay$285 copay
                            Tier 5 (Specialty Tier)25% of the costNot Offered
                            Preferred Mail Order Cost-Sharing
                            TierOne-month supplyThree-month supply
                            Tier 1 (Preferred Generic)$6 copay$0
                            Tier 2 (Non-Preferred Generic)$15 copay$0
                            Tier 3 (Preferred Brand)$45 copay$125 copay
                            Tier 4 (Non-Preferred Brand)$95 copay$275 copay
                            Tier 5 (Specialty Tier)25% of the costNot Offered
                            Standard Mail Order Cost-Sharing
                            TierOne-month supplyThree-month supply
                            Tier 1 (Preferred Generic)$6 copay$18 copay
                            Tier 2 (Non-Preferred Generic)$15 copay$45 copay
                            Tier 3 (Preferred Brand)$45 copay$135 copay
                            Tier 4 (Non-Preferred Brand)$95 copay$285 copay
                            Tier 5 (Specialty Tier)25% of the costNot Offered
                            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 but may pay more than you pay at 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 $2 960.

                            After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap.

                            Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
                            Standard Retail Cost-Sharing
                            TierDrugs CoveredOne-month supplyThree-month supply
                            Tier 1 (Preferred Generic)Some$6 copay$18 copay
                            Tier 2 (Non-Preferred Generic)Some$15 copay$45 copay
                            Tier 3 (Preferred Brand)Some$45 copay$135 copay
                            Tier 4 (Non-Preferred Brand)Some$95 copay$285 copay
                            Tier 5 (Specialty Tier)Some25% of the costNot Offered
                            Preferred Mail Order Cost-Sharing
                            TierDrugs CoveredOne-month supplyThree-month supply
                            Tier 1 (Preferred Generic)Some$6 copay$0
                            Tier 2 (Non-Preferred Generic)Some$15 copay$0
                            Tier 3 (Preferred Brand)Some$45 copay$125 copay
                            Tier 4 (Non-Preferred Brand)Some$95 copay$275 copay
                            Tier 5 (Specialty Tier)Some25% of the costNot Offered
                            Standard Mail Order Cost-Sharing
                            TierDrugs CoveredOne-month supplyThree-month supply
                            Tier 1 (Preferred Generic)Some$6 copay$18 copay
                            Tier 2 (Non-Preferred Generic)Some$15 copay$45 copay
                            Tier 3 (Preferred Brand)Some$45 copay$135 copay
                            Tier 4 (Non-Preferred Brand)Some$95 copay$285 copay
                            Tier 5 (Specialty Tier)Some25% of the costNot Offered
                            After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the greater of:
                            • 5% of the cost or
                            • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 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:  50% of the cost
                            Diabetes self-management training:
                            • In-network:  You pay nothing
                            • Out-of-network:  50% of the cost
                            Therapeutic shoes or inserts:
                            • In-network:  You pay nothing
                            • Out-of-network:  50% of the cost
                            Foot Care (podiatry services)
                            Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
                            • In-network:  $40 copay
                            • Out-of-network:  50% of the cost
                            Routine foot care (for up to 2 visit(s) every year):
                            • In-network:  $40 copay
                            • Out-of-network:  50% of the cost
                            Hearing Services
                            Exam to diagnose and treat hearing and balance issues:
                            • In-network:  $40 copay
                            • Out-of-network:  50% of the cost
                            Routine hearing exam (for up to 1 every year):
                            • In-network:  $30 copay
                            • Out-of-network:  $35 copay
                            ** Outpatient Medical Services and Supplies **
                            Outpatient Substance Abuse
                            Group therapy visit:
                            • In-network:  $100 copay
                            • Out-of-network:  50% of the cost
                            Individual therapy visit:
                            • In-network:  $100 copay
                            • Out-of-network:  50% of the cost
                            Prosthetic Devices (braces, artificial limbs, etc.)
                            Prosthetic devices:
                            • In-network:  20% of the cost
                            • Out-of-network:  50% of the cost
                            Related medical supplies:
                            • In-network:  20% of the cost
                            • Out-of-network:  50% 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 Vision
                            Benefits include:
                            • Eye Exams
                            • Eyewear
                            Additional $15.30 per month. You must keep paying your Medicare Part B premium and your $93 monthly plan premium.
                            This package does not have a deductible.
                            Our plan has a coverage limit for certain benefits.
                            ** Important Information **
                            Package 1: MyOption Vision
                            Benefits include:
                            • Eye Exams
                            • Eyewear
                            Additional $15.30 per month. You must keep paying your Medicare Part B premium and your $93 monthly plan premium.
                            This package does not have a deductible.
                            Our plan has a coverage limit for certain benefits.
                            ** Cost **
                            Package 2: MyOption Enhanced Dental PPO
                            Benefits include:
                            • Preventive Dental
                            • Comprehensive Dental
                            Additional $20.80 per month. You must keep paying your Medicare Part B premium and your $93 monthly plan premium.
                            This package does not have a deductible.
                            Our plan pays up to $1500 every year. Our plan has additional coverage limits for certain benefits.
                            ** Important Information **
                            Package 2: MyOption Enhanced Dental PPO
                            Benefits include:
                            • Preventive Dental
                            • Comprehensive Dental
                            Additional $20.80 per month. You must keep paying your Medicare Part B premium and your $93 monthly plan premium.
                            This package does not have a deductible.
                            Our plan pays up to $1500 every year. Our plan has additional coverage limits for certain benefits.

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