Plan Details
Costs and Other Important Information
Benefits
$350 per stay
Out-of-Network:
$350 per stay
$250 per visit
Out-of-Network:
$250 per visit
In-Network:
$5 per visit
Out-of-Network:
$5-90 per visit
Specialist:
In-Network:
$30 per visit
Out-of-Network:
$30-250 per visit
$0 copay
Out-of-Network:
$0 copay
$80 per visit (always covered)
Urgent care:
$5-35 per visit (always covered)
In-Network:
$0-90
Out-of-Network:
$0-90
Lab services:
In-Network:
$0-40
Out-of-Network:
$0-90
Diagnostic radiology services (e.g., MRI):
In-Network:
$30-250
Out-of-Network:
$30-250
Outpatient x-rays:
In-Network:
$5-90
Out-of-Network:
$5-90
$350 per stay
Out-of-Network:
$350 per stay
Outpatient group therapy visit with a psychiatrist:
In-Network:
$30
Out-of-Network:
$30-250
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$30
Out-of-Network:
$30-250
Outpatient group therapy visit:
In-Network:
$30
Out-of-Network:
$30-250
Outpatient individual therapy visit:
In-Network:
$30
Out-of-Network:
$30-250
$0 for days 1 through 20
$167.50 for days 21 through 100
Out-of-Network:
$0 for days 1 through 20
$167.50 for days 21 through 100
In-Network:
$10-40
Out-of-Network:
$10-40
Physical therapy and speech and language therapy visit:
In-Network:
$10-40
Out-of-Network:
$10-40
$265 or 20%
Out-of-Network:
$265 or 20%
In-Network:
$30
Out-of-Network:
$30-250
Routine foot care:
Not covered
In-Network:
20% per item
Out-of-Network:
20% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
20% per item
Diabetes supplies:
In-Network:
$0 or 10-20% per item
Out-of-Network:
$10 or 10-20% per item
In-Network:
20%
Out-of-Network:
20%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
20%
Coverage Area for HumanaChoice H5216-121 (PPO)
State | Pennsylvania |
---|---|
County | Philadelphia |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | $5 copay | $10 copay | $5 copay |
Tier 2: Non-Preferred Generic | $15 copay | $20 copay | $15 copay |
Tier 3: Preferred Brand Name | $47 copay | $47 copay | $47 copay |
Tier 4: Non-Preferred Brand Name | $97 copay | $100 copay | $97 copay |
Tier 5: Specialty Tier | 33% coinsurance | 33% coinsurance | 33% coinsurance |
90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | $15 copay | $30 copay | $0 copay |
Tier 2: Non-Preferred Generic | $45 copay | $60 copay | $0 copay |
Tier 3: Preferred Brand Name | $141 copay | $141 copay | $131 copay |
Tier 4: Non-Preferred Brand Name | $291 copay | $300 copay | $281 copay |
Tier 5: Specialty Tier |
CMS Ratings
Staying healthy - screenings, tests and vaccines
Managing Chronic Conditions
Member Experience with Health Plan
Member Complaints, and Changes in Health Plan's Performance
Health Plan Customer Service
Drug Plan Customer Service
Member Complaints, and Changes in Drug Plan's Performance
Member Experience with Drug Plan
Drug Pricing and Patient Safety
Physician Finder
Physicians that accept HumanaChoice H5216-121 (PPO) for Pennsylvania