Plan Details
Costs and Other Important Information
Benefits
$275 for days 1 through 7
$0 for days 8 through 90
$0 for days 91 and beyond
Out-of-Network:
30% per stay
$275 per visit
Out-of-Network:
30% per visit
In-Network:
$15 per visit
Out-of-Network:
30% per visit
Specialist:
In-Network:
$45 per visit
Out-of-Network:
30% per visit
$0 copay
Out-of-Network:
$0 or 30%
$80 per visit (always covered)
Urgent care:
$15-45 or 30% per visit (always covered)
In-Network:
$0-105
Out-of-Network:
30%
Lab services:
In-Network:
$0-40
Out-of-Network:
30%
Diagnostic radiology services (e.g., MRI):
In-Network:
$45-275
Out-of-Network:
30%
Outpatient x-rays:
In-Network:
$15-100
Out-of-Network:
30%
$275 for days 1 through 5
$0 for days 6 through 90
Out-of-Network:
30% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
30%
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
30%
Outpatient group therapy visit:
In-Network:
$40
Out-of-Network:
30%
Outpatient individual therapy visit:
In-Network:
$40
Out-of-Network:
30%
$0 for days 1 through 20
$167.50 for days 21 through 100
Out-of-Network:
30% per stay
In-Network:
$15-40
Out-of-Network:
30%
Physical therapy and speech and language therapy visit:
In-Network:
$15-40
Out-of-Network:
30%
$265 or 20%
Out-of-Network:
$265 or 20%
In-Network:
$45
Out-of-Network:
30%
Routine foot care:
Not covered
In-Network:
15% per item
Out-of-Network:
30% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
30% per item
Diabetes supplies:
In-Network:
$0 or 10-20% per item
Out-of-Network:
30% per item
In-Network:
20%
Out-of-Network:
20-30%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
20-30%
Coverage Area for HumanaChoice H5525-023 (PPO)
State | West Virginia |
---|---|
County | Kanawha |
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 | $7 copay | $10 copay | $7 copay |
Tier 2: Non-Preferred Generic | $17 copay | $20 copay | $17 copay |
Tier 3: Preferred Brand Name | $47 copay | $47 copay | $47 copay |
Tier 4: Non-Preferred Brand Name | $100 copay | $100 copay | $100 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 | $21 copay | $30 copay | $0 copay |
Tier 2: Non-Preferred Generic | $51 copay | $60 copay | $0 copay |
Tier 3: Preferred Brand Name | $141 copay | $141 copay | $131 copay |
Tier 4: Non-Preferred Brand Name | $300 copay | $300 copay | $290 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 H5525-023 (PPO) for West Virginia