Humana Prime Choice PPO H6609-012
Medicare Advantage Plans (Part C)
- Humana Prime Choice PPO H6609-012
- 2013 Plan
|Office Visit for Primary Doctor||$10 copay|
|Office Visit for Specialist||$25 copay|
|Doctor Choice||Any Doctor|
|Prescription Drug Coverage||No|
|Physical Exams||$0 copay|
|Hospital Services Coverage|
|Emergency Room||$65 copay.
If you are admitted to the hospital within 24-hour(s) for the same condition, then $0 copay.
|Ambulance Services||$200 copay|
|Outpatient Lab/X-Ray||$0 to $50 copay for lab services and diagnostic procedures and tests.
$10 to $50 copay for X-rays.
|Outpatient Surgery||$225 copay for each ambulatory surgical center visit.
$45 to $275 copay [or 20% of the cost] for each outpatient hospital facility visit.
|Urgent Care||30% of the cost|
|Hospitalization||Days 1 - 5: $275 copay per day;
Days 6 - 60: $0 copay per day;
Days 61 - 90: $100 copay per day;
$0 copay for each additional hospital day.
No limit to the number of days covered by the plan each hospital stay.
|Outpatient Rehabilitation Services||$45 copay for Occupational and Physical Therapy and/or Speech and Language Pathology visits.|
|Skilled Nursing Facility||Days 1 - 20: $50 copay per day;
Days 21 - 100: $150 copay per day.
Plan covers up to 100 days each benefit period;
No prior hospital stay is required.
|Home Health Care||$0 copay|
|Hospice||You must get care from a Medicare-certified hospice.
Your plan will pay for a consultative visit before you select hospice.
|Prescription Drug Coverage|
|Prescription Drug Deductible||Not Covered|
|Retail Pharmacy for Prescription Drugs|
|Mail Order Pharmacy for Prescription Drugs|
|Dental Services||$25 copay|
|Hearing Services||$25 copay for diagnostic hearing exams.
In general, supplemental routine hearing exams and hearing aids not covered.
|Vision Services||$0 copay for one pair of eyeglasses or contact lenses after cataract surgery;
$0 to $25 copay for exams to diagnose and treat diseases and conditions of the eye;
$0 copay for up to 1 supplemental routine eye exam(s) every year.
|Chiropractic Coverage||$20 copay|
|Outpatient Mental Health Coverage||$25 copay.
$50 copay for partial hospitalization program services.
(See more benefit details,
including Out of Network coverage)
|See more benefit details:
Summary of Benefits
|Medicare Brochure(s)||Medicare & You|
- You can always call our licensed agents at 1 -800-299-3116 (TTY User: 711) Mon - Fri 8AM - 8PM ET, Sat 9AM - 6PM ET if you have questions, need help comparing plans, or to complete your enrollment.
- Humana - Humana is a Medicare Advantage organization and a stand-alone prescription drug plan with a Medicare contract. Enrollment in a/this Humana plan depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
- Humana - Limitations, copayments and restrictions may apply. [Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance] may change on January 1 of each year
- Humana - For Humana RPPO only: Sometimes the selection of in-network providers is limited in certain geographic areas or in some specialties. If the network in your area doesn't offer the specialist you need, you may be allowed to go to a non-network provider at the in-network rate. Be sure to contact non-network doctors before you see them to make sure they accept Medicare assignment and have agreed to accept payment from Humana.
- Limitations, copayments, and restrictions may apply.
- Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. This is not a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE or consult www.medicare.gov (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
- You must continue to pay your Medicare Part B premium.
- For Humana RPPO only: Sometimes the selection of in-network providers is limited in certain geographic areas or in some specialties. If the network in your area doesn't offer the specialist you need, you may be allowed to go to a non-network provider at the in-network rate. Be sure to contact non-network doctors before you see them to make sure they accept Medicare assignment and have agreed to accept payment from Humana.
- You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your Medicaid Office.
- Medicare beneficiaries may also enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
- Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
- Not every plan is available statewide or in all service areas.