2016 HumanaChoice R5826-077 (Regional PPO) R5826-077 By Humana Insurance Company

2016 Medicare Advantage HumanaChoice R5826-077 (Regional PPO)

HumanaChoice R5826-077 (Regional PPO) R5826-077 is a 2016 Medicare Advantage or Medicare Part-C plan by Humana Insurance Company available to residents in Georgia South Carolina. This plan includes additional Medicare prescription drug (Part-D) coverage. The HumanaChoice R5826-077 (Regional PPO) has a monthly premium of $78.00 and has a in-network Maximum Out-of-Pocket limit of $6,700 (MOOP). This means that if you get sick or need a high cost procedure your co-pays are capped once you pay out of pocket $6,700 this can be a very nice safety net.

HumanaChoice R5826-077 (Regional PPO) is a Regional PPO. A preferred provider organization (PPO) is a medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

This plan from Humana Insurance Company works with Medicare to give you significant coverage beyond Part A and Part B benefits. If you decide to sign up for HumanaChoice R5826-077 (Regional PPO) you still retain Original Medicare. But you will get additional Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from Humana Insurance Company and not Original Medicare. With Medicare Advantage plans your always covered for urgently needed and emergency care and you receive all of the benefits of Original Medicare from this plan except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.



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2016 Humana Insurance Company Medicare Advantage Plan Details

Plan Name:
HumanaChoice R5826-077 (Regional PPO)
Plan ID:
R5826-077
Provider:Humana Insurance Company
Parent:Humana Inc.
Plan Year:2016
Plan Type: Regional PPO
Monthly Premium C+D: $78.00
MOOP: $6,700




Plan Services



Monthly premium deductible and limits on how much you pay for covered services


$78 per month. In addition you must keep paying your Medicare Part B premium. $360 per year for Part D prescription drugs except for drugs listed on Tier 1 Tier 2 and Tier 3 which are excluded from the deductible. 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.
  • $6 700 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's office visits


Primary care physician visit:
  • In-network:  $20 copay
  • Out-of-network:  $20-95 copay depending on the service
Specialist visit:
  • In-network:  $20-45 copay depending on the service
  • Out-of-network:  $45 copay or 25% of the cost depending on the service


Durable medical equipment (wheelchairs oxygen etc.)


  • In-network:  20% of the cost
  • Out-of-network:  20% 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:  $45 copay


Hearing services


Exam to diagnose and treat hearing and balance issues:
  • In-network:  $45 copay
  • Out-of-network:  $45 copay
Routine hearing exam (for up to 1 every year):
  • In-network:  You pay nothing
  • Out-of-network:  $45 copay or 25% of the cost depending on the service
Hearing aid fitting/evaluation (for up to 1 every year):
  • In-network:  You pay nothing
  • Out-of-network:  $45 copay or 25% of the cost depending on the service
Hearing aid:
  • In-network:  You pay nothing
  • Out-of-network:  $45 copay or 25% of the cost for each hearing aid depending on the type
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:  You pay nothing


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:  
    • $285 copay per day for days 1 through 5
    • You pay nothing per day for days 6 through 90
    • Out-of-network:  
      • $285 copay per day for days 1 through 5
      • You pay nothing per day for days 6 through 90
      Outpatient group therapy visit:
      • In-network:  $40 copay
      • Out-of-network:  $40 copay
      Outpatient individual therapy visit:
      • In-network:  $40 copay
      • Out-of-network:  $40 copay


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:  $20 copay
  • Out-of-network:  $20-95 copay depending on the service
Occupational therapy visit:
  • In-network:  $20-40 copay depending on the service
  • Out-of-network:  $20-95 copay depending on the service
Physical therapy and speech and language therapy visit:
  • In-network:  $20-40 copay depending on the service
  • Out-of-network:  $20-95 copay depending on the service


Outpatient substance abuse


Group therapy visit:
  • In-network:  $40-95 copay depending on the service
  • Out-of-network:  $40-95 copay depending on the service
Individual therapy visit:
  • In-network:  $40-95 copay depending on the service
  • Out-of-network:  $40-95 copay depending on the service


Outpatient surgery


Ambulatory surgical center:
  • In-network:  $235 copay
  • Out-of-network:  $235 copay
Outpatient hospital:
  • In-network:  $285 copay
  • Out-of-network:  $285 copay


Acupuncture


Not covered


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:  20% of the cost
Related medical supplies:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost


Renal dialysis


  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost


Transportation


Not covered


Urgently needed services


$20-45 copay 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:  $0-95 copay depending on the service
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 $200 every year for contact lenses and eyeglasses (frames and lenses) from any provider.


Preventive care


  • In-network:  You pay nothing
  • Out-of-network:  You pay nothing
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.


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.


Inpatient hospital care


Our plan covers an unlimited number of days for an inpatient hospital stay.
  • In-network:  
    • $285 copay per day for days 1 through 6
    • You pay nothing per day for days 7 through 90
    • You pay nothing per day for days 91 and beyond
    • Out-of-network:  
      • $285 copay per day for days 1 through 6
      • You pay nothing per day for days 7 through 90


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


Outpatient prescription drugs


For Part B drugs such as chemotherapy drugs1:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
Other Part B drugs1:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
After you pay your yearly deductible you pay the following 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. Standard Retail Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$7 copay$21 copay
Tier 2 (Generic)$17 copay$51 copay
Tier 3 (Preferred Brand)$47 copay$141 copay
Tier 4 (Non-Preferred Brand)$97 copay$291 copay
Tier 5 (Specialty Tier)25% of the costNot Offered
Standard Mail Order Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$7 copay$21 copay
Tier 2 (Generic)$17 copay$51 copay
Tier 3 (Preferred Brand)$47 copay$141 copay
Tier 4 (Non-Preferred Brand)$97 copay$291 copay
Tier 5 (Specialty Tier)25% of the costNot Offered
Preferred Mail Order Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$7 copay$0
Tier 2 (Generic)$17 copay$0
Tier 3 (Preferred Brand)$47 copay$131 copay
Tier 4 (Non-Preferred Brand)$97 copay$281 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 $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.

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$7 copay$21 copay
Tier 2 (Generic)Some$17 copay$51 copay
Tier 3 (Preferred Brand)Some$47 copay$141 copay
Tier 4 (Non-Preferred Brand)Some$97 copay$291 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$7 copay$21 copay
Tier 2 (Generic)Some$17 copay$51 copay
Tier 3 (Preferred Brand)Some$47 copay$141 copay
Tier 4 (Non-Preferred Brand)Some$97 copay$291 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$7 copay$0
Tier 2 (Generic)Some$17 copay$0
Tier 3 (Preferred Brand)Some$47 copay$131 copay
Tier 4 (Non-Preferred Brand)Some$97 copay$281 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 $4 850 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.


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:  $20-95 copay depending on the service


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:  $45 copay
Preventive dental services:
  • Cleaning (for up to 2 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 2 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:  20% of the cost
    Diabetes self-management training:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
    Therapeutic shoes or inserts:
    • In-network:  $10 copay
    • Out-of-network:  20% of the cost


    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:  $45-285 copay depending on the service
    • Out-of-network:  $45-285 copay depending on the service
    Diagnostic tests and procedures:
    • In-network:  $0-95 copay depending on the service
    • Out-of-network:  $0-95 copay or 25% of the cost depending on the service
    Lab services:
    • In-network:  $0-95 copay depending on the service
    • Out-of-network:  $0-95 copay depending on the service
    Outpatient x-rays:
    • In-network:  $20-95 copay depending on the service
    • Out-of-network:  $20-95 copay depending on the service
    Therapeutic radiology services (such as radiation treatment for cancer):
    • In-network:  $45 copay or 20% of the cost depending on the service
    • Out-of-network:  20% of the cost




    Coverage Area for HumanaChoice R5826-077 (Regional PPO)

    (Click county to compare all available plans)

    State: Georgia
    South Carolina
    County:Appling,
    Atkinson, Bacon, Baker,
    Baldwin, Banks, Barrow,
    Bartow, Ben Hill, Berrien,
    Bibb, Bleckley, Brantley,
    Brooks, Bryan, Bulloch,
    Burke, Butts, Calhoun,
    Camden, Candler, Carroll,
    Catoosa, Charlton, Chatham,
    Chattahoochee, Chattooga, Cherokee,
    Clarke, Clay, Clayton,
    Clinch, Cobb, Coffee,
    Colquitt, Columbia, Cook,
    Coweta, Crawford, Crisp,
    Dade, Dawson, Decatur,
    DeKalb, Dodge, Dooly,
    Dougherty, Douglas, Early,
    Echols, Effingham, Elbert,
    Emanuel, Evans, Fannin,
    Fayette, Floyd, Forsyth,
    Franklin, Fulton, Gilmer,
    Glascock, Glynn, Gordon,
    Grady, Greene, Gwinnett,
    Habersham, Hall, Hancock,
    Haralson, Harris, Hart,
    Heard, Henry, Houston,
    Irwin, Jackson, Jasper,
    Jeff Davis, Jefferson, Jenkins,
    Johnson, Jones, Lamar,
    Lanier, Laurens, Lee,
    Liberty, Lincoln, Long,
    Lowndes, Lumpkin, Macon,
    Madison, Marion, McDuffie,
    McIntosh, Meriwether, Miller,
    Mitchell, Monroe, Montgomery,
    Morgan, Murray, Muscogee,
    Newton, Oconee, Oglethorpe,
    Paulding, Peach, Pickens,
    Pierce, Pike, Polk,
    Pulaski, Putnam, Quitman,
    Rabun, Randolph, Richmond,
    Rockdale, Schley, Screven,
    Seminole, Spalding, Stephens,
    Stewart, Sumter, Talbot,
    Taliaferro, Tattnall, Taylor,
    Telfair, Terrell, Thomas,
    Tift, Toombs, Towns,
    Treutlen, Troup, Turner,
    Twiggs, Union, Upson,
    Walker, Walton, Ware,
    Warren, Washington, Wayne,
    Webster, Wheeler, White,
    Whitfield, Wilcox, Wilkes,
    Wilkinson, Worth, Abbeville,
    Aiken, Allendale, Anderson,
    Bamberg, Barnwell, Beaufort,
    Berkeley, Calhoun, Charleston,
    Cherokee, Chester, Chesterfield,
    Clarendon, Colleton, Darlington,
    Dillon, Dorchester, Edgefield,
    Fairfield, Florence, Georgetown,
    Greenville, Greenwood, Hampton,
    Horry, Jasper, Kershaw,
    Lancaster, Laurens, Lee,
    Lexington, Marion, Marlboro,
    McCormick, Newberry, Oconee,
    Orangeburg, Pickens, Richland,
    Saluda, Spartanburg, Sumter,
    Union, Williamsburg, York,




    Ratings for HumanaChoice R5826-077 (Regional PPO) R5826

    2016 Overall Rating
    Part C Summary Rating
    Part D Summary Rating
    Staying Healthy: Screenings, Tests, Vaccines
    Managing Chronic (Long Term) Conditions
    Member Experience with Health Plan
    Complaints and Changes in Plans Performance
    Health Plan Customer Service
    Drug Plan Customer Service
    Complaints and Changes in the Drug Plan
    Member Experience with the Drug Plan
    Drug Safety and Accuracy of Drug Pricing


    Member Experience with Health Plan

    Total Experience Rating
    Getting Needed Care
    Timely Care and Appointments
    Customer Service
    Health Care Quality
    Rating of Health Plan
    Care Coordination


    Member Complaints and Changes in HumanaChoice R5826-077 (Regional PPO) Plans Performance

    Total Rating
    Members Leaving the Plan
    Complaints about Health Plan
    Beneficiary Access
    Health Plan Quality Improvement


    Health Plan Customer Service Rating for HumanaChoice R5826-077 (Regional PPO)

    Total Customer Service Rating
    Timely Decisions About Appeals
    Reviewing Appeals Decisions
    Call Center, TTY, Foreign Language


    Staying Healthy, Screening, Testing, & Vaccines

    Total Preventative Rating
    Breast Cancer Screening
    Colorectal Cancel Screening
    Annual Flu Vaccine
    Improving Physical
    Improving Mental Health
    Monitoring Physical Activity
    Adult BMI Assessment


    Managing Chronic And Long Term Care for Older Adults

    Total Rating
    SNP Care Management
    Medication Review
    Functional Status Assessment
    Pain Screening
    Osteoporosis Management
    Diabetes Care - Eye Exam
    Diabetes Care - Kidney Disease
    Diabetes Care - Blood Sugar
    Controlling Blood Pressure
    Rheumatoid Arthritis
    Improving Bladder Control
    Reducing Risk of Falling
    Plan - Cause Readmissions


    Member Experience with the Drug Plan

    Total Rating
    Rating of Drug Plan
    Getting Needed Prescription Drugs


    Drug Safety and Accuracy of Drug Pricing

    Total Rating
    MPF Price Accuracy
    High Risk Medication
    Drug Adherence for Diabetes Medications
    Drug Adherence for Hypertension (RAS antagonists)
    Drug Adherence for Cholesterol (Statins)
    MTM Program Completion Rate for CMR


    Ratings For Member Complaints and Changes in the Drug Plans Performance

    Total Rating
    Complaints about the Drug Plan
    Members Choosing to Leave the Plan
    Beneficiary Access
    Drug Plan Quality Improvement


    HumanaChoice R5826-077 (Regional PPO) Drug Plan Customer Service ratings

    Total Rating
    Appeals Auto Forward
    Appeals Upheld
    Call Center, TTY, Foreign Language


    Part-C Premium

    Humana Insurance Company plan charges a $37.50 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.



    Part-D Deductible and Premium

    The HumanaChoice R5826-077 (Regional PPO) plan has a monthly drug premium of $40.50 and a $360.00 drug deductible. This Humana Insurance Company plan offers a $40.50 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Humana Insurance Company above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $40.50. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.



    Premium Assistance

    Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The HumanaChoice R5826-077 (Regional PPO) medicare insurance plan offers a $14.40 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $20.90 for 75% low income subsidy $27.50 for 50% and $34.00 for 25%.



    Part C Premium: $37.50
    Part D (Drug) Premium: $40.50
    Part D Supplemental Premium $0.00
    Total Part D Premium: $40.50
    Drug Deductible: $360.00
    Tiers with No Deductible: 1
    Benchmark: not below the regional benchmark
    Type of Medicare Health Plan: Enhanced Alternative
    Drug Benefit Type: Enhanced
    Full LIS Premium: $14.40
    75% LIS Premium: $20.90
    50% LIS Premium: $27.50
    25% LIS Premium: $34.00
    Gap Coverage: Yes


    Gap Coverage

    In 2016 once you and your plan provider have spent $3,310 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 45% for brand-name drugs and 58% on generic drugs unless your plan offers additional coverage. This Humana Insurance Company plan does offer additional coverage through the gap.





    Source: CMS.

    Plans as of September 9, 2015.

    Star Rating as of September 30, 2015.

    For More Information on Ratings Please See the CMS Tech Notes Here.

    Notes: Data are subject to change as contracts are finalized. For 2016, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit

    Includes 2016 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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