2020 HumanaChoice H5216-154 (PPO) H5216-154 By Humana.

2020 Medicare Advantage Plan Services for
HumanaChoice H5216-154 (PPO)

HumanaChoice H5216-154 (PPO) H5216-154 is a 2020 Medicare Advantage Plan or Medicare Part-C plan by Humana available to residents in South Carolina Georgia. This plan includes additional Medicare prescription drug (Part-D) coverage. The HumanaChoice H5216-154 (PPO) has a monthly premium of $- and has an in-network Maximum Out-of-Pocket limit of $6,700 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,700 out of pocket. This can be a extremely nice safety net.

HumanaChoice H5216-154 (PPO) is a Local 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.

Humana works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for HumanaChoice H5216-154 (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Humana and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Humana 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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2020 Humana Medicare Advantage Plan Details

HumanaChoice H5216-154 (PPO)
Type: Local PPO
Monthly Premium C+D: $-
Part C Premium:$0.00
MOOP: $6,700
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$400.00
Tiers with No Deductible:1
Gap Coverage:No
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced

Part-C Premium

Humana plan charges a $0.00 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

HumanaChoice H5216-154 (PPO) has a monthly drug premium of $0.00 and a $400.00 drug deductible. This Humana plan offers a $0.00 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 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 $0.00. 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 H5216-154 (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $0.00 for 75% low income subsidy $0.00 for 50% and $0.00 for 25%.

Full LIS Premium:$0.00
75% LIS Premium:$0.00
50% LIS Premium:$0.00
25% LIS Premium:$0.00

Gap Coverage

In 2020 once you and your plan provider have spent $4020 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Humana plan does not offer additional coverage through the gap.

Humana Drug Coverage and Formulary

A formulary is divided into tiers or levels of coverage based on the type or usage of your medication or benefit categories, according to drug costs. Each tier will have a defined out-of-pocket cost that you must pay before receiving the drug. You can see complete 2020 HumanaChoice H5216-154 (PPO) H5216-154 Formulary here.

Drug Tier Copay
1 $5 $10
2 $15 $20
3 $47 $47
4 $100 $100
5 25% 25%
*Initial Coverage Phase and 30 day supply

See the 2020 Humana Formulary

2019 Plan Services

(*2020 Plan services will be added when available)

Health plan deductible

$1,000 annual deductible

Emergency care/Urgent care

Emergency $90 per visit (always covered)
Urgent care $20-50 or 40% per visit (always covered)

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures Out-of-Network 40%
Diagnostic tests and procedures In-Network $0-100
Lab services Out-of-Network 40%
Lab services In-Network $0-50
Diagnostic radiology services (e.g., MRI) Out-of-Network 40%
Diagnostic radiology services (e.g., MRI) In-Network $50-450
Outpatient x-rays Out-of-Network 40%
Outpatient x-rays In-Network $20-100


Hearing exam Out-of-Network 40%
Hearing exam In-Network $50
Fitting/evaluation Out-of-Network $0 copay
Fitting/evaluation In-Network $0 copay
Hearing aids Out-of-Network $699-999
Hearing aids In-Network $699-999

Preventive dental

Oral exam Not covered
Cleaning Not covered
Fluoride treatment Not covered
Dental x-ray(s) Not covered

Comprehensive dental

Non-routine services Not covered
Diagnostic services Not covered
Restorative services Not covered
Endodontics Not covered
Periodontics Not covered
Extractions Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Not covered


Routine eye exam Not covered
Other Not covered
Contact lenses Not covered
Eyeglasses (frames and lenses) Not covered
Eyeglass frames Not covered
Eyeglass lenses Not covered
Upgrades Not covered

Mental health services

Inpatient hospital - psychiatric Out-of-Network 40% per stay
Inpatient hospital - psychiatric In-Network $450 per day for days 1 through 3
$0 per day for days 4 through 90
Outpatient group therapy visit with a psychiatrist Out-of-Network 40%
Outpatient group therapy visit with a psychiatrist In-Network $40
Outpatient individual therapy visit with a psychiatrist Out-of-Network 40%
Outpatient individual therapy visit with a psychiatrist In-Network $40
Outpatient group therapy visit Out-of-Network 40%
Outpatient group therapy visit In-Network $40
Outpatient individual therapy visit Out-of-Network 40%
Outpatient individual therapy visit In-Network $40

Skilled Nursing Facility

Out-of-Network 40% per stay
In-Network $0 per day for days 1 through 20
$172 per day for days 21 through 100

Rehabilitation services

Occupational therapy visit Out-of-Network 40%
Occupational therapy visit In-Network $20-40
Physical therapy and speech and language therapy visit Out-of-Network 40%
Physical therapy and speech and language therapy visit In-Network $20-40

Ground ambulance

Out-of-Network $265
In-Network $265

Other health plan deductibles?

In-Network No


Not covered

Foot care (podiatry services)

Foot exams and treatment Out-of-Network 40%
Foot exams and treatment In-Network $50
Routine foot care Not covered

Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-Network 20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) In-Network 20% per item
Prosthetics (e.g., braces, artificial limbs) Out-of-Network 25% per item
Prosthetics (e.g., braces, artificial limbs) In-Network 20% per item
Diabetes supplies Out-of-Network 40% per item
Diabetes supplies In-Network $0 or 10-20% per item

Wellness programs (e.g., fitness, nursing hotline)


Medicare Part B drugs

Chemotherapy Out-of-Network 40%
Chemotherapy In-Network 20%
Other Part B drugs Out-of-Network 40%
Other Part B drugs In-Network 20%

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$10,000 In and Out-of-network
$6,700 In-network

Optional supplemental benefits


Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

In-Network No

Inpatient hospital coverage

Out-of-Network 40% per stay
In-Network $450 per day for days 1 through 4
$0 per day for days 5 through 90
$0 per day for days 91

Outpatient hospital coverage

Out-of-Network 40% per visit
In-Network $450 per visit

Doctor visits

Primary Out-of-Network 40% per visit
Primary In-Network $20 per visit
Specialist Out-of-Network 40% per visit
Specialist In-Network $50 per visit

Preventive care

Out-of-Network $0 or 40%
In-Network $0 copay

Ratings for HumanaChoice H5216-154 (PPO) H5216

2019 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

Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer 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
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Plan All-Cause Readmissions
Statin Therapy

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 H5216-154 (PPO) Plans Performance

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

Health Plan Customer Service Rating for HumanaChoice H5216-154 (PPO)

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

HumanaChoice H5216-154 (PPO) Drug Plan Customer Service ratings

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

Ratings For Member Complaints and Changes in the Drug Plans Performance

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

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
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes

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Coverage Area for HumanaChoice H5216-154 (PPO)

(Click county to compare all available Advantage plans)

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

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Source: CMS.
Data as of September 4, 2019.
Star Rating as of October 10, 2019.
Plan Services are 2019 information as reference. 2020 information will be added when released.
Notes: Data are subject to change as contracts are finalized. For 2020, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit. Includes 2020 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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