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DAV Low Plan - H5216-805-611
$172.83
Monthly Premium
DAV Low Plan is a Medicare Advantage (Medicare Part C) plan offered by Humana Inc.
Plan ID: H5216-805-611
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$172.83
Monthly Premium
South Dakota, Utah, Pennsylvania, Texas, Georgia, Louisiana, Iowa, Tennessee, Ohio, Colorado, and Wisconsin Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about South Dakota, Utah, Pennsylvania, Texas, Georgia, Louisiana, Iowa, Tennessee, Ohio, Colorado, and Wisconsin Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $172.83 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $2,000.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $8,000.00 |
| Primary care doctor visit | In or Out of Network: $0 copayment |
| Specialty doctor visit | In or Out of Network: $20 copayment |
| Inpatient hospital care | In or Out of Network: $150 copayment/admit |
| Urgent care | In or Out of Network: $0 - $20 copayment |
| Emergency room visit | In or Out of Network: $75 copayment |Waived if admitted within 24 hours.|Worldwide Coverage: 20% coinsurance. $100 deductible per year, $25,000 Maximum Benefit per year or 60 consecutive days, whichever is reached first. Limited to emergency Medicare-covered services. |
| Ambulance transportation | In or Out of Network: $75 copayment per date of service. |Limited to Medicare-covered transportation. |
Health Care Services and Medical Supplies
DAV Low Plan covers a range of additional benefits. Learn more about DAV Low Plan benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In or Out of Network: |Medicare-covered Chiropractic Services: $20 copayment |
| Diabetes supplies, training, nutrition therapy and monitoring | Diabetes Self-Management Services|In or Out of Network: $0 copayment|Diabetes Supplies and Services|In or Out of Network: $0 copayment |
| Durable medical equipment (DME) | In or Out of Network: $0 copayment |
| Diagnostic tests, lab and radiology services, and X-rays | Diagnostic Tests, Lab and Radiology Services, and X-Rays|In or Out of Network: $0 - $75 copayment|Medicare-Covered diagnostic procedures and tests|In or Out of Network: $0 - $75 copayment|Medicare-covered diagnostic radiology services (not including x-rays)|In or Out of Network: $0 - $75 copayment|Medicare-covered lab services|In or Out of Network: $0 copayment|Medicare-covered therapeutic radiology services|In or Out of Network: $0 - $50 copayment|Medicare-covered X-rays|In or Out of Network: $0 - $75 copayment |
| Home health care | In or Out of Network: $0 copayment, excludes Personal Home Care |
| Mental health inpatient care | In or Out of Network: $150 copayment/admit |190 day lifetime limit in a psychiatric facility |
| Mental health outpatient care | In or Out of Network: $0 - $40 copayment |
| Outpatient services/surgery | Ambulatory Surgery Center|In or Out of Network: $50 copayment|Outpatient Services/Surgery|In or Out of Network: $0 - $75 copayment |
| Outpatient substance abuse care | In or Out of Network: $0 - $40 copayment |
| Over-the-counter items | In Network: $25 maximum benefit coverage per quarter (3 months) for select over-the-counter health and wellness products through CenterWell Pharmacy. |Unused amount expires at the end of the quarter. |
| Podiatry services | In or Out of Network: $20 copayment for Medicare-covered podiatry services |
| Skilled Nursing Facility (SNF) care | In or Out of Network: |$0 copayment per day for days 1-20 |$25 copayment per day for days 21-100 |Plan pays $0 after 100 days. |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In or Out of Network: $20 copayment for Medicare-covered dental services. |$0 copayment for the following preventive and comprehensive dental services: Oral evaluation or periodontal exam up to 1 every 3 years. Panoramic film or diagnostic x-rays up to 1 every 5 years. Bitewing x-rays up to 1 set(s) per year. Emergency diagnostic exam, intraoral x-rays up to 1 per year. Amalgam and/or composite filling, fluoride treatment, prophylaxis (cleaning), or simple or surgical extraction up to 2 per year. Periodontal maintenance up to 4 per year. Necessary anesthesia (inhalation of nitrous oxide/analgesia, anxiolysis) with covered service. |$500 combined maximum benefit coverage amount per year for all preventive and comprehensive benefits. |Benefits received out of network are subject to any in-network benefit maximums, limitations and/or exclusions. |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | Out of Network: $20 copayment for Medicare-covered vision services. |$0 copayment for routine eye exam (includes refraction) up to 1 per year. $175 combined maximum benefit coverage amount per year for routine exam. $100 combined maximum benefit coverage amount per year for contact lenses, eyeglasses (lenses and frames), including lens options such as ultraviolet protection and scratch resistant coating, fitting for eyeglasses (lenses and frames). |Benefits received out-of-network are subject to any in-network benefit maximums, limitations, and/or exclusions. |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | Out of Network: $20 copayment for Medicare-covered hearing services. |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | Glaucoma Screening|In or Out of Network: $0 copayment|Preventive Services|In or Out of Network: $0 copayment |
When reviewing South Dakota, Utah, Pennsylvania, Texas, Georgia, Louisiana, Iowa, Tennessee, Ohio, Colorado, and Wisconsin Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of South Dakota, Utah, Pennsylvania, Texas, Georgia, Louisiana, Iowa, Tennessee, Ohio, Colorado, and Wisconsin that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
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We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.