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HumanaChoice H5216-196 (PPO) - H5216-196-001

na* for plan year 2025

$0.00

Monthly Premium

HumanaChoice H5216-196 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Humana Inc.

Plan ID: H5216-196-001

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

New Mexico 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 New Mexico 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

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$200.00
Out-of-pocket maximum$4,900.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit Services:
Coinsurance for Medicare Covered Primary Care Office Visit 50%
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45
Inpatient hospital care
Out-of-Network:

Acute Hospital Services:
Coinsurance for Acute Hospital Services per Stay 50%
Urgent care
Urgent Care:
Copayment for Urgent Care $55

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $125
Emergency room visit
Emergency Care:
Copayment for Emergency Care $125
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $125
Copayment for Worldwide Emergency Transportation $125
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $315

Air Ambulance:
Copayment for Air Ambulance Services $630
Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

HumanaChoice H5216-196 (PPO) covers a range of additional benefits. Learn more about HumanaChoice H5216-196 (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $20
Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Medicare Covered Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 50%
Copayment for Medicare Covered Diabetic Therapeutic Shoes or Inserts $0
Durable medical equipment (DME)
Out-of-Network:

Medicare Covered Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 50%
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $55
Copayment for Medicare-covered Lab Services $0 to $55
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
$50 OP Diag Proc & Tests - OPH$0 OP Diag Proc & Tests - PCP$45 OP Diag Proc & Tests - SPC$55 OP Diag Proc & Tests - UCC$50 Sleep Study (Fac Based) - OPH$50 Sleep Study (Fac Based) - SPC$0 Sleep Study (Home Based) - Mbr's Home_

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $300
Copayment for Medicare-covered Therapeutic Radiological Services $40
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0 to $55
Home health care
Out-of-Network:

Medicare Covered Home Health Services:
Coinsurance for Medicare Covered Home Health 50%
Mental health inpatient care
Out-of-Network:

Psychiatric Hospital Services:
Coinsurance for Psychiatric Hospital per Stay 50%
Mental health outpatient care
Out-of-Network:

Medicare Covered Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 50%
Coinsurance for Medicare Covered Group Sessions 50%
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $350
Prior Authorization Required for Outpatient Hospital Services
$0 Diag Colonoscopy - OPH$20 Mental Health - OPH$350 Surgery Svcs - OPH$40 Wound Care - OPH_

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $295
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $250
Prior Authorization Required for Ambulatory Surgical Center Services
$0 Diag Colonoscopy - ASC$250 Surgery Svcs - ASC_
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $20
Copayment for Medicare-covered Group Sessions $20
Prior Authorization Required for Outpatient Substance Abuse Services
Podiatry services
Out-of-Network:

Medicare Covered Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 50%

Non-Medicare Covered Podiatry Services:
Copayment for Non-Medicare Covered Podiatry Services $45
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$10 per day for days 1 to 20
$214 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental care$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
$0 copayment for emergency diagnostic exam up to 1 per year.
$0 copayment for periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for necessary anesthesia with covered service up to unlimited per year.
Out of Network
$0 copayment for comprehensive oral evaluation or periodontal exam up to 1 every 3 years.
$0 copayment for panoramic film or diagnostic x-rays up to 1 every 5 years.
$0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year.
$0 copayment for emergency diagnostic exam up to 1 per year.
$0 copayment for periodic oral exam, prophylaxis (cleaning) up to 2 per year.
$0 copayment for periodontal maintenance up to 4 per year.
$0 copayment for necessary anesthesia with covered service up to unlimited per year.
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

CoverageDetails
Vision care
Out-of-Network:

Medicare Covered Eye Exams Services:
Coinsurance for Medicare Covered Eye Exams 50%
Copayment for Medicare Covered Eyewear $0

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $45
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $499 to $799
  • Maximum 2 Hearing Aids every year

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.

CoverageDetails
Preventive services and health/wellness education programsIn-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The HumanaChoice H5216-196 (PPO) offers prescription drug coverage, with an annual drug deductible of $200.00 (excludes Tiers 1, 2, and 3)

    Coverage & Cost
    Coverage
    Cost
    Annual drug deductible$200.00 (excludes Tiers 1, 2, and 3)
    Tier 1
    • Standard retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Preferred mail order $0.00
    • Standard mail order $10.00
    • Standard mail order $10.00
    Tier 2
    • Standard retail $12.00
    • Standard retail $12.00
    • Preferred mail order $12.00
    • Preferred mail order $12.00
    • Standard mail order $20.00
    • Standard mail order $20.00
    Tier 3
    • Standard retail $45.00
    • Standard retail $45.00
    • Preferred mail order $45.00
    • Preferred mail order $45.00
    • Standard mail order $47.00
    • Standard mail order $47.00
    Annual drug deductible$200.00 (excludes Tiers 1, 2, and 3)
    Tier 1
    • Standard retail N/A
    • Standard retail N/A
    • Preferred mail order N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    • Standard mail order N/A
    Tier 2
    • Standard retail N/A
    • Standard retail N/A
    • Preferred mail order N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    • Standard mail order N/A
    Tier 3
    • Standard retail N/A
    • Standard retail N/A
    • Preferred mail order N/A
    • Preferred mail order N/A
    • Standard mail order N/A
    • Standard mail order N/A
    Annual drug deductible$200.00 (excludes Tiers 1, 2, and 3)
    Tier 1
    • Standard retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Preferred mail order $0.00
    • Standard mail order $30.00
    • Standard mail order $30.00
    Tier 2
    • Standard retail $36.00
    • Standard retail $36.00
    • Preferred mail order $0.00
    • Preferred mail order $0.00
    • Standard mail order $60.00
    • Standard mail order $60.00
    Tier 3
    • Standard retail $135.00
    • Standard retail $135.00
    • Preferred mail order $90.00
    • Preferred mail order $90.00
    • Standard mail order $141.00
    • Standard mail order $141.00

    When reviewing New Mexico 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 New Mexico 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

    New Mexico Counties Served

    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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