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HumanaChoice H5216-001 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-001 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-001 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-001 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Eastern Wisconsin. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-001 (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about HumanaChoice H5216-001 (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For HumanaChoice H5216-001 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $81.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $615.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6200.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $6200.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The HumanaChoice H5216-001 (PPO) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, there is no copay for a 1-month or 3-month supply at standard pharmacies and through preferred mail order. Tier 2 generic drugs require a $5 copay for a 1-month supply at standard pharmacies or preferred mail order, and there is no copay for a 3-month supply when using preferred mail order. Tier 3 preferred brand drugs have a $47 copay for a 1-month supply, with a 3-month supply costing $131 through preferred mail order and $141 at standard pharmacies. For higher-tier medications, you will pay a coinsurance rather than a flat copay. Tier 4 non-preferred drugs carry a 38% coinsurance, while Tier 5 specialty drugs require a 25% coinsurance for a 1-month supply.
Additional Benefits
The HumanaChoice H5216-001 (PPO) plan offers robust coverage for essential medical services, featuring no copay for primary care visits, annual physical exams, and home health services. For specialist visits and emergency care, members will pay predictable copays, such as $45 for specialists and $150 for emergency room visits. Inpatient hospital stays require a daily copay of $250 for the first six days, with no copays required for day seven and beyond. This plan also includes valuable dental, vision, and hearing benefits, providing routine exams with no copay alongside a $1,000 annual maximum for dental care. Prescription hearing aids and vision wear are partially covered, while durable medical equipment and dialysis services generally carry a 20% coinsurance. With no coinsurance on most diagnostic services and low copays for skilled nursing care, this plan provides a clear picture of your healthcare costs.
Inpatient Hospital See details
HumanaChoice H5216-001 (PPO) covers inpatient hospital services with no coinsurance, requiring a $250 daily copay for days 1 through 6 and no copay for days 7 and beyond. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-001 (PPO) covers outpatient services with no coinsurance, offering ambulatory surgical center and outpatient blood services with no copay. Outpatient hospital services have a copay of $0 to $300, observation services carry a $250 copay per stay, and outpatient substance abuse sessions require a $30 to $35 copay.
Partial Hospitalization See details
Partial hospitalization services are covered by HumanaChoice H5216-001 (PPO) with a $35.00 copay and no coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
HumanaChoice H5216-001 (PPO) partially covers ambulance and transportation services, requiring a $335 copay and no coinsurance for ground ambulance services, and a 20% coinsurance and no copay for air ambulance services, with prior authorization required for both. Transportation services to plan-approved or any other health-related locations are not covered under this plan.
Emergency Services See details
HumanaChoice H5216-001 (PPO) covers emergency services with a $150 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $65 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are each covered with a $150 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-001 (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $45 copay and no coinsurance. Physical, occupational, and speech therapy services require a $40 copay and no coinsurance, podiatry is not covered, and for chiropractic services, some services are covered but routine and other chiropractic services are not covered.
Preventive Services See details
HumanaChoice H5216-001 (PPO) preventive services are covered with no copay and no coinsurance for annual physical exams, kidney disease education, glaucoma screenings, and memory fitness benefits. This benefit is partially covered, as additional services like health education, weight management, alternative therapies, counseling, and in-home safety or support services are not covered.
Hearing Services See details
HumanaChoice H5216-001 (PPO) covers Medicare-covered hearing exams with a $45 copay and no coinsurance, while routine exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay between $699 and $999 for up to two devices per year, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by HumanaChoice H5216-001 (PPO) with no coinsurance and copays ranging from no copay to $45, though other eye exam services, eyeglass lenses, eyeglass frames, and upgrades are not covered. Covered benefits include one annual routine eye exam and one annual pair of contact lenses or eyeglasses with no copay, up to a $75 exam limit and a $100 combined eyewear limit.
Dental Services See details
Dental services are partially covered by HumanaChoice H5216-001 (PPO) up to a $1,000 annual maximum, offering most preventive and comprehensive services with no copay and no coinsurance, Medicare-covered services with a $45 copay and no coinsurance, and prosthodontics with no copay and 30% coinsurance. Fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by HumanaChoice H5216-001 (PPO) with no copay, though prior authorization is required. Covered Part B chemotherapy, radiation, and other drugs require no copay and range from no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and ranges from no coinsurance to 20% coinsurance.
Dialysis Services See details
HumanaChoice H5216-001 (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive coverage for these services.
Medical Equipment See details
Medical equipment is covered by HumanaChoice H5216-001 (PPO), which offers durable medical equipment, prosthetics, and medical supplies with a 20% coinsurance and no copay. Diabetic supplies are covered with a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes or inserts require a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by HumanaChoice H5216-001 (PPO) with no copay for lab services and outpatient X-rays, and copays ranging from $0 to $90 for diagnostic procedures. Diagnostic services require no coinsurance, while therapeutic radiological services carry a minimum 20% coinsurance, and prior authorization is required.
Home Health Services See details
Home Health Services are covered by HumanaChoice H5216-001 (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-001 (PPO) covers Cardiac Rehabilitation Services with no copay, no coinsurance, and prior authorization required. While some services are covered, standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-001 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, though a prior three-day hospital stay is not, and additional days beyond the standard 100 days are not covered.
Other Services See details
HumanaChoice H5216-001 (PPO) partially covers other services, offering acupuncture for a $45 copay and no coinsurance up to 20 treatments per year, and chronic illness meal benefits with no copay and no coinsurance. Prior authorization is required for these covered services, while over-the-counter (OTC) items are not covered.
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