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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 2025, 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 2025.
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 $82.00. 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 $590.00 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) plan has an "Enhanced Alternative" drug benefit. This plan has a deductible of $590.00. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, for a preferred generic drug you will pay a $15.00 copay at a standard or preferred mail pharmacy. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The HumanaChoice H5216-001 (PPO) plan offers a range of benefits with varying costs. You can expect copays for inpatient hospital stays, outpatient services, and emergency services, while some services like preventive care, annual physical exams, and home health services have no copay. The plan also includes coverage for primary care, hearing, vision, and dental services, with copays for some services and no copays for others. Additionally, the plan covers ambulance services, home infusion, dialysis, medical equipment, and diagnostic services, with a mix of copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you pay a $250 copay for days 1-6, and no copay for days 7-90, and additional days for Inpatient Hospital-Acute have no copay.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered by HumanaChoice H5216-001 (PPO), with copays ranging from $0 to $300. Observation services have a $250 copay, while Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay. Individual and group outpatient substance abuse sessions have copays ranging from $40 to $90.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-001 (PPO) plan. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by HumanaChoice H5216-001 (PPO). Ground ambulance services have a $315 copay, while air ambulance services have a 20% coinsurance; transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered. Emergency Services and Worldwide Emergency Coverage have a $140 copay, while Urgently Needed Services have a $60 copay; there is no coinsurance for any of these services.
Primary Care See details
The HumanaChoice H5216-001 (PPO) plan covers primary care physician services with a $5 copay, chiropractic services with a $10 copay, occupational therapy with a $40 copay, physician specialist services with a $45 copay, mental health specialty services with a $45 copay, other health care professional services with a copay between $5 and $45, psychiatric services with a $45 copay, physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits with a copay between $0 and $60, and opioid treatment program services with a copay between $40 and $90. Routine chiropractic care is not covered, and podiatry services are not covered.
Preventive Services See details
Preventive Services includes Medicare-covered preventive services, annual physical exams, and additional preventive services. Annual physical exams have no copay, while all other services have a $0 copay.
Hearing Services See details
Hearing Services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids. Hearing exams have a $45 copay, while routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids are partially covered, but Inner Ear, Outer Ear, and Over the Ear aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
The HumanaChoice H5216-001 (PPO) plan covers eye exams with a copay of $0-$45, and eyewear with no copay. Eyeglasses (lenses and frames) and contact lenses are covered with no copay. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-001 (PPO) plan covers dental services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. There is a $45 copay for Medicare dental services, and a $0 copay for several other dental services; coinsurance applies to restorative services, prosthodontics (removable and fixed), and a maximum plan benefit coverage of $1000 per year applies. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. You will pay a $35 copay for Medicare Part B insulin drugs, as well as coinsurance between 0% and 20% for Medicare Part B insulin drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-001 (PPO) plan, with a coinsurance between 20% and 20%. Prior authorization is required for this benefit.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have a coinsurance between 10% and 20% and no copay, and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the HumanaChoice H5216-001 (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $90, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $350, Therapeutic Radiological Services have a minimum coinsurance of 20%, and Outpatient X-Ray Services have a $5 copay.
Home Health Services See details
HumanaChoice H5216-001 (PPO) covers Home Health Services with no copay and no coinsurance, but does not cover Additional Hours of Care or Personal Care Services. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
For HumanaChoice H5216-001 (PPO), cardiac rehabilitation services are not covered. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the HumanaChoice H5216-001 (PPO) plan, but require prior authorization. For days 1-20, the copay is $20, and for days 21-100, the copay is $203, with no coinsurance. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes acupuncture, which has a $45 copay, and a meal benefit with no copay. Over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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