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HumanaChoice H5216-013 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-013 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-013 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-013 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Illinois. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-013 (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 H5216-013 (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 H5216-013 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $87.00. 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 has a $700.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
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 $10100.00 (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 $10100.00 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 H5216-013 (PPO) Medicare plan features an annual prescription 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 cost as little as a $5 copay for a 1-month supply, with no copay required for a 3-month supply filled via preferred mail order. Tier 3 preferred brand drugs require a $47 copay for a 1-month supply across most pharmacy and mail order channels. Higher-tier medications require coinsurance rather than flat copays, with Tier 4 non-preferred drugs carrying a 34% coinsurance and Tier 5 specialty drugs requiring a 25% coinsurance. Choosing preferred mail order options generally offers the most cost-effective way to fill prescriptions on this plan.
Additional Benefits
The HumanaChoice H5216-013 (PPO) plan offers robust coverage for core medical services, featuring no copays or coinsurance for primary care visits, home health services, and routine preventive care. For specialist visits, patients will pay a $50 copay with no coinsurance, while emergency room visits incur a $130 copay that is waived if admitted. Inpatient hospital stays require a $360 daily copay for the first six days with no coinsurance, followed by no copay for days seven through ninety. This plan also includes essential dental, vision, and hearing benefits, offering no copays or coinsurance for routine exams, cleanings, and basic eyewear up to a $100 limit. Medicare-covered dental and hearing exams require a $50 copay with no coinsurance, and dental benefits are capped at a $1,000 annual maximum. Additionally, durable medical equipment and dialysis services are covered with a 20% coinsurance and no copay, helping members manage their ongoing healthcare costs.
Inpatient Hospital See details
HumanaChoice H5216-013 (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance and a $360 daily copay for days 1 to 6, followed by no copay for days 7 to 90. Unlimited additional acute days are covered with no copay, but additional psychiatric days, room upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
HumanaChoice H5216-013 (PPO) covers outpatient services with no coinsurance, featuring a copay of $0 to $300 for outpatient hospital services, $360 per stay for observation services, and $20 to $35 for substance abuse sessions. Ambulatory surgical center and outpatient blood services are covered with no copays and no coinsurance, though prior authorization is required for most of these services.
Partial Hospitalization See details
Partial hospitalization services are covered under the HumanaChoice H5216-013 (PPO) plan with a $35.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
HumanaChoice H5216-013 (PPO) covers ground ambulance services with a $335 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, both requiring prior authorization. Transportation services to health-related locations are not covered by this plan.
Emergency Services See details
HumanaChoice H5216-013 (PPO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services have a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered for a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-013 (PPO) offers primary care doctor visits with no copay and no coinsurance, while specialist visits require a $50 copay and no coinsurance. Physical, occupational, speech, and mental health therapy services are covered with copayments ranging from $20 to $40 and no coinsurance, whereas podiatry and chiropractic services are not covered.
Preventive Services See details
HumanaChoice H5216-013 (PPO) preventive services are partially covered with no copay and no coinsurance for annual physicals, kidney disease education, glaucoma screenings, and a memory fitness benefit. However, several services are not covered, including health education, in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, tobacco cessation, disease management, telemonitoring, remote technologies, home safety modifications, and counseling.
Hearing Services See details
HumanaChoice H5216-013 (PPO) hearing services are partially covered, featuring a $50 copay and no coinsurance for Medicare-covered exams, while routine annual exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids require a copay of $699 to $999 and no coinsurance, but OTC hearing aids, inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered under the HumanaChoice H5216-013 (PPO) plan, featuring no copay and no coinsurance for a yearly routine eye exam and annual eyewear, which includes one pair of contact lenses or eyeglasses up to a $100 combined limit. Other eye exam services, standalone eyeglass lenses, standalone eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-013 (PPO) dental benefits are partially covered up to an annual maximum of $1,000 for both in-network and out-of-network services. Preventive care like exams and cleanings features no copay and no coinsurance, while Medicare-covered dental services require a $50 copay and no coinsurance. Fluoride treatments, implants, maxillofacial prosthetics, and orthodontics are not covered under this plan.
Home Infusion bundled Services See details
HumanaChoice H5216-013 (PPO) covers Home Infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs require between no coinsurance and 20% coinsurance, while Part B insulin is covered with a $35 copay and up to 20% coinsurance.
Dialysis Services See details
HumanaChoice H5216-013 (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
HumanaChoice H5216-013 (PPO) covers durable medical equipment, prosthetics, and medical supplies with a 20% coinsurance and no copay. Covered diabetic supplies have a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes or inserts require a $10 copay and coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by HumanaChoice H5216-013 (PPO) with no copay or coinsurance for lab services, and diagnostic procedures ranging from a $0 to $95 copay with no coinsurance. Outpatient X-rays feature no copay, diagnostic radiological copays start at $0, and therapeutic radiological services require a minimum 20% coinsurance, with prior authorization required for these services.
Home Health Services See details
Home Health Services are covered by HumanaChoice H5216-013 (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-013 (PPO) does not cover Cardiac Rehabilitation Services in practice, as none of the sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are covered. Although the plan technically lists no coinsurance and requires prior authorization, there is no coverage or copay for these services.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-013 (PPO) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring prior authorization but allowing admission without a prior three-day hospital stay. You will pay a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the Medicare limit are not covered.
Other Services See details
HumanaChoice H5216-013 (PPO) provides coverage for select other services, including acupuncture with a $50 copay and no coinsurance for up to 20 treatments per year, and chronic illness meals with no copay and no coinsurance. Over-the-counter (OTC) items are not covered under this plan.
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