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HumanaChoice H5216-019 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-019 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-019 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-019 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Kentucky, West Virginia, Indiana. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-019 (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 H5216-019 (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 H5216-019 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $24.00. 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 $200.00 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 H5216-019 (PPO) plan features a $200 drug deductible and offers competitive savings on generic medications. You will pay no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through preferred mail order. For Tier 2 generic drugs, copays start at $10 for a one-month supply, with no copay required for a three-month supply filled via preferred mail order. Tier 3 preferred brand drugs require a $47 copay for a one-month supply, with a reduced $131 copay for a three-month supply through preferred mail order. Higher-tier medications are subject to coinsurance, with Tier 4 non-preferred drugs requiring 50% coinsurance and Tier 5 specialty drugs requiring 30% coinsurance. This plan structure provides clear pathways to save on prescriptions through preferred mail order services.
Additional Benefits
The HumanaChoice H5216-019 (PPO) plan offers comprehensive medical coverage featuring no copay for primary care visits, preventive services, and home health care. Specialist visits require a $55 copay, while inpatient hospital stays incur a $450 daily copay for the first five days and no copay for additional days. Emergency room visits have a $130 copay, which is waived if you are admitted, and urgent care services carry a $50 copay. For supplemental care, the plan features dental coverage up to $1,000 annually with no copay for preventive services, alongside routine vision and hearing exams that also require no copay. Prescription hearing aids are covered with copays ranging from $699 to $999, while durable medical equipment and dialysis services generally require a 20% coinsurance with no copay.
Inpatient Hospital See details
HumanaChoice H5216-019 (PPO) covers inpatient hospital services with no coinsurance, though prior authorization is required. For acute care, there is a $450 copay per day for days 1 through 5 and no copay for days 6 and beyond, while psychiatric care requires a $450 copay per day for days 1 through 4 and no copay for days 5 through 90. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered under this benefit.
Outpatient Services See details
HumanaChoice H5216-019 (PPO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital services require a $0 to $450 copay, observation services have a $450 copay per stay, and outpatient substance abuse sessions carry a $35 copay.
Partial Hospitalization See details
HumanaChoice H5216-019 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to receive coverage for this benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-019 (PPO) covers Medicare-approved ground and air ambulance services with a $335.00 copay and no coinsurance, subject to prior authorization. Transportation services to plan-approved or any other health-related locations are not covered under this plan.
Emergency Services See details
Emergency services are covered by HumanaChoice H5216-019 (PPO) with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-019 (PPO) offers primary care physician services with no copay and no coinsurance, while specialist visits require a $55 copay and no coinsurance. Other covered benefits, such as physical therapy, psychiatric services, and telehealth, have copays ranging from $0 to $55 with no coinsurance, though podiatry and routine chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by HumanaChoice H5216-019 (PPO) with no copay and no coinsurance for covered benefits, which include annual physical exams, kidney disease education, memory fitness, and diabetes self-management. However, several additional preventive services are not covered, including health education, nutritional/dietary benefits, counseling, in-home safety assessments, and personal emergency response systems.
Hearing Services See details
HumanaChoice H5216-019 (PPO) covers hearing services with no deductible, offering Medicare-covered exams for a $55 copay and routine exams or fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay of $699 to $999 for up to two aids per year, while over-the-counter (OTC), inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-019 (PPO) offers partially covered vision services with no copay and no coinsurance for covered benefits, though prior authorization is required. Routine eye exams (one per year) and eyeglasses or contact lenses (one pair per year) are covered up to annual maximums of $75 and $150 respectively, while other eye exams, individual eyeglass lenses, individual frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-019 (PPO) partially covers dental services up to a $1,000 annual limit, with no copay and no coinsurance for preventive services, a $25 copay and no coinsurance for restorative services, and a $55 copay and no coinsurance for Medicare-covered dental. Fluoride treatments, implant services, orthodontics, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-019 (PPO) covers home infusion bundled services with no copay, although prior authorization is required and step therapy may apply. Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-019 (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
HumanaChoice H5216-019 (PPO) covers durable medical equipment, prosthetics, and medical supplies with 20% coinsurance and no copay. Diabetic supplies are covered with 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes and inserts require a $10 copay and applicable coinsurance.
Diagnostic and Radiological Services See details
HumanaChoice H5216-019 (PPO) covers diagnostic and radiological services with no coinsurance for diagnostic services and no copays for lab services, diagnostic radiological services, and outpatient X-rays. Diagnostic procedures and tests carry a copay ranging from $0 to $105, while therapeutic radiological services require a minimum $45 copay and a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the HumanaChoice H5216-019 (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by HumanaChoice H5216-019 (PPO) with no coinsurance, a $10 copay, and prior authorization required. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) care is covered by HumanaChoice H5216-019 (PPO) 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, a prior three-day hospital stay is not required before admission, and additional days beyond the Medicare-covered 100-day limit are not covered.
Other Services See details
HumanaChoice H5216-019 (PPO) partially covers other services, offering acupuncture with a $55 copay and no coinsurance for up to 20 treatments per year, and a chronic illness meal benefit with no copay or coinsurance. Prior authorization is required for both covered benefits, and over-the-counter (OTC) items are not covered.
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