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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 2025, 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 2025.
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 $35.00. 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 has a $200 deductible for prescription drugs. In the initial coverage phase, after your deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, preferred generic drugs have a $15 copay at preferred and mail order pharmacies and a $20 copay at a standard pharmacy. Preferred brand drugs have 50% coinsurance. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The HumanaChoice H5216-019 (PPO) plan offers a variety of benefits with varying costs. You can expect copays for inpatient hospital stays, outpatient services, primary care visits, specialist visits, emergency services, and more. Many preventive services, such as an annual physical exam, have no copay. This plan also covers services like home health, vision, dental, and hearing, with specific copays or coinsurance amounts depending on the service. Additionally, the plan covers medical equipment, and offers a meal benefit. However, some services, such as cardiac rehabilitation, are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $450 copay for days 1-5, and no copay for days 6-90, and for Inpatient Hospital Psychiatric, you will pay a $450 copay for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered with no copay, and the plan does not cover Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, or Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient Services, as offered by HumanaChoice H5216-019 (PPO), includes coverage for all outpatient hospital services with a copay ranging from $0 to $450, observation services with a $450 copay, and Ambulatory Surgical Center (ASC) services with no copay. Outpatient Substance Abuse services have a copay between $55 and $95 for individual and group sessions, and outpatient blood services are covered with no copay.
Partial Hospitalization See details
HumanaChoice H5216-019 (PPO) covers partial hospitalization with a $55 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-019 (PPO) plan. Ground and air ambulance services have a $315 copay, with no coinsurance, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the HumanaChoice H5216-019 (PPO) plan. Emergency Services have a $125 copay with no coinsurance, Urgently Needed Services have a $55 copay with no coinsurance, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation all have a $125 copay with no coinsurance.
Primary Care See details
Primary Care Physician Services have a $10 copay, Chiropractic Services have a $20 copay, and Occupational Therapy Services have a copay between $20-$40. Physician Specialist Services have a $55 copay, and Mental Health and Psychiatric services have a $55 copay for individual and group sessions. Physical Therapy and Speech-Language Pathology Services have a copay between $20-$40, and Additional Telehealth Benefits have a copay between $0-$55. Opioid Treatment Program Services have a copay between $55-$95. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive Services include an annual physical exam with no copay, and additional preventive services, including Fitness Benefit, Kidney Disease Education Services, and Other Preventive Services. The Fitness Benefit, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit all have no copay. However, services such as Health Education, In-Home Safety Assessment, Personal Emergency Response System, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services are covered by the HumanaChoice H5216-019 (PPO) plan, including hearing exams with a $55 copay; however, routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids (all types, inner ear, outer ear, and over the ear), and OTC hearing aids are not covered.
Vision Services See details
The HumanaChoice H5216-019 (PPO) plan covers vision services, including eye exams with a copay between $0 and $55, and eyewear with no copay. Contact lenses and eyeglasses (lenses and frames) are covered with no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are covered under the HumanaChoice H5216-019 (PPO) plan, with a $1,000 maximum benefit per year. Medicare Dental Services have a $55 copay, while Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Other Preventive Dental Services, and Adjunctive General Services have no copay. Fluoride Treatment, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered. Restorative Services has a $25 copay.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-019 (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
The HumanaChoice H5216-019 (PPO) plan covers medical equipment including Durable Medical Equipment (DME) with 20% coinsurance, and Prosthetics/Medical Supplies with 20% coinsurance. Diabetic Supplies are covered with 10-20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests have a copay between $0 and $105, and Lab Services have no copay. Diagnostic Radiological Services have a copay up to $720, Therapeutic Radiological Services have a coinsurance of at least 20% and a copay of at least $45, and Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-019 (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the HumanaChoice H5216-019 (PPO) plan. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the HumanaChoice H5216-019 (PPO) plan, with a copay of $10 for days 1-20 and $214 for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for acupuncture and meal benefits, but not for 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. Acupuncture has a $55 copay, and the meal benefit has no copay.
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