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HumanaChoice H5216-023 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-023 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-023 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-023 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in IN, KY, OH and PA. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-023 (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 H5216-023 (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 H5216-023 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $21.00. 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 $350.00 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 H5216-023 (PPO) plan features an annual prescription drug deductible of $350. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month or 3-month supply at standard pharmacies and through preferred mail order. Tier 2 generic drugs are also highly affordable, starting at a $10 copay for a 1-month supply and offering no copay for a 3-month supply when using preferred mail order. For Tier 3 preferred brand drugs, the plan requires a $47 copay for a 1-month supply at standard pharmacies and mail order options. Higher-tier prescriptions transition to coinsurance, with Tier 4 non-preferred drugs requiring a 42% coinsurance and Tier 5 specialty drugs requiring a 29% coinsurance.
Additional Benefits
The HumanaChoice H5216-023 (PPO) plan offers affordable access to essential medical services, featuring no copay and no coinsurance for primary care visits, preventive care, and home health services. Specialist visits require a copay of $15 to $55, while inpatient hospital stays carry a $490 daily copay for the first several days followed by no copay for subsequent days. Emergency room visits have a $125 copay, which is waived if you are admitted within 24 hours. This plan also includes valuable dental, vision, and hearing benefits to help reduce your out-of-pocket costs. Dental care is covered up to $1,000 annually with no copay for preventive services, and routine vision exams and eyewear are covered with no copay up to a $200 annual limit. Routine hearing exams also feature no copay, while dialysis and durable medical equipment are covered with a 20% coinsurance.
Inpatient Hospital See details
HumanaChoice H5216-023 (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $490 daily copay for days 1 through 5 of acute stays and days 1 through 4 of psychiatric stays, followed by no copay for subsequent days. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by HumanaChoice H5216-023 (PPO) with no coinsurance, featuring a copay of $0 to $440 for outpatient hospital services and $490 per stay for observation services. Ambulatory surgical center and outpatient blood services have no copay and no coinsurance, while outpatient substance abuse sessions require a $35 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered under the HumanaChoice H5216-023 (PPO) plan with a $35.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-023 (PPO) covers Medicare-covered ground and air ambulance services with a $315 copay and no coinsurance, though prior authorization is required. Transportation services to plan-approved or health-related locations are not covered under this plan.
Emergency Services See details
HumanaChoice H5216-023 (PPO) covers emergency services with a $125 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 under a $125 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-023 (PPO) provides primary care physician services and telehealth benefits with no copay and no coinsurance. Specialist visits, physical and occupational therapies, and mental health services are covered with copays ranging from $15 to $55 and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
HumanaChoice H5216-023 (PPO) covers preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management training. Additional preventive services are only partially covered, as a memory fitness benefit is included but services like health education, in-home safety assessments, personal emergency response systems, and medical nutrition therapy are not covered.
Hearing Services See details
HumanaChoice H5216-023 (PPO) covers hearing services, offering routine exams and fitting evaluations with no copay and no coinsurance, while Medicare-covered exams require a $55 copay and no coinsurance. Prescription hearing aids are partially covered with copays ranging from $699 to $999 and no coinsurance, but OTC hearing aids and inner ear, outer ear, or over the ear prescription aids are not covered.
Vision Services See details
HumanaChoice H5216-023 (PPO) provides partially covered vision services with no copay and no coinsurance for one routine eye exam per year (up to a $75 limit) and select eyewear like contact lenses or full eyeglasses (up to a $200 annual limit). Other eye exam services, individual eyeglass lenses, individual frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-023 (PPO) partially covers dental services, offering up to a $1,000 annual maximum benefit for both in-network and out-of-network care. Most preventive and diagnostic services feature no copay and no coinsurance, while Medicare-covered services require a $55 copay and restorative services require a $25 copay (both with no coinsurance); however, fluoride treatments, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-023 (PPO) covers home infusion bundled services with no copay, subject to prior authorization. Associated Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
HumanaChoice H5216-023 (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
Medical equipment is covered by HumanaChoice H5216-023 (PPO), including durable medical equipment, prosthetics, and medical supplies which carry a 20% coinsurance and no copay. Diabetic supplies are covered with a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes and inserts require a $10 copay.
Diagnostic and Radiological Services See details
HumanaChoice H5216-023 (PPO) covers diagnostic and radiological services with prior authorization required. Diagnostic procedures and tests have no coinsurance and a copay ranging from $0 to $105, while lab services, diagnostic radiological services, and outpatient X-rays feature no copay. Therapeutic radiological services require a minimum $45 copay and 20% coinsurance.
Home Health Services See details
HumanaChoice H5216-023 (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the HumanaChoice H5216-023 (PPO) plan, as all associated sub-services—including standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by HumanaChoice H5216-023 (PPO) with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $214 daily copay for days 21 through 100. Prior authorization is required, a prior three-day inpatient hospital stay is not required, and additional days beyond the standard 100-day limit are not covered.
Other Services See details
HumanaChoice H5216-023 (PPO) covers select other services, including acupuncture with a $55 copay and no coinsurance for up to 20 treatments per year, and a chronic illness meal benefit with no copay and no coinsurance. Over-the-counter (OTC) items are not covered under this plan.
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