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HumanaChoice H5216-042 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-042 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-042 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-042 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Texas. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-042 (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 H5216-042 (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 H5216-042 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $60.00. 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 $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 $9000.00 (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 $9000.00 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 H5216-042 (PPO) Medicare prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, you will pay no copay for a one-month or three-month supply at standard pharmacies and through preferred mail order. Tier 2 generic drugs are also affordable, with standard pharmacy copays starting at $10 for a one-month supply and no copay for a three-month supply when using preferred mail order. Tier 3 preferred brand drugs require a $47 copay for a one-month supply, though you can save on a three-month supply by using preferred mail order for a $131 copay. For higher-tier medications, Tier 4 non-preferred drugs carry a 48% coinsurance, while Tier 5 specialty drugs require a 25% coinsurance for a one-month supply.
Additional Benefits
The HumanaChoice H5216-042 (PPO) plan offers affordable medical coverage with no copay for primary care visits and preventive services, while specialist visits require a $35 copay. For hospital care, inpatient stays require a $325 daily copay for the first five days and no copay for days 6 through 90, while outpatient services range from no copay up to a $350 copay. Emergency room visits carry a $130 copay, which is waived if you are admitted, and urgent care costs a $50 copay. This plan also features dental, vision, and hearing benefits, including routine eye and hearing exams with no copay and up to $1,500 in annual dental coverage with coinsurance up to 40%. Skilled nursing facility care requires a $10 daily copay for days 1 through 20, whereas durable medical equipment and dialysis services require a 20% coinsurance. Home health services and diagnostic lab tests are also fully covered with no copay, ensuring affordable access to essential care.
Inpatient Hospital See details
HumanaChoice H5216-042 (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $325 daily copay for days 1 through 5 and no copay for days 6 through 90. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-042 (PPO) covers outpatient services with no coinsurance, including no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $350, observation services cost a $325 copay per stay, and outpatient substance abuse sessions carry a $30 to $35 copay, with prior authorization required.
Partial Hospitalization See details
Partial hospitalization is covered by HumanaChoice H5216-042 (PPO) with a $35.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
HumanaChoice H5216-042 (PPO) covers ground ambulance services with a $335 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
HumanaChoice H5216-042 (PPO) covers emergency services 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 H5216-042 (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $35 copay and no coinsurance. Covered therapy and mental health services require copays of $25 and $30 respectively with no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered under the HumanaChoice H5216-042 (PPO) plan with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, glaucoma screenings, diabetes self-management, and memory fitness. Several supplemental services are not covered, including health education, nutritional/dietary benefits, counseling, in-home safety assessments, personal emergency response systems, and telemonitoring.
Hearing Services See details
HumanaChoice H5216-042 (PPO) covers hearing services with no coinsurance, featuring a $35 copay for Medicare-covered exams and no copay for annual routine exams and fitting evaluations. Prescription hearing aids are partially covered with copays ranging from $0 to $599 for up to two devices every three years, though OTC hearing aids and specific inner, outer, and over-the-ear prescription models are not covered.
Vision Services See details
HumanaChoice H5216-042 (PPO) partially covers vision services with no coinsurance and copays ranging from $0 to $35. Covered benefits include one routine eye exam and one pair of contact lenses or eyeglasses (lenses and frames) per year, while other eye exam services, separate eyeglass lenses, separate eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered under the HumanaChoice H5216-042 (PPO) plan, which provides up to a $1,500 annual maximum benefit for combined in-network and out-of-network care. Covered Medicare dental services require a $35 copay and no coinsurance, while other covered services range from no copay and no coinsurance up to 40% coinsurance; however, fluoride treatment, maxillofacial prosthetics, implant services, fixed prosthodontics, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered under HumanaChoice H5216-042 (PPO) with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy and other drugs have 0% to 20% coinsurance with no copay, while covered insulin requires a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-042 (PPO) plan with no copay and a 20% coinsurance, subject to prior authorization requirements.
Medical Equipment See details
HumanaChoice H5216-042 (PPO) covers durable medical equipment, prosthetic devices, and medical supplies with 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
Diagnostic and radiological services are covered by HumanaChoice H5216-042 (PPO) and require prior authorization. Diagnostic lab services and outpatient X-rays feature no copay, diagnostic tests have no coinsurance with copays ranging from $0 to $100, and therapeutic radiological services require a minimum $40 copay and 20% coinsurance.
Home Health Services See details
HumanaChoice H5216-042 (PPO) covers Home Health Services with no copay and no coinsurance, although prior authorization is required for these services.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-042 (PPO) covers some Cardiac Rehabilitation Services with no copay and no coinsurance, though prior authorization is required. However, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by HumanaChoice H5216-042 (PPO) with no coinsurance, requiring a $10 daily copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, a 3-day prior hospital stay is not required for admission, and additional days beyond the standard 100 days are not covered.
Other Services See details
HumanaChoice H5216-042 (PPO) partially covers other services, offering acupuncture for up to 20 treatments per year with a $35 copay and no coinsurance, alongside 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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