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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 2025, 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 2025.
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 $250.00 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) plan has a $250 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, for a preferred generic drug, you will pay a $12 copay at a preferred pharmacy or through mail order, and a $20 copay at a standard pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-042 (PPO) plan offers a range of benefits, including inpatient hospital stays with a $325 copay for the first five days, and no copay for days 6-90, as well as outpatient services, and emergency care services. The plan also covers primary care visits for a $5 copay, and offers additional benefits like hearing and vision services, with specific copays and coinsurance amounts for services like hearing exams, eyeglasses, and dental care. This plan includes additional benefits such as home health services with no copay, medical equipment with coinsurance, and diagnostic services with varying copays. However, this plan does not cover cardiac rehabilitation services, and skilled nursing facilities have a copay that varies depending on the length of stay.
Inpatient Hospital See details
Inpatient Hospital coverage includes a $325 copay for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Additional days for Inpatient Hospital-Acute have no copay for days 91-999. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a copay between $45 and $350, observation services with a $325 copay, ambulatory surgical center services with a $275 copay, outpatient substance abuse services with a copay between $30 and $100 for individual and group sessions, and outpatient blood services with no copay. Prior authorization is required for many of these services.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-042 (PPO) plan and requires prior authorization. The copay for this service is $45.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground ambulance services with a $315 copay and air ambulance services with 20% coinsurance. 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 H5216-042 (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay.
Primary Care See details
The HumanaChoice H5216-042 (PPO) plan covers primary care physician services with a $5 copay. Chiropractic services have a $15 copay, but routine care is not covered. Occupational therapy services have a $25 copay. Physician specialist services have a $45 copay. Mental health specialty services, including individual and group sessions, have a $30 copay. Physical therapy and speech-language pathology services have a $25 copay. Additional telehealth benefits have a copay between $0 and $55. Opioid treatment program services have a copay between $30 and $100. Other health care professional services have a copay between $5 and $45. Psychiatric services, including individual and group sessions, have a $30 copay. Podiatry Services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered zero dollar preventive services, annual physical exams with no copay, and additional preventive services, as well as kidney disease education services, and other preventive services. Some services are covered, including Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit with no copay.
Hearing Services See details
Hearing services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids. Hearing exams have a $45 copay, routine hearing exams have no copay, fitting/evaluation for hearing aids have no copay, and prescription hearing aids have a copay between $699 and $999, while OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay between $0 and $45, and eyewear with no copay for contact lenses and eyeglasses (lenses and frames). Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-042 (PPO) covers a variety of dental services, including oral exams, dental X-Rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), and oral and maxillofacial surgery. The plan has a $1,500 annual maximum benefit for in-network and out-of-network services, and some services have a copay of $0 and some services have a coinsurance between 30% and 40%.
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 under the HumanaChoice H5216-042 (PPO) plan, with a coinsurance between 20% and 20%. Prior authorization is required.
Medical Equipment See details
Medical equipment is covered under this plan, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, while Prosthetic Devices and Medical Supplies have a 20% coinsurance with no copay. Diabetic Supplies have a 10-20% coinsurance with no copay, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the HumanaChoice H5216-042 (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $100, Lab Services have no copay, and Outpatient X-Ray Services have a $5 copay. Diagnostic Radiological Services have a copay of at most $325, and Therapeutic Radiological Services have a copay of at most $40 and a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by HumanaChoice H5216-042 (PPO) with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-042 (PPO) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for these services if they were covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-042 (PPO) plan, with a copay of $10 for days 1-20, and a copay of $214 for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays are not covered.
Other Services See details
The HumanaChoice H5216-042 (PPO) plan covers acupuncture with a $45 copay, as well as a meal benefit with no copay; however, over-the-counter items, dual eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and other services are not covered. Additionally, various other services such as Private Duty Nursing Services, Case Management, and more are not covered.
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