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HumanaChoice H5216-043 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-043 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-043 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-043 (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 H5216-043 (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 H5216-043 (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 H5216-043 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $11.00. 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 $12300.00 (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 $12300.00 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 H5216-043 (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, in the initial coverage phase, you'll pay a $9 copay for preferred generic drugs at a standard or preferred mail pharmacy. For preferred brand drugs, you'll pay 43% coinsurance at any 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 H5216-043 (PPO) plan offers a range of benefits, including inpatient hospital stays with copays, and outpatient services with varying copays. It also provides coverage for emergency services, primary care, preventive services, hearing, vision, and dental, often with no copay or low copays. The plan includes additional services like home health, skilled nursing, and ambulance services with specific cost-sharing arrangements.
Inpatient Hospital See details
The HumanaChoice H5216-043 (PPO) plan covers Inpatient Hospital services, including acute and psychiatric care. For Inpatient Hospital-Acute, you will pay a $345 copay for days 1-6, and no copay for days 7-90; additional days have no copay. Inpatient Hospital Psychiatric services have a $335 copay for days 1-6, and no copay for days 7-90; additional days are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with copays ranging from $0 to $350, and observation services with a $345 copay. Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay, while Outpatient Substance Abuse Services have copays between $30 and $100 for individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-043 (PPO) plan, with a $35 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground Ambulance Services have a $315 copay, while Air Ambulance Services have a 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. Emergency Services have a $110 copay, Urgently Needed Services have a $45 copay, and Worldwide Emergency Services have a $110 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation.
Primary Care See details
HumanaChoice H5216-043 (PPO) covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $25 copay, and physician specialist services with a $40 copay. Mental health specialty services, psychiatric services, and opioid treatment program services have a copay of $30-$100 depending on the service, and physical therapy and speech-language pathology services have a $25 copay. Additional telehealth benefits range from no copay to a $45 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Annual Physical Exams with no copay, and additional preventive services, including Medicare-covered zero-dollar preventive services, Glaucoma Screenings, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKGs following Welcome Visits, all with no copay. Health Education, In-Home Safety Assessments, Personal Emergency Response Systems, 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 Benefits, 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, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. The plan also offers a fitness benefit with no copay.
Hearing Services See details
Hearing exams have a $40 copay, while routine hearing exams have no copay, and are limited to 1 per year. Fitting/Evaluation for Hearing Aid has no copay. Prescription hearing aids are covered, with a copay between $699 and $999 for all types, but not for inner ear, outer ear, or over the ear hearing aids. OTC hearing aids are not covered.
Vision Services See details
The HumanaChoice H5216-043 (PPO) plan covers vision services, including eye exams with a copay between $0 and $40. The plan also covers eyewear, including contact lenses and eyeglasses (lenses and frames), with a $0 copay, but does not cover eyeglass lenses, eyeglass frames, or upgrades.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $40 copay, Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), and Other Preventive Dental Services with no copay. Fluoride Treatment, Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the HumanaChoice H5216-043 (PPO) plan, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, with a coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-043 (PPO) plan, with prior authorization required. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment benefits include durable medical equipment with 20% coinsurance, and medical supplies, prosthetic devices, and diabetic equipment with varying cost-sharing. The plan does not cover durable medical equipment for use outside the home. Diabetic supplies have a 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 include coverage for all diagnostic services, diagnostic procedures/tests with a copay between $0 and $175, and lab services with no copay. Outpatient X-Ray Services have no copay, while Diagnostic Radiological Services have a copay up to $325, and Therapeutic Radiological Services have a copay up to $45 and coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-043 (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the HumanaChoice H5216-043 (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-043 (PPO) plan, but require prior authorization. There is no copay for days 1-20, but there is a $214 copay for days 21-100; additional days beyond Medicare coverage and non-Medicare-covered stays are not covered.
Other Services See details
The HumanaChoice H5216-043 (PPO) plan covers acupuncture with a $40 copay, and a meal benefit with no copay. However, over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing, 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 are not covered.
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