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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 2026, 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 2026.
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 $20.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $2.00. You must continue to pay paying your reduced 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 $420.00 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 $13900.00 (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 $13900.00 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) Medicare plan features an annual drug deductible of $420. 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, costing as little as a $5 copay for a 1-month supply, or no copay for a 3-month supply when using preferred mail order. Tier 3 preferred brand drugs require a $47 copay for a 1-month supply across standard pharmacies and mail-order options. Higher-tier medications require coinsurance, with Tier 4 non-preferred drugs carrying a 48% coinsurance and Tier 5 specialty drugs requiring a 28% coinsurance. Understanding these tier-based copays and coinsurance rates helps you accurately estimate your out-of-pocket prescription costs with this HumanaChoice PPO plan.
Additional Benefits
The HumanaChoice H5216-043 (PPO) plan offers robust medical coverage with no copay or coinsurance for preventive services and primary care physician visits. Specialist visits require a $40 copay, while inpatient hospital stays feature no coinsurance and a daily copay of $335 to $345 for the first six days. Outpatient services, including ambulatory surgical center visits and home health care, are also highly accessible with no copays and no coinsurance. This plan also features valuable supplemental benefits, including routine dental, vision, and hearing exams with no copay or coinsurance. Dental services are supported by a $1,000 combined annual maximum, while vision benefits cover one routine exam and eyewear per year up to set limits. Additionally, members can access covered over-the-counter items, chronic illness meals, and up to 20 acupuncture treatments with no coinsurance.
Inpatient Hospital See details
HumanaChoice H5216-043 (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $345 copay for days 1-6 of an acute stay and a $335 copay for days 1-6 of a psychiatric stay, followed by no copay for remaining covered days. Prior authorization is required, and certain services like upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-043 (PPO) covers outpatient services with no coinsurance, although prior authorization is required for most care. Under this plan, there is no copay for ambulatory surgical center and blood services, while outpatient hospital services cost a $0 to $350 copay, observation services cost a $345 copay per stay, and outpatient substance abuse sessions require a $30 to $35 copay.
Partial Hospitalization See details
Partial hospitalization is covered under the HumanaChoice H5216-043 (PPO) plan with a $35.00 copay and no coinsurance. Prior authorization is required to receive these services.
Ambulance and Transportation Services See details
HumanaChoice H5216-043 (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 for both. Transportation services to plan-approved or health-related locations are not covered under this plan.
Emergency Services See details
Emergency services are covered by HumanaChoice H5216-043 (PPO) with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $115 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-043 (PPO) offers primary care physician services with no copay and no coinsurance, while specialist visits require a $40 copay and no coinsurance. Other covered benefits feature no coinsurance and various copays, including $25 for physical, occupational, and speech therapy, $30 for mental health and psychiatric services, and $0 to $40 for telehealth, though podiatry and routine chiropractic services are not covered.
Preventive Services See details
HumanaChoice H5216-043 (PPO) preventive services are covered with no copay and no coinsurance, including annual physical exams, kidney disease education, memory fitness, glaucoma screenings, and diabetes self-management training. However, several additional preventive services are not covered, such as health education, weight management programs, nutritional/dietary benefits, and in-home safety assessments.
Hearing Services See details
HumanaChoice H5216-043 (PPO) covers hearing services with no copay and no coinsurance for annual routine exams, fitting evaluations, and OTC hearing aids. Medicare-covered exams require a $40 copay and no coinsurance, while prescription hearing aids are partially covered with no coinsurance and copays ranging from $699 to $999 for up to two devices per year. However, inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered by HumanaChoice H5216-043 (PPO) with no deductible, no coinsurance, and no copay for one routine eye exam and one pair of eyeglasses or contact lenses per year. Annual coverage limits of $75 for exams and $150 for eyewear apply, while other eye exam services, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-043 (PPO) offers partially covered dental services with a combined annual maximum benefit of $1,000 for in-network and out-of-network care. Medicare-covered dental services require a $40 copay and no coinsurance, while other covered dental services have no copay and no coinsurance, though fluoride, removable prosthodontics, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-043 (PPO) covers Home Infusion bundled Services with no copay and no coinsurance, though prior authorization is required. Medicare Part B drugs, including chemotherapy, are covered with no copay and coinsurance ranging from no coinsurance to 20%, while Part B insulin has a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-043 (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required to receive these services.
Medical Equipment See details
HumanaChoice H5216-043 (PPO) covers durable medical equipment (DME) with a 15% coinsurance and no copay, and 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 or inserts require a $10 copay and coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under HumanaChoice H5216-043 (PPO), featuring no copay for lab services or outpatient X-rays and no coinsurance for diagnostic services. Diagnostic procedures and tests have a copay ranging from $0 to $175, while therapeutic radiological services require a minimum $45 copay and 20% coinsurance. Prior authorization is required for these services.
Home Health Services See details
HumanaChoice H5216-043 (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-043 (PPO) covers Cardiac Rehabilitation Services with no coinsurance and prior authorization required, though only some services are covered in practice because standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-043 (PPO) covers skilled nursing facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, while additional days beyond the standard 100-day limit are not covered.
Other Services See details
Other services are partially covered by HumanaChoice H5216-043 (PPO), as Other 1, Other 2, and Other 3 services are not covered. Covered benefits include acupuncture (up to 20 treatments yearly) for a $40 copay and no coinsurance, as well as over-the-counter items and chronic illness meals, which both require no copay and no coinsurance.
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