A non-government entity
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 $15.00. 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 has a $750.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
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 $11000.00 (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 $11000.00 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:
Sign up for HumanaChoice H5216-043 (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The HumanaChoice H5216-043 (PPO) Medicare prescription drug plan features an annual drug deductible of $420. For Tier 1 preferred generic drugs, there is no copay for 1-month and 3-month supplies at standard pharmacies or through preferred mail order. Tier 2 generic drugs are also highly affordable, starting at a $5 copay for a 1-month supply and offering no copay for a 3-month supply through preferred mail order. For Tier 3 preferred brand drugs, you will pay a $47 copay for a 1-month supply at standard pharmacies and mail-order services. Higher-tier prescriptions are subject to coinsurance rather than flat copays, with Tier 4 non-preferred drugs requiring a 48% coinsurance and Tier 5 specialty drugs requiring a 28% coinsurance.
Additional Benefits
The HumanaChoice H5216-043 (PPO) plan offers comprehensive medical coverage with no copay for primary care visits, preventive services, and home health care. For specialist visits, members pay a $40 copay, while inpatient hospital stays require a $390 daily copay for the first six days and no copay for additional days. Emergency room visits carry a $115 copay, which is waived if you are admitted to the hospital within 24 hours. This plan also features essential dental, vision, and hearing benefits, including no copay for routine eye and hearing exams, alongside a $2,000 annual limit for covered dental services. Durable medical equipment and dialysis services require a 20% coinsurance, while Medicare Part B drugs range from 0% to 20% coinsurance. Skilled nursing facility stays are also covered with no copay for the first 20 days.
Inpatient Hospital See details
HumanaChoice H5216-043 (PPO) covers inpatient acute hospital stays with no coinsurance and a $390 copayment per day for days 1 through 6, with no copayment for days 7 and beyond. Inpatient psychiatric care is also covered with no coinsurance and a $339 copayment per day for days 1 through 6, and no copayment for days 7 through 90. Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by HumanaChoice H5216-043 (PPO) with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Medicare-covered outpatient hospital services have a $0 to $350 copay, observation services require a $390 copay per stay, and outpatient substance abuse sessions carry a $30 to $35 copay.
Partial Hospitalization See details
Partial hospitalization is covered under the HumanaChoice H5216-043 (PPO) plan with a $35 copay and no coinsurance. Prior authorization is required for 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. Prior authorization is required for ambulance services, and transportation services to health-related locations are not covered.
Emergency Services See details
HumanaChoice H5216-043 (PPO) covers emergency services 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, and specialist visits with a $40 copay and no coinsurance. Physical and occupational therapy require a $25 copay and no coinsurance, while chiropractic services are partially covered (excluding routine and other chiropractic care) for a $15 copay and no coinsurance, and podiatry is 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, glaucoma screenings, diabetes self-management training, digital rectal exams, EKGs, and a memory fitness benefit. However, this benefit is only partially covered, as the plan does not cover health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, additional smoking cessation, disease management, telemonitoring, remote access technologies, home safety modifications, and counseling services.
Hearing Services See details
Hearing services are partially covered by HumanaChoice H5216-043 (PPO) with no deductible and no coinsurance, requiring a $40 copay for Medicare-covered exams and no copay for annual routine exams and fittings. Up to two prescription hearing aids are covered per year with copays ranging from $699 to $999, though OTC, inner ear, outer ear, and over-the-ear models are not covered.
Vision Services See details
HumanaChoice H5216-043 (PPO) offers partially covered vision services with no deductible, no coinsurance, and no copay for routine exams and covered eyewear, though other exams may require a copay up to $40. This plan covers one routine exam (up to $75) and one pair of select eyeglasses or contact lenses (up to $150) annually, but other eye exams, separate lenses, separate frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-043 (PPO) provides partially covered dental services up to a $2,000 annual limit, requiring a $40 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other covered dental services. Fluoride treatments, 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, though prior authorization and step therapy are required. Under this plan, Medicare Part B chemotherapy, radiation, and other drugs have no copay and 0% to 20% coinsurance, while insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
HumanaChoice H5216-043 (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
HumanaChoice H5216-043 (PPO) covers durable medical equipment (DME), prosthetics, 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. Prior authorization is required for these covered medical equipment benefits, and diabetic supplies must be from specified manufacturers.
Diagnostic and Radiological Services See details
HumanaChoice H5216-043 (PPO) covers diagnostic and radiological services, offering lab services and outpatient X-rays with no copay. Diagnostic procedures and tests require no coinsurance and a copay between $0 and $175, while therapeutic radiological services require a minimum $45 copay and a minimum 20% coinsurance.
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
Cardiac Rehabilitation Services are partially covered by HumanaChoice H5216-043 (PPO) with no coinsurance, though prior authorization is required. While some additional cardiac rehabilitation services are covered, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-043 (PPO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a three-day prior hospital stay is not required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
HumanaChoice H5216-043 (PPO) partially covers other services, featuring acupuncture with a $40 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, and prior authorization is required for the covered benefits.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved