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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 $26.00. 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 $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 $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:
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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. For example, you will pay a $9 copay for preferred generic drugs at a standard or mail-order pharmacy. For preferred brand drugs, you pay 43% coinsurance.
Additional Benefits
The HumanaChoice H5216-043 (PPO) plan offers a range of benefits with varying costs. This plan includes coverage for hospital stays, outpatient services, and mental health services, with copays ranging from $5 to $390 depending on the service. Preventive services, home health, and some vision and dental services are available with no copay, while other services like hearing aids, vision exams, and ambulance services have copays. The plan also offers coverage for home infusion, dialysis, and medical equipment with coinsurance requirements.
Inpatient Hospital See details
Inpatient Hospital benefits are covered under HumanaChoice H5216-043 (PPO), with a copay of $390 for days 1-6, and no copay for days 7-90 for Inpatient Hospital-Acute, and a copay of $339 for days 1-6, and no copay for days 7-90 for Inpatient Hospital Psychiatric. Additional days for Inpatient Hospital-Acute have no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered by the HumanaChoice H5216-043 (PPO) plan, including outpatient hospital services with a copay between $35 and $350, observation services with a $390 copay, ambulatory surgical center (ASC) services with a $255 copay, outpatient substance abuse services with a copay between $30 and $100 for individual and group sessions, and outpatient blood services with no copay.
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, and 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 H5216-043 (PPO) plan. Emergency Services have a $110 copay, and no coinsurance. Urgently Needed Services have a $45 copay and no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation all have a $110 copay, and no coinsurance.
Primary Care See details
The HumanaChoice H5216-043 (PPO) plan covers primary care physician services with a $5 copay, chiropractic services with a $15 copay, occupational therapy with a $25 copay, physician specialist services with a $45 copay, and physical therapy and speech-language pathology services with a $25 copay. The plan also covers mental health specialty services, psychiatric services, and opioid treatment program services with a copay, and additional telehealth benefits with a copay between $0 and $45. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, an annual physical exam with no copay, and additional preventive services with copays that are not specified. Additionally, this plan covers kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit, all with no copay. Health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission 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.
Hearing Services See details
HumanaChoice H5216-043 (PPO) covers hearing exams with a $45 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $699 and $999, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, as are OTC hearing aids.
Vision Services See details
The HumanaChoice H5216-043 (PPO) plan covers vision services, including eye exams with a copay between $0 and $45, and eyewear with a copay of $0. Contact lenses and eyeglasses (lenses and frames) are covered with no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-043 (PPO) covers Medicare Dental Services with a $45 copay, and other 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, all with no copay. Fluoride treatment, maxillofacial prosthetics, implant services, prosthodontics, fixed, and orthodontics are not covered. The plan has a maximum benefit of $2000 per year. Restorative services and prosthodontics, removable have a coinsurance of 30% - 40% and 30% respectively.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-043 (PPO) plan. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. DME has a 20% coinsurance and requires authorization, while Diabetic Supplies have no copay and a 20% coinsurance. Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
For HumanaChoice H5216-043 (PPO), diagnostic and radiological services are covered. Diagnostic Procedures/Tests have a copay between $0 and $175, Lab Services have no copay, Diagnostic Radiological Services have a copay between $35 and $325, Therapeutic Radiological Services have a copay of at least $45 and at least 20% coinsurance, and Outpatient X-Ray Services have a $5 copay.
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. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and 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, and a $214 copay for days 21-100, while additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for acupuncture with a $45 copay and a limit of 20 treatments per year, and a meal benefit with no copay. Over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, 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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