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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 $0.00. 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 $11900.00 (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 $11900.00 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 prescription 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 low as a $5 copay for a 1-month supply at standard pharmacies, 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 most pharmacy options, with a slightly reduced $131 copay for a 3-month supply via preferred mail order. Higher-tier medications are subject to coinsurance rather than flat copays, including a 48% coinsurance for Tier 4 non-preferred drugs and a 28% coinsurance for Tier 5 specialty drugs.
Additional Benefits
The HumanaChoice H5216-043 (PPO) plan offers robust medical coverage with affordable cost-sharing, featuring no copay and no coinsurance for primary care visits, routine preventive services, and home health care. Specialist visits require a $30 copay with no coinsurance, while inpatient hospital stays carry a daily copay of $340 for the first six days of acute stays. Outpatient services also feature no coinsurance, with copays ranging from no copay for ambulatory surgical center visits up to $300 for outpatient hospital visits. This plan also includes valuable dental, vision, and hearing benefits, highlighted by no copay and no coinsurance for most preventive dental care up to a $2,000 annual limit. Routine vision and hearing exams are covered with no copay, alongside allowances of up to $150 for eyewear and structured copays for prescription hearing aids. For durable medical equipment and dialysis services, members pay no copay but are responsible for coinsurance ranging from 10% to 20%.
Inpatient Hospital See details
HumanaChoice H5216-043 (PPO) covers inpatient hospital services with no coinsurance, requiring prior authorization and a daily copay of $340 for days 1 to 6 of acute stays and $335 for days 1 to 6 of psychiatric stays, followed by no copay for subsequent days. This benefit is partially covered as unlimited additional acute days are included with no copay, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
HumanaChoice H5216-043 (PPO) covers outpatient services with no coinsurance, including ambulatory surgical center and blood services with no copay. Outpatient hospital visits require a copay of $0 to $300, observation services carry a $340 copay per stay, and outpatient substance abuse sessions have a copay of $30 to $35.
Partial Hospitalization See details
HumanaChoice H5216-043 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-043 (PPO) covers ambulance services with prior authorization, requiring a $335 copay and no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport. Transportation services are not covered, including trips to plan-approved or any other health-related locations.
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) provides primary care physician services with no copay and no coinsurance, and specialist visits with a $30 copay and no coinsurance. Physical, occupational, and speech therapy services require a $25 copay and no coinsurance, while podiatry and routine chiropractic care are not covered.
Preventive Services See details
HumanaChoice H5216-043 (PPO) covers preventive services, including annual physical exams, kidney disease education, and glaucoma screenings, with no copay and no coinsurance. Additional preventive benefits are only partially covered; the plan includes a memory fitness benefit with no copay but does not cover health education, weight management, nutritional benefits, or in-home support services.
Hearing Services See details
HumanaChoice H5216-043 (PPO) covers hearing services with no coinsurance, featuring no copay for routine exams, fitting evaluations, and OTC hearing aids, and a $30 copay for Medicare-covered exams. Prescription hearing aids are partially covered with copays from $699 to $999 for up to two aids per year, though inner ear, outer ear, and over-the-ear models are not covered.
Vision Services See details
Vision services are partially covered by HumanaChoice H5216-043 (PPO) with no coinsurance, featuring no copay to a $30 copay for eye exams and no copay for covered eyewear, subject to prior authorization. One routine eye exam is covered annually up to $75, and contact lenses or eyeglasses are covered up to a combined $150 yearly limit, though other eye exams, separate eyeglass lenses, frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by HumanaChoice H5216-043 (PPO), featuring no copay and no coinsurance for most preventive and comprehensive dental care up to a $2,000 annual maximum, while Medicare-covered dental requires a $30 copay and no coinsurance. Excluded services that are not covered under this benefit include fluoride treatments, removable prosthodontics, maxillofacial prosthetics, implants, and orthodontics.
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. Covered Medicare Part B chemotherapy and other drugs have no copay and between no coinsurance and 20% coinsurance, while insulin drugs have a $35 copay and between no coinsurance and 20% coinsurance.
Dialysis Services See details
HumanaChoice H5216-043 (PPO) covers dialysis services with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
HumanaChoice H5216-043 (PPO) covers medical equipment, including durable medical equipment (DME) with an 18% coinsurance and no copay, and 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 or inserts require a $10 copay and applicable coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under HumanaChoice H5216-043 (PPO) with prior authorization, offering diagnostic services with no coinsurance, no copay for lab tests, and a $0 to $175 copay for other diagnostic procedures. Radiological services feature no copay for outpatient X-rays, copays starting at $0 for diagnostic radiology, and a minimum $45 copay with 20% coinsurance for therapeutic radiology.
Home Health Services See details
HumanaChoice H5216-043 (PPO) covers Home Health Services with no copay and no coinsurance. Prior authorization is required to receive these covered services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered under HumanaChoice H5216-043 (PPO) with no coinsurance and require prior authorization, meaning some services are covered, but standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered in practice.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-043 (PPO) covers Skilled Nursing Facility (SNF) care with no coinsurance, featuring no copay for days 1 through 20 and a $218 copay per day for days 21 through 100. Prior authorization is required, a prior three-day inpatient hospital stay is not required, and additional days beyond the standard 100 days are not covered.
Other Services See details
Other services are covered by HumanaChoice H5216-043 (PPO), featuring acupuncture with a $30 copay and no coinsurance for up to 20 treatments per year. Additionally, over-the-counter items and chronic illness meal benefits are available with no copay and no coinsurance, though prior authorization is required for acupuncture and meal services.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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