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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 $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $1.00. 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 $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 $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) plan has a $250 deductible for prescription drugs. After you meet your deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. For example, in the initial coverage phase, you'll pay a $9 copay for preferred generic drugs at a standard or preferred mail pharmacy. You will pay 43% coinsurance for preferred brand drugs. After your total drug costs reach $2000, you move to the catastrophic coverage phase where you pay nothing for your Part D covered drugs.
Additional Benefits
The HumanaChoice H5216-043 (PPO) plan offers comprehensive coverage, including inpatient and outpatient hospital services with varying copays, and no copays for many services like primary care, preventive services, and home health. This plan also includes additional benefits such as hearing, vision, and dental services, along with coverage for ambulance, emergency, and skilled nursing facility services.
Inpatient Hospital See details
Inpatient Hospital services, including Acute and Psychiatric, are covered, with a copay of $340 for days 1-6 and no copay for days 7-90 for Acute, and a copay of $335 for days 1-6 and no copay for days 7-90 for Psychiatric. Additional days for Inpatient Hospital-Acute are covered with 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 include coverage for all outpatient hospital services with a copay between $0 and $435, observation services with a $340 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a copay between $30 and $100 for individual or group sessions. Outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-043 (PPO) plan, with a $35 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
The HumanaChoice H5216-043 (PPO) plan covers ambulance services, including ground ambulance services with a $315 copay, and air ambulance services with 20% coinsurance; transportation services to health-related locations are not covered. Prior authorization is required for all ambulance services.
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 Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $110 copay.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services with no copay, Chiropractic Services with a $15 copay, Occupational Therapy Services with a $25 copay, Physician Specialist Services with a $35 copay, and Mental Health Specialty Services with a $30 copay. Additionally, Physical Therapy and Speech-Language Pathology Services have a $25 copay, Additional Telehealth Benefits have a copay between $0 and $45, and Opioid Treatment Program Services have a copay between $30 and $100. Routine Chiropractic Care is not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, and annual physical exams with no copay. Additional preventive services, including fitness benefit, kidney disease education, and other preventive services like glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit, are covered 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 benefit, 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
Hearing Services include hearing exams with a $35 copay, routine hearing exams with no copay, fitting/evaluation for hearing aids with no copay, and OTC hearing aids with a maximum benefit of $50 every three months. Prescription hearing aids are partially covered, with a copay between $699 and $999 for all types, but not covered for inner, outer, or over-the-ear aids.
Vision Services See details
Vision services include eye exams with a copay between $0 and $35, as well as eyewear with no copay. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are covered, with a maximum plan benefit of $2000 every year for both in-network and out-of-network services. Medicare Dental Services have a $35 copay. Other covered services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventative dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (fixed), and oral and maxillofacial surgery with no copay. Fluoride treatment, prosthodontics (removable), maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, while the other drug benefits have a coinsurance between 0% and 20%.
Dialysis Services See details
HumanaChoice H5216-043 (PPO) covers dialysis services, but prior authorization is required. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, while Prosthetic Devices and Medical Supplies also have a 20% coinsurance; Diabetic Supplies have a 10-20% coinsurance and no copay, and 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 ranging from $0 to $175, and lab services with no copay. Radiological services include coverage for diagnostic radiological services with a maximum copay of $325, therapeutic radiological services with a maximum copay of $45 and a coinsurance of up to 20%, and outpatient X-Ray services with no 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. The plan does not cover any sub-services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD 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. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
Other Services include acupuncture, over-the-counter (OTC) items, and a meal benefit. Acupuncture has a $35 copay and is limited to 20 treatments per year. This plan also offers an OTC benefit with a maximum of $50 every three months, and a meal benefit with no copay.
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