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HumanaChoice H5216-048 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-048 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-048 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-048 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in ID, MT, OR, UT, WA, WY. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-048 (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 H5216-048 (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 H5216-048 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $118.00. 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 $100.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $590.00 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 $10000.00 (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 $10000.00 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 H5216-048 (PPO) plan has an enhanced alternative drug benefit. The plan has a $590 deductible for prescription drugs. During the initial coverage phase, after the deductible is met, you will pay 25% coinsurance for all tiers of drugs at standard, preferred, and mail order pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-048 (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, with no copay for most days, while outpatient services often have copays or coinsurance. Emergency, primary care, and preventive services often have no copay, while services like hearing aids, cardiac rehabilitation, and some dental services are either limited or not covered.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric care, are covered, but require prior authorization. For days 1-4, there is a $325 copay, and for days 5-90, there is no copay. Additional days for inpatient hospital-acute have no copay.
Outpatient Services See details
Outpatient Services includes coverage for Outpatient Hospital Services with a $0-$30 copay and 20% coinsurance, Observation Services with a $325 copay, Ambulatory Surgical Center (ASC) Services with a $0 copay and 20% coinsurance, Outpatient Substance Abuse Services with a $30-$35 copay for both individual and group sessions, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will pay an $80 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the HumanaChoice H5216-048 (PPO) plan. Ground ambulance services have a $315 copay, while air ambulance services have a $1250 copay, and there is no coinsurance for either. 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 by HumanaChoice H5216-048 (PPO). Emergency Services has a $125 copay, and Urgently Needed Services has a $55 copay, while all services have no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation all have a $125 copay.
Primary Care See details
The HumanaChoice H5216-048 (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $30 copay, physician specialist services with a $35 copay, and mental health specialty services with no copay for individual and group sessions. The plan also covers physical therapy and speech-language pathology services with a $30 copay, additional telehealth benefits with a copay between $0-$55, and opioid treatment program services with a copay between $30-$35. However, routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include Medicare-covered services and annual physical exams, with no copay. The plan also covers services such as Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit with no copay.
Hearing Services See details
Hearing services are partially covered by the HumanaChoice H5216-048 (PPO) plan. Hearing exams have a $35 copay, while routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids (all types), prescription hearing aids - inner ear, prescription hearing aids - outer ear, prescription hearing aids - over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are covered by HumanaChoice H5216-048 (PPO), including eye exams with a copay between $0 and $35, and eyewear with no copay. Eyewear coverage excludes contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
The HumanaChoice H5216-048 (PPO) plan offers dental services with a $1,000 annual maximum. Medicare dental services have a $35 copay, oral exams, dental x-rays, other diagnostic services, prophylaxis (cleaning), and other preventive services have no copay, and Prosthodontics, fixed has a 30% coinsurance, while fluoride treatment, Prosthodontics removable, Maxillofacial Prosthetics, Implant Services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-048 (PPO) plan, with a coinsurance of 20%. Prior authorization is required for this benefit.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and prior authorization required, Prosthetic Devices with a 20% coinsurance, Medical Supplies with a 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have a 10-20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, with a copay for Medicare-covered diagnostic procedures, tests, and lab services, and a maximum copay of $55 for diagnostic procedures and tests. Radiological Services are also covered, with a copay for Medicare-covered diagnostic and therapeutic radiological services, and X-rays have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-048 (PPO) plan with no copay and no coinsurance. However, Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the HumanaChoice H5216-048 (PPO) plan, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required for covered services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-048 (PPO) plan, requiring prior authorization. There is no copay for days 1-20 and 71-100, but there is a $214 copay for days 21-70; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The HumanaChoice H5216-048 (PPO) plan covers acupuncture with a $35 copay, and a meal benefit with no copay; however, 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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