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HumanaChoice H5216-053 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-053 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-053 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-053 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Central Indiana Area. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-053 (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 H5216-053 (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 H5216-053 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $49.00. 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 does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $200.00 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 $10100.00 (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 $10100.00 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 H5216-053 (PPO) plan has a $200 deductible for prescription drugs. After the deductible, you'll 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 $17 copay for preferred generic drugs at a standard or preferred mail pharmacy. For preferred brand drugs, you'll pay 50% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-053 (PPO) plan offers a wide range of benefits with varying costs. You can expect a $430 copay for inpatient hospital stays for the first five days, and coverage for outpatient services with copays ranging from $0 to $430. The plan includes coverage for primary care visits with a $10 copay, specialist visits with a $60 copay, and other services like hearing exams, vision services, and dental services with copays ranging from $0 to $60. Other benefits include ambulance services with a $315 copay, and home health services with no copay.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care. For acute care, you will pay a $430 copay for days 1-5, and no copay for days 6-90; additional days for acute care have no copay. For psychiatric care, you will pay a $430 copay for days 1-5, and no copay for days 6-90. Non-Medicare-covered stays and upgrades for acute and psychiatric care are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $430, Observation Services with a $430 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with copays between $60 and $100 for individual and group sessions, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial hospitalization is covered by the HumanaChoice H5216-053 (PPO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground and Air Ambulance Services have a $315 copay, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency services are covered, with a $125 copay for emergency services and worldwide emergency coverage, urgent coverage, and transportation. Urgently needed services have a $55 copay, and there is no coinsurance for any of these services.
Primary Care See details
The HumanaChoice H5216-053 (PPO) plan covers primary care physician services with a $10 copay, chiropractic services with a $15 copay, and occupational therapy services with a $45 copay. The plan also covers physician specialist services with a $60 copay, mental health specialty services with a $60 copay, physical therapy and speech-language pathology services with a $45 copay, and additional telehealth benefits with a copay ranging from $0 to $60. Psychiatric services and Opioid Treatment Program Services are covered with a copay between $60 and $100. Podiatry services are not covered.
Preventive Services See details
Preventive services include Medicare-covered services and an annual physical exam with no copay, as well as additional services including fitness benefits, kidney disease education, and other preventive services, all of which have no copay. However, 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, 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 counseling services are not covered.
Hearing Services See details
Hearing services include hearing exams with a $60 copay. Routine hearing exams are covered with no copay for one exam per year, and fitting/evaluation for hearing aids are covered with no copay. Prescription hearing aids are covered, with a copay between $99 and $699 for hearing aids of all types, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-053 (PPO) covers vision services, including eye exams with a copay between $0 and $60, and eyewear with no copay. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-053 (PPO) plan covers dental services, including Medicare Dental Services with a $60 copay, oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, and prosthodontics, fixed 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 are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-053 (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 20% coinsurance, Prosthetics/Medical Supplies with no copay and 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have no copay with 10-20% coinsurance, 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, with a copay for Medicare-covered diagnostic procedures/tests, and lab services with no copay. Diagnostic Radiological Services have a copay of at most $720, while Therapeutic Radiological Services have a copay of at most $45 and a coinsurance of at most 20%. Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-053 (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but not in practice because the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by HumanaChoice H5216-053 (PPO) with prior authorization. For days 1-20, there is a $10 copay, and for days 21-100, the copay is $214; there is no coinsurance. Additional days beyond Medicare-covered SNF and non-Medicare-covered SNF stays are not covered.
Other Services See details
The HumanaChoice H5216-053 (PPO) plan covers acupuncture with a $60 copay and a limit of 20 treatments per year, and also covers 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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