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HumanaChoice H5216-088 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-088 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-088 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-088 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in North and South Dakota. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-088 (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 H5216-088 (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 H5216-088 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $101.00. 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 $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 $9550.00 (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 $9550.00 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 H5216-088 (PPO) plan has a $590.00 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and the pharmacy. For example, in the initial coverage phase, you will pay $15.00 or $20.00 for preferred generic drugs depending on the pharmacy. For preferred brand drugs, you will pay 50% coinsurance. After your total drug costs reach $2000.00, you will enter the catastrophic coverage phase where you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The HumanaChoice H5216-088 (PPO) plan offers a range of benefits, including inpatient hospital stays with a $300 copay for the first five days and no copay thereafter. Outpatient services have varying copays, and emergency services have a $125 copay. Primary care visits are covered with no copay, and many preventive services also have no copay. This plan includes coverage for hearing exams, vision services, and dental services, each with specific copays or no copays depending on the service. Additionally, the plan provides coverage for ambulance services, home infusion, medical equipment, and other services with varying copays, coinsurance, and prior authorization requirements.
Inpatient Hospital See details
Inpatient Hospital benefits for HumanaChoice H5216-088 (PPO) include a $300 copay for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Additional days for Inpatient Hospital-Acute have no copay, while Non-Medicare-covered stays 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, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $300, observation services have a $300 copay, ambulatory surgical center services have no copay, individual and group outpatient substance abuse sessions have a copay between $20 and $85, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-088 (PPO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
The HumanaChoice H5216-088 (PPO) plan covers ambulance services, with a $315 copay for ground ambulance services and 20% coinsurance for air ambulance services. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, are covered under the HumanaChoice H5216-088 (PPO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a $55 copay. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services with no copay, Chiropractic Services with a $20 copay, Occupational Therapy Services with a $40 copay, Physician Specialist Services with a $20 copay, Mental Health Specialty Services with a $20 copay for individual and group sessions, and Physical Therapy and Speech-Language Pathology Services with a $40 copay. Additional Telehealth Benefits have a copay between $0 and $55, and Opioid Treatment Program Services have a copay between $20 and $85. Podiatry Services are not covered.
Preventive Services See details
HumanaChoice H5216-088 (PPO) covers preventive services, including an annual physical exam with no copay, and other preventive services such as Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit with no copay. This plan does not cover Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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, or Counseling Services.
Hearing Services See details
The HumanaChoice H5216-088 (PPO) plan covers hearing exams with a $20 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 inner ear, outer ear, and over the ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-088 (PPO) offers vision services including eye exams with a copay between $0 and $20, and eyewear. Contact lenses and eyeglasses (lenses and frames) have no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-088 (PPO) plan covers Medicare Dental Services with a $20 copay, and offers other dental services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and other preventive dental services with no copay. However, fluoride treatment, restorative services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered, with a coinsurance of 20%. Prior authorization is required for this benefit.
Medical Equipment See details
Medical Equipment benefits are covered by the HumanaChoice H5216-088 (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance and requires authorization, while Prosthetics/Medical Supplies have a 20% coinsurance with no copay. Diabetic Supplies have between a 10-20% coinsurance and no copay, and 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 between $0 and $95, and lab services with no copay. Therapeutic Radiological Services have a coinsurance of at most 20%, and Diagnostic Radiological Services have a copay of at most $350.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-088 (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but none of the sub-services are covered, including Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, and Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, the copay is $10 per day, and for days 21-100, the copay is $203 per day; 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 $20 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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