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HumanaChoice H5216-089 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-089 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-089 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-089 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in MT. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-089 (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 H5216-089 (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 H5216-089 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $27.00. 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 $300.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $350.00 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 $8950.00 (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 $8950.00 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 H5216-089 (PPO) plan has a $350 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, you will pay a $12 copay for preferred generic drugs at a standard or preferred mail pharmacy. For preferred brand drugs, you will pay 50% coinsurance, and for non-preferred drugs, you will pay 28% coinsurance.
Additional Benefits
The HumanaChoice H5216-089 (PPO) plan offers coverage for a variety of services with varying costs. You'll have a $400 copay for inpatient hospital stays (days 1-5), and no copay for outpatient services such as ASC services, outpatient blood services, and preventive services. Emergency services have a $125 copay, and primary care has a $5 copay. The plan also covers home health services with no copay, and skilled nursing facility services with a $0 copay for days 1-20 and 66-100, and a $214 copay for days 21-65. Other benefits include coverage for ambulance services, hearing exams, vision exams, and dental services.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered with a $400 copay for days 1-5 and no copay for days 6-90. Additional days for Inpatient Hospital-Acute have no copay, while Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional days for Inpatient Hospital Psychiatric and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $400, Observation Services with a $400 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a copay between $40 and $90 for individual and group sessions, and Outpatient Blood Services with no copay. Prior authorization is required for all services.
Partial Hospitalization See details
Partial hospitalization is covered under this plan, but requires prior authorization. The copay for partial hospitalization is $105.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-089 (PPO) plan, with prior authorization required for all ambulance services. Medicare-covered ground ambulance services have a $315 copay, and air ambulance services have a $1250 copay, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by HumanaChoice H5216-089 (PPO), with a $125 copay, and no coinsurance. Urgently Needed Services have a $55 copay and no coinsurance. Worldwide Emergency Services, including Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, are also covered, each with a $125 copay and no coinsurance.
Primary Care See details
The HumanaChoice H5216-089 (PPO) plan covers primary care physician services with a $5 copay. Chiropractic services, occupational therapy, physician specialist services, mental health specialty services, psychiatric services, physical therapy, speech-language pathology services, and opioid treatment program services are covered with various copays. Additional telehealth benefits are covered with a copay between $0 and $55. Podiatry services are not covered.
Preventive Services See details
Preventive Services include Medicare-covered zero dollar services, annual physical exams with no copay, and additional preventive services. Additional preventive services include a Fitness Benefit and Kidney Disease Education Services, both with no copay. Other preventive services cover Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay.
Hearing Services See details
HumanaChoice H5216-089 (PPO) covers hearing exams with a $40 copay, but routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids are not covered. OTC hearing aids are also not covered.
Vision Services See details
The HumanaChoice H5216-089 (PPO) plan covers eye exams with a copay between $0 and $40, and eyewear with no copay. Routine eye exams, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-089 (PPO) plan covers Medicare Dental Services with a $40 copay, while oral exams, dental x-rays, other diagnostic dental services, other preventive dental services, and prophylaxis (cleaning) have no copay. However, fluoride treatment, restorative services, endodontics, periodontics, prosthodontics (both removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered. Adjunctive general services are covered with no copay.
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 by the HumanaChoice H5216-089 (PPO) plan, and require prior authorization. The coinsurance for these services is 20%.
Medical Equipment See details
The HumanaChoice H5216-089 (PPO) plan covers durable medical equipment with an 18% coinsurance and requires prior authorization. Prosthetics and medical supplies are covered with an 18% coinsurance. Diabetic equipment is covered, with some services requiring a copay and coinsurance, including diabetic supplies with a 10-20% coinsurance and no copay, and diabetic therapeutic shoes/inserts with no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests with a copay between $0 and $90, and lab services with no copay. Radiological services are also covered, with a copay for diagnostic services up to $400 and a 20% coinsurance for therapeutic services. Outpatient X-ray services have a $5 copay.
Home Health Services See details
Home Health Services are covered by HumanaChoice H5216-089 (PPO) with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-089 (PPO) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the HumanaChoice H5216-089 (PPO) plan, with a $0 copay for days 1-20 and 66-100, and a $214 copay for days 21-65. Additional days beyond Medicare coverage and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The HumanaChoice H5216-089 (PPO) plan covers acupuncture with a $40 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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