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HumanaChoice H5216-092 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-092 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-092 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-092 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in MN, ND and SD. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-092 (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 H5216-092 (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 H5216-092 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $47.00. 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 $615.00 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 $13900.00 (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 $13900.00 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 H5216-092 (PPO) Medicare prescription drug plan features an annual drug deductible of $615. Under this plan, Tier 1 preferred generic drugs have no copay for 1-month and 3-month supplies filled at standard pharmacies or through preferred mail order. Tier 2 generic drugs offer low copays starting at $5 for a 1-month supply at standard pharmacies, and you will pay no copay for a 3-month supply when using preferred mail order. For Tier 3 preferred brand drugs, the plan copay is $47 for a 1-month supply at standard pharmacies and through mail order. Tier 4 non-preferred drugs require a 31% coinsurance for both 1-month and 3-month supplies, while Tier 5 specialty drugs require a 25% coinsurance for a 1-month supply. These cost-sharing details help you understand your potential out-of-pocket expenses when choosing this PPO plan.
Additional Benefits
The HumanaChoice H5216-092 (PPO) plan offers comprehensive medical coverage with no copay for primary care physician visits, while specialist visits require a $50 copay. Inpatient hospital stays require a daily copay of $362 for the first seven days of acute care, with no copay for subsequent days. Emergency room visits have a $115 copay, which is waived if you are admitted, and urgent care services require a $40 copay. Routine vision, dental, and hearing exams are covered with no copay, though prescription hearing aids and Medicare-covered dental services carry additional copays. Home health services are fully covered with no copay, while skilled nursing facility care has no copay for the first 20 days. Standard diagnostic services, lab work, and outpatient X-rays are also highly accessible, often requiring no copay.
Inpatient Hospital See details
HumanaChoice H5216-092 (PPO) covers inpatient hospital services with no coinsurance, requiring a $362 daily copay for days 1-7 of acute stays and a $276 daily copay for days 1-7 of psychiatric stays, with no copay for subsequent days. Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-092 (PPO) covers outpatient hospital services with no copay to a $50 copay and 20% coinsurance, observation services with a $362 copay per stay, and ambulatory surgical center services with no copay and 20% coinsurance. Outpatient substance abuse sessions require a $30 copay and 20% coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
HumanaChoice H5216-092 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-092 (PPO) covers ambulance services with a $335 copay for ground transport and a 20% coinsurance for air transport, both of which require prior authorization. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
HumanaChoice H5216-092 (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services are covered with a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $115 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-092 (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $50 copay and no coinsurance. Physical, occupational, and speech therapy services are covered with no copay and 20% coinsurance, whereas mental health and psychiatric services require a $30 copay with no coinsurance, and chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are covered by HumanaChoice H5216-092 (PPO) with no copay and no coinsurance for annual physical exams, kidney disease education, memory fitness, and screenings. This benefit is only partially covered, as it excludes health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, additional smoking cessation, disease management, telemonitoring, remote access, home safety modifications, and counseling.
Hearing Services See details
Hearing services are covered by HumanaChoice H5216-092 (PPO), featuring a $50 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for annual routine exams and fitting evaluations. Prescription hearing aids are partially covered with a $699 to $999 copay and no coinsurance for up to two aids per year, though OTC, inner-ear, outer-ear, and over-the-ear hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-092 (PPO) features partially covered vision services with no deductibles, no copays, and no coinsurance for routine eye exams, contact lenses, and eyeglasses (lenses and frames). Other eye exam services, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-092 (PPO) dental services are partially covered, offering Medicare-covered dental services for a $50 copay and no coinsurance, and other covered dental services with no copay and no coinsurance. Fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered under this plan.
Home Infusion bundled Services See details
HumanaChoice H5216-092 (PPO) covers home infusion bundled services with no copay, subject to prior authorization and step therapy. Covered Medicare Part B chemotherapy and other drugs have coinsurance ranging from no coinsurance to 20%, while Part B insulin requires a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis services are covered under the HumanaChoice H5216-092 (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
HumanaChoice H5216-092 (PPO) covers durable medical equipment and prosthetics with a 20% coinsurance and no copay, subject to prior authorization. Diabetic supplies from specified manufacturers are covered with no copay and a 10% to 20% coinsurance, while diabetic therapeutic shoes and inserts require a $10 copay.
Diagnostic and Radiological Services See details
HumanaChoice H5216-092 (PPO) covers diagnostic and radiological services with prior authorization, requiring a 20% coinsurance for these benefits. Members pay no copay for lab services, outpatient X-rays, and diagnostic radiological services, while diagnostic procedures and tests carry a copay ranging from no copay up to $50.
Home Health Services See details
HumanaChoice H5216-092 (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the HumanaChoice H5216-092 (PPO) plan, meaning there is no coverage for intensive cardiac, pulmonary, or supervised exercise therapy rehabilitation services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is partially covered by HumanaChoice H5216-092 (PPO) with no coinsurance, as additional days beyond the Medicare-covered limit are not covered. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and prior authorization is required.
Other Services See details
HumanaChoice H5216-092 (PPO) partially covers other services, offering acupuncture for up to 20 treatments per year with a $50 copay and no coinsurance, and a chronic illness meal benefit with no copay and no coinsurance. Prior authorization is required for these covered benefits, while over-the-counter items are not covered.
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