A non-government entity
HumanaChoice H5216-097 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-097 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-097 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-097 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in TN, AR, MS. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-097 (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 H5216-097 (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 H5216-097 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $55.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $6.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $1000.00 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 $13300.00 (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 $13300.00 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:
Sign up for HumanaChoice H5216-097 (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The HumanaChoice H5216-097 (PPO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590.00. In the initial coverage phase, after you pay your deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, you'll pay a $10.00 copay for preferred generic drugs at a standard pharmacy. Once your total drug costs reach $2,000.00, you enter the next coverage phase.
Additional Benefits
The HumanaChoice H5216-097 (PPO) plan offers a range of benefits, including inpatient and outpatient hospital care, with varying copays. Emergency and urgent care services have copays, and primary care visits cost $20. The plan also includes preventive services with no copay, hearing and vision services with no copay for routine exams and eyewear, and dental services with no copay for many services. Additional benefits include ambulance services with copays or coinsurance, home health services with no copay, and skilled nursing facility care with a copay after 20 days. Diagnostic and radiological services, along with medical equipment, are covered with copays or coinsurance. The plan also covers other services, such as acupuncture and meal benefits, with a copay.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered, with a copay of $325 for days 1-6 and no copay for days 7-90 for Acute and days 1-5 for Psychiatric; there is no copay for days 6-90 for Psychiatric. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and additional days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, and outpatient substance abuse services, are covered by the HumanaChoice H5216-097 (PPO) plan. Outpatient hospital services have a copay between $0 and $250, observation services have a $325 copay, individual and group sessions for outpatient substance abuse have a $40 copay, and ambulatory surgical center services and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-097 (PPO) plan, with a $40 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by HumanaChoice H5216-097 (PPO). Ground ambulance services have a copay of $315, and air ambulance services have a 20% coinsurance; however, transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the HumanaChoice H5216-097 (PPO) plan. Emergency Services have a $110 copay, and Urgently Needed Services have a $45 copay; both have no coinsurance. Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation have a $110 copay, and no coinsurance.
Primary Care See details
The HumanaChoice H5216-097 (PPO) plan covers primary care physician services with a $20 copay, chiropractic services with a $15 copay, occupational therapy services with a $20 copay, physician specialist services with a $45 copay, and physical therapy and speech-language pathology services with a $20 copay. Mental health and psychiatric individual and group sessions are covered with a $40 copay. Other health care professional services and opioid treatment program services are covered with a copay between $20 and $45, and additional telehealth benefits have a copay between $0 and $45. Routine chiropractic care is not covered, and podiatry services are not covered.
Preventive Services See details
Preventive services include no copay for annual physical exams, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit. Other preventive services are covered, but have a copay. Additional services like Health Education, In-Home Safety Assessment, and others are not covered.
Hearing Services See details
Hearing services with the HumanaChoice H5216-097 (PPO) plan include hearing exams with a $45 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 $399 and $699, while prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$45, routine eye exams with no copay, and eyewear with no copay. Eyewear includes contact lenses and eyeglasses (lenses and frames). Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-097 (PPO) plan covers dental services, including oral exams with no copay, dental x-rays with no copay, other diagnostic dental services with no copay, prophylaxis (cleaning) with no copay, other preventive dental services with no copay, restorative services with a 30%-40% coinsurance and no copay, adjunctive general services with no copay, endodontics with no copay, periodontics with no copay, prosthodontics, removable with a 30% coinsurance and no copay, prosthodontics, fixed with a 30%-40% coinsurance and no copay, and oral and maxillofacial surgery with no copay. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered. The plan has a maximum benefit of $1500 per year for in-network and out-of-network services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%. Other Medicare Part B drugs may have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetic/Medical Supplies with a 20% coinsurance, as well as Diabetic Equipment, which may have a copay and coinsurance depending on the service. Diabetic Supplies have a 10-20% coinsurance with no copay, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a copay between $0 and $90, Lab Services with no copay, Diagnostic Radiological Services with a copay up to $325, Therapeutic Radiological Services with a copay between $45 and $60, and Outpatient X-Ray Services with a $20 copay. Prior authorization is required for these services.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-097 (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the HumanaChoice H5216-097 (PPO) plan. Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are also not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-097 (PPO) plan, with a $0 copay for days 1-20 and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include acupuncture with a $45 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.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved