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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 2026, 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 2026.
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 $1.00. 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:
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Drug Coverage
The HumanaChoice H5216-097 (PPO) plan features an Enhanced Alternative drug benefit with a $590.00 annual prescription drug deductible. After meeting this deductible, you will pay a $5.00 copay for Tier 1 preferred generic drugs and a $47.00 copay for Tier 2 standard generic drugs at standard pharmacies or through preferred mail order. For higher tiers, members pay a 40% coinsurance for Tier 3 preferred brand drugs and a 26% coinsurance for Tier 4 non-preferred drugs. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and will pay nothing for covered Medicare Part D prescriptions. Additionally, beneficiaries who qualify for the low-income subsidy can lower their monthly Part D premium from $55.00 to $28.40.
Additional Benefits
The HumanaChoice H5216-097 (PPO) plan offers comprehensive medical coverage with no copay for primary care visits, while specialist visits require a $35 copay. For inpatient hospital stays, members pay a $325 daily copay for the first few days, after which there is no copay, and emergency room visits carry a $115 copay that is waived if admitted. Outpatient services generally feature no coinsurance, with copays ranging from no copay for ambulatory surgical centers up to $250 for outpatient hospital services. This plan also includes valuable extra benefits, featuring no copay or coinsurance for routine dental cleanings, annual eye exams, and routine hearing tests. Covered eyewear is eligible for up to a $200 annual maximum with no copay, while prescription hearing aids require a copay between $399 and $699. For specialized needs, home health services have no copay, while durable medical equipment and dialysis services require a 20% coinsurance with no copay.
Inpatient Hospital See details
HumanaChoice H5216-097 (PPO) partially covers inpatient hospital services, excluding upgrades, non-Medicare-covered stays, and additional psychiatric hospital days. Covered acute care has a $325 daily copay for days 1 through 6 and no copay for days 7 through 999, while psychiatric care requires a $325 daily copay for days 1 through 5 and no copay for days 6 through 90, both with no coinsurance.
Outpatient Services See details
HumanaChoice H5216-097 (PPO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services have a copay ranging from $0 to $250, while outpatient substance abuse sessions require a $35 copay, and observation services carry a $325 copay per stay.
Partial Hospitalization See details
HumanaChoice H5216-097 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to access these covered benefits.
Ambulance and Transportation Services See details
HumanaChoice H5216-097 (PPO) partially covers Ambulance and Transportation Services, as transportation services to plan-approved or any health-related locations are not covered. Covered ground ambulance services require a $335 copay with no coinsurance, while air ambulance services require a 20% coinsurance with no copay, with prior authorization required for all ambulance services.
Emergency Services See details
HumanaChoice H5216-097 (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 require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered under a $115 copay and no coinsurance.
Primary Care See details
Primary care benefits under HumanaChoice H5216-097 (PPO) are offered with no copay and no coinsurance for primary care doctor visits, and a $35 copay with no coinsurance for specialist and psychiatric sessions. Physical and occupational therapies require a $20 copay with no coinsurance, while podiatry and routine chiropractic care are not covered.
Preventive Services See details
Preventive Services are partially covered by HumanaChoice H5216-097 (PPO) with no copay and no coinsurance for covered services, including annual physical exams, fitness benefits, and in-home support. However, several sub-services are not covered, such as health education, weight management programs, alternative therapies, and personal emergency response systems.
Hearing Services See details
HumanaChoice H5216-097 (PPO) provides partially covered hearing services with no deductible, featuring routine hearing exams and fitting evaluations for no copay or coinsurance, and Medicare-covered exams for a $35 copay and no coinsurance. Prescription hearing aids are covered with a $399 to $699 copay and no coinsurance for up to two devices per year, but OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-097 (PPO) partially covers vision services, offering one annual routine eye exam and eyewear, such as contact lenses or eyeglasses (lenses and frames), with no copay and no coinsurance. Other eye exams have a copay ranging from $0 to $35 and no coinsurance, up to a $75 annual limit, while covered eyewear is capped at a $200 annual maximum. Individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by HumanaChoice H5216-097 (PPO) up to a $1,750 annual limit, though fluoride treatments, implant services, maxillofacial prosthetics, and orthodontics are not covered. Most covered services like cleanings and exams have no copay and no coinsurance, while Medicare-covered dental requires a $35 copay with no coinsurance, and restorative or prosthodontic care has no copay but carries a 30% to 40% coinsurance.
Home Infusion bundled Services See details
HumanaChoice H5216-097 (PPO) covers Home Infusion bundled Services with prior authorization, offering chemotherapy, radiation, and other Part B drugs with no copay and no coinsurance to 20% coinsurance. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
HumanaChoice H5216-097 (PPO) covers Dialysis Services with a 20% coinsurance and no copay. Prior authorization is required to receive these covered services.
Medical Equipment See details
HumanaChoice H5216-097 (PPO) covers medical equipment, including durable medical equipment (DME) with a 20% coinsurance and no copay. Diabetic supplies are covered with a 10% to 20% coinsurance and no copay, diabetic therapeutic shoes and inserts require a $10 copay, and prosthetics and medical supplies carry a 20% coinsurance.
Diagnostic and Radiological Services See details
HumanaChoice H5216-097 (PPO) covers diagnostic and radiological services, with prior authorization required. Lab services and outpatient X-rays have no copay and no coinsurance, while diagnostic tests range from no copay to a $90 copay with no coinsurance, diagnostic radiology ranges from no copay to a $335 copay with no coinsurance, and therapeutic radiology requires a $35 copay and 20% coinsurance.
Home Health Services See details
HumanaChoice H5216-097 (PPO) covers Home Health Services with no copay and no coinsurance. Prior authorization is required to receive these services.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-097 (PPO) states that some services are covered, but in practice, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Because these services are not covered, there are no copays or coinsurance fees.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-097 (PPO) partially covers Skilled Nursing Facility (SNF) services, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, with no coinsurance required. Prior authorization is required for these services, and additional days beyond Medicare-covered SNF stays are not covered.
Other Services See details
HumanaChoice H5216-097 (PPO) offers partially covered Other Services, with acupuncture costing a $35 copay and no coinsurance, and meal benefits available with no copay and no coinsurance. Over-the-counter (OTC) items and Dual Eligible SNPs with highly integrated services are not covered.
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