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HumanaChoice H5216-120 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-120 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-120 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-120 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select counties in Pennsylvania. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-120 (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 H5216-120 (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 H5216-120 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $94.00. 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 $7600.00 (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 $7600.00 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 H5216-120 (PPO) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month or 3-month supply at standard pharmacies and through preferred mail order. Tier 2 generic drugs cost as little as a $5 copay for a 1-month supply at standard pharmacies, with no copay for a 3-month supply when using preferred mail order. Tier 3 preferred brand drugs require a $47 copay for a 1-month supply across standard pharmacies and mail order services. Higher-tier prescriptions transition to coinsurance, with Tier 4 non-preferred drugs requiring a 47% coinsurance and Tier 5 specialty drugs requiring a 25% coinsurance for a 1-month supply. Choosing preferred mail order options can help lower your out-of-pocket costs for select generic tiers.
Additional Benefits
The HumanaChoice H5216-120 (PPO) plan offers comprehensive medical coverage featuring no copay for primary care visits and a $30 copay for specialists. Inpatient hospital stays require a $350 copay per admission with no coinsurance, while outpatient services range from no copay up to a $400 copay. Emergency room visits are covered with a $115 copay, which is waived if you are admitted to the hospital within 24 hours. This plan also includes strong supplemental benefits, offering preventive care, routine eye exams, and preventive dental services with no copay or coinsurance. Dental benefits are covered up to a $2,000 annual limit, and eyewear is covered up to $200 annually with no copay. Additionally, routine hearing exams have no copay, while covered hearing aids require a copay between $699 and $999.
Inpatient Hospital See details
HumanaChoice H5216-120 (PPO) covers inpatient acute and psychiatric hospital stays with a $350 copay per admission and no coinsurance, requiring prior authorization. Unlimited additional days for acute stays are covered with no copay, but additional psychiatric days, non-Medicare-covered stays, and room upgrades are not covered.
Outpatient Services See details
HumanaChoice H5216-120 (PPO) covers outpatient services with no coinsurance, featuring a $0 to $400 copay for outpatient hospital services and a $350 copay per stay for observation services. Ambulatory surgical center and blood services have no copay and no coinsurance, while outpatient substance abuse sessions require a $30 to $35 copay with no coinsurance.
Partial Hospitalization See details
HumanaChoice H5216-120 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to access this covered benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-120 (PPO) covers emergency ground and air ambulance services with a $335 copay and no coinsurance, with prior authorization required. While some transportation services are covered, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
HumanaChoice H5216-120 (PPO) covers emergency services with a $115 copay and no coinsurance, with the copay 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 available with a $115 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-120 (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $30 copay and no coinsurance. Other benefits like physical therapy, mental health, and telehealth are covered with copays up to $40 and no coinsurance, though chiropractic and podiatry services are not covered.
Preventive Services See details
HumanaChoice H5216-120 (PPO) offers preventive services with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, glaucoma screenings, diabetes training, digital rectal exams, EKGs, and a memory fitness benefit. However, additional preventive benefits are only partially covered, excluding services such as 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/dietary benefits, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, remote access, home safety modifications, and counseling.
Hearing Services See details
Hearing services are covered by HumanaChoice H5216-120 (PPO), featuring a $30 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 no coinsurance and a copay ranging from $699 to $999 (limited to two per year), but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-120 (PPO) partially covers vision services with no deductibles, no coinsurance, and prior authorization required. Covered benefits include one routine eye exam per year with no copay (up to $75) and eyeglasses or contact lenses with no copay (up to $200 annually), while other eye exams, separate eyeglass lenses, separate eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-120 (PPO) dental services are partially covered up to a $2,000 annual limit, featuring no copay and no coinsurance for preventive care like cleanings and exams, and a $30 copay with no coinsurance for Medicare-covered dental. Restorative services require a $25 copay and no coinsurance, while fluoride, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-120 (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy and other drugs require no copay and 0% to 20% coinsurance, while Part B insulin has a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
HumanaChoice H5216-120 (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive coverage for these services.
Medical Equipment See details
HumanaChoice H5216-120 (PPO) covers medical equipment, including durable medical equipment (DME), prosthetics, and medical supplies, with a 20% coinsurance and no copay. Diabetic supplies are covered with a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes and inserts require a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by HumanaChoice H5216-120 (PPO) with prior authorization required, featuring no copays for lab services and outpatient X-rays. Outpatient diagnostic procedures have no coinsurance and a copay between $0 and $90, while diagnostic radiological services start at a $0 copay and therapeutic radiological services require a $30 copay and 20% coinsurance.
Home Health Services See details
HumanaChoice H5216-120 (PPO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by HumanaChoice H5216-120 (PPO) with no coinsurance and required prior authorization, although only some services are covered. Standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered, requiring copayments between $10 and $30.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-120 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
HumanaChoice H5216-120 (PPO) partially covers other services, offering acupuncture with a $30 copay and no coinsurance for up to 20 treatments per year, and chronic illness meal benefits with no copay and no coinsurance. Prior authorization is required for these covered benefits, while over-the-counter (OTC) items are not covered.
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