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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 2025, 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 2025.
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 $105.00. 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 $300.00 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) plan has a $300 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, for a standard generic drug at a standard pharmacy, you will pay a $47 copay. For a preferred brand drug, you will pay 45% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-120 (PPO) plan offers comprehensive coverage, including inpatient hospital stays with a $350 copay per admission, outpatient services with varying copays, and emergency services with a $110 copay. The plan also covers primary care with a $5 copay, preventive services with no copay, and hearing and vision services with low or no copays, as well as dental services with no copay for some services and a $25 copay for restorative services. Additional benefits include coverage for ambulance, home health, and skilled nursing facility services, with varying copays and coinsurance amounts. The plan also covers home infusion, medical equipment, diagnostic and radiological services, and other services such as acupuncture with a $30 copay, while excluding certain services like routine chiropractic care, podiatry, and orthodontics.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For a Medicare-covered stay, there is a $350 copay per admission or stay, and additional days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, as well as additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services for the HumanaChoice H5216-120 (PPO) plan include coverage for all outpatient hospital services with a copay between $0 and $400, observation services with a $350 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a copay between $30 and $80 for individual and group sessions. Outpatient blood services are also covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-120 (PPO) plan, but requires prior authorization. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the HumanaChoice H5216-120 (PPO) plan. Ground and Air Ambulance Services have a $315 copay. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the HumanaChoice H5216-120 (PPO) plan. Emergency Services have a $110 copay, and Urgently Needed Services have a $45 copay, while Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $110 copay.
Primary Care See details
The HumanaChoice H5216-120 (PPO) plan covers primary care physician services with a $5 copay, chiropractic services with a $15 copay, occupational therapy services with a $20-$30 copay, physician specialist services with a $30 copay, and mental health specialty services with a $30 copay. The plan also covers physical therapy and speech-language pathology services with a $20-$30 copay, additional telehealth benefits with a $0-$45 copay, and opioid treatment program services with a $30-$80 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive services include no copay for Medicare-covered services, annual physical exams, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit, with the Fitness Benefit covered with no copay. Other preventive services like health education, in-home safety assessments, and others are not covered.
Hearing Services See details
Hearing services include hearing exams with a $30 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a copay between $699 and $999, but inner ear, outer ear, and over the ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
The HumanaChoice H5216-120 (PPO) plan covers vision services, including eye exams with a copay between $0 and $30, and eyewear with no copay. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-120 (PPO) plan covers a range of 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, and restorative services with a $25 copay. Other preventive dental services are covered with no copay. Fluoride treatment, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered. The plan has a maximum benefit of $2,000 per year for both 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, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%, with the specific coinsurance amount depending on the drug.
Dialysis Services See details
Dialysis Services are covered with a coinsurance of 20%. Prior authorization is required.
Medical Equipment See details
Medical Equipment is covered by HumanaChoice H5216-120 (PPO). Durable Medical Equipment (DME) has a 17% coinsurance and requires authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a 20% coinsurance, and Medical Supplies have a 20% coinsurance. Diabetic Supplies have a 10% to 10% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests with a copay between $0 and $90, lab services with no copay, diagnostic radiological services with a copay up to $275, therapeutic radiological services with a copay up to $30 and 20% coinsurance, and outpatient X-ray services with a $5 copay. All services require prior authorization.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-120 (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
For HumanaChoice H5216-120 (PPO), Cardiac Rehabilitation Services are technically covered, but none of the listed sub-services are covered, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214 per day; there is no coinsurance.
Other Services See details
Other Services includes acupuncture with a $30 copay, and a meal benefit with no copay. 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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