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HumanaChoice H5216-131 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-131 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-131 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-131 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in UT. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-131 (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 H5216-131 (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 H5216-131 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $8950.00 (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 $8950.00 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 H5216-131 (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs have a $12 copay at preferred mail order pharmacies, while standard generic drugs have a $47 copay. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you will pay nothing for Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The HumanaChoice H5216-131 (PPO) plan offers a range of benefits with varying costs. You'll have no copay for many services, including primary care, preventive services, vision and dental exams, and home health services. Other services have copays, such as inpatient hospital stays, outpatient services, ambulance services, and specialist visits. The plan also provides coverage for hearing, vision, and dental services, as well as some outpatient services like substance abuse and mental health.
Inpatient Hospital See details
Inpatient Hospital benefits with HumanaChoice H5216-131 (PPO) include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, both of which require prior authorization. For Inpatient Hospital-Acute, you will pay a $395 copay for days 1-5, and no copay for days 6-90, while additional days (91-999) have no copay; Inpatient Hospital Psychiatric services have the same cost structure. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $295, Observation Services with a $395 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a copay between $40 and $50 for both individual and group sessions, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-131 (PPO) plan, with a $105 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-131 (PPO) plan. Ground Ambulance Services have a $315 copay, while Air Ambulance Services have a $1250 copay, but Transportation Services are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the HumanaChoice H5216-131 (PPO) plan. Emergency Services have a $125 copay, while Urgently Needed Services have a $55 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation all have a $125 copay. There is no coinsurance for any of these services.
Primary Care See details
The HumanaChoice H5216-131 (PPO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $20 copay, and physician specialist services with a $10 copay. This plan also covers mental health specialty services, psychiatric services, physical therapy and speech-language pathology services with a $20 copay, additional telehealth benefits with a copay between $0 and $55, and opioid treatment program services with a copay between $40 and $50.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, and annual physical exams with no copay. Additional preventive services like health education, in-home safety assessment, and others are not covered. Additional services like glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit are covered with no copay.
Hearing Services See details
Hearing exams, including those not usually covered by Medicare, have a $10 copay, and routine hearing exams have no copay for one exam per year. Fitting/evaluation for hearing aids also has no copay. Prescription hearing aids are partially covered, with a copay between $699 and $999 for all types, but not for Inner Ear, Outer Ear, or Over the Ear hearing aids. OTC hearing aids are covered with a maximum benefit of $60 every three months.
Vision Services See details
HumanaChoice H5216-131 (PPO) covers vision services, including eye exams with a copay of $0-$10 and eyewear with no copay. Contact lenses and eyeglasses (lenses and frames) are covered with no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-131 (PPO) covers dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, with a $3,500 annual maximum. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery have no copay. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and the coinsurance ranges from 0% to 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-131 (PPO) plan. This benefit has a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetic Devices with a 20% coinsurance. Diabetic Supplies have a 10-20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the HumanaChoice H5216-131 (PPO) plan, with a copay for outpatient diagnostic procedures, tests, and lab services, ranging from $0 to $55. Outpatient X-Ray services have no copay, while diagnostic radiological services have a copay up to $350, and therapeutic radiological services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-131 (PPO) plan with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-131 (PPO) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for these services if they were covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by HumanaChoice H5216-131 (PPO) with a copay of $10 for days 1-20, $214 for days 21-65, and no copay for days 66-100. Additional days beyond Medicare coverage and non-Medicare-covered stays are not covered.
Other Services See details
The HumanaChoice H5216-131 (PPO) plan covers acupuncture with a $10 copay, up to 20 treatments per year, and also covers over-the-counter items with a maximum benefit of $60 every three months. The plan also provides a meal benefit with no copay for a chronic illness. However, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and many other services are not covered.
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