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HumanaChoice H5216-168 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-168 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-168 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-168 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Wisconsin. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-168 (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 H5216-168 (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 H5216-168 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $154.00. 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 $6200.00 (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 $6200.00 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 H5216-168 (PPO) plan features an annual prescription drug deductible of $615. For Tier 1 preferred generic drugs, there is no copay for a 1-month or 3-month supply filled at standard pharmacies or through preferred mail order. Tier 2 generic drugs are available for a $5 copay for a 1-month supply, and you pay no copay for a 3-month supply filled via preferred mail order. For Tier 3 preferred brand drugs, you will pay a $47 copay for a 1-month supply at standard pharmacies or through mail order. Tier 4 non-preferred drugs require a 50% coinsurance, while Tier 5 specialty tier drugs carry a 25% coinsurance for a 1-month supply.
Additional Benefits
The HumanaChoice H5216-168 (PPO) plan offers comprehensive medical coverage, featuring no copay and no coinsurance for primary care visits, specialist consultations, and home health services. For hospital care, members pay a $380 copay per admission for inpatient stays, while outpatient hospital services require a copay of up to $300 with no coinsurance. Emergency room visits carry a $150 copay, and urgent care services require a $65 copay, with both options waiving coinsurance entirely. This PPO plan also covers essential ancillary benefits, including dental, vision, and hearing services with no copay or coinsurance for routine exams. Prescription hearing aids are covered with a copay ranging from $699 to $999, and members receive a $100 annual allowance for eyeglasses or contacts. Furthermore, diagnostic lab services and outpatient X-rays require no copay, while durable medical equipment and dialysis services carry a 20 percent coinsurance.
Inpatient Hospital See details
HumanaChoice H5216-168 (PPO) covers inpatient acute and psychiatric hospital stays with a $380.00 copayment per admission and no coinsurance, though prior authorization is required. While unlimited additional days are covered with no copay for acute stays, additional days for psychiatric stays, room upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
HumanaChoice H5216-168 (PPO) outpatient services are covered with no coinsurance, featuring no copay for ambulatory surgical center and outpatient blood services. Medicare-covered outpatient hospital services require a copay of $0 to $300 ($380 per stay for observation), while outpatient substance abuse sessions carry a $30 to $35 copay.
Partial Hospitalization See details
HumanaChoice H5216-168 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to receive coverage for this benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-168 (PPO) covers ground ambulance services with a $335 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required. While some transportation services are covered, trips to plan-approved health-related locations and any other health-related locations are not covered.
Emergency Services See details
HumanaChoice H5216-168 (PPO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $65 copay and no coinsurance, while worldwide emergency, urgent care, and emergency transportation are covered with a $150 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-168 (PPO) features primary care and specialist visits with no copay and no coinsurance, while occupational, physical, and speech therapies require a $40 copay and no coinsurance. Mental health and psychiatric services have a $30 copay and no coinsurance, but podiatry and chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered under HumanaChoice H5216-168 (PPO) with no copay and no coinsurance for covered benefits such as annual physical exams, kidney disease education, and memory fitness. Non-covered sub-services include 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, home-based palliative care, in-home support, caregiver support, additional tobacco cessation, enhanced disease management, telemonitoring, remote access technologies, home safety modifications, and counseling.
Hearing Services See details
HumanaChoice H5216-168 (PPO) covers hearing exams with no copay and no coinsurance, though prior authorization is required. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $699.00 to $999.00 for up to two devices per year, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-168 (PPO) features partially covered vision services with no copay, no coinsurance, and no deductible for covered services, although prior authorization is required. While routine eye exams (up to $75 yearly) and contact lenses or eyeglasses (up to $100 yearly) are covered, other eye exam services, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-168 (PPO) provides partially covered dental services with no copay and no coinsurance for most covered preventive, diagnostic, and restorative procedures. However, fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by HumanaChoice H5216-168 (PPO) with no copay, while associated Medicare Part B drugs require no coinsurance to 20% coinsurance. Covered Part B insulin carries a $35 copay and no coinsurance to 20% coinsurance, with none of these drug costs counting toward a plan-level deductible.
Dialysis Services See details
HumanaChoice H5216-168 (PPO) covers Dialysis Services with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
HumanaChoice H5216-168 (PPO) covers durable medical equipment, prosthetics, and medical supplies with a 20% coinsurance and no copay, subject to prior authorization. Covered diabetic supplies have no copay and a 10% to 20% coinsurance, while diabetic therapeutic shoes or inserts require a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under HumanaChoice H5216-168 (PPO) with no copay or coinsurance for lab services, and a copay of $0 to $85 with no coinsurance for diagnostic procedures. Diagnostic radiological services feature a copay starting at $0, outpatient X-rays have no copay, and therapeutic radiological services require a copay and a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by HumanaChoice H5216-168 (PPO) with no copay and no coinsurance. Prior authorization is required to receive these services.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by HumanaChoice H5216-168 (PPO) with no copay and no coinsurance, meaning some services are covered, but standard cardiac, intensive cardiac, pulmonary, and SET for PAD services are not covered. Prior authorization is required for covered services.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-168 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $20.00 daily copay for days 1 through 20 and a $218.00 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not needed, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
HumanaChoice H5216-168 (PPO) partially covers other services, offering acupuncture for up to 20 treatments per year and a chronic illness meal benefit with no copay and no coinsurance, though prior authorization is required. Over-the-counter (OTC) items are not covered under this plan.
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