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HumanaChoice H5216-175 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-175 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-175 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-175 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Maine. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-175 (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 H5216-175 (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 H5216-175 (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 has a $65.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $250.00 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 $9400.00 (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 $9400.00 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 H5216-175 (PPO) plan has a $250 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, Tier 1 preferred generics have a $5 copay at preferred or mail order pharmacies, while Tier 2 standard generics have a $47 copay. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-175 (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services and emergency services have their own copays. The plan provides coverage for primary care, preventive, vision, dental, and hearing services, with some services having no copay. Additionally, it covers home health services, medical equipment, and other services like ambulance, with certain copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with a copay of $325 for days 1-7, and no copay for days 8-90 for Inpatient Hospital-Acute, and a copay of $310 for days 1-7, and no copay for days 8-90 for Inpatient Hospital Psychiatric. The plan does not cover Non-Medicare-covered stays or upgrades for Inpatient Hospital-Acute, nor does it cover Additional Days or Non-Medicare-covered stays for Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay of $35-$310, Observation Services with a $325 copay, Ambulatory Surgical Center (ASC) Services with a $240 copay, and Outpatient Substance Abuse Services with a copay of $35-$100 for individual and group sessions. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-175 (PPO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services, including ground and air ambulance, are covered by HumanaChoice H5216-175 (PPO) with a copay of $315, while transportation services to a plan-approved health-related location have no copay and are limited to 24 one-way trips per year. 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 H5216-175 (PPO) plan. Emergency Services has a $125 copay, and Urgently Needed Services has a $55 copay, while Worldwide Emergency Services includes Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, each with a $125 copay.
Primary Care See details
The HumanaChoice H5216-175 (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, and occupational therapy services with a $35 copay. Physician specialist services have a $35 copay, while mental health and psychiatric individual and group sessions each have a $35 copay, and physical therapy and speech-language pathology services have a $35 copay. Additional telehealth benefits have a copay between $0 and $55, and opioid treatment program services have a copay between $35 and $100.
Preventive Services See details
The HumanaChoice H5216-175 (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services include Fitness Benefit with no copay, and all other services have a copay.
Hearing Services See details
The HumanaChoice H5216-175 (PPO) plan covers hearing exams with a $35 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $699 and $999, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and over-the-counter hearing aids are not covered.
Vision Services See details
The HumanaChoice H5216-175 (PPO) plan covers vision services, including eye exams with a copay between $0 and $35, and eyewear with no copay. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-175 (PPO) plan covers Medicare and other dental services, with a $1,500 annual maximum benefit. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and other preventive dental services are covered with no copay, but fluoride treatment, maxillofacial prosthetics, implant services, prosthodontics fixed, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay and 0-20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-175 (PPO) plan, but require prior authorization. The plan has a coinsurance of 20% for dialysis services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment with a 16% coinsurance and Prosthetics/Medical Supplies with a 16% coinsurance, and Diabetic Equipment, including Diabetic Supplies with a 10% coinsurance and no copay, and Diabetic Therapeutic Shoes/Inserts with no copay. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
The HumanaChoice H5216-175 (PPO) plan covers Diagnostic and Radiological Services. Diagnostic Procedures/Tests have a copay between $0 and $85, while Lab Services have no copay. Diagnostic Radiological Services have a copay up to $300, and Therapeutic Radiological Services have a 20% coinsurance. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-175 (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
Cardiac Rehabilitation Services are covered by HumanaChoice H5216-175 (PPO), but not in practice, as none of the sub-services are covered. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-175 (PPO) plan, but require prior authorization. For days 1-20, the copay is $10 per day, and for days 21-100, the copay is $214 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The HumanaChoice H5216-175 (PPO) plan covers acupuncture with a $35 copay, limited to 20 treatments per year, and meal benefits 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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