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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 2026, please refer to our full plan details page.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
HumanaChoice H5216-175 (PPO) is a PPO plan offered by Humana Insurance Company available for the 2026 plan year to people living in Maine. This plan received an overall rating of 3.5 out of 5 stars in 2026.
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.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan has a $40.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $500.00 drug deductible that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6700.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $6700.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $10000.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $10000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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) prescription drug plan features an annual drug deductible of $500. For Tier 1 preferred generic drugs, there is no copay for a 1-month or 3-month supply at standard pharmacies and through preferred mail order. Tier 2 generic drugs cost $5 for a 1-month supply at standard pharmacies or preferred mail order, 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 options, though a 3-month preferred mail order supply offers a slightly reduced cost of $131. Tier 4 non-preferred drugs require a 50% coinsurance, while Tier 5 specialty drugs have a 27% coinsurance for a 1-month supply. These structured costs help you plan your healthcare expenses depending on your specific medication tier and fulfillment method.
Additional Benefits
The HumanaChoice H5216-175 (PPO) plan offers robust medical coverage with no copay and no coinsurance for primary care visits, home health services, and preventive care. For specialist visits and physical therapy, you will pay a $35 copay, while inpatient hospital stays require a $325 daily copay for the first seven days. Emergency room visits carry a $130 copay, which is waived if you are admitted, and ambulance services require a $335 copay per service. This plan also includes valuable dental, vision, and hearing benefits, featuring no copays for routine eye exams, eyewear up to a $200 limit, and preventive dental care up to a $1,000 annual maximum. Routine hearing exams also have no copay, though prescribed hearing aids require a copay between $699 and $999. For dialysis, durable medical equipment, and prosthetics, you can expect a 20% coinsurance with no copay.
Inpatient Hospital See details
HumanaChoice H5216-175 (PPO) covers inpatient hospital services with no coinsurance, though prior authorization is required. For acute care, there is a $325 daily copay for days 1 through 7 and no copay for days 8 and beyond, while psychiatric care requires a $310 daily copay for days 1 through 7 and no copay for days 8 through 90. Upgrades and non-Medicare-covered stays are not covered under this benefit.
Outpatient Services See details
HumanaChoice H5216-175 (PPO) covers outpatient services with no coinsurance, offering no copays for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $345, while outpatient substance abuse sessions have a $35 copay and observation services carry a $325 copay per stay.
Partial Hospitalization See details
Partial hospitalization is covered by HumanaChoice H5216-175 (PPO) with a $35.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
HumanaChoice H5216-175 (PPO) covers ground and air ambulance services with a $335 copay and no coinsurance per service. Transportation services are partially covered with no copay and no coinsurance for up to 24 one-way trips per year to plan-approved locations, while transportation to any health-related location is not covered.
Emergency Services See details
HumanaChoice H5216-175 (PPO) covers emergency services with a $130 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 $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are available with a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-175 (PPO) provides primary care physician services with no copay and no coinsurance, while specialist, physical therapy, and mental health services require a $35 copay and no coinsurance. Telehealth benefits are available with a $0 to $50 copay and no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
HumanaChoice H5216-175 (PPO) preventive services are partially covered with no copay and no coinsurance for covered services, which include annual physical exams, kidney disease education, memory fitness, and select screenings. Sub-services that are not covered under this plan include health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission 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 counseling, enhanced disease management, telemonitoring, remote access technologies, home/bathroom safety modifications, and counseling services.
Hearing Services See details
HumanaChoice H5216-175 (PPO) covers hearing services, offering Medicare-covered exams for a $35 copay and no coinsurance, alongside routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with a copay ranging from $699 to $999 and no coinsurance for up to two aids per year, while OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-175 (PPO) provides partially covered vision services with no deductible and no coinsurance, featuring one annual routine eye exam with no copay up to a $75 limit. Eyewear is also covered with no copay and no coinsurance up to a $200 annual limit for one pair of contacts or eyeglasses, though other eye exams, separate eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-175 (PPO) dental services are partially covered up to a $1,000 annual maximum for both in-network and out-of-network care. Medicare-covered dental services require a $35 copay and no coinsurance, while other covered preventive and comprehensive services have no copay and no coinsurance, though fluoride, implants, fixed prosthodontics, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the HumanaChoice H5216-175 (PPO) plan with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs have no copay and range from no coinsurance to 20% coinsurance, while Part B insulin is covered with a $35 copay and ranges from no coinsurance to 20% coinsurance.
Dialysis Services See details
HumanaChoice H5216-175 (PPO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization is required for these covered services.
Medical Equipment See details
HumanaChoice H5216-175 (PPO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance, subject to prior authorization. Diabetic supplies from specified manufacturers are covered with no copay and a 10% to 20% coinsurance, while diabetic therapeutic shoes and inserts require a $10 copay.
Diagnostic and Radiological Services See details
HumanaChoice H5216-175 (PPO) covers diagnostic services with no coinsurance, featuring no copay for lab services and a $0 to $85 copay for diagnostic procedures. Covered radiological services require prior authorization, with a $0 minimum copay for diagnostic radiology, no copay for outpatient X-rays, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
HumanaChoice H5216-175 (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 H5216-175 (PPO) with no coinsurance, though prior authorization is required. While some services are covered, standard cardiac rehabilitation (copay of $30 to $35), intensive cardiac rehabilitation (copay of $30 to $35), pulmonary rehabilitation ($15 copay), and supervised exercise therapy ($25 copay) are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-175 (PPO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services covered by the HumanaChoice H5216-175 (PPO) plan are partially covered and include acupuncture with a $35 copay and no coinsurance for up to 20 treatments yearly, and chronic illness meal benefits with no copay and no coinsurance. Over-the-counter (OTC) items are not covered under this plan.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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