A non-government entity
HumanaChoice H5216-177 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-177 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-177 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-177 (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 H5216-177 (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 H5216-177 (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 H5216-177 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $28.00. 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 $405.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $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 $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:
Sign up for HumanaChoice H5216-177 (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The HumanaChoice H5216-177 (PPO) plan has a $300 deductible for prescription drugs. After you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For preferred generic drugs, you may pay a $5 copay if you use a preferred pharmacy or preferred mail order, or a $20 copay at a standard mail order pharmacy. For standard generic drugs, you will pay a $47 copay. Brand name drugs have a 45% coinsurance, and non-preferred drugs have a 29% coinsurance.
Additional Benefits
The HumanaChoice H5216-177 (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services have copays depending on the specific service. Emergency services have a $125 copay, and ambulance services have a $315 copay. The plan covers primary care with no copay for many services, as well as preventive services, hearing exams, and dental services with no copay. The plan also includes coverage for home health services and skilled nursing facilities with copays for some services.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a copay of $295 for days 1-6 and no copay for days 7-90. Additional days for inpatient hospital-acute have no copay for days 91-999, while non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $30 and $725, Observation Services with a $295 copay, Ambulatory Surgical Center (ASC) Services with a $200 copay, Outpatient Substance Abuse Services with a copay between $30 and $95, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-177 (PPO) plan and requires prior authorization. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-177 (PPO) plan, which includes a $315 copay for both ground and air ambulance services, with no coinsurance. 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 H5216-177 (PPO) plan. Emergency Services have a $125 copay, and no coinsurance, while Urgently Needed Services have a $55 copay and no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay.
Primary Care See details
Primary Care includes a variety of services. Primary Care Physician Services have no copay, while Chiropractic Services have a $10 copay for routine care. Occupational Therapy Services have a $30 copay, Physician Specialist Services have a $30 copay, and Physical Therapy and Speech-Language Pathology Services have a $30 copay. Mental Health Specialty Services, Psychiatric Services, Other Health Care Professional, and Opioid Treatment Program Services have varying copays depending on the service. Additional Telehealth Benefits have a copay between $0 and $55. Podiatry Services are not covered.
Preventive Services See details
Preventive services include coverage for Medicare-covered services with no copay, and an annual physical exam with no copay. Additional preventive services include Fitness Benefit, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay. Other services like Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), and more are not covered.
Hearing Services See details
HumanaChoice H5216-177 (PPO) covers 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, while inner ear, outer ear, and over the ear prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
The HumanaChoice H5216-177 (PPO) plan covers vision services, including routine 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
Dental Services include coverage for 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; however, fluoride treatment, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered. This plan has a maximum benefit of $1,500 per year for both in-network and out-of-network services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay and the coinsurance is between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-177 (PPO) plan, with a coinsurance of 20%. Prior authorization is required.
Medical Equipment See details
Medical equipment, including Durable Medical Equipment (DME), Prosthetics, Medical Supplies, and Diabetic Equipment, is covered. DME has a 14% coinsurance and requires authorization, while Prosthetic Devices have a coinsurance of 14% and Medical Supplies have a 14% coinsurance. Diabetic Supplies have a 10% coinsurance with no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests with a copay between $0 and $80, lab services with no copay, diagnostic radiological services with a copay between $25 and $300, therapeutic radiological services with a coinsurance of at least 20%, and outpatient X-ray services with no copay. All services require prior authorization.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-177 (PPO) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-177 (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.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by HumanaChoice H5216-177 (PPO) with a copay of $10 for days 1-20 and $214 for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Under "Other Services", acupuncture is covered with a $30 copay, and a limit of 20 treatments per year, while the meal benefit is covered 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.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved