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HumanaChoice H5216-196 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-196 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-196 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-196 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in New Mexico. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-196 (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 H5216-196 (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 H5216-196 (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 $3.00. 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 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 $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 H5216-196 (PPO) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month or 3-month supply through standard pharmacies and preferred mail order. Tier 2 generic drugs are also highly affordable, costing an $8 copay for a 1-month supply at standard pharmacies and featuring 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, with a 3-month supply costing $94 through preferred mail order. Higher-tier medications require coinsurance, with Tier 4 non-preferred drugs carrying a 47% coinsurance and Tier 5 specialty drugs requiring a 25% coinsurance for a 1-month supply. Utilizing preferred mail order channels generally offers the most significant savings on your prescription drug costs under this plan.
Additional Benefits
The HumanaChoice H5216-196 (PPO) plan offers comprehensive medical coverage with no copays for primary care visits, routine physicals, and home health services. For hospital care, inpatient stays require a $295 daily copay for the first six days and no copay for days 7 through 90, while specialist visits carry a $45 copay. Emergency room visits have a $130 copay, which is waived if you are admitted, and urgent care services are available for a $50 copay. This plan also includes valuable supplemental benefits, such as dental coverage up to a $1,750 annual maximum with no copays for most preventive and comprehensive care. Routine vision and hearing exams are covered with no copay, and members receive a $300 annual eyewear allowance alongside hearing aid coverage with copays ranging from $299 to $899. Diagnostic lab services and home infusion are also covered with no copays, while durable medical equipment requires a 15% coinsurance.
Inpatient Hospital See details
HumanaChoice H5216-196 (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $295 daily copay for days 1 through 6 and no copay for days 7 through 90. Unlimited additional acute care days are covered at no copay, but upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-196 (PPO) covers outpatient services with no coinsurance, featuring no copays for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $325, observation services carry a $295 copay per stay, and outpatient substance abuse sessions have a copay of $25 to $35.
Partial Hospitalization See details
HumanaChoice H5216-196 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to access these covered services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by HumanaChoice H5216-196 (PPO), featuring a $335 copay for ground ambulance services and a $630 copay for air ambulance services, with no coinsurance required for either. Transportation services to plan-approved or other health-related locations are not covered under this plan.
Emergency Services See details
HumanaChoice H5216-196 (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services have a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-196 (PPO) features primary care physician services with no copay and no coinsurance, and specialist visits with a $45 copay and no coinsurance. Therapy services require a $30 copay with no coinsurance, while some chiropractic services are covered with a $15 copay and no coinsurance, though routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are covered by HumanaChoice H5216-196 (PPO) with no copay and no coinsurance for annual physicals, kidney disease education, diabetes self-management, glaucoma screenings, digital rectal exams, EKGs, and a memory fitness benefit. However, additional preventive benefits are only partially covered, excluding 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, smoking cessation, enhanced disease management, telemonitoring, remote access technologies, home safety modifications, and counseling.
Hearing Services See details
HumanaChoice H5216-196 (PPO) covers Medicare-covered hearing exams with a $45 copay, no coinsurance, and no deductible, while routine exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids are partially covered with a copay of $299 to $899 and no coinsurance (limit two per year), but OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by HumanaChoice H5216-196 (PPO), offering one routine eye exam per year with no copay and other exams with a $0 to $45 copay, both with no coinsurance. Up to $300 in annual eyewear is covered with no copay and no coinsurance for one pair of eyeglasses or contact lenses, while individual eyeglass lenses, eyeglass frames, upgrades, and other eye exam services are not covered.
Dental Services See details
Dental services are partially covered by HumanaChoice H5216-196 (PPO) up to a $1,750 annual maximum, with most covered preventive and comprehensive care requiring no copay and no coinsurance, while Medicare-covered dental has a $45 copay (no coinsurance) and prosthodontics require a 30% coinsurance (no copay). Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-196 (PPO) covers home infusion bundled services with no copay, subject to prior authorization. Associated Medicare Part B chemotherapy and other drugs have no copay and coinsurance ranging from no coinsurance to 20%, while Part B insulin requires a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
HumanaChoice H5216-196 (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
Medical equipment is covered by HumanaChoice H5216-196 (PPO), featuring a 15% coinsurance and no copay for durable medical equipment (DME) and medical supplies. Prosthetic devices require a 20% coinsurance, while diabetic supplies have a 10% to 20% coinsurance with no copay and diabetic shoes or inserts carry a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by HumanaChoice H5216-196 (PPO), with prior authorization required. Diagnostic tests and procedures have no coinsurance and a $0 to $50 copay, lab and diagnostic radiological services have no copay, and therapeutic radiological services require a minimum 20% coinsurance and a minimum $40 copay.
Home Health Services See details
Home health services are covered by HumanaChoice H5216-196 (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under HumanaChoice H5216-196 (PPO) with no copay and no coinsurance, though prior authorization is required. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered in practice.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is partially covered by HumanaChoice H5216-196 (PPO) with no coinsurance, requiring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, no prior three-day hospital stay is needed, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
HumanaChoice H5216-196 (PPO) partially covers other services, offering acupuncture for a $45.00 copay and no coinsurance for up to 20 treatments per year, and chronic illness meal benefits with no copay and no coinsurance. Prior authorization is required for both of these covered benefits, while over-the-counter (OTC) items are not covered.
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