A non-government entity
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 $19.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $2.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $25.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $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 $13900.00 (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 $13900.00 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 H5216-196 (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 H5216-196 (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 at standard pharmacies and through preferred mail order. Tier 2 generic drugs cost $8 for a 1-month supply at standard pharmacies and preferred mail order, with no copay required for a 3-month supply filled via preferred mail order. Tier 3 preferred brand drugs carry a $47 copay for a 1-month supply, but you can save on a 3-month supply with a $94 copay through preferred mail order compared to $141 at standard pharmacies. Finally, higher-tier medications require coinsurance rather than flat copays, with Tier 4 non-preferred drugs requiring 47% coinsurance and Tier 5 specialty drugs requiring 25% coinsurance.
Additional Benefits
The HumanaChoice H5216-196 (PPO) plan offers robust coverage with no copay and no coinsurance for primary care visits, home health services, and routine preventive care. For specialist visits, patients pay a $40 copay, while inpatient hospital stays require a $470 daily copay for the first five days followed by no copay for unlimited additional days. Emergency room visits have a $115 copay, which is waived if admitted, and urgent care costs a $40 copay. Additional benefits include routine dental, vision, and hearing exams with no copay, featuring a $300 annual allowance for eyewear and a $750 maximum limit for dental care. Skilled nursing facility stays feature no copay for the first 20 days, followed by a $218 daily copay up to day 100. Durable medical equipment is covered with a 15% coinsurance and no copay, while over-the-counter items and chronic illness meals are provided with no copay.
Inpatient Hospital See details
HumanaChoice H5216-196 (PPO) covers inpatient acute hospital stays with no coinsurance and a $470 daily copay for days 1 to 5, followed by no copay for unlimited additional days, excluding upgrades and non-Medicare-covered stays. Inpatient psychiatric care is also covered with no coinsurance and a $400 daily copay for days 1 to 5 and no copay for days 6 to 90, though additional psychiatric days and non-Medicare-covered stays are not covered.
Outpatient Services See details
HumanaChoice H5216-196 (PPO) covers outpatient services with no coinsurance, although prior authorization is required for most of these benefits. Patients will pay no copay for ambulatory surgical center and blood services, while copays range from no copay to $325 for outpatient hospital services, $470 per stay for observation services, and $25 to $35 for outpatient substance abuse sessions.
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 this benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-196 (PPO) covers emergency ground ambulance services with a $335 copay and air ambulance services with a $630 copay, both requiring prior authorization and having no coinsurance. Routine transportation services to health-related locations are not covered under this plan.
Emergency Services See details
HumanaChoice H5216-196 (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $115 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-196 (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $40 copay and no coinsurance. Other services like physical therapy, mental health, and podiatry feature no coinsurance and copays ranging from $0 to $40, though routine and other chiropractic services are not covered.
Preventive Services See details
HumanaChoice H5216-196 (PPO) preventive services are partially covered with no copay and no coinsurance for annual physical exams, kidney disease education, glaucoma screenings, diabetes self-management training, digital rectal exams, EKGs, and memory fitness benefits. However, this benefit does not cover health education, in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, home modifications, and counseling.
Hearing Services See details
HumanaChoice H5216-196 (PPO) covers routine hearing exams, fitting evaluations, and OTC hearing aids with no deductible, no copay, and no coinsurance, while Medicare-covered exams require a $40 copay and no coinsurance. Prescription hearing aids are partially covered with no deductible, no coinsurance, and a $699 to $999 copay for up to two devices per year, though inner ear, outer ear, and over the ear models are not covered.
Vision Services See details
HumanaChoice H5216-196 (PPO) offers partially covered vision services with no deductibles and no coinsurance, featuring no copay for one routine yearly eye exam and no copay for contact lenses or eyeglasses up to a $300 annual limit. Other eye exam services, individual eyeglass lenses, eyeglass frames, and upgrades are not covered under this plan.
Dental Services See details
Dental services are partially covered by HumanaChoice H5216-196 (PPO), offering a $750 annual maximum benefit for combined in- and out-of-network care. Most covered preventive and comprehensive services have no copay and no coinsurance, while Medicare-covered dental requires a $40 copay (no coinsurance), prosthodontics require a 30% coinsurance (no copay), and fluoride treatments, implants, orthodontics, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-196 (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B chemotherapy and other drugs are covered with no copay and no coinsurance to 20% coinsurance, while insulin is covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by HumanaChoice H5216-196 (PPO) with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
HumanaChoice H5216-196 (PPO) covers durable medical equipment and medical supplies with a 15% coinsurance and no copay, and prosthetic devices with a 20% coinsurance and no copay. Diabetic supplies are covered with a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes and inserts require a $10 copay and no coinsurance.
Diagnostic and Radiological Services See details
HumanaChoice H5216-196 (PPO) covers diagnostic and radiological services with prior authorization required, offering no copay for lab services, outpatient X-rays, and diagnostic radiological services. Diagnostic procedures and tests have a copay of $0 to $50 with no coinsurance, while therapeutic radiological services require a minimum $50 copay and a minimum 20% coinsurance.
Home Health Services See details
HumanaChoice H5216-196 (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-196 (PPO) offers Cardiac Rehabilitation Services with no copay, no coinsurance, and prior authorization required. However, in practice only some services are covered, as cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-196 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services covered by HumanaChoice H5216-196 (PPO) include acupuncture, over-the-counter (OTC) items, and a chronic illness meal benefit. Acupuncture requires a $40 copay and no coinsurance for up to 20 treatments per year, while OTC items and meal benefits are offered with no copay and no coinsurance.
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