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HumanaChoice H5216-211 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-211 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-211 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-211 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in North Carolina. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-211 (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 H5216-211 (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 H5216-211 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $54.00. 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 $500.00 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:
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Drug Coverage
The HumanaChoice H5216-211 (PPO) Medicare plan features an annual prescription drug deductible of $615. For Tier 1 preferred generic drugs, you will pay no copay at standard pharmacies and through preferred mail order for both 1-month and 3-month supplies. Tier 2 generic drugs are also highly affordable, starting at a $5 copay for a 1-month supply at standard pharmacies and featuring no copay for a 3-month supply when using preferred mail order. For Tier 3 preferred brand drugs, copays start at $47 for a 1-month supply at standard pharmacies and mail order. Tier 4 non-preferred drugs require a 38% coinsurance across standard pharmacies and mail order services. Specialty drugs in Tier 5 carry a 25% coinsurance for a 1-month supply, helping you plan for higher-cost medication needs.
Additional Benefits
The HumanaChoice H5216-211 (PPO) plan offers comprehensive coverage for core medical needs, featuring no copay and no coinsurance for primary care visits and preventive services. Specialist visits and urgent care require a $40 copay, while emergency room visits carry a $115 copay. Inpatient hospital stays require a $375 daily copay for the first several days, after which there is no copay. Additionally, members benefit from dental, vision, and hearing coverage, with no copay for routine exams and cleanings. Home health services also feature no copay, while dialysis and durable medical equipment require a 20% coinsurance with no copay. Skilled nursing facility care is covered with no copay for the first 20 days, followed by a daily copay for longer stays.
Inpatient Hospital See details
HumanaChoice H5216-211 (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring prior authorization. Acute stays require a $375 daily copay for days 1-7 (no copay for days 8-999), while psychiatric stays require a $375 daily copay for days 1-5 (no copay for days 6-90); however, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-211 (PPO) covers outpatient services with no coinsurance, offering no copays for ambulatory surgical center and outpatient blood services. Outpatient hospital services carry a copay of $0 to $450, observation services require a $375 copay per stay, and outpatient substance abuse sessions have a $35 copay.
Partial Hospitalization See details
HumanaChoice H5216-211 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to receive these covered services.
Ambulance and Transportation Services See details
HumanaChoice H5216-211 (PPO) covers Medicare-approved ground and air ambulance services with a $335 copay and no coinsurance, though prior authorization is required. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
HumanaChoice H5216-211 (PPO) emergency services are covered with a $115 copay and no coinsurance, with the copay waived if admitted to the hospital within 24 hours. Urgently needed care has a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are available for a $115 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-211 (PPO) offers primary care physician services with no copay and no coinsurance, and specialist visits with a $40 copay and no coinsurance. Physical, occupational, and speech therapy require a $25 copay and no coinsurance, while mental health and psychiatric sessions have a $35 copay and no coinsurance. Some chiropractic services are covered with a $15 copay and no coinsurance, but routine and other chiropractic services are not covered, and podiatry services are not covered.
Preventive Services See details
HumanaChoice H5216-211 (PPO) offers partially covered preventive services with no copay and no coinsurance for covered care such as annual physical exams, kidney disease education, glaucoma screenings, diabetes self-management training, digital rectal exams, EKGs, and memory fitness. 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, re-admission prevention, wigs for hair loss from chemotherapy, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation counseling, enhanced disease management, telemonitoring, remote access technologies, home and bathroom safety modifications, and counseling.
Hearing Services See details
HumanaChoice H5216-211 (PPO) covers hearing services, featuring a $40 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for annual routine exams and fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and a $699 to $999 copay for up to two aids per year, though OTC hearing aids and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
HumanaChoice H5216-211 (PPO) offers partially covered vision services with no deductible, featuring no coinsurance and copays ranging from $0 to $40 for eye exams, and no copay or coinsurance for covered eyeglasses or contact lenses. Routine exams have a $75 annual limit and covered eyewear has a $100 annual limit, but other eye exams, separate eyeglass lenses, separate frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-211 (PPO) dental services are partially covered, with fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics excluded from coverage. Medicare-covered dental services require a $40 copay and no coinsurance, while other covered preventive and comprehensive dental services are available with no copay and no coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered by HumanaChoice H5216-211 (PPO) with no copay, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs carry a 0% to 20% coinsurance, while Medicare Part B insulin is available for a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-211 (PPO) plan with no copay and a 20% coinsurance, although prior authorization is required.
Medical Equipment See details
HumanaChoice H5216-211 (PPO) covers durable medical equipment, prosthetics, and medical supplies 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.
Diagnostic and Radiological Services See details
HumanaChoice H5216-211 (PPO) covers diagnostic and radiological services, offering lab and outpatient X-ray services with no copay. Diagnostic procedures and tests carry no coinsurance and a copay of $0 to $120, while therapeutic radiological services require a minimum $40 copay and 20% coinsurance.
Home Health Services See details
Home health services are covered under the HumanaChoice H5216-211 (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by HumanaChoice H5216-211 (PPO) with no coinsurance, but some services are covered while standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) rehabilitation are not covered. These rehabilitation services require prior authorization and carry copayments ranging from $20 to $30.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by HumanaChoice H5216-211 (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, and while a prior three-day inpatient hospital stay is not required for admission, additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
HumanaChoice H5216-211 (PPO) partially covers other services, featuring acupuncture coverage with a $40 copay, no coinsurance, and a limit of 20 treatments per year with prior authorization. Supplemental benefits such as over-the-counter items and meal benefits are not covered.
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