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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 2025, 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 North Carolina. This plan received an overall rating of 3.5 out of 5 stars in 2025.
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 $66.00. 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 $350.00 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 $14000.00 (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 $14000.00 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) plan has a $350 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, Tier 1 drugs have a $12 copay at preferred pharmacies and $20 at standard pharmacies. For Tier 3 drugs, you pay 50% coinsurance regardless of the pharmacy. After your total drug costs reach $2000, you enter the catastrophic coverage phase, and you will pay nothing for Part D covered drugs.
Additional Benefits
The HumanaChoice H5216-211 (PPO) plan offers a range of benefits, including inpatient and outpatient hospital care, with varying copays depending on the service. The plan also covers primary care visits with no copay, specialist visits for $45, and offers additional coverage for hearing, vision, and dental services. Emergency services, ambulance, and home health services are also covered, with specific copays and coinsurance amounts.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $399 copay for days 1-6, and no copay for days 7-90, while additional days have no copay; for Inpatient Hospital Psychiatric, you will pay a $399 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
The HumanaChoice H5216-211 (PPO) plan covers outpatient services including outpatient hospital services with a copay between $0 and $450, observation services with a $399 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a copay between $45 and $100 for individual and group sessions, and outpatient blood services with no copay. All services require prior authorization.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-211 (PPO) plan, with a $80 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with both ground and air ambulance services requiring a $315 copay, and no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered. Emergency Services and Worldwide Emergency Coverage each have a $110 copay and no coinsurance, while Urgently Needed Services have a $45 copay and no coinsurance. Worldwide Urgent Coverage and Worldwide Emergency Transportation also have a $110 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-211 (PPO) covers primary care physician services with no copay. Chiropractic services have a $15 copay, while occupational therapy services have a $25 copay. Physician specialist services have a $45 copay. Mental health and psychiatric individual and group sessions each have a $45 copay. Physical therapy and speech-language pathology services have a $25 copay. Additional telehealth benefits have a copay of $0-$45. Opioid treatment program services have a copay between $45 and $100. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The HumanaChoice H5216-211 (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services are covered, but some services are not covered, including Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services. The plan also covers Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, EKG following Welcome Visit, and Fitness Benefit with no copay.
Hearing Services See details
The HumanaChoice H5216-211 (PPO) plan covers hearing exams with a $45 copay and Routine Hearing Exams, and Fitting/Evaluation for Hearing Aids with no copay. Prescription hearing aids are partially covered, with Prescription Hearing Aids (all types) covered with a copay between $699 and $999, while Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered, and OTC Hearing Aids are also not covered.
Vision Services See details
The HumanaChoice H5216-211 (PPO) plan covers vision services, including eye exams with a copay between $0 and $45. Eyewear is covered with no copay, and a combined maximum benefit of $100 per year. Contact lenses and eyeglasses (lenses and frames) are covered with no copay, while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-211 (PPO) plan covers Medicare Dental Services with a $45 copay, and covers Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), and Other Preventive Dental Services with no copay. This plan does not cover Fluoride Treatment, Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics, but does cover Adjunctive General Services with no copay.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-211 (PPO) plan, but require prior authorization. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment with a coinsurance and copay. Diabetic Supplies have a 10-20% coinsurance and no copay, and Diabetic Therapeutic Shoes/Inserts have a $10 copay. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures/tests with a copay between $0 and $120, and lab services with no copay. The plan also covers all radiological services, including diagnostic radiological services with a copay up to $325, therapeutic radiological services with a copay up to $45 and a coinsurance of at least 20%, and outpatient X-ray services with no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-211 (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-211 (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 under the HumanaChoice H5216-211 (PPO) plan, but require prior authorization. There is no copay for days 1-20, but there is a $214 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes acupuncture and a meal benefit. Acupuncture has a $45 copay and is limited to 20 treatments per year, while the meal benefit has no copay. However, over-the-counter items, Dual Eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing, case management, institution for mental disease services, services in an intermediate care facility, 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.
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