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HumanaChoice H5216-223 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-223 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-223 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-223 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Colorado, New Mexico. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-223 (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 H5216-223 (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 H5216-223 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $7.00. 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 $750.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $200.00 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 $10000.00 (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 $10000.00 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 H5216-223 (PPO) plan has a $200 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance for your medications, depending on the drug tier and where you purchase them. For example, for preferred generic drugs, you will pay a $12 copay at preferred pharmacies and via mail order, and a $20 copay at standard pharmacies. For preferred brand drugs, you will pay 45% coinsurance.
Additional Benefits
The HumanaChoice H5216-223 (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay of $300 for the first six days, while outpatient services include copays from $0 to $300. Many services, such as primary care visits, preventive services, and routine hearing exams, have no copay, while others, such as specialist visits and dental services, have copays ranging from $20 to $45. This plan also covers emergency services, ambulance services, and home health services, each with its own cost-sharing structure. Hearing aids, vision services, and dental services are included with specific copays or no copay, and some services like durable medical equipment and dialysis have coinsurance. Prior authorization is required for some services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a $300 copay for days 1-6 and no copay for days 7-90 for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Additional days for Inpatient Hospital-Acute have no copay for days 91-999, while Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay between $0 and $300, observation services with a $300 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a $45 copay for both individual and group sessions, and outpatient blood services with no copay. This plan also waives the three-pint deductible for outpatient blood services.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-223 (PPO) plan, with a $100 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-223 (PPO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a $315 copay, while air ambulance services have a $630 copay, and there is 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 H5216-223 (PPO) plan. Emergency Services have a $125 copay and no coinsurance, Urgently Needed Services have a $55 copay and no coinsurance, and Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay and no coinsurance.
Primary Care See details
The HumanaChoice H5216-223 (PPO) plan covers Primary Care Physician Services with no copay, and Chiropractic Services with a $20 copay. The plan also covers Occupational Therapy Services with a $45 copay, Physician Specialist Services with a $45 copay, and Mental Health Specialty Services with a $45 copay for individual and group sessions. Additionally, Podiatry Services have a $45 copay, Other Health Care Professional services have a copay between $0 and $45, Psychiatric Services have a $45 copay for individual and group sessions, Physical Therapy and Speech-Language Pathology Services have a $45 copay, Additional Telehealth Benefits have a copay between $0 and $55, and Opioid Treatment Program Services have a $45 copay.
Preventive Services See details
The HumanaChoice H5216-223 (PPO) plan covers preventive services, including an annual physical exam with no copay. Kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit are covered with no copay. However, health education, in-home safety assessments, personal emergency response systems, and other services are not covered.
Hearing Services See details
HumanaChoice H5216-223 (PPO) covers hearing exams for a $45 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $399 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 H5216-223 (PPO) plan covers vision services, including eye exams with a copay between $0 and $45, and eyewear with no copay. Contact lenses and eyeglasses (lenses and frames) are covered with no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services under the HumanaChoice H5216-223 (PPO) plan include a $45 copay for Medicare Dental Services, and no copay for Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Other Preventive Dental Services, and Prophylaxis (Cleaning), with a maximum plan benefit of $2000 per year. Fluoride Treatment, Endodontics, Prosthodontics, removable, Maxillofacial Prosthetics, Implant Services, Prosthodontics, fixed, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-223 (PPO) plan. You will pay 20% coinsurance for dialysis services.
Medical Equipment See details
Medical equipment benefits include Durable Medical Equipment (DME) with 18% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have a 10-20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services and radiological services. Diagnostic Procedures/Tests have a copay of at most $100, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $300, Therapeutic Radiological Services have a copay of at most $40 and a coinsurance of 20% at minimum, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-223 (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
Cardiac Rehabilitation Services are covered, but the plan does not cover any of the sub-services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, with a copay of $10 for days 1-20 and $214 for days 21-100. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered. Prior authorization is required.
Other Services See details
Other Services include acupuncture with a $45 copay, and a meal benefit with no copay; however, over-the-counter items, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and several other services are not covered. Acupuncture is limited to 20 treatments per year.
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