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HumanaChoice H5216-226 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-226 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-226 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-226 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Kentucky and Indiana. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-226 (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 H5216-226 (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 H5216-226 (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 $24.00. 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 $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 $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 H5216-226 (PPO) plan has a $200 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, you will pay a $10 copay for preferred generic drugs at a standard or preferred mail pharmacy, and 50% coinsurance for preferred brand drugs. After your total drug costs reach $2000, you will enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-226 (PPO) plan offers a range of benefits with varying costs. You'll have no copay for primary care visits, preventive services, and many dental services, as well as home health services. Costs for other services include copays for inpatient hospital stays, outpatient services, specialist visits, and hearing exams, along with coinsurance for dialysis and medical equipment.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a copay of $470 for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute, and a copay of $470 for days 1-4 and no copay for days 5-90 for Inpatient Hospital Psychiatric. Additional days for Inpatient Hospital-Acute have no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are also not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $470, observation services with a $470 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a copay between $45 and $100 for individual or group sessions, and outpatient blood services with no copay. Prior authorization is required for all of these services.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-226 (PPO) plan, but requires prior authorization. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-226 (PPO) plan. Ground and Air Ambulance Services have a $315 copay, with no coinsurance, while 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 by the HumanaChoice H5216-226 (PPO) plan. Emergency Services has a $110 copay with no coinsurance, Urgently Needed Services has a $45 copay with no coinsurance, and Worldwide Emergency Services has a $110 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, with no coinsurance.
Primary Care See details
The HumanaChoice H5216-226 (PPO) plan covers primary care physician services with no copay. Chiropractic services have a $15 copay, but routine care is not covered. Occupational therapy services have a $35 copay. Physician specialist services have a $50 copay. Individual and group sessions for mental health and psychiatric services have a $45 copay. Physical therapy and speech-language pathology services have a $35 copay. Additional telehealth benefits have a copay between $0 and $50. Opioid treatment program services have a copay between $45 and $100.
Preventive Services See details
Preventive services include 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 also have no copay. However, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and other services are not covered.
Hearing Services See details
The HumanaChoice H5216-226 (PPO) plan covers hearing exams with a $50 copay, and routine hearing exams and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $699 and $999, but prescription hearing aids for the inner, outer, or over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services offer eye exams with a copay of $0-$50, and no coinsurance. Eyewear is covered with no copay and no coinsurance, but contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-226 (PPO) plan offers dental services with a $1,500 annual maximum. Medicare Dental Services require a $50 copay, while Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Other Preventive Dental Services, Restorative Services, and Prosthodontics (fixed) have no copay, but Restorative Services and Prosthodontics (fixed) have 30-40% coinsurance, and Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), and Other Preventive Dental Services have limitations on the number of visits. Fluoride Treatment, Prosthodontics (removable), Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
The HumanaChoice H5216-226 (PPO) plan covers Home Infusion bundled Services, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-226 (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 19% coinsurance and prior authorization required, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have a coinsurance between 10% and 20% and no copay, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services and lab services with a copay of $0-$105, and outpatient x-ray services with no copay. Diagnostic Radiological Services have a copay of at most $720, and Therapeutic Radiological Services have a coinsurance of at most 20% and a copay of at most $45.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-226 (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-226 (PPO) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the HumanaChoice H5216-226 (PPO) plan, requiring prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services include acupuncture and a meal benefit. Acupuncture has a $50 copay and is limited to 20 treatments per year. The meal benefit has no copay. Over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, 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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