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HumanaChoice H5216-249 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-249 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-249 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-249 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Massachusetts. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-249 (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 H5216-249 (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 H5216-249 (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.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 $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 $7000.00 (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 $7000.00 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 H5216-249 (PPO) prescription drug plan features an annual drug deductible of $350. For Tier 1 preferred generic drugs, members pay no copay for a one-month or three-month supply at standard pharmacies and through preferred mail order. Tier 2 generic medications are also highly affordable, with standard pharmacy copays starting at $1 and no copay for a three-month supply filled via preferred mail order. For Tier 3 preferred brand drugs, copays start at $44 for a one-month supply at standard pharmacies and preferred mail order. Tier 4 non-preferred drugs carry a 43% coinsurance across standard pharmacies and mail order options for both one-month and three-month supplies. Tier 5 specialty tier drugs require a 29% coinsurance for a one-month supply at standard pharmacies, preferred mail order, and standard mail order.
Additional Benefits
The HumanaChoice H5216-249 (PPO) plan offers affordable healthcare coverage, featuring no copay for primary care doctor visits, preventive care services, and home health care. Specialist visits require a $30 copay, while emergency room services have a $130 copay that is waived upon hospital admission. For inpatient hospital stays, members pay a $350 daily copay for days one through six, with no copay required for days seven through 90. Additional benefits include routine dental, vision, and hearing services, featuring no copay for annual exams and up to 24 free one-way transportation trips to approved health locations. Dental care is covered up to a $1,000 annual limit, with most preventive services requiring no copay or coinsurance. For specialized needs, skilled nursing facility stays require a $10 daily copay for the first 20 days, while durable medical equipment and dialysis services are covered with a 20% coinsurance.
Inpatient Hospital See details
HumanaChoice H5216-249 (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $350 copay per day for days 1 through 6 and no copay for days 7 through 90 for acute and psychiatric stays. Unlimited additional acute days are covered at no copay, but additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
HumanaChoice H5216-249 (PPO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a $0 to $525 copay, observation services have a $350 copay per stay, and outpatient substance abuse sessions carry a $35 copay.
Partial Hospitalization See details
Partial hospitalization services are covered by the HumanaChoice H5216-249 (PPO) plan with a $35.00 copay and no coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
HumanaChoice H5216-249 (PPO) covers Medicare-covered ground and air ambulance services with a $335 copay and no coinsurance, requiring prior authorization. Transportation services are partially covered with no copay or coinsurance for up to 24 one-way trips per year to plan-approved health-related locations, though trips to any health-related location are not covered.
Emergency Services See details
Emergency services are covered by HumanaChoice H5216-249 (PPO) with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $130 copay per service and no coinsurance.
Primary Care See details
HumanaChoice H5216-249 (PPO) features primary care physician services with no copay and no coinsurance, while specialist visits require a $30 copay and no coinsurance. Physical, occupational, and speech therapies have a $15 copay and no coinsurance, whereas podiatry and routine or other chiropractic services are not covered. Mental health, psychiatric, and opioid treatment services are covered with a $35 copay and no coinsurance.
Preventive Services See details
HumanaChoice H5216-249 (PPO) provides preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, select screenings, and a memory fitness benefit. However, these benefits are only partially covered, as services such as health education, nutritional counseling, personal emergency response systems, and in-home safety assessments are not covered.
Hearing Services See details
HumanaChoice H5216-249 (PPO) covers hearing services with no coinsurance, featuring a $30 copay for Medicare-covered exams, no copay for routine annual exams, and no copay for OTC hearing aids. Prescription hearing aids are partially covered with a copay ranging from $0 to $299 and no coinsurance for up to two devices every three years, though inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered by HumanaChoice H5216-249 (PPO), featuring no coinsurance and no copay for one routine annual eye exam and one annual pair of eyeglasses or contact lenses. There is no deductible, but maximum annual limits of $75 for exams and $250 for eyewear apply, while other eye exams, individual lenses, individual frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-249 (PPO) partially covers dental services up to a $1,000 annual limit for both in-network and out-of-network care. Most covered preventive and comprehensive services feature no copay and no coinsurance, while Medicare-covered dental has a $30 copay with no coinsurance, and restorative and fixed prosthodontics require no copay and a 30% to 40% coinsurance. Fluoride, implants, orthodontics, maxillofacial prosthetics, and removable prosthodontics are not covered under this plan.
Home Infusion bundled Services See details
HumanaChoice H5216-249 (PPO) covers home infusion bundled services with no copay, subject to prior authorization and step therapy. Covered Medicare Part B chemotherapy, radiation, and other drugs require 0% to 20% coinsurance and no copay, while Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the HumanaChoice H5216-249 (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required to receive this covered benefit.
Medical Equipment See details
HumanaChoice H5216-249 (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, with prior authorization required for most medical equipment.
Diagnostic and Radiological Services See details
HumanaChoice H5216-249 (PPO) covers diagnostic and radiological services, both of which require prior authorization. Diagnostic services feature no coinsurance, with no copay for lab services and a $0 to $90 copay for procedures, while radiological services require no copay for X-rays and diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
HumanaChoice H5216-249 (PPO) covers Home Health Services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the HumanaChoice H5216-249 (PPO) plan with no coinsurance, though prior authorization is required. While some services are covered, in practice, cardiac rehabilitation, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are not covered, with copayments ranging from $15 to $25.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-249 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a daily copay of $10 for days 1 through 20 and $218 for days 21 through 100. Prior authorization is required, and additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
HumanaChoice H5216-249 (PPO) partially covers other services, offering acupuncture with a $30.00 copay and no coinsurance for up to 20 treatments per year, subject to prior authorization. Over-the-counter (OTC) items and chronic illness meal benefits are also covered with no copay and no coinsurance, though meals require prior authorization.
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