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HumanaChoice H5216-255 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-255 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-255 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-255 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in MT. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-255 (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 H5216-255 (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 H5216-255 (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 $3.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $675.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $400.00 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 $8900.00 (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 $8900.00 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 H5216-255 (PPO) plan has a $400 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, for preferred generic drugs, you'll pay a $10 copay at preferred and mail-order pharmacies, and a $20 copay at a standard pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs.
Additional Benefits
The HumanaChoice H5216-255 (PPO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with varying copays, and emergency services with copays. The plan also provides coverage for primary care, preventive services, and home health services with no copay. Additional benefits include hearing and vision services with copays, dental services with no copay for many procedures, and medical equipment with coinsurance. The plan also covers services like ambulance, partial hospitalization, and skilled nursing facility stays with copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered under HumanaChoice H5216-255 (PPO), with a copay of $430 for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Additional Days for Inpatient Hospital-Acute has no copay for days 91-999, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services have a copay between $0 and $430, while Observation Services have a $430 copay. Ambulatory Surgical Center Services and Outpatient Blood Services have no copay, and Outpatient Substance Abuse Services have a copay between $40 and $95 for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will pay a $105 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-255 (PPO) plan. Ground Ambulance Services have a $315 copay, and Air Ambulance Services have a $1250 copay, with no coinsurance for either. 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 by the HumanaChoice H5216-255 (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay. There is no coinsurance for any of these services.
Primary Care See details
The HumanaChoice H5216-255 (PPO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $45 copay, physician specialist services with a $55 copay, and mental health specialty services with no copay for individual or group sessions. It also covers physical therapy and speech-language pathology services with a $45 copay, additional telehealth benefits with a copay ranging from $0 to $55, and opioid treatment program services with a copay between $40 and $95. Routine chiropractic care is not covered, and podiatry services are also not covered.
Preventive Services See details
The HumanaChoice H5216-255 (PPO) plan covers preventive services with no copay for the annual physical exam. Additional preventive services are not covered. Kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following the Welcome Visit are covered with no copay.
Hearing Services See details
Hearing Services are partially covered by the HumanaChoice H5216-255 (PPO) plan, with a $55 copay for hearing exams, but routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids are not covered. OTC hearing aids are also not covered.
Vision Services See details
The HumanaChoice H5216-255 (PPO) plan covers eye exams with a copay between $0 and $55, but routine eye exams are not covered. Eyewear is covered with no copay, but contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-255 (PPO) plan covers dental services with a $2,000 annual maximum benefit for both in-network and out-of-network services. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery have no copay, while fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
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 H5216-255 (PPO) plan, and require prior authorization. The coinsurance for this service is 20%.
Medical Equipment See details
Medical equipment is covered, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment. Durable Medical Equipment has a 4% coinsurance and requires authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetic devices have a 4% coinsurance, and medical supplies have a 4% coinsurance. 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, diagnostic procedures/tests with a copay between $0 and $95, lab services with no copay, and outpatient X-ray services with no copay. Diagnostic Radiological Services have a copay of at most $430, and Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-255 (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the HumanaChoice H5216-255 (PPO) plan, but none of the sub-services are covered. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-255 (PPO) plan, but require prior authorization. For days 1-20 and 66-100, there is no copay, and for days 21-65, the copay is $214.
Other Services See details
The HumanaChoice H5216-255 (PPO) plan covers acupuncture with a $55 copay and a limit of 20 treatments per year, and also covers a meal benefit with no copay. Other services such as 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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