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HumanaChoice H5216-263 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-263 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-263 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-263 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Greater Arizona. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-263 (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 H5216-263 (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 H5216-263 (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 $1.00. 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 $300.00 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 $8750.00 (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 $8750.00 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 H5216-263 (PPO) medicare plan features an Enhanced Alternative drug benefit with an annual prescription drug deductible of $300.00. During the initial coverage phase, 30-day copays at standard pharmacies and preferred mail-order services are $8.00 for preferred generic drugs and $47.00 for standard generics. For higher tiers, you will pay a 50% coinsurance for preferred brands and a 29% coinsurance for non-preferred drugs until total drug costs reach $2,100.00. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for covered Part D prescriptions. Additionally, individuals who qualify for the low-income subsidy can receive a premium reduction with no copay for their Part D drug costs.
Additional Benefits
The HumanaChoice H5216-263 (PPO) plan offers comprehensive medical coverage with no copay for primary care visits, preventive services, and home health care. For inpatient hospital stays, members pay a $325 daily copay for the first five days and no copay for days six through 90. Outpatient services and emergency care are also covered, featuring a $130 copay for emergency room visits and no copay for ambulatory surgical center services. This plan also includes valuable everyday benefits, such as routine dental, vision, and hearing exams with no copay, alongside a $350 annual allowance for eyewear and a $1,750 limit for dental services. While medical equipment and prosthetics require a 15% to 20% coinsurance, members can enjoy no copay on covered over-the-counter items and meal benefits. Additionally, specialist visits are highly accessible with a predictable $35 copay and no coinsurance.
Inpatient Hospital See details
HumanaChoice H5216-263 (PPO) covers inpatient acute and psychiatric hospital stays with a $325 daily copay for days 1 to 5, no copay for days 6 to 90, and no coinsurance. The benefit is partially covered, as upgrades and non-Medicare-covered stays for acute care, as well as additional days and non-Medicare-covered stays for psychiatric care, are not covered.
Outpatient Services See details
Outpatient services are covered by HumanaChoice H5216-263 (PPO) with no coinsurance, offering no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $375, observation services have a $325 copay per stay, and outpatient substance abuse sessions carry a copay of $25 to $35.
Partial Hospitalization See details
HumanaChoice H5216-263 (PPO) covers partial hospitalization services with a $35 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-263 (PPO) partially covers ambulance and transportation services, as transportation services to health-related locations are not covered. Covered ground ambulance services require a $335 copay and no coinsurance, while air ambulance services have a $630 copay and no coinsurance.
Emergency Services See details
HumanaChoice H5216-263 (PPO) covers emergency services 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 with no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-263 (PPO) covers primary care physician visits with no copay and no coinsurance, whereas specialist and therapy visits require a $35 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance, as routine chiropractic care is not covered. Other benefits, including mental health, psychiatry, podiatry, and telehealth services, feature copays ranging from $0 to $50 and no coinsurance.
Preventive Services See details
HumanaChoice H5216-263 (PPO) partially covers preventive services, offering covered services like annual physical exams, smoking cessation, and fitness benefits with no copay or coinsurance. However, several supplemental services, including health education, weight management programs, and personal emergency response systems, are not covered.
Hearing Services See details
HumanaChoice H5216-263 (PPO) covers hearing exams and hearing aids with no coinsurance, offering routine exams, fitting evaluations, and OTC hearing aids with no copay. Medicare-covered exams require a $35 copay, and prescription hearing aids are partially covered with a $599 to $899 copay for up to two devices per year, though inner ear, outer ear, and over-the-ear models are not covered.
Vision Services See details
HumanaChoice H5216-263 (PPO) covers routine eye exams with no copay and other eye exams with a $0 to $35 copay, with no deductible or coinsurance required. Eyewear is partially covered with no copay, no deductible, and no coinsurance up to a $350 annual limit for contact lenses and eyeglasses (lenses and frames), though individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-263 (PPO) partially covers dental services up to a $1,750 annual limit, offering no copay or coinsurance for cleanings, exams, x-rays, and most restorative care, a $35 copay (no coinsurance) for Medicare-covered dental, and a 30% coinsurance (no copay) for prosthodontics. Fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-263 (PPO) covers home infusion bundled services with prior authorization, offering chemotherapy, radiation, and other Part B drugs with no copay and coinsurance ranging from no coinsurance to 20%. Covered Part B insulin drugs require a $35 copay alongside coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
HumanaChoice H5216-263 (PPO) covers Dialysis Services with a 20% coinsurance and no copay. Prior authorization is required for these covered services.
Medical Equipment See details
HumanaChoice H5216-263 (PPO) covers durable medical equipment (DME) with a 15% coinsurance and no copay, and prosthetic devices with a 20% coinsurance. Diabetic supplies are covered with a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes and inserts require a $10 copay.
Diagnostic and Radiological Services See details
HumanaChoice H5216-263 (PPO) covers diagnostic and radiological services with no copay or coinsurance for lab services and outpatient X-rays. Diagnostic tests and diagnostic radiology require copays ranging from $0 to $300 with no coinsurance, while therapeutic radiology requires a $50 copay and 20% coinsurance.
Home Health Services See details
Home health services are covered by HumanaChoice H5216-263 (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-263 (PPO) indicates that some services are covered under Cardiac Rehabilitation Services, but in practice, Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are not covered. As these services are not covered by the plan, there are no applicable copays or coinsurance.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-263 (PPO) partially covers Skilled Nursing Facility (SNF) services, requiring a $10 daily copay for days 1 to 20 and a $218 daily copay for days 21 to 100, with no coinsurance. Prior authorization is required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
HumanaChoice H5216-263 (PPO) provides partial coverage for other services, though Dual Eligible SNPs with Highly Integrated Services are not covered. Acupuncture requires a $35 copay and no coinsurance, while meal benefits and over-the-counter items are offered with no copay and no coinsurance.
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