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HumanaChoice H5216-265 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-265 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-265 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-265 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Maricopa Pima Pinal. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-265 (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 H5216-265 (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 H5216-265 (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 $2.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $680.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $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 $8950.00 (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 $8950.00 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 H5216-265 (PPO) plan has a $300 deductible for prescription drugs. Once you meet your deductible, you will pay a copay or coinsurance for your prescriptions, depending on the drug tier and pharmacy. For example, in the initial coverage phase, you will pay $8.00 for preferred generic drugs at a standard pharmacy, while you will pay 40% coinsurance for preferred brand drugs. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you will pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-265 (PPO) plan offers a range of benefits, including inpatient hospital stays with a $325 copay for the first six days and no copay thereafter. Outpatient services have varying copays, while emergency services have a $125 copay, and primary care visits are available with no copay. Preventive services, such as an annual physical, are covered with no copay, and vision services, including routine eye exams and eyewear, are available with no copay. The plan also includes hearing exams with a $35 copay, as well as dental services, and a $2,000 annual maximum. Additional benefits include home health services with no copay, home infusion bundled services with a $35 copay, and ambulance services with copays ranging from $315-$630. Medical equipment is covered with a coinsurance, and diagnostic and radiological services have varying copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a $325 copay for days 1-6, and no copay for days 7-90; additional days have no copay. For Inpatient Hospital Psychiatric, you'll pay a $325 copay for days 1-6, and no copay for days 7-90. Non-Medicare-covered stay and upgrades for Inpatient Hospital-Acute, as well as 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 of $0 - $350, observation services with a $325 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services have a $35 copay for both individual and group sessions, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-265 (PPO) plan, and requires prior authorization. There is a $100 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the HumanaChoice H5216-265 (PPO) plan. Ground Ambulance Services have a $315 copay, while Air Ambulance Services have a $630 copay, and there is no coinsurance for either. 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 H5216-265 (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Services have a $125 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation. There is no coinsurance for any of these services.
Primary Care See details
HumanaChoice H5216-265 (PPO) offers primary care services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $35 copay, physician specialist services with a $35 copay, and mental health specialty services with a $35 copay. The plan also covers podiatry services with a $35 copay, other health care professional services with a copay from $0-$35, psychiatric services with a $35 copay, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a copay from $0-$55, and opioid treatment program services with a $35 copay.
Preventive Services See details
The HumanaChoice H5216-265 (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, such as health education, in-home safety assessments, and others are not covered. Kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit have no copay.
Hearing Services See details
Hearing Services include hearing exams with a $35 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 $699 and $999, while inner ear, outer ear, and over-the-ear prescription hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay of $0-$35, while routine eye exams have no copay, and eyewear has no copay. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-265 (PPO) plan covers Medicare Dental Services with a $35 copay, Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Other Preventive Dental Services and Restorative Services with a copay of $25, and Adjunctive General Services with no copay. Fluoride Treatment, Endodontics, Periodontics, Prosthodontics (removable, fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered. There is a $2,000 annual maximum for dental services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. 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 with a coinsurance of 20%. Prior authorization is required for this benefit.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME) with a 10% coinsurance, Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have a coinsurance between 10% and 20% and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, lab services with no copay, and outpatient x-ray services with no copay. Diagnostic procedures and tests have a copay between $0 and $125, and therapeutic radiological services have a copay up to $50 and coinsurance up to 20%.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-265 (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 not covered by the HumanaChoice H5216-265 (PPO) plan. This includes Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-265 (PPO) plan, but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214; there is no coinsurance.
Other Services See details
Other Services include acupuncture, which has a $35 copay, and a meal benefit with 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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