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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 2026, 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 2026.
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 $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 $615.00 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 $9500.00 (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 $9500.00 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) Medicare plan offers an Enhanced Alternative drug benefit with an annual prescription drug deductible of $615.00. After meeting this deductible, you will pay a $5.00 copay for Tier 1 preferred generics at standard pharmacies and preferred mail order, or a $47.00 copay for Tier 2 standard generics. For brand-name and non-preferred drugs, the plan requires a 39% coinsurance for Tier 3 preferred brands and a 25% coinsurance for Tier 4 non-preferred drugs. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for covered Medicare Part D drugs. Additionally, beneficiaries who qualify for the low-income subsidy, also known as Extra Help, will have no copays for their Part D coverage.
Additional Benefits
The HumanaChoice H5216-265 (PPO) plan offers affordable access to essential medical services, featuring no copay or coinsurance for primary care visits, covered preventive services, and home health care. For specialist visits, patients will pay a copay ranging from $25 to $35, while emergency room visits carry a $130 copay, which is waived if hospitalized within 24 hours. Inpatient hospital stays require a $350 daily copay for the first six days, after which there is no copay or coinsurance for days seven through ninety. This plan also includes valuable dental, vision, and hearing benefits, with no copay for routine eye exams, covered eyewear up to a $250 annual limit, and routine hearing services. Dental care is covered up to a $2,000 annual limit, offering preventive services with no copay and restorative services with a 30% to 40% coinsurance. For durable medical equipment and diabetic supplies, members can expect coinsurance rates ranging from 10% to 20% with no copay.
Inpatient Hospital See details
HumanaChoice H5216-265 (PPO) partially covers inpatient hospital services, requiring a $350 copay per day for days 1 through 6 and no copay or coinsurance for days 7 through 90 for acute and psychiatric stays. Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-265 (PPO) covers outpatient services with no coinsurance and no deductible, offering ambulatory surgical center and blood services with no copay. Outpatient hospital services have a copay ranging from $0 to $350, observation services cost a $350 copay per stay, and outpatient substance abuse sessions require a $25 to $35 copay.
Partial Hospitalization See details
HumanaChoice H5216-265 (PPO) covers partial hospitalization benefits with a $35.00 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
HumanaChoice H5216-265 (PPO) partially covers ambulance and transportation services, as transportation services to plan-approved and any health-related locations are not covered. Covered ground ambulance services require a $335 copay and air ambulance services require a $630 copay, both with no coinsurance.
Emergency Services See details
HumanaChoice H5216-265 (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are hospitalized within 24 hours. Urgently needed services are available with a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-265 (PPO) covers primary care physician services with no copay and no coinsurance. Specialist visits, therapy sessions, and mental health services require copays ranging from $25 to $35 with no coinsurance, while chiropractic benefits are only partially covered because routine chiropractic care is excluded.
Preventive Services See details
Preventive services are partially covered by HumanaChoice H5216-265 (PPO), featuring no copay and no coinsurance for covered options like annual physical exams, kidney disease education, and glaucoma screenings. However, additional services such as health education, in-home safety assessments, personal emergency response systems, and fitness benefits are not covered.
Hearing Services See details
Hearing services are partially covered by HumanaChoice H5216-265 (PPO) with no coinsurance. Routine exams, fittings, and OTC hearing aids have no copay, Medicare-covered exams require a $35 copay, and covered prescription hearing aids carry a $699 to $999 copay, though inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
HumanaChoice H5216-265 (PPO) offers partially covered vision services with no deductibles or coinsurance, featuring no copay for yearly routine eye exams and covered eyewear up to a $250 annual limit. Other eye exams carry a copay of $0 to $35, while separate eyeglass lenses, frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by HumanaChoice H5216-265 (PPO) up to a $2,000 annual limit, excluding fluoride treatment, removable prosthodontics, maxillofacial prosthetics, implant services, and orthodontics. Covered preventive services, exams, endodontics, and oral surgery have no copay and no coinsurance, while Medicare dental services require a $35 copay and no coinsurance. Restorative and fixed prosthodontics require a 30% to 40% coinsurance and no copay.
Home Infusion bundled Services See details
Home infusion bundled services are covered by HumanaChoice H5216-265 (PPO) with prior authorization, featuring no copay and no coinsurance to 20% coinsurance for chemotherapy, radiation, and other Part B drugs. Part B insulin drugs are also covered under this benefit with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
HumanaChoice H5216-265 (PPO) covers Dialysis Services with a 20% coinsurance and no copay. Prior authorization is required for these covered services.
Medical Equipment See details
HumanaChoice H5216-265 (PPO) covers durable medical equipment (DME) with a 15% coinsurance and no copay. The plan also covers prosthetic devices at a 20% coinsurance, medical supplies at a 15% coinsurance, and diabetic supplies at a 10% to 20% coinsurance with no copay, while diabetic therapeutic shoes or inserts require a $10 copay.
Diagnostic and Radiological Services See details
HumanaChoice H5216-265 (PPO) covers diagnostic and radiological services, requiring prior authorization for both categories. Lab services and outpatient X-rays have no copay or coinsurance, while diagnostic procedures cost a $0 to $125 copay, diagnostic radiology costs a $0 to $300 copay, and therapeutic radiology requires a $50 copay and 20% coinsurance.
Home Health Services See details
Home Health Services are covered by HumanaChoice H5216-265 (PPO) with no copay and no coinsurance. Prior authorization is required to access these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered in practice under the HumanaChoice H5216-265 (PPO) plan. Although the benefit is technically listed, all individual sub-services—including cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services—are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-265 (PPO) partially covers Skilled Nursing Facility (SNF) services, which require a $10 copay for days 1-20 and a $218 copay for days 21-100, with no coinsurance. Prior authorization is required, and additional days beyond Medicare-covered SNF stays are not covered.
Other Services See details
Other Services are partially covered by HumanaChoice H5216-265 (PPO), excluding Dual Eligible SNPs with Highly Integrated Services. Covered benefits include up to 20 acupuncture treatments per year for a $35 copay and no coinsurance, as well as over-the-counter items and meal benefits for no copay and no coinsurance.
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