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HumanaChoice H5216-280 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-280 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-280 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-280 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select counties in Georgia and South Carolina. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-280 (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 H5216-280 (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 H5216-280 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $40.00. 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 $590.00 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 $14000.00 (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 $14000.00 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 H5216-280 (PPO) plan has a $590.00 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, in the initial coverage phase, you will pay a $20.00 copay for preferred generic drugs at standard and mail-order pharmacies. For preferred brand drugs, you will pay 33% coinsurance at all pharmacies. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-280 (PPO) plan offers a wide range of benefits, including no copay for primary care, specialist visits, hearing exams, vision exams, and many dental services. This plan also covers inpatient hospital stays with a copay, outpatient services with varying copays, and emergency services with a $110 copay. This plan also includes coverage for ambulance services, home health services, and skilled nursing facility stays, along with additional benefits such as acupuncture and a meal benefit. While the plan offers extensive coverage, some services like cardiac rehabilitation, certain hearing aids, and specific vision and dental procedures are not covered.
Inpatient Hospital See details
Inpatient Hospital services, including those not usually covered by Medicare, are covered by the HumanaChoice H5216-280 (PPO) plan. For Inpatient Hospital-Acute, you'll pay a $399 copay for days 1-6, and no copay for days 7-90, while for Inpatient Hospital Psychiatric, you'll pay a $399 copay for days 1-5 and no copay for days 6-90. Additional Days for Inpatient Hospital-Acute has no copay for days 91-999, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered. Outpatient Hospital Services have a copay between $0 and $450, while Observation Services have a copay of $399. Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay, while Outpatient Substance Abuse Services have a copay between $45 and $100 for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-280 (PPO) plan, and requires prior authorization. The copay for this service is $80.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the HumanaChoice H5216-280 (PPO) plan. Ground and Air Ambulance Services have a $315 copay, and there is no coinsurance, while 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 H5216-280 (PPO) plan. Emergency Services have a $110 copay, and Urgently Needed Services have a $45 copay; both have no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $110 copay, with no coinsurance.
Primary Care See details
Under the HumanaChoice H5216-280 (PPO) plan, primary care physician and specialist services have no copay, while chiropractic services have a $15 copay and occupational therapy services have a $25 copay. Mental health and psychiatric individual and group sessions have a $45 copay, and physical therapy and speech-language pathology services have a $25 copay. Additional telehealth benefits have a copay between $0 and $45, and opioid treatment program services have a copay between $45 and $100. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The HumanaChoice H5216-280 (PPO) plan covers preventive services, including an annual physical exam with no copay. The plan also covers additional preventive services, including Fitness Benefit, Kidney Disease Education Services, and Other Preventive Services, with no copay. Some other preventive services like Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing exams, including routine hearing exams and fitting/evaluation for hearing aids, are covered with no copay. Prescription hearing aids are covered, with a copay between $699 and $999 for all types, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
The HumanaChoice H5216-280 (PPO) plan covers vision services with no copay for eye exams, including routine eye exams. Eyewear is also covered, with no copay for contact lenses and eyeglasses (lenses and frames), but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered, with a $1,000 maximum benefit per year 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 are covered with no copay. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
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%. 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 with a coinsurance of 20%. Prior authorization is required for coverage.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance, while Diabetic Equipment has varying copays and coinsurance. Durable Medical Equipment for use outside the home is not covered. Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have a copay between $0 and $120, Lab Services have no copay, Diagnostic Radiological Services have a copay up to $325, and Therapeutic Radiological Services have a 20% coinsurance and no copay. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by HumanaChoice H5216-280 (PPO) with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-280 (PPO) does not cover cardiac rehabilitation services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services require prior authorization and are covered by HumanaChoice H5216-280 (PPO). There is no copay for days 1-20, and a $214 copay for days 21-100.
Other Services See details
The HumanaChoice H5216-280 (PPO) plan covers acupuncture with no copay and a limit of 20 treatments per year, as well as a meal benefit with no copay. Over-the-counter items, Dual Eligible SNPs, 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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