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HumanaChoice H5216-289 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-289 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-289 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-289 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Connecticut. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-289 (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 H5216-289 (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 H5216-289 (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 has a $335.00 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 $6950.00 (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 $6950.00 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 H5216-289 (PPO) plan has a $300 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For generic drugs, the copay ranges from $5 to $47 depending on the pharmacy. For preferred brand drugs, you pay 45% coinsurance, and for non-preferred drugs, you pay 29% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-289 (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services have copays that vary by service type. Emergency, primary care, and preventive services are covered with copays ranging from $0 to $125. This plan also includes coverage for hearing, vision, and dental services, with copays and varying coverage for hearing aids and eyewear. Additional benefits include ambulance services, home health, and medical equipment with copays or coinsurance. Dialysis Services have 20% coinsurance, and Skilled Nursing Facility (SNF) services have copays for covered days.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you'll pay a $335 copay for days 1-7, and no copay for days 8-90, with no coinsurance. For Inpatient Hospital Psychiatric, you'll pay a $311 copay for days 1-7, and no copay for days 8-90, with no coinsurance.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay of $40 to $660, Observation Services with a copay of $335, Ambulatory Surgical Center (ASC) Services with a copay of $240, and Outpatient Substance Abuse Services with a copay of $35 to $100 for individual or group sessions. Outpatient Blood Services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-289 (PPO) plan, with a $55 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-289 (PPO) plan. Ground and air ambulance services have a copay of $315.00, and transportation services to a plan-approved health-related location have no copay for up to 24 one-way trips per year.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services and Urgently Needed Services, are covered under the HumanaChoice H5216-289 (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services have a $55 copay, and all services have no coinsurance.
Primary Care See details
The HumanaChoice H5216-289 (PPO) plan offers coverage for primary care physician services with no copay, chiropractic services with a $15 copay, and occupational therapy services with a $40 copay. Physician specialist services have a $40 copay, and physical therapy and speech-language pathology services have a $40 copay. Additional telehealth benefits have a copay between $0 and $55, and Opioid Treatment Program Services have a copay between $35 and $100. Mental Health and Psychiatric services are covered, with a $40 copay for individual and group sessions. Routine chiropractic care is not covered, and Podiatry Services are not covered.
Preventive Services See details
Preventive services include Medicare-covered and additional preventive services with no copay for annual physical exams. Additional services such as Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), and other services are not covered.
Hearing Services See details
HumanaChoice H5216-289 (PPO) covers hearing services, including hearing exams with a $40 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are partially covered, with a copay of $399-$699 for all types, while inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are covered up to $45 every three months.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay of $0-$40, and eyewear has no copay, with a combined maximum of $200 per year for all eyewear.
Dental Services See details
The HumanaChoice H5216-289 (PPO) plan covers Medicare dental services with a $40 copay, as well as oral exams, dental x-rays, other diagnostic dental services, other preventive dental services, and prophylaxis (cleaning) with no copay, but does not cover fluoride treatment. Orthodontic Services and Adjunctive General Services are covered with no copay, while the plan does not cover Restorative Services, Endodontics, Periodontics, Prosthodontics, Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered and require prior authorization, with coinsurance costs that vary depending on the specific drug. Medicare Part B Insulin Drugs have a $35 copay and coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-289 (PPO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment is covered by HumanaChoice H5216-289 (PPO), including Durable Medical Equipment (DME) with 5% coinsurance and Prosthetic Devices with 6% coinsurance. Diabetic Supplies have a coinsurance between 6% and 10%, and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
The HumanaChoice H5216-289 (PPO) plan covers Diagnostic and Radiological Services. Diagnostic Procedures/Tests have a copay between $0 and $85, and Lab Services have no copay; Diagnostic Radiological Services have a copay up to $320, and Therapeutic Radiological Services have 20% coinsurance. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-289 (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the HumanaChoice H5216-289 (PPO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, there is a $10 copay, and for days 21-100, there is a $214 copay. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The HumanaChoice H5216-289 (PPO) plan covers acupuncture with a $40 copay, up to 20 treatments per year, and also covers over-the-counter items with a maximum benefit of $45 every three months. The plan also covers a meal benefit with no copay and a chronic illness focus. However, other services like EPSDT, private duty nursing, and case management are not covered.
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