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HumanaChoice H5216-313 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-313 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-313 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-313 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Honolulu, Kauai, and Maui counties. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-313 (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 H5216-313 (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 H5216-313 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $14.00. 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 $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 $10100.00 (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 $10100.00 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 H5216-313 (PPO) prescription drug plan has an annual drug deductible of $615. For Tier 1 preferred generic drugs, you pay no copay at standard pharmacies or through preferred mail order. Tier 2 generic drugs have a low $5 copay for a one-month supply at standard pharmacies, and you pay no copay for a three-month supply filled through preferred mail order. Tier 3 preferred brand drugs require a $47 copay for a one-month supply, but you can save on a three-month supply with a $94 copay through preferred mail order compared to $141 at standard pharmacies. Higher-tier medications are subject to coinsurance, with Tier 4 non-preferred drugs requiring 34% coinsurance and Tier 5 specialty drugs requiring 25% coinsurance for a one-month supply.
Additional Benefits
The HumanaChoice H5216-313 (PPO) plan offers robust coverage with no copay or coinsurance for primary care visits, select telehealth services, and covered preventive care. For hospital stays, members pay no coinsurance, though acute inpatient admissions require a $390 daily copay for the first four days. Emergency room visits carry a $130 copay, which is waived if you are admitted to the hospital within 24 hours. This plan also includes dental, vision, and hearing benefits featuring no deductibles and no copays for preventive dental care, routine eye exams, and over-the-counter hearing aids. More specialized services, such as durable medical equipment and dialysis, generally require a 20% coinsurance with no copay. Additionally, routine home health services are fully covered with no copay or coinsurance.
Inpatient Hospital See details
HumanaChoice H5216-313 (PPO) inpatient hospital services are partially covered with no coinsurance, requiring a $390 daily copay for days 1-4 of acute stays (no copay for days 5 and beyond) and a $390 daily copay for days 1-3 of psychiatric stays (no copay for days 4-90). Prior authorization is required, and non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by HumanaChoice H5216-313 (PPO) with no coinsurance, featuring no copays for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $400 (or $390 per stay for observation services), while outpatient substance abuse sessions carry a copay of $25 to $35.
Partial Hospitalization See details
HumanaChoice H5216-313 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-313 (PPO) covers ambulance services with no coinsurance, requiring a $165 copay for ground ambulance and a $1,250 copay for air ambulance services. While some transportation services are covered, transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
HumanaChoice H5216-313 (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 are covered with a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are all covered with a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-313 (PPO) features primary care physician services and select telehealth benefits with no copay and no coinsurance. Specialist visits, physical therapy, and mental health services are covered with copays ranging from $25 to $40 and no coinsurance, though chiropractic services are not covered.
Preventive Services See details
HumanaChoice H5216-313 (PPO) offers partially covered preventive services with no copay and no coinsurance for covered care such as annual physical exams, kidney disease education, select screenings, and a fitness benefit. However, several additional preventive services are not covered, including health education, in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, smoking cessation, enhanced disease management, telemonitoring, remote access, home modifications, and counseling.
Hearing Services See details
Hearing services under HumanaChoice H5216-313 (PPO) feature no deductible and no coinsurance, offering Medicare-covered exams for a $35 copay, routine exams and fitting evaluations for no copay, and OTC hearing aids for no copay. Prescription hearing aids are partially covered with no coinsurance and a $299 to $899 copay for up to two devices per year, though inner ear, outer ear, and over-the-ear types are not covered.
Vision Services See details
HumanaChoice H5216-313 (PPO) covers vision services with no deductibles or coinsurance, offering copays ranging from no copay to $35 for covered eye exams and no copay for covered eyewear. This benefit is partially covered, providing up to $40 annually for one routine exam and a combined $300 annual limit for eyeglasses or contact lenses, while excluding other eye exam services, standalone lenses, standalone frames, and upgrades.
Dental Services See details
Dental services are partially covered by HumanaChoice H5216-313 (PPO) up to a $3,000 annual maximum, featuring no copays and no coinsurance for preventive care and most comprehensive services. Restorative and fixed prosthodontics require a 30% to 40% coinsurance with no copay, Medicare-covered dental has a $35 copay with no coinsurance, and fluoride, removable prosthodontics, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-313 (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy may be required. Covered Medicare Part B drugs, including chemotherapy and insulin, feature coinsurance ranging from no coinsurance up to 20%, with insulin capped at a $35 copay and other Part B drugs requiring no copay.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-313 (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
HumanaChoice H5216-313 (PPO) covers durable medical equipment, prosthetics, and medical supplies with a 20% coinsurance and no copay. Diabetic supplies are covered with a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes or inserts require a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under HumanaChoice H5216-313 (PPO) with prior authorization, featuring no copay for lab services, diagnostic radiology, and outpatient X-rays. Diagnostic procedures and tests require a copay of up to $200 and 20% coinsurance, while therapeutic radiological services require a copay and 20% coinsurance.
Home Health Services See details
Home health services are covered by HumanaChoice H5216-313 (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-313 (PPO) covers Cardiac Rehabilitation Services with no coinsurance and prior authorization required, but in practice some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-313 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, though a prior three-day inpatient hospital stay is not required for admission.
Other Services See details
HumanaChoice H5216-313 (PPO) provides partially covered other services, featuring acupuncture for a $10 copay and no coinsurance, as well as over-the-counter (OTC) items and meal benefits with no copay and no coinsurance. Specific sub-services including Other 1, Other 2, Other 3, and Dual Eligible SNPs with Highly Integrated Services are not covered.
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