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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 2025, 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 2025.
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 $23.00. 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 has a $100.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $9100.00 (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 $9100.00 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) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying copays or coinsurance amounts depending on the drug tier and pharmacy type. For example, in the initial coverage phase, this plan has no copay for preferred generic drugs at a standard pharmacy, and a $20 copay at a standard mail order pharmacy. For preferred brand drugs, you will pay 35% coinsurance at both preferred and standard pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs.
Additional Benefits
The HumanaChoice H5216-313 (PPO) plan offers a range of benefits with varying costs. This plan includes coverage for inpatient hospital stays with a copay, outpatient services with copays from $0 to $300, and emergency services with a $125 copay. The plan also covers primary care visits with no copay, hearing exams with a $35 copay, and vision services including eye exams and eyewear with no copay. Dental services are covered with a $3,000 yearly maximum, and home health services are covered with no copay.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a copay of $390 for days 1-4 and no copay for days 5-90 for Inpatient Hospital-Acute. Additional days for Inpatient Hospital-Acute have no copay for days 91-999. Inpatient Hospital Psychiatric has a copay of $390 for days 1-3 and no copay for days 4-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and 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 copays ranging from $0 to $300, observation services with a $390 copay, and Ambulatory Surgical Center (ASC) Services with no copay. Outpatient substance abuse services have copays between $30 and $40, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with a $100 copay, and requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-313 (PPO) plan. Ground ambulance services have a $315 copay, and air ambulance services have a $1250 copay, with no coinsurance for either service; however, 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. For Emergency Services, there is a $125 copay and no coinsurance, while Urgently Needed Services have a $55 copay and no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation all have a $125 copay, with no coinsurance.
Primary Care See details
Primary Care services include no copay for Primary Care Physician services, a $20 copay for Chiropractic Services, and a $40 copay for Occupational Therapy Services. Physician Specialist Services have a $35 copay, while Mental Health Specialty Services, Psychiatric Services, and Opioid Treatment Program Services have a copay between $30 and $40 for individual and group sessions. Podiatry Services and Other Health Care Professional visits have a copay between $0 and $35, and Physical Therapy and Speech-Language Pathology Services have a $40 copay. Additional Telehealth Benefits have a copay between $0 and $55.
Preventive Services See details
Preventive Services include coverage for Annual Physical Exams with no copay, and other services such as Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay. 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, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing services include hearing exams with a $35 copay, and routine hearing exams with no copay for one exam per year, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are partially covered, but inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are covered up to $30 every three months.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay between $0 and $35, and eyewear has no copay. Contact lenses and eyeglasses (lenses and frames) have no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-313 (PPO) plan covers dental services with a yearly maximum of $3,000 for both in-network and out-of-network services. Oral exams, dental X-rays, other diagnostic dental services, prophylaxis (cleaning), and other preventive dental services are covered with no copay, while restorative services and prosthodontics, fixed have a 30% to 40% coinsurance and no copay. Fluoride treatment, prosthodontics (removable), maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and between 0% to 20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0% to 20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-313 (PPO) plan, 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), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, and Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a 20% coinsurance, and Medical Supplies have a 20% coinsurance. Diabetic Supplies have a coinsurance between 10% and 20%, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
The HumanaChoice H5216-313 (PPO) plan covers diagnostic and radiological services, including diagnostic procedures/tests with a coinsurance of up to 20% and a copay up to $200, and lab services with no copay. Diagnostic radiological services have a copay up to $390, and therapeutic radiological services have a coinsurance of up to 20%. Outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-313 (PPO) plan with no copay and no coinsurance. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
For the HumanaChoice H5216-313 (PPO) plan, Cardiac Rehabilitation Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by HumanaChoice H5216-313 (PPO), but require prior authorization. For days 1-20, there is a $10 copay, and for days 21-100, the copay is $214; there is no coinsurance.
Other Services See details
Under "Other Services," HumanaChoice H5216-313 (PPO) covers acupuncture with a $10 copay, up to 25 treatments per year, and over-the-counter (OTC) items up to $30 every three months. The plan also covers a meal benefit with no copay. However, 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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