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HumanaChoice H5216-352 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-352 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-352 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-352 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select Counties in Texas. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-352 (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 H5216-352 (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 H5216-352 (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.
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 $250.00 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 H5216-352 (PPO) plan has a $250 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you will pay a $9 copay at preferred mail-order pharmacies, and a $20 copay at standard mail order pharmacies. For preferred brand drugs, you will pay 48% 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 H5216-352 (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay for the first few days, with no copay for most days. Outpatient services and primary care visits may have copays, while many preventive, vision, and dental services, along with home health and other services, have no copay. The plan also covers ambulance services, emergency services, and offers coverage for hearing and medical equipment, with copays or coinsurance depending on the specific service. Dialysis services and diagnostic and radiological services are covered, but may require prior authorization and have coinsurance. Additionally, the plan provides coverage for home infusion, skilled nursing facilities, and other services like acupuncture and over-the-counter items, each with its own cost-sharing structure.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For days 1-6, there is a $310 copay, and for days 7-90, there is no copay, while additional days for Inpatient Hospital-Acute have no copay for days 91-999.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $450, Observation Services with a $310 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a copay between $30 and $100 for individual and group sessions, and Outpatient Blood Services with no copay. These services may require prior authorization.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-352 (PPO) plan, with a $35 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by HumanaChoice H5216-352 (PPO). Ground ambulance services have a copay of $315, while air ambulance services have a 20% coinsurance. 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 H5216-352 (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $125 copay.
Primary Care See details
The HumanaChoice H5216-352 (PPO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy services with a $25 copay, physician specialist services with a $35 copay, and mental health specialty services with a $30 copay for individual and group sessions. The plan also covers physical therapy and speech-language pathology services with a $25 copay, additional telehealth benefits with a copay between $0 and $55, and opioid treatment program services with a copay between $30 and $100.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, Annual Physical Exams with no copay, and additional preventive services, including Fitness Benefit, with a copay. Some services, such as Health Education, are not covered.
Hearing Services See details
Hearing exams are covered with a $35 copay. Routine hearing exams are covered with no copay, up to 1 visit per year. Fitting/evaluation for hearing aids is covered with no copay. Prescription hearing aids are partially covered, and the plan covers prescription hearing aids (all types) with a copay between $299 and $899 for 2 visits per year, while Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered. OTC hearing aids are covered.
Vision Services See details
Vision services include coverage for eye exams with a copay of $0-$35, and eyewear with no copay, including contact lenses and eyeglasses (lenses and frames). Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services include a $35 copay for Medicare Dental Services, and no copay for Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Other Preventive Dental Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics, fixed, and Oral and Maxillofacial Surgery. Fluoride Treatment, Prosthodontics, removable, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
The HumanaChoice H5216-352 (PPO) plan covers Home Infusion bundled Services, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, as well as Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-352 (PPO) plan, but require prior authorization. The coinsurance for Dialysis Services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and authorization required, Prosthetic Devices with a 20% coinsurance, Medical Supplies with a 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have a 10-20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
The HumanaChoice H5216-352 (PPO) plan covers diagnostic and radiological services, including diagnostic procedures and tests with a copay between $0 and $175, and lab services with no copay. Radiological services have a copay, with diagnostic radiological services having a copay up to $325 and therapeutic radiological services having a copay up to $45 and a coinsurance of at least 20%. Outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-352 (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the specific services of 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 are not covered. There is a copay for covered services, but the specific amount is not provided.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214; there is no coinsurance.
Other Services See details
The HumanaChoice H5216-352 (PPO) plan covers acupuncture with a $35 copay, over-the-counter items with a maximum benefit coverage amount of $75 every three months, and a meal benefit with no copay. This plan does not cover Dual Eligible SNPs with Highly Integrated Services, or the additional services listed.
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