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HumanaChoice H5216-353 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-353 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-353 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-353 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in El Paso County. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-353 (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 H5216-353 (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 H5216-353 (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 $3.00. You must continue to pay paying your reduced 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 $9550.00 (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 $9550.00 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 H5216-353 (PPO) plan has a $250 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, for preferred generic drugs, you'll pay a $9 copay at preferred and mail order pharmacies, and a $20 copay at standard pharmacies. For preferred brand drugs, you'll pay 35% coinsurance at all pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-353 (PPO) plan offers a range of benefits, including inpatient hospital stays with a copay, and outpatient services with varying copays depending on the service. It also provides coverage for emergency services, primary care, and preventive services with no copays for many services, but does not include routine chiropractic or podiatry services. Additionally, this plan covers hearing, vision, and dental services, with specific copays or no copays for exams and other services, and has an annual maximum plan benefit for dental services.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered. For Inpatient Hospital-Acute, you have a $245 copay for days 1-5, and no copay for days 6-90, and for the additional days (91-999) there is no copay.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $275, Observation Services with a $245 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a copay between $30 and $100 for both individual and group sessions, and Outpatient Blood Services with no copay. This plan also includes an enhanced benefit of three pints of blood with the deductible waived.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-353 (PPO) plan. The plan has a $35 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required. Ground ambulance services have a $315 copay, and air ambulance services have a 20% coinsurance. Transportation services to a plan-approved health-related location are covered with no copay, up to 24 one-way trips per year, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the HumanaChoice H5216-353 (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 H5216-353 (PPO) plan covers primary care physician services with no copay, and chiropractic services with a $20 copay. Occupational therapy services have a $30 copay, and physician specialist services have a $30 copay. Mental health and psychiatric services, physical therapy, and speech-language pathology services have a $30 copay. Additional telehealth benefits have a copay between $0 and $55, and opioid treatment program services have a copay between $30 and $100. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, Annual Physical Exams with no copay, and Additional Preventive Services. The plan does not cover 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, Counseling Services. The plan offers Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit with no copay.
Hearing Services See details
Hearing services include hearing exams with a $30 copay, routine hearing exams with no copay, fitting/evaluation for hearing aids with no copay, and prescription hearing aids with a copay between $699 and $999 depending on the type of hearing aid; however, prescription hearing aids - inner ear, outer ear, and over the ear are not covered. OTC hearing aids are also covered, up to $50 every three months.
Vision Services See details
The HumanaChoice H5216-353 (PPO) plan covers vision services, including eye exams with a copay of $0-$30, and eyewear with no copay, but does not cover eyeglass lenses, eyeglass frames, or upgrades. Contact lenses and eyeglasses (lenses and frames) are covered with no copay.
Dental Services See details
The HumanaChoice H5216-353 (PPO) plan covers Medicare Dental Services with a $30 copay, Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), and Other Preventive Dental Services with no copay. The plan also covers Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics, and Oral and Maxillofacial Surgery with no copay, but does not cover Fluoride Treatment, Maxillofacial Prosthetics, Implant Services, Prosthodontics (fixed), or Orthodontics. There is a $2,000 maximum plan benefit per year for both in-network and out-of-network services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, coinsurance is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-353 (PPO) plan, with a coinsurance of 20%. Prior authorization is required.
Medical Equipment See details
Medical Equipment benefits are covered, including Durable Medical Equipment (DME) with 20% coinsurance, Prosthetic Devices with 20% coinsurance, and Medical Supplies with 20% coinsurance. Diabetic Supplies have a 10-20% coinsurance and no copay, while Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic services, diagnostic procedures/tests, and outpatient X-ray services are covered. Lab Services have no copay, while Diagnostic Procedures/Tests have a copay up to $60.00. Diagnostic Radiological Services have a copay up to $325.00, and Therapeutic Radiological Services have a copay up to $40.00 and 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-353 (PPO) plan with no copay and no coinsurance. However, Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the specific services including 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. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-353 (PPO) plan, with a copay of $10 for days 1-20 and $214 for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
The HumanaChoice H5216-353 (PPO) plan covers acupuncture with a $30 copay, and up to 20 treatments per year. Over-the-counter (OTC) items are covered, with a maximum benefit of $50 every three months, and the plan offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit. Meal benefits are covered with no copay.
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