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HumanaChoice H5216-359 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-359 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-359 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-359 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Twin Cities, Rochester, Duluth Areas. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-359 (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 H5216-359 (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 H5216-359 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $10.00. 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 H5216-359 (PPO) Medicare plan features an annual drug deductible of $615. Under this plan, you will pay no copay for Tier 1 preferred generic drugs when using standard retail pharmacies or preferred mail order services. Tier 2 generic medications cost as low as a $5 copay for a one-month supply at standard pharmacies, with no copay required for a three-month supply filled through preferred mail order. For Tier 3 preferred brand drugs, copays start at $47 for a one-month supply across standard pharmacies and mail order options. Higher-tier prescriptions require coinsurance, with Tier 4 non-preferred drugs carrying a 50% coinsurance and Tier 5 specialty drugs requiring a 25% coinsurance.
Additional Benefits
The HumanaChoice H5216-359 (PPO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care visits and key preventive services. Specialist visits require a $45 copay, while inpatient hospital stays incur a $360 daily copay for the first five days and no copay thereafter. Emergency room visits have a $130 copay, and urgent care services require a $50 copay. For ancillary care, the plan features no copay for routine dental exams, cleanings, and routine annual eye exams, with a $1,000 annual maximum benefit for dental services. Prescription hearing aids are covered with copays ranging from $699 to $999, while durable medical equipment requires a 20% coinsurance. Skilled nursing facility stays feature a $10 daily copay for the first 20 days and a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
HumanaChoice H5216-359 (PPO) covers inpatient acute hospital stays with no coinsurance, requiring a $360 daily copay for days 1 through 5 and no copay for days 6 and beyond, while upgrades and non-Medicare-covered stays are not covered. Inpatient psychiatric hospital care is also covered with no coinsurance, requiring a $318 daily copay for days 1 through 5 and no copay for days 6 through 90, though additional days and non-Medicare-covered stays are not covered.
Outpatient Services See details
HumanaChoice H5216-359 (PPO) covers outpatient services with no coinsurance, featuring copays of $0 to $300 for outpatient hospital services, a $360 copay per stay for observation services, and no copay for ambulatory surgical center and blood services. Outpatient substance abuse group and individual sessions have a copay of $30 to $35, and prior authorization is required for most of these services.
Partial Hospitalization See details
HumanaChoice H5216-359 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under the HumanaChoice H5216-359 (PPO) plan, which requires a $335 copay (and no coinsurance) for ground ambulance services and a 20% coinsurance (and no copay) for air ambulance services. Although some transportation services are covered, transportation to plan-approved health-related locations and any other health-related locations is not covered.
Emergency Services See details
HumanaChoice H5216-359 (PPO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $130 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-359 (PPO) primary care benefits feature no copay and no coinsurance for primary care provider visits, and a $45 copay with no coinsurance for specialists. Physical, occupational, and speech therapies require a $40 copay with no coinsurance, mental health services require a $30 copay with no coinsurance, while podiatry is not covered and chiropractic services are only partially covered with routine care excluded.
Preventive Services See details
HumanaChoice H5216-359 (PPO) covers key preventive services—including annual physical exams, kidney disease education, and select screenings—with no copayments and no coinsurance. While a memory fitness benefit is covered, other supplemental benefits like health education, nutritional services, and in-home safety assessments are not covered.
Hearing Services See details
HumanaChoice H5216-359 (PPO) hearing services are partially covered with no deductible, featuring medicare-covered exams for a $45 copay and routine exams or fitting evaluations with no copay and no coinsurance. Up to two prescription hearing aids (all types) are covered per year with a copay of $699 to $999 and no coinsurance, though OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-359 (PPO) offers vision services with no coinsurance and copays from $0 to $45, which includes no copay for a routine annual eye exam and select eyewear. However, the benefit is only partially covered because other eye exams, individual eyeglass lenses, individual frames, and upgrades are not covered, and services require prior authorization and are subject to annual limits of $75 for exams and $100 for eyewear.
Dental Services See details
HumanaChoice H5216-359 (PPO) offers partially covered dental services with a $1,000 annual maximum benefit, featuring no copay and no coinsurance for preventive care like cleanings and exams. Medicare-covered dental services require a $45 copay and restorative services require a $25 copay, both with no coinsurance, while fluoride treatments, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by HumanaChoice H5216-359 (PPO) with no copay, though prior authorization is required and step therapy may apply. Covered Medicare Part B chemotherapy, radiation, and other drugs have no copay and 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by HumanaChoice H5216-359 (PPO) with no copay and a 20% coinsurance. Prior authorization is required for these services.
Medical Equipment See details
HumanaChoice H5216-359 (PPO) covers durable medical equipment, prosthetics, and medical supplies with a 20% coinsurance and no copay, requiring prior authorization. Diabetic supplies feature a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes and inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by HumanaChoice H5216-359 (PPO), with prior authorization required for both categories. Diagnostic procedures and tests feature no coinsurance and copays ranging from $0 to $95, while lab services and outpatient X-rays have no copays. Diagnostic radiological services have copays starting at $0, and therapeutic radiological services require a copay and a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the HumanaChoice H5216-359 (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-359 (PPO) features no coinsurance for cardiac rehabilitation services, though prior authorization is required and only some services are covered. Specifically, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for peripheral artery disease (PAD) are not covered in practice, with copays for these services ranging from $15 to $40.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-359 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard 100 days are not covered.
Other Services See details
HumanaChoice H5216-359 (PPO) partially covers other services, offering acupuncture with a $45 copay and no coinsurance for up to 20 treatments per year, as well as chronic illness meal benefits with no copay and no coinsurance. Prior authorization is required for these covered benefits, while over-the-counter (OTC) items are not covered.
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