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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 2025, 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 2025.
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 $11.00. 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 $590.00 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) plan has an enhanced alternative drug benefit. The plan has a deductible of $590.00. After the deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. For preferred generic drugs, you will pay a $15 copay at preferred and mail order pharmacies, and a $20 copay at a standard pharmacy. For standard generic drugs, you will pay a $47 copay regardless of the pharmacy. For preferred brand drugs, you will pay 50% coinsurance, and for non-preferred drugs, you will pay 25% coinsurance. Once your yearly out-of-pocket drug costs reach $2000.00, you will pay nothing for your Part D covered drugs.
Additional Benefits
The HumanaChoice H5216-359 (PPO) plan offers comprehensive coverage, including inpatient hospital stays with varying copays, outpatient services, and ambulance services. It also covers primary care visits with a $15 copay, and offers no copay for many preventive, hearing, vision, and dental services. This plan provides coverage for emergency services, home health services, and durable medical equipment, with associated copays or coinsurance. Additionally, the plan covers services like home infusion, dialysis, and skilled nursing facilities, often requiring prior authorization and specific cost-sharing arrangements.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you'll pay a copay of $360 for days 1-5, and no copay for days 6-90, while additional days (91-999) have no copay; Non-Medicare-covered stays and upgrades are not covered. For Inpatient Hospital Psychiatric, you'll pay a copay of $318 for days 1-5, and no copay for days 6-90; additional days and Non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $300, observation services with a $360 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services have a copay between $40 and $95 for individual and group sessions, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-359 (PPO) plan, with a $55 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-359 (PPO) plan, with a $315 copay for ground ambulance services and a 20% coinsurance for air ambulance services. 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 by the HumanaChoice H5216-359 (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services have a $55 copay. Worldwide Urgent Coverage and Worldwide Emergency Transportation also have a $125 copay.
Primary Care See details
The HumanaChoice H5216-359 (PPO) plan covers primary care physician services with a $15 copay, chiropractic services with a $20 copay, occupational therapy services with a $40 copay, physician specialist services with a $45 copay, mental health specialty services with a $45 copay, other health care professional services with a copay between $15 and $45, psychiatric services with a $45 copay, physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits with a copay between $0 and $55, and opioid treatment program services with a copay between $40 and $95. Routine Chiropractic Care and podiatry services are not covered.
Preventive Services See details
The HumanaChoice H5216-359 (PPO) plan covers preventive services with no copay for the annual physical exam, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Additional preventive services, including Fitness Benefit, are covered, but may have a copay. Some services, such as Health Education, are not covered.
Hearing Services See details
Hearing services include hearing exams with a $45 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $699 and $999. Prescription hearing aids - inner ear, outer ear, and over the ear, along with OTC hearing aids, are not covered.
Vision Services See details
Vision Services include eye exams with a copay of $0 - $45, and eyewear with no copay. Contact lenses and eyeglasses (lenses and frames) are covered with no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-359 (PPO) plan covers dental services, including oral exams with no copay, dental x-rays with no copay, other diagnostic dental services with no copay, prophylaxis (cleaning) with no copay, and restorative services with a $25 copay. This plan also offers other preventive dental services with no copay and has an annual maximum benefit of $1,000. Fluoride treatment, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and the coinsurance is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-359 (PPO) plan, but require prior authorization. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. DME has a 17% coinsurance, while Prosthetic Devices and Medical Supplies have a 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 include coverage for all diagnostic services with a copay ranging from $0 to $95, and lab services with no copay. Diagnostic radiological services have a copay of up to $350, therapeutic radiological services have a coinsurance of at least 20%, and outpatient X-ray services have a $15 copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-359 (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the HumanaChoice H5216-359 (PPO) plan, but none of the sub-services are covered. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-359 (PPO) plan, but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $203.
Other Services See details
Other Services includes coverage for acupuncture, with a $45 copay, and meal benefits, with no copay; however, over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, 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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