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HumanaChoice H5216-360 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-360 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-360 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-360 (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 2026.
It's important to know that HumanaChoice H5216-360 (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 H5216-360 (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 H5216-360 (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 $420.00 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 $8950.00 (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 $8950.00 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 H5216-360 (PPO) Medicare prescription drug plan features an annual drug deductible of $420. For Tier 1 preferred generic drugs, you will pay no copay for a one-month or three-month supply through standard pharmacies and preferred mail order. Tier 2 generic drugs are also highly affordable, costing as little as a $5 copay for a one-month supply at standard pharmacies, or no copay for a three-month supply when using preferred mail order. For Tier 3 preferred brand drugs, copays start at $45 for a one-month supply at standard pharmacies and preferred mail order. Tier 4 non-preferred drugs require a 46% coinsurance across standard pharmacies and mail order options. Tier 5 specialty drugs are subject to a 28% coinsurance for a one-month supply.
Additional Benefits
The HumanaChoice H5216-360 (PPO) plan offers comprehensive medical coverage with no copay for primary care doctor visits, annual physical exams, and home health services. Specialized care is highly accessible, featuring a $30 copay for specialist visits and a $130 copay for emergency room visits, which is waived if you are admitted. For hospital stays, inpatient care requires a $310 daily copay for the first six days and no copay thereafter, while outpatient hospital services range from no copay up to a $335 copay. This plan also provides robust supplemental benefits, including no copay for routine vision and hearing exams, up to $250 annually for eyewear, and up to $2,000 for preventive and comprehensive dental care. Diagnostic lab services and home infusions are covered with no copay, while durable medical equipment and dialysis services require a 20% coinsurance. Additional perks like acupuncture, over-the-counter items, and meals for chronic conditions are fully covered with no copay.
Inpatient Hospital See details
Inpatient hospital care is covered by HumanaChoice H5216-360 (PPO) with no coinsurance and a copayment of $310 per day for days 1 through 6, and no copayment for days 7 through 90. Unlimited additional days for acute care are covered with no copayment, though additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
HumanaChoice H5216-360 (PPO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $335, observation services require a $310 copay per stay, and outpatient substance abuse sessions carry a copay of $30 to $35.
Partial Hospitalization See details
HumanaChoice H5216-360 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required for this covered benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-360 (PPO) covers ground ambulance services with a $335 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required for both. Transportation services are not covered under this plan.
Emergency Services See details
Emergency services are covered by HumanaChoice H5216-360 (PPO) 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 H5216-360 (PPO) primary care benefits feature no copay and no coinsurance for primary care doctor visits, and a $30 copay with no coinsurance for specialist and mental health services. Physical, occupational, and speech therapies require a $25 copay and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
HumanaChoice H5216-360 (PPO) provides partially covered preventive services with no copays and no coinsurance for annual physical exams, kidney disease education, memory fitness, and screenings like glaucoma and diabetes self-management. However, several supplemental benefits are not covered, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and weight management programs.
Hearing Services See details
Hearing services covered by HumanaChoice H5216-360 (PPO) include routine hearing exams and fitting evaluations with no copay and no coinsurance, while Medicare-covered exams require a $30 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a $399 to $699 copay (inner ear, outer ear, and over-the-ear models are not covered), while over-the-counter hearing aids are covered with no copay and no coinsurance.
Vision Services See details
HumanaChoice H5216-360 (PPO) provides partially covered vision services with no deductibles and no coinsurance, featuring no copay for routine eye exams and up to $250 annually for eyeglasses or contact lenses. Copays for other eye exams range from $0 to $30, while separate eyeglass lenses, eyeglass frames, upgrades, and other eye exam services are not covered.
Dental Services See details
HumanaChoice H5216-360 (PPO) partially covers dental services with a $30 copay and no coinsurance for Medicare-covered services, and no copay or coinsurance for other covered preventive and comprehensive services up to a $2,000 annual limit. Non-covered services under this plan include fluoride treatments, removable prosthodontics, maxillofacial prosthetics, implant services, and orthodontics.
Home Infusion bundled Services See details
HumanaChoice H5216-360 (PPO) covers Home Infusion bundled Services with no copay, though prior authorization and step therapy are required. Associated Medicare Part B drugs, including chemotherapy and other drugs, carry a coinsurance of 0% to 20%, with Part B insulin specifically featuring a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the HumanaChoice H5216-360 (PPO) plan with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
HumanaChoice H5216-360 (PPO) covers medical equipment, including durable medical equipment (DME), prosthetics, and medical supplies, with a 20% coinsurance and no copay. Diabetic supplies are covered with no copay and a 10% to 20% coinsurance, while diabetic therapeutic shoes and inserts require a $10 copay and applicable coinsurance, with prior authorization required for these benefits.
Diagnostic and Radiological Services See details
HumanaChoice H5216-360 (PPO) covers diagnostic and radiological services, with prior authorization required. Lab services feature no copay and no coinsurance, diagnostic tests range from a $0 to $175 copay with no coinsurance, and therapeutic radiological services require a minimum $45 copay and 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the HumanaChoice H5216-360 (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are partially covered by the HumanaChoice H5216-360 (PPO) plan with no coinsurance, though copayments may apply and prior authorization is required. Standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-360 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, and while a prior three-day inpatient hospital stay is not needed, additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered under the HumanaChoice H5216-360 (PPO) plan, excluding dual eligible SNPs with highly integrated services. Covered benefits include acupuncture limited to 25 treatments per year, over-the-counter items, and meals for chronic or medical conditions, all of which require no copay and no coinsurance.
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