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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 2025, 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 2025.
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. Additionally, this plan comes with a Part B Premium reduction of $2.00. 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 $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) plan has a $250 deductible for prescription drugs. After meeting your deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. For example, you will pay a $9 copay for preferred generic drugs at a standard pharmacy. You will pay 36% coinsurance for preferred brand drugs.
Additional Benefits
The HumanaChoice H5216-360 (PPO) plan offers a range of benefits, including inpatient hospital stays with a copay, and outpatient services with copays varying from $0 to $375. The plan also covers ambulance services, emergency services, and a variety of primary care services, such as no copay for primary care physician visits. Preventive, hearing, vision, and dental services are covered, with varying copays or no copays for specific services like eye exams and dental cleanings. Additionally, the plan includes coverage for home infusion, dialysis, medical equipment, and diagnostic services, with some services requiring coinsurance.
Inpatient Hospital See details
Inpatient Hospital services are covered, including acute and psychiatric services. For days 1-6, there is a $310 copay, and for days 7-90, there is no copay.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with copays ranging from $0 to $375. Observation services have a copay of $310, while Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay. Individual and Group Sessions for Outpatient Substance Abuse have copays ranging from $30 to $100.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-360 (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 the HumanaChoice H5216-360 (PPO) plan. Ground ambulance services have a $315 copay, while air ambulance services have a 20% coinsurance; however, transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are covered under the HumanaChoice H5216-360 (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services have a $55 copay, and there is no coinsurance for any of these services.
Primary Care See details
Primary Care benefits include no copay for Primary Care Physician Services. Chiropractic Services have a $20 copay, Occupational Therapy Services have a $25 copay, and Physician Specialist Services have a $30 copay. Mental Health and Psychiatric Services have a $30 copay. Physical Therapy and Speech-Language Pathology Services have a $25 copay. Additional Telehealth Benefits have a copay ranging from $0 to $55, and Opioid Treatment Program Services have a copay ranging from $30 to $100.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, an annual physical exam with no copay, and additional preventive services, including fitness benefits, with a copay. Other services like Health Education, In-Home Safety Assessment, and others are not covered.
Hearing Services See details
Hearing exams are covered with a $30 copay, while routine hearing exams are covered with no copay. Fitting/evaluation for hearing aids have no copay. Prescription hearing aids are partially covered, with Prescription Hearing Aids (all types) having a copay between $399 and $699. OTC hearing aids are covered with a maximum benefit of $50 every three months.
Vision Services See details
Vision services include eye exams with a copay between $0 and $30, and eyewear with no copay. Contact lenses and eyeglasses (lenses and frames) are covered with no copay, while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-360 (PPO) plan covers dental services, including oral exams with no copay, and dental x-rays with no copay. Other covered services include Medicare dental services, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics fixed, and oral and maxillofacial surgery, all with no copay. The plan does not cover fluoride treatment, prosthodontics removable, maxillofacial prosthetics, implant services, or orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. You will pay a $35 copay for Medicare Part B Insulin Drugs, and coinsurance between 0% and 20% for Medicare Part B Chemotherapy/Radiation Drugs, Other Medicare Part B Drugs, and Medicare Part B Insulin Drugs.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-360 (PPO) plan. You will pay 20% coinsurance for dialysis services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered by the HumanaChoice H5216-360 (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, Prosthetics/Medical Supplies has a 20% coinsurance, and Diabetic Supplies have a 10-20% coinsurance with no copay, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the HumanaChoice H5216-360 (PPO) plan, with a copay for Diagnostic Procedures/Tests ranging from $0 to $175, and no copay for Lab Services. Diagnostic Radiological Services have a copay of at most $325, while Therapeutic Radiological Services have a coinsurance of at most 20% and a copay of at most $45, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-360 (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the HumanaChoice H5216-360 (PPO) plan. This includes Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-360 (PPO) plan, 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 H5216-360 (PPO) plan covers acupuncture with a $30 copay, over-the-counter items with a $50 maximum benefit every three months, and a meal benefit with no copay. However, 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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