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HumanaChoice H5216-395 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-395 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-395 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-395 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Southern OH and Northern West Virginia Area. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-395 (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 H5216-395 (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 H5216-395 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $17.00. 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 $400.00 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 H5216-395 (PPO) prescription drug plan features an annual drug deductible of $400. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month or 3-month supply at standard pharmacies and through preferred mail order. Tier 2 generic drugs are also highly affordable, costing a $5 copay for a 1-month supply at standard pharmacies, or no copay for a 3-month supply when using preferred mail order. Tier 3 preferred brand drugs carry a $47 copay for a 1-month supply, or $131 for a 3-month supply through preferred mail order. Higher-tier medications transition to coinsurance, with Tier 4 non-preferred drugs requiring 50% coinsurance and Tier 5 specialty drugs requiring 28% coinsurance. These cost-sharing details help you understand your out-of-pocket prescription expenses under this Medicare PPO plan.
Additional Benefits
The HumanaChoice H5216-395 (PPO) plan offers robust coverage with no copay and no coinsurance for primary care visits, preventive services, and home health care. For specialist visits, patients will pay a $55 copay, while inpatient hospital stays require a $440 daily copay for the first five days of acute stays before transitioning to no copay. Emergency room visits have a $125 copay, which is waived if you are admitted, and urgent care services require a $50 copay. This plan also includes key supplemental benefits, featuring no copay for preventive dental care up to a $1,000 annual limit, and no copay for routine hearing and vision exams. Prescription hearing aids are covered with copays ranging from $699 to $999, while medical equipment and dialysis services generally require a 20% coinsurance with no copay. These predictable copayments and low coinsurance options make this PPO plan a strong choice for managing your healthcare costs.
Inpatient Hospital See details
HumanaChoice H5216-395 (PPO) inpatient hospital care is partially covered with no coinsurance, requiring a $440 daily copay for days 1 through 5 of acute stays and days 1 through 4 of psychiatric stays, with no copay for remaining covered days. Non-Medicare-covered stays, hospital upgrades, and additional psychiatric days beyond 90 days are not covered.
Outpatient Services See details
HumanaChoice H5216-395 (PPO) covers outpatient services with no coinsurance, featuring a copay of $0 to $440 for outpatient hospital services and $440 per stay for observation services. Ambulatory surgical center and outpatient blood services are covered with no copay or coinsurance, while outpatient substance abuse sessions require no coinsurance and a $35 copay.
Partial Hospitalization See details
HumanaChoice H5216-395 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to access this covered benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-395 (PPO) covers ground and air ambulance services with a $315 copay and no coinsurance, subject to prior authorization. For transportation benefits, some services are covered but transportation to plan-approved health-related locations and any other health-related locations is not covered.
Emergency Services See details
HumanaChoice H5216-395 (PPO) covers emergency services with a $125 copay and no coinsurance, which is 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 $125 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-395 (PPO) features primary care physician services with no copay and no coinsurance, while specialist visits require a $55 copay and no coinsurance. Other covered benefits, including physical therapy, mental health, and telehealth services, have copays ranging from $0 to $55 with no coinsurance, though podiatry and routine chiropractic services are not covered.
Preventive Services See details
HumanaChoice H5216-395 (PPO) covers preventive services, including annual physical exams, kidney disease education, and diabetes training, with no copay and no coinsurance. Additional preventive benefits are only partially covered; a memory fitness benefit is included with no copay and no coinsurance, but services like health education, in-home safety assessments, and personal emergency response systems are not covered.
Hearing Services See details
Hearing services are partially covered by HumanaChoice H5216-395 (PPO), offering Medicare-covered exams for a $55 copay and no coinsurance, alongside routine exams and fitting evaluations with no copay and no coinsurance. Up to two prescription hearing aids are covered per year with a $699 to $999 copay and no coinsurance, while OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-395 (PPO) features partially covered vision services with no coinsurance, offering a $0 to $55 copay for eye exams and no copay for covered eyewear. Routine eye exams and select eyewear are covered up to annual limits, but other eye exams, standalone eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-395 (PPO) partially covers dental services up to a $1,000 annual limit, featuring no copay and no coinsurance for preventive care, a $25 copay and no coinsurance for restorative services, and a $55 copay and no coinsurance for Medicare-covered dental. Fluoride treatments, maxillofacial prosthetics, implants, and orthodontics are not covered under this plan.
Home Infusion bundled Services See details
HumanaChoice H5216-395 (PPO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other infusion drugs incur no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance without applying to the plan deductible.
Dialysis Services See details
Dialysis services are covered under the HumanaChoice H5216-395 (PPO) plan with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
HumanaChoice H5216-395 (PPO) covers medical equipment, including durable medical equipment, prosthetics, and medical supplies, with a 20% coinsurance and no copay. Diabetic supplies are covered with a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes and inserts require a $10 copay, with prior authorization and manufacturer limitations applying to certain services.
Diagnostic and Radiological Services See details
HumanaChoice H5216-395 (PPO) covers diagnostic services with no coinsurance, offering lab services with no copay and diagnostic tests with a copay ranging from $0 to $105. Covered radiological services feature diagnostic radiology and outpatient X-rays starting at no copay, while therapeutic radiological services require a minimum $45 copay and a minimum 20% coinsurance.
Home Health Services See details
HumanaChoice H5216-395 (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-395 (PPO) covers some cardiac rehabilitation services with no coinsurance, but cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) services are not covered.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-395 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a daily copay of $10 for days 1 to 20 and $214 for days 21 to 100. Prior authorization is required, a 3-day prior hospital stay is not required for admission, and additional days beyond the Medicare-covered 100 days are not covered.
Other Services See details
HumanaChoice H5216-395 (PPO) other services are partially covered, offering acupuncture with a $55 copay and no coinsurance for up to 20 treatments per year, and chronic illness meal benefits with no copay and no coinsurance. Prior authorization is required for these benefits, and over-the-counter (OTC) items are not covered.
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