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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 2025, 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 2025.
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 $28.00. 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) plan has a $400 deductible for prescription drugs. After meeting the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, in the initial coverage phase, you will pay $17 or $20 for preferred generic drugs, and 50% coinsurance for preferred brand drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-395 (PPO) plan offers a range of benefits, including inpatient and outpatient hospital services, with varying copays depending on the service. Emergency, urgent, and worldwide emergency services are covered, with copays ranging from $55 to $125. Primary care services have a 20% coinsurance, and preventive services are covered, including an annual physical exam with no copay. The plan also covers hearing exams with a $55 copay, and routine eye exams with no copay. Dental services have a $55 copay for Medicare-covered services, with a $1,000 annual maximum. Home health services have no copay, while medical equipment, diagnostic services, and dialysis services have varying coinsurance amounts.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, both requiring prior authorization. For Inpatient Hospital-Acute, you will pay a $440 copay for days 1-5, and no copay for days 6-90, while Additional Days for Inpatient Hospital-Acute has no copay for days 91-999. Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. For Inpatient Hospital Psychiatric, you will pay a $440 copay for days 1-4, and no copay for days 5-90. Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $440, observation services have a $440 copay, ambulatory surgical center services have no copay, individual and group substance abuse sessions have a copay between $55 and $100, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-395 (PPO) plan, with a $55 copay and prior authorization required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-395 (PPO) plan, including both ground and air ambulance services with a $315 copay, and no coinsurance. 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. Emergency Services have a $125 copay, and Urgently Needed Services have a $55 copay, while Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation all have a $125 copay.
Primary Care See details
The HumanaChoice H5216-395 (PPO) plan covers primary care physician services with a 20% coinsurance. Chiropractic services have a $15 copay, while occupational therapy services have a $15-$40 copay, and physical therapy and speech-language pathology services have a $15-$40 copay. Physician specialist services have a $55 copay. Mental health specialty services, individual and group psychiatric sessions, and opioid treatment program services all have a $55-$100 copay. Additional telehealth benefits have a $0-$55 copay.
Preventive Services See details
The HumanaChoice H5216-395 (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services are covered, and some services have a $0 copay, including glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and an EKG following a welcome visit. The plan does not cover health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices, and counseling services.
Hearing Services See details
Hearing Services are partially covered by the HumanaChoice H5216-395 (PPO) plan. Hearing exams require a $55 copay, while routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids of all types, and OTC hearing aids are not covered.
Vision Services See details
The HumanaChoice H5216-395 (PPO) plan covers vision services, including routine eye exams with a copay between $0 and $55. Eyewear is covered with no copay, including contact lenses and eyeglasses (lenses and frames), and a combined maximum of $100 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with a $55 copay. Oral exams, dental X-rays, other diagnostic dental services, other preventive dental services, and prophylaxis (cleaning) are covered with no copay. However, fluoride treatment, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered. This plan has a maximum benefit of $1,000 per year for in-network and out-of-network services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, as well as Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and Prosthetic Devices with 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Diabetic Supplies have a coinsurance between 10-20% and no copay, and Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic and radiological services, are covered. Diagnostic Procedures/Tests may have a copay of up to $105.00 and a coinsurance of at most 20%, while Lab Services have no copay, and Diagnostic Radiological Services have a copay of up to $720.00. Therapeutic Radiological Services have a copay of up to $45.00 and a coinsurance of at most 20%, and Outpatient X-Ray Services have a $45.00 copay and a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-395 (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-395 (PPO) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-395 (PPO) plan, but require prior authorization. For days 1-20, there is a $10 copay, and for days 21-100, the copay is $214. Additional days beyond Medicare coverage and non-Medicare covered stays for SNF are not covered.
Other Services See details
Other Services includes acupuncture with a $55 copay, and a meal benefit with no copay. 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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