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HumanaChoice H5216-421 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-421 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-421 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-421 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in Select counties in Georgia. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-421 (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 H5216-421 (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 H5216-421 (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 has a $400.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $450.00 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 $13900.00 (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 $13900.00 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 H5216-421 (PPO) prescription drug plan features an annual drug deductible of $450. Beneficiaries enjoy no copay for Tier 1 preferred generic and Tier 2 generic drugs when using a standard pharmacy or preferred mail order for 1-month and 3-month supplies. Standard mail order for these tiers requires a copay of $10 for Tier 1 and $20 for Tier 2 for a 1-month supply. For Tier 3 preferred brand drugs, there is a $47 copay for a 1-month supply, with savings available on 3-month supplies through preferred mail order. Tier 4 non-preferred drugs carry a 48% coinsurance, while Tier 5 specialty drugs require a 27% coinsurance for a 1-month supply. This clear pricing structure allows you to accurately project your out-of-pocket prescription medication costs.
Additional Benefits
The HumanaChoice H5216-421 (PPO) plan offers affordable access to core healthcare services, featuring no copay or coinsurance for primary care visits and routine preventive care. Specialist visits require a $40 copay, while inpatient hospital stays have a $375 daily copay for the first five to seven days and no copay thereafter. Emergency room visits have a $115 copay, which is waived if you are admitted, and urgent care services carry a $40 copay. For ancillary care, the plan provides robust dental benefits up to a $3,000 annual limit with no copay for preventive services, alongside routine vision and hearing exams featuring no copay. Prescription hearing aids require copays ranging from $699 to $999, while durable medical equipment and dialysis services generally require a 20% coinsurance with no copay. Home health services are covered with no copay, whereas skilled nursing facility care starts with no copay for the first 20 days.
Inpatient Hospital See details
HumanaChoice H5216-421 (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $375 daily copay for days 1 to 7 of acute stays (with no copay for days 8 and beyond) and a $375 daily copay for days 1 to 5 of psychiatric stays (with no copay for days 6 to 90). Non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-421 (PPO) covers outpatient services with no coinsurance, including ambulatory surgical center and outpatient blood services which feature no copay. Outpatient hospital services have a copay ranging from no copay to $450, observation services require a $375 copay per stay, and outpatient substance abuse sessions require a $35 copay.
Partial Hospitalization See details
HumanaChoice H5216-421 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-421 (PPO) covers ground and air ambulance services with a $335 copay and no coinsurance, though prior authorization is required. For transportation services, some services are covered but transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
HumanaChoice H5216-421 (PPO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with a $115 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-421 (PPO) offers primary care physician services with no copay and no coinsurance, and specialist visits with a $40 copay and no coinsurance. Physical, occupational, and speech therapies require a $25 copay with no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
HumanaChoice H5216-421 (PPO) offers preventive services with no copay and no coinsurance, covering annual physical exams, kidney disease education, glaucoma screenings, and a memory fitness benefit. The plan's preventive services are partially covered, excluding health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, weight management, alternative therapies, and home-based support.
Hearing Services See details
HumanaChoice H5216-421 (PPO) hearing services are partially covered, featuring routine exams and fitting evaluations with no copay and no coinsurance, and Medicare-covered exams for a $40 copay and no coinsurance. Prescription hearing aids are covered for a $699 to $999 copay with no coinsurance, though OTC hearing aids and inner ear, outer ear, and over-the-ear prescription aids are not covered.
Vision Services See details
HumanaChoice H5216-421 (PPO) partially covers vision services with no coinsurance, featuring eye exams with a $0 to $40 copay and eyewear with no copay. While routine eye exams, contact lenses, and eyeglasses are covered up to annual limits, other eye exams, separate eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-421 (PPO) partially covers dental services up to a $3,000 annual limit, offering preventive care, endodontics, periodontics, and oral surgery with no copay and no coinsurance. Restorative and prosthodontic services require no copay and a 30% to 40% coinsurance, while Medicare-covered dental has a $40 copay and no coinsurance; however, fluoride treatments, implant services, orthodontics, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
HumanaChoice H5216-421 (PPO) covers home infusion bundled services with no copay, although prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs require no copay and no coinsurance to 20% coinsurance, while Part B insulin drugs have a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the HumanaChoice H5216-421 (PPO) plan with no copay and a 20% coinsurance, and prior authorization is required.
Medical Equipment See details
HumanaChoice H5216-421 (PPO) covers durable medical equipment, prosthetic devices, 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.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by HumanaChoice H5216-421 (PPO) with prior authorization required. Lab services have no copay and no coinsurance, diagnostic procedures and tests have a $0 to $120 copay with no coinsurance, and therapeutic radiological services require a minimum $40 copay and a minimum 20% coinsurance.
Home Health Services See details
HumanaChoice H5216-421 (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by HumanaChoice H5216-421 (PPO) with no coinsurance and require prior authorization, though some services are covered while others are not. Standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy for peripheral artery disease are not covered under this plan, carrying copays ranging from $20 to $30.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-421 (PPO) covers Skilled Nursing Facility (SNF) care with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and while a prior three-day hospital stay is not needed, additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
HumanaChoice H5216-421 (PPO) partially covers other services, offering acupuncture for a $40 copay and no coinsurance for up to 20 treatments per year, and a meal benefit with no copay and no coinsurance, both requiring prior authorization. Over-the-counter (OTC) items are not covered under this plan.
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