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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 2025, 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 2025.
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. Additionally, this plan comes with a Part B Premium reduction of $4.00. You must continue to pay paying your reduced 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 $14000.00 (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 $14000.00 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) plan has a $450 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. For preferred generic drugs, you will have no copay at preferred pharmacies and preferred mail order, and a $20 copay at standard mail order. Standard generic drugs have a $47 copay, while preferred brand drugs have a 45% coinsurance.
Additional Benefits
The HumanaChoice H5216-421 (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services have copays that vary. Emergency services have a copay, and primary care visits have no copay. Preventive services, including an annual physical exam, have no copay, while hearing and vision services have copays. Dental services have a maximum annual benefit, and other services like home infusion and dialysis have cost-sharing through copays or coinsurance. The plan also covers home health services with no copay.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric with prior authorization. For Inpatient Hospital-Acute, the copay is $399 for days 1-6, and no copay for days 7-90, and for Inpatient Hospital Psychiatric the copay is $399 for days 1-5, and no copay for days 6-90.
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 $450, observation services have a $399 copay, ambulatory surgical center services have no copay, individual and group sessions for outpatient substance abuse have a copay between $45 and $100, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-421 (PPO) plan, with a $80 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-421 (PPO) plan. Ground and Air Ambulance Services have a copay of $315.00, with no coinsurance, while Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including urgently needed services and worldwide emergency services, are covered by the HumanaChoice H5216-421 (PPO) plan. Emergency services have a $110 copay, urgently needed services have a $45 copay, and worldwide emergency services have a $110 copay for worldwide emergency coverage, worldwide urgent coverage, and worldwide emergency transportation.
Primary Care See details
The HumanaChoice H5216-421 (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, and occupational therapy services with a $25 copay. Physician specialist services have a $50 copay, and physical therapy and speech-language pathology services have a $25 copay. Mental health and psychiatric services, as well as opioid treatment program services, have a copay of $45-$100. Additional telehealth benefits have a copay of $0-$50. Podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with no copay, an annual physical exam with no copay, and additional preventive services with a copay, including Fitness Benefit with no copay, as well as Kidney Disease Education Services, Other Preventive Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay. Some preventive services, including Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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 Benefit, 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 (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing exams are covered with a $50 copay, and routine hearing exams are covered with no copay, with a limit of one exam per year. Prescription hearing aids are covered with a copay between $699 and $999, with a limit of two per year, but inner ear, outer ear, and over the ear hearing aids are not covered, and OTC hearing aids are also not covered.
Vision Services See details
The HumanaChoice H5216-421 (PPO) plan covers vision services, including eye exams with a copay of $0-$50, and eyewear with no copay. Contact lenses and eyeglasses (lenses and frames) are covered with no copay, and a combined maximum of $200 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
HumanaChoice H5216-421 (PPO) covers Medicare and other dental services, including oral exams with no copay, and dental x-rays with no copay, with a maximum plan benefit of $2,000 per year. Restorative services and prosthodontics, removable are covered with no copay and 30-40% coinsurance, while fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, while the other services have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-421 (PPO) plan, with prior authorization required. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, is covered by the HumanaChoice H5216-421 (PPO) plan. Durable Medical Equipment has a 12% coinsurance, and Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies - Non-Medicare benefit has coinsurance, and Medical Supplies and Prosthetic Devices have 20% coinsurance. Diabetic Supplies have between 10% and 20% coinsurance with no copay, and Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services with a copay for Medicare-covered diagnostic procedures/tests and lab services, and a copay for Medicare-covered diagnostic and therapeutic radiological services and X-ray services. The plan also covers lab services with no copay, and outpatient X-ray services with no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-421 (PPO) plan with no copay and no coinsurance, though additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-421 (PPO) plan, with a $0 copay for days 1-20 and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The HumanaChoice H5216-421 (PPO) plan covers acupuncture with a $50 copay, and it covers 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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