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HumanaChoice H5216-423 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-423 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-423 (PPO) in 2026, please refer to our full plan details page.
HumanaChoice H5216-423 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in South Carolina. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that HumanaChoice H5216-423 (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 H5216-423 (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 H5216-423 (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 $250.00 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 $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 H5216-423 (PPO) prescription drug plan features an annual drug deductible of $450. For Tier 1 preferred generic and Tier 2 generic medications, there is no copay for 1-month or 3-month supplies filled at standard pharmacies or through preferred mail order. If you choose standard mail order for these generic tiers, 1-month copays range from $10 to $20. Tier 3 preferred brand drugs require a $47 copay for a 1-month supply across standard pharmacies and mail order options. For higher-tier medications, Tier 4 non-preferred drugs carry a 43% coinsurance, while Tier 5 specialty tier drugs require a 27% coinsurance. These straightforward costs make it easy to understand your potential out-of-pocket prescription expenses under this plan.
Additional Benefits
The HumanaChoice H5216-423 (PPO) plan offers robust coverage for everyday healthcare needs, featuring no copay and no coinsurance for primary care doctor visits and preventive services. For specialized care, members pay a $35 copay for specialist visits, while emergency room services require a $115 copay. Inpatient hospital stays require a $345 daily copay for the first few days of your stay, with no copay required for the remaining covered days. This plan also includes generous dental, vision, and hearing benefits, including no copay for routine preventive dental care up to a $3,000 annual limit. Routine hearing exams are available with no copay, while routine vision exams and covered eyewear feature low to no copays. For medical equipment and dialysis services, members will generally face a 10% to 20% coinsurance with no copay.
Inpatient Hospital See details
HumanaChoice H5216-423 (PPO) inpatient hospital benefits are partially covered with no coinsurance, requiring a $345 daily copay for days 1 to 8 of acute stays and days 1 to 6 of psychiatric stays, with no copay for remaining covered days. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
HumanaChoice H5216-423 (PPO) covers outpatient services with no coinsurance, featuring a copay of $0 to $450 for outpatient hospital services and $345 per stay for observation services. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $35 copay and no coinsurance.
Partial Hospitalization See details
HumanaChoice H5216-423 (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
HumanaChoice H5216-423 (PPO) covers ground and air ambulance services with a $335 copay per service and no coinsurance, subject to prior authorization. Transportation services to plan-approved or any other health-related locations are not covered under this plan.
Emergency Services See details
HumanaChoice H5216-423 (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services are covered with a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are available with a $115 copay and no coinsurance.
Primary Care See details
HumanaChoice H5216-423 (PPO) offers primary care physician services with no copay and no coinsurance, while specialist visits, mental health, and psychiatric services require a $35 copay and no coinsurance. Physical, occupational, and speech therapies have a $25 copay with no coinsurance, telehealth services range from a $0 to $50 copay with no coinsurance, and podiatry and chiropractic services are not covered.
Preventive Services See details
HumanaChoice H5216-423 (PPO) covers preventive services, such as annual exams, kidney education, and memory fitness, with no copay and no coinsurance. The benefit is partially covered, excluding health education, in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, remote access, safety devices, and counseling.
Hearing Services See details
Hearing services are covered by HumanaChoice H5216-423 (PPO), offering annual routine exams and unlimited fitting evaluations with no copay and no coinsurance, while Medicare-covered exams have a $35 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays between $0 and $599 for up to two devices every three years, though inner ear, outer ear, over the ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
HumanaChoice H5216-423 (PPO) partially covers vision services with no coinsurance, featuring a $0 to $35 copay for eye exams and no copay for covered eyewear. While one routine exam (up to $40 yearly) and eyeglasses or contact lenses (up to $350 yearly) are covered, other eye exams, upgrades, and individual eyeglass lenses or frames are not covered.
Dental Services See details
Dental Services are partially covered by the HumanaChoice H5216-423 (PPO) plan, which features a $35 copay and no coinsurance for Medicare-covered dental care, and no copay or coinsurance for most preventive and comprehensive services up to a $3,000 annual limit. Fluoride treatments, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by HumanaChoice H5216-423 (PPO) with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
HumanaChoice H5216-423 (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive coverage for these services.
Medical Equipment See details
HumanaChoice H5216-423 (PPO) covers medical equipment, offering durable medical equipment, prosthetics, and medical supplies with a 20% coinsurance and no copay. Diabetic supplies feature a 10% to 20% coinsurance and no copay, while diabetic therapeutic shoes and inserts require a $10 copay and applicable coinsurance.
Diagnostic and Radiological Services See details
HumanaChoice H5216-423 (PPO) covers diagnostic and radiological services, requiring prior authorization. Diagnostic lab services and outpatient X-rays have no copay, diagnostic procedures range from a $0 to $120 copay with no coinsurance, and therapeutic radiological services require a minimum 20% coinsurance and a minimum $35 copay.
Home Health Services See details
Home health services are covered by HumanaChoice H5216-423 (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered by HumanaChoice H5216-423 (PPO) with no coinsurance and required prior authorization, although some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered. The non-covered rehabilitation services carry copayments ranging from $25 to $40.
Skilled Nursing Facility (SNF) See details
HumanaChoice H5216-423 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, and while a prior three-day hospital stay is not required for admission, additional days beyond the standard 100 days are not covered.
Other Services See details
HumanaChoice H5216-423 (PPO) partially covers other services, offering acupuncture with a $35 copay and no coinsurance for up to 20 treatments per year, and a meal benefit for qualifying medical conditions with no copay and no coinsurance. Both of these covered benefits require prior authorization, while over-the-counter (OTC) items are not covered.
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