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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 2025, 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 2025.
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. Additionally, this plan comes with a Part B Premium reduction of $3.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $275.00 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 H5216-423 (PPO) plan has a $450 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, you will pay no copay for preferred generic drugs at a standard pharmacy or preferred mail order, but $20 for a standard mail order. For standard generic drugs, you will pay a $47 copay, and for preferred brand drugs, you will pay 43% coinsurance. Once your total yearly drug costs reach $2000, you will enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The HumanaChoice H5216-423 (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay for the first few days, while outpatient services have copays that vary by service. Emergency services, including worldwide coverage, have a copay, and primary care visits are covered with no copay. The plan also covers preventive services, including an annual physical exam, with no copay. Hearing, vision, and dental services are included, with copays for some services and no copays for others. Home health services, Skilled Nursing Facility (SNF) services, and dialysis services are covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a $365 copay for days 1-6 and no copay for days 7-90 for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Additional days for Inpatient Hospital-Acute have no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute and 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, with copays ranging from $0 to $450, observation services with a $365 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services are covered with copays between $45 and $100, and outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the HumanaChoice H5216-423 (PPO) plan, but requires prior authorization. You will have to pay a $80 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by HumanaChoice H5216-423 (PPO). Ground and Air Ambulance Services have a $315 copay, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency services are covered under the HumanaChoice H5216-423 (PPO) plan, with a $110 copay and no coinsurance. Urgently needed services have a $45 copay and no coinsurance. Worldwide emergency services, worldwide urgent coverage, and worldwide emergency transportation each have a $110 copay and no coinsurance.
Primary Care See details
The HumanaChoice H5216-423 (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, and occupational therapy services with a $25 copay. The plan also covers physician specialist services with a $40 copay, and physical therapy and speech-language pathology services with a $25 copay. Additional telehealth benefits are covered with a copay between $0 and $45.
Preventive Services See details
The HumanaChoice H5216-423 (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services may have a copay, and some services like health education, in-home safety assessments, and others are not covered. Other preventive services like glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit have no copay.
Hearing Services See details
Hearing Services includes hearing exams with a $40 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a copay between $599 and $899, while OTC hearing aids, and inner, outer, and over the ear prescription hearing aids are not covered.
Vision Services See details
The HumanaChoice H5216-423 (PPO) plan covers vision services, including eye exams with a copay between $0 and $40, and eyewear with no copay. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-423 (PPO) plan covers Medicare Dental Services with a $40 copay, and other dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery with no copay. The plan does not cover fluoride treatment, maxillofacial prosthetics, implant services, or orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay, with coinsurance between 0% and 20%. Other Medicare Part B drugs, including Chemotherapy/Radiation Drugs, have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-423 (PPO) plan, with a coinsurance of 20%. Prior authorization is required.
Medical Equipment See details
Medical Equipment is covered by the HumanaChoice H5216-423 (PPO) plan, including Durable Medical Equipment (DME) with 11% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have no copay and between 10% and 20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic services, diagnostic procedures/tests, lab services, all radiological services, diagnostic radiological services, therapeutic radiological services, and outpatient X-Ray services, are covered. Diagnostic procedures/tests have a minimum copay of $0 and a maximum copay of $120, while lab services have no copay. Diagnostic radiological services have a maximum copay of $325, and therapeutic radiological services have a coinsurance of up to 20% and a maximum copay of $40. Outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-423 (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but not in practice. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-423 (PPO) plan, with no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The HumanaChoice H5216-423 (PPO) plan covers acupuncture with a $40 copay, and a limit of 20 treatments per year, as well as 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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