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HumanaChoice H5216-437 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HumanaChoice H5216-437 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HumanaChoice H5216-437 (PPO) in 2025, please refer to our full plan details page.
HumanaChoice H5216-437 (PPO) is a PPO plan offered by Humana Inc. available for enrollment in 2025 to people living in CO, NM. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that HumanaChoice H5216-437 (PPO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about HumanaChoice H5216-437 (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 H5216-437 (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 $100.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6200.00 (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 $6200.00 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
Prescription drugs are not covered by HumanaChoice H5216-437 (PPO).
Additional Benefits
The HumanaChoice H5216-437 (PPO) plan offers comprehensive coverage, including inpatient hospital stays with a copay, and outpatient services with varying copays. This plan also includes coverage for primary care, preventive, hearing, vision, and dental services, often with no copay. Additionally, the plan provides coverage for ambulance, emergency, and home health services, as well as medical equipment and diagnostic services.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered. For acute care, you will pay a $320 copay for days 1-5, and no copay for days 6-90; additional days have no copay. Psychiatric care has the same cost-sharing as acute care, but additional days and non-Medicare covered stays are not covered.
Outpatient Services See details
Outpatient services, including outpatient hospital services, observation services, ambulatory surgical center (ASC) services, and outpatient substance abuse services are covered. Outpatient hospital services have a copay between $0 and $350, and observation services have a $320 copay. Individual and group outpatient substance abuse sessions have a copay of $40. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by HumanaChoice H5216-437 (PPO) with a $100 copay, and requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-437 (PPO) plan, with no coinsurance. Ground ambulance services have a $315 copay, and air ambulance services have a $630 copay, while transportation services to a plan-approved health-related location have no copay for up to 24 one-way trips per year. 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 by the HumanaChoice H5216-437 (PPO) plan. Emergency Services have a $140 copay, and Urgently Needed Services have a $40 copay, while there is a $140 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation.
Primary Care See details
The HumanaChoice H5216-437 (PPO) plan covers a variety of primary care services. Primary Care Physician Services have no copay, Chiropractic Services have a $20 copay, Occupational Therapy Services have a $20 copay, and Physician Specialist Services have a $40 copay. Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, and Opioid Treatment Program Services also have copays. Physical Therapy and Speech-Language Pathology Services have a $20 copay, and Additional Telehealth Benefits have a copay between $0 and $40.
Preventive Services See details
The HumanaChoice H5216-437 (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, including Medicare-covered glaucoma screenings, diabetes self-management training, and other services, are covered with no copay.
Hearing Services See details
Hearing exams are covered with a $40 copay, routine hearing exams are covered with no copay, and fitting/evaluation for hearing aids have no copay. Prescription hearing aids are partially covered, with only "Prescription Hearing Aids (all types)" covered with a copay between $699 and $999, and OTC hearing aids are covered.
Vision Services See details
The HumanaChoice H5216-437 (PPO) plan covers vision services including eye exams with a copay of $0-$40, and eyewear with no copay. Contact lenses and eyeglasses (lenses and frames) are covered with no copay, while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-437 (PPO) plan covers Medicare and other dental services, with a $2,500 annual maximum. Oral exams, dental X-rays, other diagnostic services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics fixed, and oral and maxillofacial surgery are covered with no copay, while fluoride treatment, prosthodontics removable, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, and other Medicare Part B Drugs and Medicare Part B Chemotherapy/Radiation Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-437 (PPO) plan, but require prior authorization. The coinsurance for this benefit is 20%.
Medical Equipment See details
Medical Equipment is covered by the HumanaChoice H5216-437 (PPO) plan, including Durable Medical Equipment (DME) with an 18% coinsurance, Prosthetics/Medical Supplies with a 20% coinsurance, and Diabetic Equipment with a 10-20% coinsurance and no copay for Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
The HumanaChoice H5216-437 (PPO) plan covers diagnostic and radiological services, with a maximum copay of $50 for diagnostic procedures and tests, and no copay for lab services. Diagnostic radiological services have a maximum copay of $300, and therapeutic radiological services have a maximum 20% coinsurance and a maximum copay of $30.
Home Health Services See details
Home Health Services are covered by the HumanaChoice H5216-437 (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
HumanaChoice H5216-437 (PPO) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the HumanaChoice H5216-437 (PPO) plan, with a copay of $20 for days 1-20, and a copay of $214 for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include acupuncture with no copay, and a meal benefit with no copay. Over-the-counter items are covered with a maximum benefit of $90 every three months. However, services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and others are not covered.
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