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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 provides coverage for a variety of services, including inpatient and outpatient hospital care, with varying copays depending on the specific service. The plan also offers coverage for primary care, specialist visits, and mental health services, generally with copays ranging from $20 to $40. Additional benefits include coverage for hearing and vision services, dental care, and medical equipment, with specific copays and coinsurance amounts. Emergency services, ambulance, and diagnostic services are covered, as well as home health and skilled nursing facility care, with specific copays and coinsurance amounts.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a $320 copay for days 1-5 and no copay for days 6-90, and no coinsurance. Additional days for Inpatient Hospital-Acute are covered with no copay and no coinsurance for days 91-999. Inpatient Hospital Psychiatric benefits are covered, with a $320 copay for days 1-5 and no copay for days 6-90, and no coinsurance. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional Days for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered by the HumanaChoice H5216-437 (PPO) plan, including outpatient hospital services with a copay between $0 and $350, observation services with a $320 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a $40 copay for both individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the HumanaChoice H5216-437 (PPO) plan, but requires prior authorization. You will have a $100 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HumanaChoice H5216-437 (PPO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a $315 copay, while air ambulance services have a $630 copay, but 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 under the HumanaChoice H5216-437 (PPO) plan. Emergency Services have a $140 copay, while Urgently Needed Services have a $40 copay, and Worldwide Emergency Services have a $140 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation. There is no coinsurance for any of these services.
Primary Care See details
The HumanaChoice H5216-437 (PPO) plan covers Primary Care Physician Services with no copay, and Chiropractic Services with a $20 copay. It also covers Occupational Therapy Services with a $20 copay, Physician Specialist Services with a $40 copay, and Mental Health Specialty Services with a $40 copay. Additionally, Podiatry Services and Other Health Care Professional services have a $40 copay, Psychiatric Services have a $40 copay, Physical Therapy and Speech-Language Pathology Services have a $20 copay, Additional Telehealth Benefits have a $0 - $40 copay, and Opioid Treatment Program Services have a $40 copay.
Preventive Services See details
The HumanaChoice H5216-437 (PPO) plan covers a variety of preventive services. Annual physical exams have no copay, while other services like Additional Sessions of Smoking and Tobacco Cessation Counseling and Fitness Benefit have no copay. Other preventive services such as 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, and Enhanced Disease Management are not covered.
Hearing Services See details
HumanaChoice H5216-437 (PPO) covers 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 partially covered, while OTC hearing aids are covered up to $90 every three months.
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) have no copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The HumanaChoice H5216-437 (PPO) plan covers dental services, with a $2,500 annual maximum. Medicare dental services have a $40 copay, while oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics fixed, and oral and maxillofacial surgery have no copay. Fluoride treatment, prosthodontics removable, maxillofacial prosthetics, implants, 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%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the HumanaChoice H5216-437 (PPO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment is covered under the HumanaChoice H5216-437 (PPO) plan. Durable Medical Equipment (DME) has an 18% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance for Medicare-covered items, and Diabetic Supplies have a 10-20% coinsurance with no copay. Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the HumanaChoice H5216-437 (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $50, Lab Services have no copay, Diagnostic Radiological Services have a copay up to $300, Therapeutic Radiological Services have a copay up to $30 and coinsurance up to 20%, and Outpatient X-Ray Services have no copay.
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
Cardiac Rehabilitation Services are covered, but not the 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, and require prior authorization. The copay is $20 for days 1-20, and $214 for days 21-100.
Other Services See details
The HumanaChoice H5216-437 (PPO) plan covers acupuncture with no copay, but requires prior authorization and is limited to 25 treatments per year. Over-the-counter items are covered, with a maximum benefit of $90 every three months, and Nicotine Replacement Therapy and Naloxone are offered as a Part C OTC benefit, though not all drugs on the CMS OTC list are covered. However, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and several other services are not covered.
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